CPAP primer for the otolaryngologist - AOCOOHNS primer for the otolaryngologist Tod C. Huntley, MD FACS [email protected]

CPAP primer for the otolaryngologist

Tod C. Huntley, MD [email protected]

OSA panelOSA treatment: medical and surgical

Tod C. Huntley, MD FACSIndianapolis, IN

CPAP for Dummies The preferred initial treatment option

Roles in OSA treatment1. Definitive long-term therapy2. Temporary bridge until definitive therapy3. As combo therapy with surgery or oral appliance4. Testing modality for mild OSA:

If symptoms persist, rethink the diagnosis

Preferred by insurance, usually covered

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APAP: auto-titrating PAPPressure needs can vary with body position and stage of sleep

APAP avoids a fixed pressure

Measures airflow breath-by-breath by measuring resistance to breathing

Adjusts to flow limitationAdjusts pressure slowly

Does not adapt to each event

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BPAP: Bi-level PAP 2 levels of pressure

IPAP: higher inspiratory pressureEPAP: lower expiratory pressure Allows for easier exhalation

When to consider:“I can’t breathe out against the machine”

Allows for easier exhalation

IPAP and EPAP settings independently adjusted

Starting point: 4 cwp insp/exp gradient (e.g.: 20/16 cwp)

Generally for patients with higher pressure needs (~ > 14 cwp)

Expiratory Pressure Relief (EPR): “Poor man’s BiPAP” 5

Optional PAP features Heated humidifier Heated tubing

Ramp Exhalation pressure relief (C-flex, A-flex, EPR) Altitude adjustment

Compliance meters, downloadability

Chin straps Mask liners

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CPAP goals Reduction or elimination of respiratory events

Reduction of morbidities associated with OSAObjective: cardiovascular events, hypertensionSubjective:Daytime somnolenceBedpartner satisfaction

Your job:Educate patientOptimize patient acceptanceMaximize long term adherence

Make patient healthier if planning surgery7

Adherence: 4 hr/night for 70% of nights

Non-adherence rate: 46-83% (!)Weaver TE, Grunstein RR. Proc Am Thorac Soci 2008;5:173–8.

Self-reported CPAP usage over-estimates nightly use cf download data by 1 hour

CPAP side effects:• insomnia• nocturnal awakenings• upper airway irritation• sneezing• nasal dryness• rhinorrhea• epistaxis

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CPAP effectiveness & adherence

Data is continuously recorded Downloads by card or wirelessly

Usage dataNightly Cumulative

Mask leak: > 0.1-0.4 L/sec = poor mask fit

Residual event detection (AHI) Pressure data:

Mean pressureMean peak pressure90th percentile pressure

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CPAP downloads

Pressure determination: options1. In-lab titration followed by fixed pressure CPAP

• Gold standard used by most sleep docs• Most expensive

2. Empiric APAP with lab titration when needed• Increasingly utilized; my preferred method

3. Fixed pressure CPAP after 1 week of APAP• Alternative to #2 preferred by some insurance

4. Fixed pressure CPAP determined by algorithm• Least precise, less efficacious with BP

normalization than other modalities

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The sleep lab titration Objective pressure determination in the sleep lab Sleep parameters studied at different pressures Optimal pressure reported

Most labs: Done automatically as soon as OSA dx’dWorst night on CPAP is the first night--

why spend it in the expensive lab?

Pro: Most robust dataTime-proven

Con:CostAPAP proven as an effective alternative

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The sleep lab titrationOptimal role : my opinion

Determination of optimal pressures in a patient already compliant with PAP therapy

Treatment of the more difficult patientSuspected complex OSAPersistent symptoms despite PAPHigh AHI with APAPSevere OSA Confirmation of APAP pressures

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Empiric APAP vs. lab titrations APAP saves $$ by eliminating lab titration Reduces sleep lab’s revenue

APAP more expensive than CPAP

Many studies show similar outcomesPatient adherence and satisfaction may

be better with APAPBoth improve AHI to similar levels

Caveats:APAP might miss the rare complex OSA ptCaution: AHI from APAP download not a true

surrogate for PSG AHI (but is validated)

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My usual CPAP algorithm Sleep study: Know what you are treating

Introduce. Educate. Show masks.

