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CENTRAL SLEEP APNEA: Treatment Yüksel Peker MD, PhD Sleep Medicine Unit, Skaraborg Hospital

CENTRAL SLEEP APNEA: Treatment Yüksel Peker MD, PhD Sleep Medicine Unit, Skaraborg Hospital Skövde, Sweden. Hypercapnic Central Sleep Apnea. Alveolar hypoventilation Central Neurological disease Stroke Peripheral Neurological disease Polyneuropathy ALS

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CENTRAL SLEEP APNEA: Treatment Yüksel Peker MD, PhD Sleep Medicine Unit, Skaraborg Hospital

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  1. CENTRAL SLEEP APNEA: Treatment Yüksel Peker MD, PhD Sleep Medicine Unit, Skaraborg Hospital Skövde, Sweden

  2. Hypercapnic Central Sleep Apnea • Alveolar hypoventilation • Central Neurological disease • Stroke • Peripheral Neurological disease • Polyneuropathy ALS • Mononeuropathy, phrenic diaphragm • Chest wall compliance • Skeletal deformity, Congenital Kyphoscoliosis • Abnormal Lung mechanics • COPD

  3. Hypercapnic Central Sleep Apnea: treatment • Optimise lung mechanics (bronchodilators) • Avoid hypoventilation • positioning, CPAP • Removal of dead space • tracheostomy • Ventilatory stabilisation • Avoid respiratory depressants, sleep state manipulation (REM avoidance) • BiPAP

  4. Normo- Hypocapnic Central Sleep Apnea • Altitude • Metabolic disorders, Acromegaly, Hypothyroidism, Renal failure • Stroke • Obesity / idiopathic • Congestive cardiac failure

  5. Normo- Hypocapnic Central Sleep Apnea:treatment • Treat underlying disease • Respiratory stimulants • Oxygen • CPAP / BiPAP /Adaptive servo-ventilation (ASV) • Acetazolamide

  6. Theophylline + Medroxyprogesterone + Oestrogen ? Acetazolamide + Opiate antagonists – Nicotine – (causes sleep disruption) SSRI s (no effect) Respiratory stimulants

  7. Acetazolamide • Mild diuretic and respiratory stimulant • Treatment of periodic breathing at high altitude • Impact on central sleep apnea associated with heart failure? • 12 male patients with systolic heart failure and AHI >15 /h • Randomized, double-blind, cross-over protocol • Acetazolamide or placebo, 1 h before bedtime 6 nights with 2 wk wash-out Javaheri S. AJRCCM 2006 Jan 15; 173 (2) 234-237.

  8. Acetazolamide • Baseline vs placebo • No significant differences • Acetazolamide vs placebo • Central apne index: 23 (21) vs 49 (28); p=0.004 • Time spent < Sat. 90%: 6 (13) vs 19 (32); p= 0.01) • Improved sleep quality (p=0.003) • Feeling rested on awakening (p=0.007) • Improved daytime fatigue (p=0.02) • Improved falling asleep daytime (p=0.002) • No significant changes regarding arterial blood gases, pulmonary function tests and LVEF Javaheri S. AJRCCM 2006 Jan 15; 173 (2) 234-237.

  9. CONCLUSIONS: Acetazolamide In patients with heart failure, administration of a single dose of acetazolamide before sleep improves central apnea and related daytime symtoms. Javaheri S. AJRCCM 2006 Jan 15; 173 (2) 234-237.

  10. Oxygen: Short-term • 51 patients with stable CHF, mean age 79 (12) yrs • 38 had sleep apnea (75%) • 49% with CSA-CSR, 51% with OSA • Oxygen 2 liter/min during 2 consecutive nights • AHI and ODI declined in the patients with CSA-CSR • No significant changes in CHF patients with OSA Sakakibara M et al. J Cardiol 2005, Aug; 46 (2): 53-61

  11. Oxygen: Long-term (1) • Impact of nocturnal oxygen during 3 months • 22 patients with severe CHF, median age 71 yrs • PSG, echocardiography, 6 min walk test, questionnaires at baseline and after 3 months • 41% of patients with CSA-CSR Broström A et al. J Cardiovasc Nurs 2005, Nov-Dec; 20 (6): 385-396

  12. Oxygen: Long-term (2) • Improved functional capacity in all patients (p<0.01) and in patients with CSA-CSR (p<0.05). • No improvement in cardiac function, objective sleep, subjective sleep or CSA-CSR except for ODI (p<0.05) • No improvement in quality of life measures • Long-term nocturnal oxygen treatment improves functional capacity in patients with severe CHF, with or without CSA-CSR. Broström A et al. J Cardiovasc Nurs 2005, Nov-Dec; 20 (6): 385-396

  13. Transplant free survival in CHF with and without CSR Sin DD et al, Circulation 2000;102:61–66

  14. CPAP in CHF Sin DD et al, Circulation 2000;102:61–66

  15. CPAP in CHF without CSR Sin DD et al, Circulation 2000;102:61–66

  16. CPAP in CHF with CSR Sin DD et al, Circulation 2000;102:61–66

  17. Patient Characteristics HF, LVEF <40%, CSA (AHI ≥ 15/hr) CANPAP Multicenter Study RANDOMIZATION n > 400 Control Group: Optimal Medical Therapy Alone, n > 200 Treatment Group: Optimal Medical Therapy + CPAP, n > 200 Primary outcome♦Combined rate of mortality and heart transplantation Secondary Outcomes♦ AHI, mean nocturnal SaO2 ♦ LVEF ♦ 6-minute walk distance ♦ Atrial Natriuretic Peptide ♦ Plasma Norepinephrine ♦ Hospital admissions ♦ Chronic Heart Failure Questionnaire Scores Bradley TD et al., Can J Cardiol 2001;17:677

