sensors back to basics · 2018-07-19 · disclosure richard a. bonato, ph.d., m.a., rpsgt ceo and...
TRANSCRIPT
DISCLOSURE
Richard A. Bonato, Ph.D., M.A., RPSGT
CEO and Co-Founder of BRAEBON® Medical Corporation
Has been involved in the study of sleep and its disorders since
1986, has taught courses on Sleeping & Dreaming at Carleton
University, was the director of a sleep disorders laboratory, and
has been an author, co-author, reviewer, and examiner in
various educational organizations within the sleep field,
including the AASM, AAST, BRPT, and has served on the
Executive of the Canadian Sleep Society.
BRAEBON manufactures and sells wearable sleep sensors,
home apnea recorders, and a micro-recorder, DentiTrac, for
tracking oral appliance compliance.
Copyright 2017 BRAEBON
Oral Appliance Therapy for OSA
and Measuring Compliance in
Custom Oral Devices for OSA
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Objectives
• How does OAT (and CPAP) work and how do
you know it is working?
• Compliance and why measure it?
• Test Treat Trac®
• Technology: understanding what to use
• Types of patients who may benefit from oral
appliance compliance measurement
• Evaluation of oral appliance success:
compliance reporting
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iOS & Droid App – Free Dental Sleep Study Guide
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Sleep Disordered Breathing Spectrum
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Two key questions for DSM:
1. How does OAT work, how do you
know oral appliance therapy (OAT) is
working for an apnea patient?
2. How do you know if a patient is
wearing their oral appliance?
®
Change….
• Omnipresent
• Very difficult for many people
• Technology change (Test. Treat. Trac.)
• What was life like in the year 1900?
• What was the environmental crisis of
the day?
Technology we use…..
Lab (PSG) vs home (HSAT)
Type 1 PSG Type 2 HST Type 3 HSAT Type 4 HSAT
Sleep Tech in
Sleep Lab
No Tech, Home
(MediPalm/Byte)
No Tech
Home (MediByte)
No Tech,
Home (Oximeter)
16 or more
channels: EEG,
EOG, EMG, EKG,
Legs
7 or more: EEG,
EOG, EMG
4 or more 1 or 2
Thermal airflow,
Pressure airflow,
Ventilatory effort,
Snoring, Body Pos
Thermal airflow,
Pressure airflow,
Ventilatory effort,
Snoring, Body Pos
Thermal airflow,
Pressure airflow,
Ventilatory effort,
Snoring, Body Pos
Perhaps pressure
airflow
SpO2 SpO2 SpO2 SpO2
SCOPER Scale: Collop et al. 2011
Polysomnogram = PSG (full PSG or full poly)
1989: >200 lbs; 6’ high
Full Polysomnograpy (Type 1)
2003: ½ lb; 4.75” x 2.75” x 0.75” (L x W x H)
Polysomnogram = multiple sleep graph recording
EEG EOG
Chin EMG
Legs EMG
SpO2
Chest effort
Abdominal effort
EKG
Body Position
Airflow
Type 1
With in-lab PSG (Type 1)….
• We can evaluate virtually all sleep
disorders (about 90)
• Plus MSLT & MWT
• But PSG is NOT a gold standard for OSA
• There is no anatomical or biological
gold standard for OSA
• Best at the time and we got stuck with it
Home sleep apnea testing (HSAT): Type 2 / 3
2006: 93 grams; 2.75” x 2” x 0.70”
Type 2 Home Sleep Recording
Type 2: EEG, EOG, EMG + cardiopulmonary
Unambiguous Stage REM sleep….
Type 1 or Type 2
EEG During sleep stages
Beta = 16 to 30 Hz EEG
Gamma = > 30 Hz EEG
CNV & DC Potentials
Alpha EEG = 8 to 12 Hz
Theta EEG = 4 to 8 Hz
Delta EEG = 0.5 to 4 Hz
Sleep Spindle = 12 to 14 Hz
NREM REM Sleep Cycle
Copyright 2011 Braebon
OSA SNORING EKG BRUXISM
Different tests are easily configured:
bruxism, EKG, snoring, PLMs (legs), etc.
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ORAL CPAP PAP INDUCED
APPLIANCE AUTOPAP PLMS
Different therapies can be monitored.
