Obstructive Sleep Apnea Medical Treatment including nPAP

1. Obstructive Sleep ApneaMedical Treatment including nPAP A. Valipour, MD, FCCP Department of Respiratory and Critical Care Medicine Otto-Wagner-Hospital Vienna

2. Prevalence: ~2-4% of population • Risk Factors: • Obesity • Male Gender • Anatomic Risk Factors • Symptoms: • Excessive Sleepiness • Snoring/Apneas/Choking • Cognitive Dysfunction/Depression • Cardiovascular and metabolic morbidity and mortality

3. OSA: Medical Treatment • Weight Loss • Positional Therapy • Drugs • Nasal dilators • nPAP • Alternatives?

4. 10% weightgainpredicts 32% increase in AHI 10% weightlosspredicts 26% decrease in AHI Peppard PE, JAMA 2000

5. Peppard PE, JAMA 2000

6. 160 untreated Patients with Sleep Apnea • Age 50 ± 11yr • BMI 29 ± 5 kg/m2 • AHI 23 ± 22/hr • Follow-Up Polysomnographic Recordings (5 ± 3 yrs) Berger G, Eur Respir J 2009

7. Baseline vs. Follow-Up 15% Improvement 46% Stable 39% Deterioriation Berger G, Eur Respir J 2009

8. Δ BMI 1kg/m2/yr ↓ Δ AHI 5/hr Berger G, Eur Respir J 2009

9. Treatment: PositionalTherapy Positional therapy can yield moderate reductions in AHI but is clearly inferior to CPAP and long term compliance is poor. Predictors of response: young age, lower AHI, less obese ERS Task Force „Non-CPAP therapies in Sleep Apnoea“, ERJ in press 2010

10. Treatment: Drugs Antidepressants→ suppression of REM sleep → increasingairway tone Acetazolamide → metabolicacidosis → resp. drive↑ Theophylline→ respiratorydrive↑ Doxapram→ respiratorydrive↑ NO EVIDENCE THAT ANY DRUG IS LIKELY TO BENEFIT IN PATIENTS WITH OSA ERS Task Force „Non-CPAP therapies in Sleep Apnoea“, ERJ in press 2010

11. Treatment: Nasal Dilators Principle: Nasal dilation → Nasal resistance↓→ fraction of oral ventilation↓ Evidence: No consistenteffect → snoring → apneas → sleeparchitecture ERS Task Force „Non-CPAP therapies in Sleep Apnoea“, ERJ in press 2010

12. Treatment: Positive AirwayPressureTherapy Pneumatic Splint of Upper Airway

13. Positive AirwayPressureTherapy: CPAP ↓ „Normalization“ of upperairwaydimensions Schwab RJ, AJRCCM 1996

14. Positive AirwayPressureTherapy: Schwab RJ, AJRCCM 1996

15. Indicationsfor CPAP treatment • AHI > 30/hr regardless of symptoms • AHI 5-30/hr with symptoms, e.g. • Excessive daytime sleepiness • Insomnia • Impaired cognition • Cardiovascular disease Loube DI, Chest 1999

16. Cassel W, EurRespir J 1996

17. Becker HF, Circulation 2003

18. Dernaika TA, J ClinSleepMed 2009

19. Drager LF, Am J Respir Crit Care Med 2007

21. CPAP-Treatment: Reduction in cardiovascularmorbidity and mortality Marin J et al., Lancet 2005

22. CPAP use in a clinicalsetting • Compliance/Adherence • Side effects • Humidification • Auto-CPAP • Expiratorypressurerelief

23. Pépin JL et al, AJRCCM 1999

24. Kingshott RN, AJRCCM 2000

25. Regular use within first threemonths predicts long-term use McArdle N et al, AJRCCM 1999

26. Sucena M, EurRespir J 2006

27. Up to 30% refuse or stop CPAP therapy due to side effects Gay P, Sleep 2006

28. CPAP: Side effects • Mask problems • Nasal intolerance • Noise of the machine • Claustrophobia Massie CA, Chest 1999

29. Potential strategiesaimed at improvingcompliance and decreasingsideeffects • Education and training • Local therapy (Nose, Full Face Mask,…..) • Humidification • Auto-CPAP • Expiratory Pressure Relief

30. Massie CA, CHEST 1999

31. 86% preferred Auto-CPAP over fixed CPAP Nussbaumer Y, Chest 2006

32. CPAP vs. Auto-CPAP: no change in hours of use Ayas NT, SLEEP 2004;27:249-53.

33. Patruno V, Chest 2007

34. CPAP: Expiratorypressurerelief

35. No difference in complianceafter 7 weeks of treatment Nilius G, Chest 2006

36. Potential benefitforExpiratoryPressure Relief PAP EPR-PAP Less side effects to the upper airways ↓ Need for humidification ↓ Valipour A, ERS 2008

37. Pts. withsymptomatic OSA requiring CPAP 3 sleep labs Retrospective review of medical and insurance reports CPAP EPR-PAP Matching: age, sex, BMI, OSA severity, sleepiness, CPAP pressure 24 months 24 months Need for humidification? Need for humidification? Valipour A, ERS 2008

38. 37% reduction in humidifierprescriptionwith EPR-PAP p = 0.02 Valipour A, ERS 2008

39. Alternatives to treat OSA with CPAP? • High flowtransnasalinsufflation (TNI) • Expiratory nasal valves • „Didgeridoo“

40. „High Flow“ Transnasal Insufflation (TNI) TNI creates positive pharyngealpressure High Flow Insufflation 10L/min - 20L/min

41. McGinley BM, Am J RespirCrit Care Med 2007

42. Responders: Upper Airway Resistance Syndrome Sleep-Hypopnea-Syndrome Mild OSAS Nilius G, Chest 2009 McGinley BM, Am J RespirCrit Care Med 2007

43. Nasal valvetreatment: Expiratoryresistancecreates positive upperairwaypressure Expiratory Nasal Valves

44. Colrain IM, J Clin Sleep Med 2008

45. Conclusions • Weight reduction: first line treatment • Drugs inefficient • Nasal dilators inefficient

46. Conclusions • CPAP: Gold standard treatment • Side-Effects: Humidification: Auto-CPAP, EPR-PAP • TNI, Nasal Valves → mild OSA

47. Aim: Keeptheupperairwayopen Thankyouforyourattention

48. Positive airway pressure alternatives?

49. Puhan MA, British Medical Journal 2006

50. Puhan MA, British Medical Journal 2006