Set up with APAPSufficiently wide pressure range (6-20 cwp)Mask of choiceHeated humidifier

Troubleshooting:VendorOffice staff

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My usual CPAP algorithm

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Follow up at 6 weeksPatient brings the CPAP machine & mask to visit Data download and subjective report from patient Trouble shoot

If patient adherent and willing to continue: Continue with APAP if sufficiently improved Follow up 3-6 months later with downloads Follow up every 6-12 months and prn

Consider lab titration for Patient who is past over the honeymoon period Persistent symptoms, severe cases, etc.

My usual CPAP algorithm

If nasal obstruction interfering: treat the nose

If patient won’t use and can’t be convinced:Thorough discussion of risks, benefits, alternativesConsider oral appliance if applicableConsider appropriate surgical procedures

Communication and education: the keys to success

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CPAP adherence problems Lack of education / communication / follow up

Overly eager patient or surgeon

Improper set-upMask fit (like buying shoes)Too little pressure (still snoring or tired)Too much pressure (aerophagia, arousals)Difficulty in exhalation: consider EPR, BiPAPImproper humidificationToo short of ramp

Claustrophobia, discomfort Lifestyle: travel, camping, etc. Nasal obstruction, sinus issues

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CPAP masks: nasal

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Profile LiteWisp

CPAP masks: pillows

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Nasalaire

Adam Circuit

Comfort Lite

CPAP masks: full face

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CPAP masks: other

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CPAP Pro

Oracle

Hybrid

“Just like buying shoes”

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CPAP ordering It’s not rocket science

Involve the patient

Know your vendorsHands on examination of masksAvailability, communication

Manufacturers will provide demos:Samples of masksDummy machinesEducational materials

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HOW TO IMPROVE CPAP ADHERENCE

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Motivate your patient

Nasal obstruction prevalence in CPAP users: 25-45%Hoffstein V et al. Am Rev Respir Dis 1992;145:841–5, Brander PE et al. Respir Int Rev Thorac Dis 1999;66:128–35, Pep JL et al. Chest1995;107:375–81

Compliance affected by • Nasal airway volume & cross-sectional volume Li et al. Sleep 2005;28:1554–9

• Increased nasal resistance Sleep 2005;28:1554–9

• Poiseuille’s Law: resistance to airflow is directly proportional to the length & inversely proportional to the fourth-power of the radius.

• 10% increase in cross-sectional area of the nasal airway can result in an increase of 21% of nasal airflow

Multiple studies: Nasal surgery reduces CPAP pressures and/or improves CPAP acceptance, compliance, tolerance, adherence, or use.

Don’t forget the nose!

Nasal obstruction? Consider C-flex or BiPAP

PAPFlex will improve adherence in patients with high nasal resista

Meta-analysis of isolated nasal surgery on CPAP

18 articles, 279 patients

Isolated nasal surgery results in:• CPAP mean pressure reduction of 2.66 cwp (0.8-4.8)

• Best results: septoplasty with turbs, though results observed independent of surgery subset addressed

• CPAP use increase (11 studies)• Regular use increased from 38.7% to 90.2%• Mean hrs of use incr from 3.0 + 3.1 to 5.5 + 2.0 hr

Nasal surgery can help CPAP use

ORAL APPLIANCES

SomnoMed

TAP EMA

Oasis

Klearway

PM Positioner

OPAP

SomnoGuard AP

Titratable thermoplastic appliances

ORAL APPLIANCE

Success (AHI < 10): varies with severity Mild OSA: 81%

Moderate OSA: 60%Severe OSA: 25%

EFFICACY

AHI reductionAll studies:

