central apnea · 2020-07-22 · at the end of this presentation, the learner will be able to : 1....
TRANSCRIPT
![Page 1: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/1.jpg)
Central Apnea
![Page 2: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/2.jpg)
• No financial disclosure
• Past President, American Academy of Sleep Medicine
• Member, ABIM Board of Directors
Disclosures
![Page 3: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/3.jpg)
At the end of this presentation, the learner will be able to :
1. Describe the etiology and risk factors of central apnea in different patient population.
2. Describe the relationship between central and obstructive apnea
3. Outline a management approach, including diagnosis and treatment.
Objectives
![Page 4: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/4.jpg)
• 86 year old male
• Evaluation of snoring, fragmented sleep and dyspnea on exertion.
• Previous smoking history
• PFTs: Poor effort and mild airflow obstruction
• Echocardiography: EF= 40%
![Page 5: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/5.jpg)
A. Upper Airway obstruction
B. REM sleep
C. Hypocapnia
D. Diaphragmatic dysfunction
Question #1
What is the underlying mechanism of the phenomenon indicated by the arrow?
![Page 6: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/6.jpg)
A. Upper Airway obstruction
B. REM sleep
C. Hypocapnia
D. Diaphragmatic dysfunction
Question # 1
What is the underlying mechanism of the phenomenon indicated by the arrow?
![Page 7: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/7.jpg)
Effect of NREM sleep on VentilationThe hypocapnic apneic threshold
NREM sleep unmasks a reproducible, highly sensitive, hypocapnic apneic threshold
The CO2 reserve
Skatrud et al. JAP. 55:813-22, 1983
![Page 8: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/8.jpg)
Upper airway changes
1. Reduced activity of upper airway dilators
2. Loss of load compensation3. Reduced pharyngeal caliber4. Reduced tidal volume (VT)
Effect of NREM sleep on Ventilation
![Page 9: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/9.jpg)
Classification of Central Apnea
• Central sleep apnea with Cheyne-Stokes breathing
• Central sleep apnea due a medical disorder without Cheyne-Stokes breathing
• Central sleep apnea due to high altitude periodic breathing
• Central sleep apnea due to a medication or substance
• Primary central sleep apnea
• Treatment-emergent central sleep apnea
![Page 10: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/10.jpg)
•Hypoventilation• Sleep related hypoventilation: CNS, neuromuscular or chest wall disease
• Inadequate ventilatory reserve: hypercapnia not required
• May not meet the criteria for “central” or apnea”
•Post- hyperventilation • No daytime alveolar hypoventilation
• Hyperventilation
• The most common type of central apena
Central Sleep ApneaPathophysiologic Classification
![Page 11: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/11.jpg)
• 86 year old male
• Evaluation of snoring, fragmented sleep and dyspnea on exertion.
• Previous smoking history
• PFTs: Poor effort and mild airflow obstruction
• Echocardiography: EF= 40%
• AHI=60/hour of sleep
• CAI= 20/hour of sleep
• ABGs: PaO2= 82 torr, PaCO2= 34 torr
![Page 12: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/12.jpg)
A. Impaired arousal response
B. Low loop gain
C. Hypercapnia
D. High controller gain
Question # 2
What is/are the potential underlying mechanism (s) of recurrent central apnea?
![Page 13: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/13.jpg)
A. Impaired arousal response
B. Low loop gain
C. Hypercapnia
D. High controller gain
What is/are the potential underlying mechanism (s) of recurrent central apnea?
