spreecast with mytap video
TRANSCRIPT
Definition: Sleep Disordered Breathing
• A disorder of breathing during sleep only, or significantly affected by sleep. In general, the patient has little or no problem breathing while awake.
• Not a true sleep disorder
Categories
• Mechanical : The inappropriate collapse of the pharynx during sleep– Snoring
– Inspiratory Flow Limitation
– Obstructive sleep apnea
• Chemical : Central Sleep Apnea
• Neuromuscular : paralysis of involuntary muscle (diaphragm) or lack of adequate tidal volume requiring ventilation at night
Continuum of Sleep Disordered Breathing:Treatment
SeverityLeast Most
ChemicalCpapVpapOral AppliancesCombinationOxygen
NeuromuscularVentilatorTracheotomyCombination
MechanicalOral AppliancesCPAPCombinationSurgeryTracheostomy
Continuum of Sleep Disordered Breathing:
Treatment Success
SeverityLeast Most
Chemical?
NeuromuscularVentilator +Tracheotomy = 100%?TAP-PAP = 100%?
MechanicalCPAP <50%OA’s >50%TAP-PAP > 95%Tracheotomy 100% ?
Why is the Passive Pharynx So Important???
© W. Keith Thornton D.D.S.
• Pharyngeal muscles are hypotonic during sleep
• REM sleep causes atonia of pharyngeal muscles.
• Allows the airway to collapse
Physics of Airway Collapse
• Poiseuille's Law– Size of tube and effect on negative pressure to
breath and speed of airflow
• Bernoulli’s law– Increase in speed of airflow decreases size of
flexible tube
• Pathology– Large negative Inspiratory pressure
– And/or total collapse
© W. Keith Thornton D.D.S.
Esophagealpressure
Inspiratory Flow Limitation : IFL
© W. Keith Thornton DDS
NormalAirflow
Normal
IFL
5 Minutes, RDI 0, T90 = approx. 80%, Severe HypoventilationSevere Inspiratory Flow Limitation, No heart rate variability
Severe IFL, no OSA90%
90%
67 bpm
50bpm
2 Minutes, Severe, RDI=96
16 events, RDI = 96T90 = approx 20%Little heart rate variablity 50to 67Lowest desat 83%
90%
67 bpm
50bpm
2 Minutes, Severe, RDI=96
16 events, RDI = 96T90 = approx 20%Little heart rate variablity 50to 67Lowest desat 83%
10 minutes, severe osa, RDI=66
80bpm
40bpm
90%
RDI = 66, T90= 75%, heart rate variability = 40-80Lowest desat= 63
2 minutes, severe osa, RDI=66
80bpm
40bpm
90%
RDI = 66, T90= 75%, heart rate variability = 40-80Lowest desat= 63
RDI = 66, T90= 70%, heart rate variability = 40-80Lowest desat= 63
2 minutes, severe osa, RDI=66
80bpm
40bpm
90%
Dose dependent improvement of pharyngeal
collapsibility in response to mandibular advancement
-10
-5
0
5
P’close
(cmH2O)
Velopharynx
-15
-10
-5
0
5
Oropharynx
Kato et al., (2000, Chest)© W. Keith Thornton D.D.S.
0 2 4 6
0.00
0.05
0.10
0.15
0.2010 mm
8 mm
6 mm
4 mm
2 mm
0 mm
0 2 4 6
0.00
0.05
0.10
0.15
Airflow
(L/s)
Preliminary results
Oropharyngeal pressure (cmH2O)
Patient #1
No IFL at 4mm advancementPatient #2
No IFL at 10 mm advancement
(unpublished)
© W. Keith Thornton D.D.S.
Conclusions
© W. Keith Thornton D.D.S.
• Protrusion increases the cross-sectional area
• Protrusion produces a hypotonic genioglossus
• Efficacy is dose dependant
Patient History
• Loud snoring, excessive fatigue, several wrecks
• Uncontrolled hypertension, 5 different medications per day
• Morning blood pressure on medication 175/120
• Stroke 5 years previous
• Four psg’s, no osa, no diagnosis, tried and failed cpap
• HST: RDI 3, significant upper airway resistance
5. Macroglossia, Maxillary Hypoplasia
Narrow arch,High palate without room for tongue
Normal mandibular arch size
Immediate TAP CS
• Moved screw forward to compensate for maxillary hypoplasia
• Opened vertical 15 mm to accommodate tongue
• Patient titrated himself 5mm beyond maximum protrusion in first week
• Blood pressure on awakening 145/90
• No snoring, head aches, fatigue
Final TAP III appliance
Initial vertical 8mmAdded 6mm to plate, 3mm to barTotal vertical, 17mm
6mm 17mm
Neuromuscular Patients
• Post Polio
• ALS
• Muscular dystrophy
• Brain tumors affecting motor function
• Congenital
• Spinal Cord Injuries
Neuromuscular Patients
• Generally need ventilatory assistance during the day
• Paralysis of diaphragm
• Intercostal muscle deterioration
• Limited function of limbs
• Adequate dentition for retention
Neuromuscular Patients:Treatment
• Tracheotomy (medical)
• Custom mask, oral appliance combination (dental)
• No other choices except iron lung
Neuromuscular Patients:History
45 yo, post polioParalyzed from neck downMask developed by DRI using “bite block”Pressure: 45 cmwVolume ventilatorCould use intercostals during dayInserted by biting into trays
Neuromuscular Patients:History
Problems:Fabrication techniquesRetentionLeakageReparabilityBulkTechnique sensitivityCaregiver issues
HPI2003
• Hx of loud snoring starting in dental school
• Recent weight gain of 100 lbs (300 lbs)
• Hypersomnolence
• Acid reflux
• Htn
Family and Social Hx
• Divorced and remarried
• Father died at age 51 of HA
– Professional football player with very large neck
• Son and grandchild have osa by symptoms
• Orthodontist
– Focused on treating non-extraction and developing airways
– Very knowledgeable in tmd and occlusion
Treatment Hx
• No initial sleep study or consultation with physician
• Numerous oral appliances tried over 1 yr– Herbst
– Silencer
– Snore guard
– Silent Knight
• Failure of all appliances
• Appliances still fit
PSG 2/2/2009
Diagnostic CPAP alone TAP (4/4/09)
RDI 82.2 23.6 18.2
Minimum O2 Sat 74 77 75
Sleep Efficiency 88.1 65.9 NA
PLM 99 22 NA
Tried Bilevel CPAP at 11/7 cmwCould not tolerate
PSG 12/28/2010TAP TAP-PAP
CustomTAP-PAPUniversal
TAP-PAPNasal
RDI/ AHI 20.7/18.9 2.5/2.5 0/0 0/0
Mean O2 Sat 92.6 % 94% 93 to 94% 94 to 98%
Lowest O2 Sat 86.0% 94% 90% 94%
Time< 90% 4.8% 0% 0% 0%
CPAP pressure 12-13 cmw 9 to 10 cmw 10 to 11 cmw
Comments Inadequately treated alone
Mask leak,Mask was not attached correctly
Sealed well,Preferred by patient