  18. CPAP for CSA and Heart FailureBradley TD et al, N Engl J Med 2005; 353:2025-33 • N=258 • CSR CHF stage III/IV LVEF ~24.5% • AHI ~40 • CPAP use 3.6 hrs during 2 yrs follow-up • Improved LVEF (2.2 %) • Distance walked in 6 min (20meters) • Better oxygenation • Reduced Norepinephrine • AHI reduced to ~20

  19. CPAP for CSA and Heart Failure • Trial stopped early • No difference in transplant free survival • No change in Quality of life • Early deaths in CPAP group • CANPAP data do not support the use of CPAP to extend life in CHF with CSR Bradley TD et al, N Engl J Med 2005; 353:2025-33

  20. Potential problems with CPAP in CSR • Patient selection difficult • Poor compliance to CPAP • Lack of experience in adjusting CPAP • The time needed for optimal pressure can be up to 4 weeks • CPAP titration criteria still unclear • Alleviation of the respiratory event is not mandatory • The pressure never exceeds 10 cmH20

  21. CPAP vs BiPAP • 18 patients • LVEF <35% • CSR AHI >15 • Randomised crossover 2 week blocks AHI pre/hr AHI CPAP AHI BIPAP 26.7 (10.7)7.7 (5.6)6.5 (6.6) AI pre /hr AI CPAP AI BIPAP 31.115.716.4 • Both improved sleep quality, daytime fatigue and NYHA class Kohnlein et al, ERJ;2002;20;934-41

  22. BiPAP for 3 months • 14 patients with CSR-CSA • 7 received BiPAP, 7 only conventional medication • BiPAP group vs baseline • LVEF 36.3% vs 46.0% (p=0.02) • BNP 993.6 pg/ml vs 474.0 pg/ml (p=0.02) • NYHA functional class 3.1 vs 2.1 (p=0.03) • Control group vs baseline • No significant changes • Conclusion: Treatment with BiPAP improved cardiac functions in CHF patients with CSR-CSA. Kasai T et al . Circ J 2005, Aug; 69 (8): 913-921

  23. BiPAP: adverse effect on central apneas? • Retrospective analysis of all sleep studies during 2 yrs • 95 patients treated with BiPAP • 80 out of these 95 had been treated with CPAP as well. • BiPAP was more likely to worsen than improve CSR (p=0.002), non-CSR central apneas (p<0.001). • Higher BiPAP levels worsened central events in 28% of patients while 7% were improved. Johnson KG, Johnson DC. Chest 2005, Oct; 128 (4): 2141-2150

  24. Adaptive pressure support servo-ventilation (ASV) • To provide the hydrostatic benefits of low levels of CPAP while directly suppressing CSA/CSR and attendant sleep disturbance without causing overventilation. • The adaptive servo-ventilator provides a baseline degree of ventilatory support (4 cmH20) and maximum support 10 cmH20 (automatically). • End-expiratory pressure 4-6 cmH20 with the intention of eliminating any obstructive sleep apnea.

  25. ASV in CHF with CSR Acute changes Teschler et al AJRCCM, 2001; 164:614-619

  26. Teschler et al AJRCCM, 2001; 164:614-619 One singel night, respectively

  27. One singel night, respectively Teschler et al AJRCCM, 2001; 164:614-619

  28. Adaptive Servo-Ventilation: effects on symptoms, BNP and catecholamines (1 month) Pepperell et al, AJRCCM 2003;168:1109-1114

  29. Adaptive Servo-Ventilation improves daytime sleepiness Pepperell et al, AJRCCM 2003; 168:1109-1114

  30. ASV versus Nocturnal oxygen therapy; 2 yr follow up baseline 2yrs O2 2yrsASV Patients (nr) 23 12 11 AHI (events/hr)38228* Arousals (/hr)423312* 6MWD (m)220265332* Ejection fraction (%)293237*,** Usage (hrs/day)8.35.1 Days in hospital618* Death (n)42 * p<0.05 baseline, ** p<0.05 O2 Vogt Ladner AJRCCM A836, 2003

  31. CPAP corrects CSR Allows PaCO2 to rise in CSR Reduces sympathetic activation and hyperventilation Reduces blood pressure and heart rate Improves LVEF No reduction in mortality rate No impact on transplant free survival CANPAP data do not support the use of CPAP to extend life in CHF with CSR Conclusions: CPAP in CHF with CSR

  32. BiPAP corrects CSR BiPAP reduces arousals Improves LVEF, NYHA, fatigue No better than CPAP in small trial Might induce central apnéer due to hypocapnia secondary to overventilation Probably to prefer in hypercapnic central apnéas in COPD Conclusions: BiPAP in CHF with CSR

  33. Autoset CS ASV corrects CSR Autoset CS ASV reduces arousals Reduces AHI and AI more than CPAP Improves daytime sleepiness, BNP, catecholamines, hyperventilation No difference in Quality of life Conclusions: Autoset CS ASV in CHF with CSR • Larger comparative trials are needed with clinical endpoints • ie mortality

  34. Do not forget to treat CONGESTIVE HEART FAILURE! Treatment of Cheyne-Stokes Respiration and central apneas in congestive heart failure

  35. Do not forget to PREVENT congestive heart failure: Treat obstructive sleep apneas!

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