Copyright 2011 Braebon
Simultaneously record:
1. EEG
2. EOG
3. EMG
4. EKG
5. Snore
6. Pressure Airflow
7. Flow Limitation
8. Thermal Airflow
9. Chest Effort
10. Abdominal Effort
11. Sum
12. SpO2
13. Pulse Rate
14. Body Position
15. *PPG (Photoplethysmogram)
16. User Events
HSAT Type 3 simpler cardiopulmonary recorder
2008: 91 grams; 2.75” x 2” x 0.70”
BRAEB
ON
Type 3 but with fewer channels
Copyright 2011 Braebon
Simultaneously record:
1. Snore
2. Pressure Airflow
3. Flow Limitation
4. Chest Effort
5. SpO2
6. Pulse Rate
7. Body Position
8. *PPG (Photoplethysmogram)
9. User Events
Type 4: overnight pulse oximetry
Type 4: Pulse Oximetry (+ more?)
Simultaneously record:
1. Snore
2. Pressure Airflow
3. Flow Limitation
4. SpO2
5. Pulse Rate
6. *PPG (Photoplethysmogram)
DentiTrac micro-recorder
2015: 5 grams; ~12 x 11 x 5 mm
What do these devices have in common?
• They are ALL recorders
What do we do with this info?
• SDB: AHI is often focus
• Why?
• Other measures: Arousals, RDI, flow
limitation, RERAs, PRV, etc.
• Goal is successful treatment: CPAP or
OAT
How does CPAP work?
• A CPAP machine blows room air into
your airway so it doesn't collapse when
you breathe in.
• Interface covers nose (maybe mouth,
but nose better)
• Think of CPAP as an air splint
• Effective but usually low compliance
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CPAP (cont’d)
• Bedside blower size is usually not an
issue for people
• Blowers are getting smaller for easier
travel: Travel PAP
• Mask interfaces remain the largest
issue for most people
How does OAT work?
• A device is placed in the mouth and
holds the mandible and / or tongue
forward, usually with increased vertical
opening, which acts as a mechanical
splint to increase airway space so your
airway doesn’t collapse (as much) when
you breathe in
• TRD vs MRD
How does OAT work?
• Custom usually better than boil & bite
• Titratable usually better than non
• Bite registration?
• Phonetic
• George Gauge
86% increase
in anterior-
posterior
area
How does OAT compare to CPAP?
Chan & Cistulli, 2009
Are you better off using something
that works well (i.e., CPAP with AHI &
PSG measures) but using it less OR
are you better off using something
that does not work quite as well (i.e.,
OAT) but using it more?
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Amer J Resp Crit Care Med 2013
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• Measured cardiovascular (24-h blood
pressure, arterial stiffness), subjective
sleepiness, driving simulator
performance, and quality of life
(Functional Outcomes of Sleep
Questionnaire-36)
• Randomly assigned 126 (108
completed) patients with moderate to
severe OSA
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What This Study Adds to the Field
In the short term, health outcomes in patients with moderate
to severe OSA were similar after treatment with
CPAP and MAD. This was likely explained by the greater
efficacy of CPAP being offset by inferior compliance relative
to MAD. These findings strongly challenge current
practice parameters recommending MAD treatment be
considered only in patients with mild to moderate OSA.
Long-term comparative effectiveness studies between
CPAP and MAD that include objectively measured treatment
compliance are needed to better define treatment
strategies for patients with OSA.
CPAP reduced AHI better, but moderate to
severe OSA patients were similar after
treatment with CPAP and oral appliance.
Because patients wear oral appliances
more than they wear CPAP.
Long-term studies needed to compare
CPAP and MAD using objective
compliance measurement [e.g., DentiTrac].
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• Why did Philips et al (2013) find this?
• “Mean Disease Alleviation” (later)
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• Q/ How do you know if CPAP Tx is
working for the patient?
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Pt with Hx of MI, TIA….
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• Q/ How do you know if OA Tx is
working for the patient?
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Before: AHI 9.5 After: AHI 11.2
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Before: AHI 9.5
After: AHI 11.2 Patient feels better now
Pulse Rate Variability from 60 to 120
Overall AHI / RDI = 15.7 / 24.2
But supine this person falls into mild….
Follow-up: Baseline vs OAT Tx
16.3
3.8
CPAP Noncompliant patient using temp appliance (in a tent)
38
11
72
6
Copyright 2012 Braebon
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• We’ve talked about technology, we’ve
talked about how CPAP & OAT work,
how to measure their success
• How do you actually know if people
are actually complying or adhering to
treatment?
What is compliance?
• “Extent to which a person’s behavior (taking
meds, following a diet) coincides with medical
or health advice” (Haynes et al., 1979)
• Also, adherence, concordance or cooperation
(not passive terms, suggest more choice, etc.)
• For dental sleep medicine or orthodontics:
extent to which the person is using prescribed
therapy
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Direct or Indirect compliance measurement
• Direct:
• Use physiological measures (airflow, body temp)
• Less subject to bias
• This is where CPAP has been
• Indirect:
• Self-reports are more frequently used and easier
• More subject to bias
• This is where OAT has been
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Why is it important to measure?
