dr. fulsen bozkuŞ akdeniz university medical school

Effect of Upper Airway Location, Effect of Upper Airway Location, Identified by Flextupe Identified by Flextupe

Reflectometry, on CPAP Pressure in Reflectometry, on CPAP Pressure in Obstructive Sleep Apne Syndrome Obstructive Sleep Apne Syndrome

PatientsPatients

Dr. Fulsen BOZKUŞAkdeniz University Medical School

Obstructive Sleep Apne Syndrome

It is a syndrome characterized by repeated upper airway obstruction and frequently accompanied by decrease in oxygen saturation.

OSAS PREVALENCE

~% 2-4

Results of OSAS

Cardiovascular Pulmonary Pulmonary results Neurologycal Neurologycal results Psychiatric Psychiatric results Endocrynological results Nephrologycal results Gastrointestinal results Hematologycal results Socioeconomic results Mortality Other

A DISEASE A DISEASE THAT SHOULD THAT SHOULD

ABSOLUTELY BE ABSOLUTELY BE TREATED TREATED

OSAS Pathophysiology

The airway wall is drawn inside with the negative intraluminal pressure composed during inspiration and decrease in oropharengeal muscle tonus.

OSAS Pathophysiology

Oclusion develop and apnea occur via the progresive increase of airway resistance.

OSAS Pathophysiology

It is thought that continuous positive pressure applied to upper airway can resolve that oclusion.

CPAP TreatmentCPAP Treatment

Sullivan et. al, gave continuous pressure to upper airway with a nasal mask and inhibited pharynx wall collaps and so apnea.

Upper airway obstruction Upper airway obstruction locations in OSASlocations in OSAS

RetropalathalRetropalathal RetrolingualRetrolingual MixMix

Flextube reflectometryFlextube reflectometry ((RhinosleepRhinosleep))

It is a technique that objective, It is a technique that objective, done during sleep,easy to do, done during sleep,easy to do, easy to tolerate,can show easy to tolerate,can show obstruction location and/or obstruction location and/or locations at the same time.locations at the same time.

Rinosleep equipment anterior (left) and posterior appearance (rigth)

Rinosleep equipment lateral, miniprobe (left lower) and pump used in rinoflex tube attachment (left upper)

Marking of nasal cavity length in Flextube reflectometry

Rhinoflex tube “0” point should be placed ritghly, uvula length marked and tube placed

Rinosleep study principle.

AIMAIM

To determine if there is an effect of upper airway location, identified by flextupe reflectometry, on CPAP pressure in obstructive sleep apne syndrome patients or not.

Material - MethodMaterial - Method

July 2005 – December 2007July 2005 – December 2007 AUMS Chest Medicine – ENT AUMS Chest Medicine – ENT

clinicsclinics Patient that OSAS was Patient that OSAS was

diagnosed and CPAP is indicated, diagnosed and CPAP is indicated, were included.were included.

Retrospective and prospectiveRetrospective and prospective

Material - MethodMaterial - Method

Questionnaire for patient and friendQuestionnaire for patient and friend Epworth slepiness scale > 12 Epworth slepiness scale > 12

PSGPSG AHİ>30 and AHİ 5-30 with day time AHİ>30 and AHİ 5-30 with day time

slepiness CPAP titrasyonuslepiness CPAP titrasyonu Upper airway obstruction locationUpper airway obstruction location

flekstube reflectometryflekstube reflectometry

Material - MethodMaterial - Method

Obstruction number and Obstruction number and obstruction locations:obstruction locations:

Retropalathal (0-4 cm)Retropalathal (0-4 cm) Retrolingual (4-9 cm)Retrolingual (4-9 cm) MixMix

VFO determined with rinosleep

DKO determined with rinosleep

mix obstruction determined with rinosleep

Material - MethodMaterial - Method

Exclusion criteriasExclusion criterias Polysomnography and rhinosleep Polysomnography and rhinosleep

records technically inadequate records technically inadequate patientspatients

>3 months between >3 months between polysomnography and rhinosleep polysomnography and rhinosleep

Material - MethodMaterial - Method

Any other treatment other than Any other treatment other than corrective obstruciton surgery corrective obstruciton surgery applied between applied between Polysomnography and rhinosleepPolysomnography and rhinosleep

Remarkable weigth difference Remarkable weigth difference between Polysomnography and between Polysomnography and rhinosleeprhinosleep

Material - MethodMaterial - Method

Patients with COPD (Overlap Patients with COPD (Overlap Syndrome), chest wall deformity, Syndrome), chest wall deformity, airway obstruction and airway obstruction and paranchymal lung diseaseparanchymal lung disease