![Page 14: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/14.jpg)
Recurrent Central Apnea: Apnea
![Page 15: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/15.jpg)
Hyperventilation
Hypocapnia
Central apnea
ΔPaO2, PaCO2
Δ Sleep State
![Page 16: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/16.jpg)
Hyperventilation
Hypocapnia
Central apnea
ΔPaO2, PaCO2
Δ Sleep State
Apnea Begets Apnea
![Page 17: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/17.jpg)
Central Pattern
Generator
“Controller”
Airways, Lung,
Chest wall
“Plant”
△Ventilation
Controller gain△PCO2
Plant Gain
• Diffusion, Mixing,
• Circulation
The Loop Gain : An engineering Construct
![Page 18: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/18.jpg)
Mechanisms of hypocapnic Central ApneaLoop Gain
Changing ventilation:
Controller gain (CG) or
chemoreflex sensitivity
Input parameter = PaCO2
Output parameter= VE
CG= ∆ VE / ∆ PaCO2
Reducing PCO2
Plant gain
Input = VE
Output= PaCO2
Plant gain: ∆ PaCO2 / ∆ VE
Manisty C. et al. J.Phys. 577. 1: 387-401)
![Page 19: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/19.jpg)
0 532 34 36 38 40 42 440
1
2
3
4
5
6
7
8
9
10
VE, L/min Isometabolic line
Effect of Chemoreceptor Sensitivity
PaCO2 mm Hg
CO2 Reserve
![Page 20: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/20.jpg)
0 532 34 36 38 40 42 440
1
2
3
4
5
6
7
8
9
10
VE, L/min Isometabolic line
A
Effect of Prevailing PaCO2
PaCO2 mm Hg
Ventilatory Reserve
![Page 21: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/21.jpg)
0 532 34 36 38 40 42 440
1
2
3
4
5
6
7
8
9
10
VE, L/min Isometabolic line
A
Eucapnia
Effect of PrevailingPaCO2
PaCO2 mm Hg
Low PaCO2
B
![Page 22: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/22.jpg)
0 532 34 36 38 40 42 440
1
2
3
4
5
6
7
8
9
10
VE, L/min Isometabolic line
A
Eucapnia
Effect of PrevailingPaCO2
PaCO2 mm Hg
Low PaCO2
B
![Page 23: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/23.jpg)
0 532 34 36 38 40 42 440
1
2
3
4
5
6
7
8
9
10
VE, L/min Isometabolic line
A
Eucapnia
Effect of PrevailingPaCO2
PaCO2 mm Hg
Low PaCO2
B
![Page 24: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/24.jpg)
A. No effect- unchanged chemo-sensitivity
B. Increased- PaCO2 closer to the hypocapnic apneic threshold.
C. Decreased- decreased plant gain.
D. Increased- decreased CO2 stores.
Question # 3
The effect of decreased steady state PaCO2 on susceptibility to central apnea is:
![Page 25: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/25.jpg)
A. No effect- unchanged chemo-sensitivity
B. Increased- PaCO2 closer to the hypocapnic apneic threshold.
C. Decreased- decreased plant gain.
D. Increased- decreased CO2 stores.
Question # 3
The effect of decreased steady state PaCO2 on susceptibility to central apnea is:
![Page 26: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/26.jpg)
•Age, gender and menopause
•Medical Conditions
• CHF, CVA, Atrial fibrillation ?
• Narcotics
• Endocrine: Hypothyroidism, Acromegaly
•Idiopathic central apnea ?
CENTRAL APNEA RISK FACTORS
![Page 27: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/27.jpg)
A. N1
B. N2
C. N3
D. REM
Question # 4:
Which sleep state is least prone to central apnea
![Page 28: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/28.jpg)
A. N1
B. N2
C. N3
D. REM
Question # 4:
Which sleep state is least prone to central apnea
![Page 29: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/29.jpg)
•Congestive Heart Failure
•Opiate analgesics
•Obstructive sleep apnea• Treatment-Emergent Central Apnea
Central Apnea and Associated Conditions
![Page 30: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/30.jpg)
Polysomnographic findings in male heart failure patients with either central (CSA) or obstructive
(OSA) sleep apnea.
Javaheri S et al. Circulation. 1998;97:2154-2159
Copyright © American Heart Association, Inc. All rights reserved.