• Better compliance = better results: reduced
treatment time (ortho)
• Noncompliance = waste of resources =
insurance payers will no longer pay (CPAP)
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Achilles heel of CPAP = compliance
CPAP Achilles heel: compliance
• mask is a huge issue
• not size of blower
• not humidity
• not hose
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Two Achilles heels of OAT
1. Objective compliance
measurement
2. A priori determination of
successful OAT candidate
Definition of compliance: CPAP
• To qualify to retain funding for CPAP after an
initial 3-month trial, a patient must
demonstrate “continued use of CPAP therapy”:
• > 4 hrs per night for > 70% of all nights
during a 30-day period of the initial 90-day
trial
• Historical def’n is >4 hrs nightly five
nights per week
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Europe
Qualifying for continued CPAP funding
• France: > 3 hrs per night 7 days per week
• Germany: > 4 hrs per night
• Italy: > 3 hours per night
• Spain: > 5 hours per night
Which definition is more correct?
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CPAP machines & the luxury of size
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A CPAP report…..
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AHI, Pressure (cm H20), leak, hours of use
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Let me tell you about our patient Juan…
• Juan is from Columbia
• Juan is a bit of a round individual
• Juan has a BMI of 32.5
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• Mallampati score of 0 (or less)
• Weight = 1.36kg and Height = 8”
Meet Juan….
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Juan needs CPAP @ 11 cmH20
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Gaming CPAP compliance
• Quick & dirty demonstration of CPAP
compliance deception:
• Cannot guarantee that it is actually
that patient wearing that particular
CPAP
• Could be bedpartner or a simple or
more sophisticated simulation
• This has important implications for the
future
CPAP Compliance / Intolerance
• When adherence is defined as greater than 4
hours of nightly use, 46 to 83% of patients with
obstructive sleep apnea have been reported to
be nonadherent to treatment.
Weaver & Grunstein (2008). Proc Am Thorac Soc Vol 5. pp
173–178, 2008
• CPAP Intolerance is a large target market for
dentists
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CPAP is state of the art treatment but…
After about a year 50% of people
stop using it
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Kribbs, Pack, Kline, Getsy, Schuett, Henry,
Maislin, Dinges. Effects of one night without
nasal CPAP treatment on sleep and sleepiness
in patients with obstructive sleep apnea.
Am Rev Respir Dis 1993;147:1162–1168.
Sleeping without CPAP for one night
reversed virtually all of the sleep and
daytime alertness gains derived from
sleeping with CPAP.
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AASM OA Practice Parameters: 2005
• Adherence data for OAs mostly relies on
subjective reports.
• In contrast, CPAP compliance is
routinely monitored objectively.
• Development of similar capabilities for
OA therapy should be pursued for both
research and clinical purposes.
What about OAT compliance measurement?
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Two Achilles heels of OAT
1. Objective compliance
measurement
What is OAT compliance?
1. How compliant are you everyday?
2. How compliant are you on days you are
wearing it for at least 15 min?
3. How compliant are you > 4 hrs daily for 5
out of 7 days for the entire data collection
period? (historical CPAP def’n)
4. How compliant are you > 4 hrs daily during
a 30-day period of the initial 90-day usage?
(this is the new CPAP def’n)
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4. How compliant are you if you changed
appliances and now have a new one
(i.e., more than one)?
5. How compliant are you since the last
time we looked (uploaded) at the data?
What is OAT compliance? (cont’d)
• Headgear timer: miniature electronic watch with memory
• Pts increased wearing time when told about monitoring.
• Hours increased from 35-50 / week to 100 / week.
Northcutt, M. E. The timing headgear. J. Clin. Orthod.
V.8, p.321-324, Jun. 1974.
• Timing headgear neckband and timer
• Timing headgear readout monitor
• Neckband placed on monitor for readout
Orthokinetics: Compliance Science System
• Objectively inform orthodontists and patients the
number of hours the headgear is being worn
• Compliance Science System in 46 patients (blind)
• After two months two groups set up:
• uncooperative <16 hrs daily now informed of monitor
• cooperative > 16 hrs daily remain blind to monitor
• 4 months later: statistically significant increase in
usage in the uncooperative group
Creative children found a way around it….
Temperature sensor with periodic sampling
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What is an OAT compliance
monitor (DentiTrac)?