• Success rate (AHI < 10): 54%

• Response rate (50+% ↓ AHI, AHI > 10): 21%

Randomized, cross-over, placebo-controlled trials:

• Success rate: 50%; response rate: 14%

Snoring

Review of 89 studiesn = 3,027

Compliance at 1 year 24% discontinuation (148/619)

Best predictors of successNo nasal obstruction

Positional OSA (defined as lateral AHI < 10) Women

Mild OSA or non-apneic snoring

POOR PREDICTORS FOR OAInadequate dentition:

8-10 teeth/arch, > 2 posterior teethSignificant periodontal disease

< 25 mm opening, unable to protrude > 7 mm

Active TMJ

Progressive neuromuscular disease

Steep mandibular plane

Neck circumference > 20” men, 17” womenChronic nasal obstruction

SIDE EFFECTS OF OA THERAPY

Most common

• Excessive salivation

• Pain -- tooth, TMJ, headache, tongue

• Dental / occlusion changes in up to 85% of patients• Variable and progressive• Not always clinically relevant• Usually reversible over 1st 6 months

• Long term follow up necessary

• OSA control supercedes maintenance of baseline occlusion

AM Aligner

Other surgical options

Hyoid and tongue base suspension

Siesta MedicalAirlift system

Inspire Upper airway stimulation

The Inspire® system

No stimulation Stimulation on

Reference: 2 slices

Palate

Tongue base

Off

Off

On

On

Drug-induced sleep endoscopy

Resultsn = 126 (124 completed f/u at 12 mo)• AHI 32 + 11.8, BMI 28.4 + 2.6 (18.4-32.5)• 22 prior UPPP• Mean age 54.5 yr (31-80)• All non-adherent to CPAP therapy• Self-reported daily use: 86%; average objective use: > 5 hr / noc

Median AHI reduction: 68% (29.3 to 9.0)Median ODI reduction: 70% (25.4 to 7.4)Reduction or AHI >50% and AHI <20: 66% (83 of 126)ODI reduction of >25%: 75% subjectsFOSQ & ESS changes: clinical significantMedian % sleep time <90%: 5.4% to 0.9%

RESULTS DURABLE TO 3 YEARS

Strollo et al. NEJM 370; 2 1/9/2014

Woodson et al, Oto HNS epub before print 9/9/2014

Therapy effect on AHI and ODI at baseline, 12 months, randomized controlled therapy (RCT), and 18 months

(mean and standard error)aP < 0.05 vs baseline; bP < 0.05 vs 12 mo; cP < 0.05 vs RCT

Adverse adventsSerious device-related adverse events requiring repositioning:

• n = 2 (discomfort)

Serious non-related adverse events: n = 33• Most (88%) within 30 days of procedure• Sore throat from ETT, incisional pain, muscle soreness

Temporary tongue weakness: 18% of subjects• Resolved after 2 weeks in 100%

Other— most resolved with acclimation: • 40% with some discomfort with stimulation• 21% with tongue soreness

Strollo et al. NEJM 370; 2 1/9/2014

n = 126 total subjects

Tod C. Huntley, MD 5/9/2015

da Vinci® TORS BOT reduction

What the surgery entailsTransoral endoscopic resection of lingual tonsillar tissue w/ or w/o underlying muscle

Resection of 25-30 cc, up to 50 cc

May safely resect < 10 mm thickness within entire BOT limits w/o neurovascular risk

May resect additional 5 mm deep strip within 5 mm of midline if needed

Optional partial epiglottidectomy with mucosal resection in vallecula

Secondary intention healing pulls epiglottis forward, in attempt to tighten supraglottis

Based on tongue base TORS work done at UPenn

Target area

surfaceLymphoid

tissue

Muscle

Selection criteria“triple L”: low, localized, lymphatic

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da Vinci® TORS BOT reduction

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da Vinci® TORS BOT reduction