![Page 31: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/31.jpg)
Baseline: Pre-CPAP
![Page 32: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/32.jpg)
On CPAP
![Page 33: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/33.jpg)
A. TECSA develops in the majority of patients undergoing split-night titration
B. Indicates the need for BPAP therapy.
C. Only patients with central apnea in the baseline study develop TECSA
D. The majority will experience complete resolution over a few weeks to months.
Question #5
Which of the following statements regarding treatment-emergent central sleep apnea (TECSA) is correct
![Page 34: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/34.jpg)
A. TECSA develops in the majority of patients undergoing split-night titration
B. Indicates the need for BPAP therapy.
C. Only patients with central apnea in the baseline study develop TECSA
D. The majority will experience complete resolution over a few weeks to months.
Question #5
Which of the following statements regarding treatment-emergent central sleep apnea (TECSA) is correct
![Page 35: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/35.jpg)
Dernaika, T. et al. Chest 2007;132:81-87
Change in CSAI in ith CPAP-related CSA
•CSA •CPAP-Emergent•N=14
![Page 36: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/36.jpg)
• 86 year old male
• Evaluation of snoring, fragmented sleep and dyspnea on exertion.
• Previous smoking history
• PFTs: Poor effort and mild airflow obstruction
• Echocardiography: EF= 40%
• AHI=60/hour of sleep
• CAI= 20/hour of sleep
• ABGs: PaO2= 82 torr, PaCO2= 34 torr
• What is your treatment recommendations
![Page 37: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/37.jpg)
A. BPAP
B. CPAP
C. ASV
D. Oral acetazolamide
Which of the following is considered as STANDARD treatment for central sleep apnea related to heart failure
![Page 38: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/38.jpg)
A. BPAP
B. CPAP
C. ASV
D. Oral acetazolamide
Which of the following is considered as STANDARD treatment for central sleep apnea related to heart failure
![Page 39: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/39.jpg)
Treatment of Central Apnea
• There is no specific treatment for central apnea • Most modalities dampen post apneic overshoot.• Positive Pressure
• CPAP, BPAP, ASV
• Altering chemical stimuli• Supplemental O2 or CO2
• Sleep State: hypnotics• Ventilatory Drive: Acetzolamide• Phrenic nerve Stimulation
![Page 40: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/40.jpg)
•Association with OSA
•Decreasing overshoot: Plant Gain• Opening the upper airway
• Increasing O2 stores
•CPAP has been used for CSR in CHF
•Improvement in intermediate outcome
•
Does nasal CPAP ameliorate central apnea?
![Page 41: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/41.jpg)
Central Apnea
Central Hypopnea
Upper airway obstruction
Breathing Instability
Treatment of Central Apnea
![Page 42: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/42.jpg)
Oropharyngeal airway occlusion during spontaneous CSA
![Page 43: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/43.jpg)
N= 258NCPAP: 128 No-CPAP: 1302-year Follow up
The Canadian Continuous Positive Airway Pressure trial (Can PAP)
Bradley T et al. N Engl J Med 2005;353:2025-2033
![Page 44: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/44.jpg)
Bradley T et al. N Engl J Med 2005;353:2025-2033
Heart-Transplantation-free Survival
![Page 45: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/45.jpg)
• CPAP vs. placebo at 3 months▪ AHI
▪ EF
▪ Mean nocturnal oxyhemoglobin saturation
▪ Plasma nor-epinephrine levels
▪ Six-minute walk,
• N-CPAP had no effect on survival
The Canadian Continuous Positive Airway Pressure trial (CanPAP)
![Page 46: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/46.jpg)
Johnson, K. G. et al. Chest 2005;128:2141-2150
Effect of Bi-level PAPon central apnea index
![Page 47: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/47.jpg)
![Page 48: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/48.jpg)
Adaptive Pressure Support Servo-Ventilation
• Small and variable ventilatory support
• The hydrostatic benefits of low levels of nasal CPAP ( 5 cm H20)
• Baseline pressure swing is 4 cm H2O
• Increases to provide 90% of the long-term average VE.
• No hyperventilation
Teschler et al. AJRCCM, 164, 4, 614-619,2001
![Page 49: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/49.jpg)
Adaptive Pressure Support Servo-Ventilation
Javaheri et al. 146#2 CHEST AUGUST 2014
![Page 50: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/50.jpg)
Teschler et al. AJRCCM, 164, 4, 614-619,2001
![Page 51: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/51.jpg)
Adaptive Pressure Support Servo-Ventilation
• Prospective, randomized, cross-over design
• N=16; gender?