Is it a sensor? NO
Is it a chip? NO
Is it a micro-recorder? YES
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Both are dataloggers (recorders)
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Having a lab embed a recorder into an appliance
is as simple as inserting a label…
•We anticipate most dentists will
check a box when ordering the
appliance
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Auxilary can do much of this:
• Data is read by the base station and
uploaded to the cloud portal for analysis
and reporting
• Reading data is as simple as placing the
OA into the base station
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DentiTrac processed data
2. CWhenWorn = 91%
1. Ceveryday = 87%
3. C5 of 7 = 95%
4. C90 = 100%
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CPAP compliance &
OAT compliance data
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CPAP & OAT Compliance Data Detailed View
Pearson r = 0.92, r2 = .85; t-test = NS
Definition of compliance: OAT
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Vanderveken et al. 2013: Thorax
• Objective compliance measurement &
OAT
• Compared objective and subjective OAT
compliance
• Introduced “mean disease alleviation”
Vanderveken et al. 2013
• Objective OAT compliance measurement
allows calculation of mean disease
alleviation, defined as a combined function of
efficacy and compliance, being a measure of
overall therapeutic effectiveness
• Effectiveness = compliance x efficacy.
• OA efficacy (%) = baseline AHI minus
AHI with OA (e.g., 10 – 4.4 = 56%)
• Mean Disease Alleviation = product of
adjusted compliance (worn 91.2% of the
time) with therapeutic OA efficacy (56%
above = 51.1%
Vanderveken et al. 2013
Mean disease alleviation
CPAP example…
• If the AHI on CPAP drops from 50 to 2
then it is a 96% reduction
• If the patient only wears the CPAP 50%
of the time then Mean Disease
Alleviation = 50% x 96% = 48%
• Higher compliance with OAT = similar
adjusted effectiveness as compared
with CPAP
• OAT is not as good as CPAP in
reducing AHI, but MDA values might be
comparable with CPAP because of the
higher compliance with OA therapy (and
that’s what Philips et al. 2013 said too)
Vanderveken et al. 2013
More research using objective OA compliance…
51 patients with mild to moderate OSA
Dieltjens et al. 2015 JAMA Oto Head & Neck
• Neither anthropometric & polysomnographic
parameters nor reports of excessive daytime
sleepiness correlated with OAT compliance
• Two parameters which correlated with higher
OAT objective compliance were decreased
snoring and dry mouth
Journal Dental Sleep Medicine: 2015
CPAP & OAT have limitations: CPAP Tx often
has low patient acceptance, poor tolerance and
suboptimal compliance; OAT usually has inferior
PSG efficacy when compared to CPAP
According to MDA concept….
• OSA Tx with CPAP, OAT or other non-
CPAP modalities, as a single treatment,
usually means incomplete elimination of
the disorder with average MDA index,
as a marker of real clinical
effectiveness, ranging from 40 to 59%
Vanderveken 2015….
• Greater CPAP efficacy is offset by its
inferior compliance relative to OAT
• This is not imaginary, and results in a
similar overall effectiveness for both
therapeutic modalities
• Mandibular advancement + tongue
protrusion = effective treatment for
moderate-to-severe OSA: tongue bulb
added to MRD provides further
therapeutic effectiveness.
Vanderveken 2015: Combo Tx
Dort & Remmers
JCSM 2012
• OAT + multilevel upper airway surgery
• OAT + positional Tx
• Recent study reported MDA increased
from 42% to 70% when OAT was
combined with positional Tx
(Dieltjens et al., 2014)
Vanderveken 2015: Combo Tx
But can we game OAT same as CPAP?
• It is much more difficult to deceive OAT
with DentiTrac objective compliance
than to deceive CPAP with Juan
• My OA won’t fit my bedpartner
• My dog luvs my OA as a chew toy
• Juan is not a substitute
• What about a heated water bath?
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• Bϋchi heating bath deception
• 2 litres of water warmed to 35 C (95 F)
between 2100 and 0700 to simulate wearing
• Off 0700 to 1400
• On again 1400 to 1600 and 1700 to 1900
• Off 1900 to 2100
• Thus, total of 14 hrs wearing & 10 non-
wearing every 24 hours
Schott & Goz, Journal of Orofacial
Orthopedics, 2010, 79, pp 339-347.
Copyright 2017 BRAEBON
With a simple temp measurement device,
they concluded that the warm water
bath could deceive the temperature
sensing technology and report wearing
when not actually worn
The DentiTrac was not susceptible to
this deception because more than
temperature is being recorded and
anti-deception algorithms are
implemented
To conclude:
• Exciting times for OA Tx
• OAT compliance measurement is a
rapidly expanding frontier of dental
sleep medicine
• New standards evolving
• Modeled after the existing CPAP
compliance paradigm
• Test. Treat. Trac.®
Where to go from here?
• Principles & Practice of Sleep Medicine (6th Ed)
• ASBA Diplomate Exam