Psychiatric problems and/or Psychiatric problems and/or sedative drug usagesedative drug usage

Material - MethodMaterial - Method AgeAge SexSex BMI (kg/m2)BMI (kg/m2) Neck CircumferenceNeck Circumference Epworth Slepyness Scale Epworth Slepyness Scale AHI AHI Obstruction locations and number, Obstruction locations and number,

determined by Rinosleep determined by Rinosleep CPAP titration pressureCPAP titration pressure

FindingsFindings

Total 102 patientsTotal 102 patients 40 patients accepted 40 patients accepted 7 patients excluded7 patients excluded 33 patients included33 patients included 28 (%84.84) male, 5 (%15.16) 28 (%84.84) male, 5 (%15.16)

femalefemale

Parametre Minimum Maximum mean SD*

AGE (year) 33 74 51.55 10.417

BMI (kg/m2) 24.60 41 31.14 3.666

Neck circumference(cm) 39 48 42.52 2.347

CPAP pressure(cm h20) 5 15 11.18 2.910

EPWORTH sleep scale 3 24 12.67 5.521

AHI 15.10 81.40 45.875 19.076

Rinosleep obstruction number 5.8 80.0 36.32 18.06

* Değişkenler ± SD olarak verilmiştir.

Schedule 1. patients demographic data

With Flextube reflektometry 9 With Flextube reflektometry 9 patients (%27.2) retropalathal, patients (%27.2) retropalathal, 12 patients (%36.3) retrolingual 12 patients (%36.3) retrolingual and 12 patients (%36.3) mix and 12 patients (%36.3) mix obstruction. There was no obstruction. There was no significant correlation between significant correlation between obstruction locations and obstruction locations and obstruction number (p:0,886) obstruction number (p:0,886) (schedule 2.). (schedule 2.).

obstruction location determined by rinosleep

Patient number (n=33)/ %

obstruction number determined by rinosleep

(Ort±SD)

VFO 9 / 27.4 33,37 ± 12,34

DKO 12 / 36.3 36,02 ± 19,45

MİX 12 / 36.3 38,83 ± 21,12

Schedule 2. patients obstruction locations and number determined by rinosleep

0

5

10

15

20

25

30

35

40

VFO DKO MiX

Figure .1. Obstruction locations determined by rinosleep.

There was no significant There was no significant difference between patients difference between patients according to obstruction according to obstruction locations in respect to age, sex, locations in respect to age, sex, BMI, AHI, Epwoth sleep Scale, BMI, AHI, Epwoth sleep Scale, neck circumferenceneck circumference

There was a statistically There was a statistically significant correlation between significant correlation between obstruction number determined obstruction number determined by flextube reflektometry and by flextube reflektometry and AHI obtained with PSG . (pearson AHI obtained with PSG . (pearson correlation coefficient, r:0.451, correlation coefficient, r:0.451, p:0.008) (figure 1.)p:0.008) (figure 1.)

80,0060,0040,0020,00

80,00

60,00

40,00

20,00

0,00

AHI determined by PSG

o: intersections between AHİ determined by PSG and obstruction numbers determined by rinosleep

Figure 2. Obstruction numbers determined by rinosleep and AHI determined by PSG.

When patients are categorised according When patients are categorised according to obstruction locations; to obstruction locations;

CPAP pressure in RCPAP pressure in Retrolingual group was etrolingual group was statistically higher than in Retropalathal statistically higher than in Retropalathal group, (p:0,003) group, (p:0,003)

CPAP pressure in Mix obstructionCPAP pressure in Mix obstruction group was group was statistically higher than in Retropalathal statistically higher than in Retropalathal group (p:0,001)group (p:0,001)

obstruction location determined by rinosleep

MinimumCPAP

pressure

MaximumCPAPpressure

Mean CPAP pressure

SD*

VFO 5 11 8,22 * ⁿ 1,98

DKO 9 15 11,58 * 2,31

MİX 9 15 13 ⁿ 2.33

* p:0.003 ⁿ p:0.001

Schedule 3. Obstruction locations and mean CPAP pressures.

MİXTONGUE BASE GROUPSOFT PALATE GROUP

cp

ap

p

ressu

re

15

12,5

10

7,5

5

schedule.3. CPAP pressure distribution according to obstruction locations determined by rinosleep

Conclusion

Tongue base obstruction migth be one of the reasons that increase CPAP titration pressure in OSAS

In patients who can not tolarate CPAP with flekstube reflektometry we can determine obstruction location, and if it is retrolingual obstruction, we can plan treatment modalities ( radyofrequency, tongue base suspension,...) to the tongue base.