• Desaturation index (3%) > 15/h
• Five consecutive nights
• CPAP
• Supplemental O2 @ 2L/NC
• Bi-level –ST mode
• ASV
Teschler et al. AJRCCM, 164, 4, 614-619,2001
![Page 52: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/52.jpg)
Teschler et al. AJRCCM, 164, 4, 614-619,2001
Adaptive Pressure Support Servo-Ventilation
2l/NCST mode
![Page 53: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/53.jpg)
A. CPAP in patients with Heart failure and preserved EF
B. BPAP in patients with opioid-associated central sleep apnea
C. Adaptive-Servo ventilation in patients with heart failure and reduced ejection fraction
D. CPAP in patients with heart failure and reduced ejection fraction
Which of the following treatments is associated with increased mortality risk in patients with predominantly central apnea
![Page 54: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/54.jpg)
Cowie MR et al. N Engl J Med 2015;373:1095-1105.
Cumulative Incidence Curves for the Primary End Point, Death from Any Cause, and Cardiovascular
Death.
• N=1325 patients • HF-rEF• AHI≥15/hour of sleep• Predominance of central apnea
![Page 55: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/55.jpg)
A. CPAP in patients with Heart failure and preserved EF
B. BPAP in patients with opioid-associated central sleep apnea
C. Adaptive-Servo ventilation in patients with heart failure and reduced ejection fraction
D. CPAP in patients with heart failure and reduced ejection fraction
Which of the following treatments is associated with increased mortality risk in patients with predominantly central apnea
![Page 56: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/56.jpg)
•N=20, 9 weeks
•AHI 30.0 ± 18.1 to 13.5 ± 13.3 (p =0.001),
•CAHI 26.0 ± 17.2 to 7.1 ± 11.8 (p <0.001)
•Arousals 24.0 ± 11.6 to 15.1 ± 7.7 (p <0.001)
•ESS 13 ± 5 to 8 ± 5 (p < 0.001).
•OSA increased in 3 patients
•In the absence of a randomized, controlled trial, zolpidem cannot be recommended for treatment of ICSA at this time.
Improvement of Idiopathic Central Sleep Apnea with Zolpidem
Quadri et al. J Clin Sleep Med. 2009 April 15; 5(2): 122–129.
![Page 57: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/57.jpg)
Effect of Supplemental Oxygen on AHI in Patients with CHF
![Page 58: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/58.jpg)
Costanzo MR et al. Transvenous neurostimulation for central sleep apnoea: a randomised controlled trial.2016 Sep 3;388(10048):974-82
Transvenous neurostimulation for central apnea
![Page 59: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/59.jpg)
Costanzo MR et al. Transvenous neurostimulation for central sleep apnoea: a randomised controlled trial.2016 Sep 3;388(10048):974-82
![Page 60: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/60.jpg)
•Similar principles in CSA and PAP-emergent CSA
•Treat the underlying condition
•Initiate CPAP is the initial treatment
•No ASV or BPAP for CSA with HFrEF ( EF<45%)
•CPAP failure/intolerance in HFrEF patients with CSA • Nocturnal oxygen
• Medical management of heart failure.
Our ApproachWhen Data are few; experts are many !
![Page 61: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/61.jpg)
•Patients with HFpEF or primary CSA • A trial of CPAP
• A trial of ASV
• A trial of BPAP with a back-up respiratory rate
• Intolerant of PAP: A trial of acetazolamide
Our ApproachWhen Data are few; experts are many !
![Page 62: Central Apnea · 2020-07-22 · At the end of this presentation, the learner will be able to : 1. Describe the etiology and risk factors of central apnea in different patient population](https://reader034.vdocument.in/reader034/viewer/2022050312/5f74dff7068bd424fd379227/html5/thumbnails/62.jpg)
Questions?