Keith thornton spreecast
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Keith thornton spreecast Keith thornton spreecast Presentation Transcript

  • Awake Airway Dilator Muscles © W. Keith Thornton DDS Temporalis Masseter
  • Digastric-Hyoid Sling © W. Keith Thornton D.D.S.
  • Medial Pterygoid © W. Keith Thornton D.D.S.
  • Lateral Pterygoid © W. Keith Thornton D.D.S.
  • Normal Breathing: Awake © W. Keith Thornton DDS pharynx P muscle P muscle
  • Neuromuscular Factors © W. Keith Thornton DDS P mus –P lum > atmosphere Pharynx Open
  • 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
  • © W. Keith Thornton DDS Airway Dilator Muscles During Sleep
  • Sleep Eliminates Pharyngeal Reflexes © W. Keith Thornton DDS
  • 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.
  • Poiseuille's Law (Tube Law) © W. Keith Thornton D.D.S. The volume (V) of a homogeneous fluid passing per unit time (T) through a tube (flow) is directly proportional to the pressure difference between its ends (Δ P) and to the fourth power of its internal radius (R) , and inversely proportional to its length (L) and to the viscosity (Vis) of the fluid V/T (flow) = L x Vis = R4 ΔP R4 ΔP
  • Poiseuille's Law (Tube Law) and Breathing • Volume per minute is constant (tidal volume) to maintain proper saturation • Variable is diameter of pharynx • Pressure change is to fourth power P4 • Speed increased to second power S2 © W. Keith Thornton D.D.S. 1 1/2 -4 cmw -64 cmw 1 x Speed 4 x Speed
  • Bernoulli's principle “As the speed of a moving fluid (liquid or gas) increases, the pressure within the fluid decreases.” Examples: shower curtains, sail boats and jet wings © W. Keith Thornton D.D.S.
  • Bernoulli's principle © W. Keith Thornton D.D.S. S 4S -P
  • Bernoulli's principle © W. Keith Thornton D.D.S. S 4S -P - 4P - 4P
  • Neuromuscular Factors © W. Keith Thornton DDS Pharynx closed P mus - P lumin < atmospheric
  • Genioglossal EMG in OSA © W. Keith Thornton DDS
  • No Mandibular Protrusion (Oshima et al.) © W. Keith Thornton D.D.S.
  • Mandibular Protrusion (Oshima et al.) © W. Keith Thornton D.D.S.
  • Inspiratory Flow Limitation © W. Keith Thornton DDS
  • Critical (closing) Pressure is Elevated in OSA © W. Keith Thornton DDS
  • Genioglossal EMG is Elevated in Awake OSA © W. Keith Thornton DDS
  • Esophageal pressure Inspiratory Flow Limitation : IFL © W. Keith Thornton DDS Normal Airflow Normal IFL
  • 5 Minutes, RDI 6, T90 = approx. 80%, Severe Hypoventilation Severe Inspiratory Flow Limitation, No heart rate variability Mild OSA, 5 min 90%
  • 5 Minutes, RDI 6, T90 = approx. 80%, Severe Hypoventilation Severe Inspiratory Flow Limitation, No heart rate variability 2 Minutes 90%
  • 10 Minutes, Severe, RDI=96 16 events, RDI = 96 T90 = approx 20% Little heart rate variability, 50-67
  • 90% 67 bpm 50bpm 2 Minutes, Severe, RDI=96 16 events, RDI = 96 T90 = approx 20% Little heart rate variablity 50to 67 Lowest desat 83%
  • 90% 67 bpm 50bpm 2 Minutes, Severe, RDI=96 16 events, RDI = 96 T90 = approx 20% Little heart rate variablity 50to 67 Lowest desat 83%
  • 10 minutes, severe osa, RDI=66 80bpm 40bpm 90% RDI = 66, T90= 75%, heart rate variability = 40-80 Lowest desat= 63
  • 2 minutes, severe osa, RDI=66 80bpm 40bpm 90% RDI = 66, T90= 75%, heart rate variability = 40-80 Lowest desat= 63
  • RDI = 66, T90= 70%, heart rate variability = 40-80 Lowest desat= 63 2 minutes, severe osa, RDI=66 80bpm 40bpm 90%
  • ? • What is your treatment approach on Monday morning? • What appliance and why? • How do you determine endpoints? • What do you do with oral appliance failures?
  • 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), requiring ventilation at night
  • Continuum of Sleep Disordered Breathing Mechanical SeverityLeast Most Chemical Neuromuscular
  • Continuum of Sleep Disordered Breathing: Treatment SeverityLeast Most Chemical Cpap Vpap Oral Appliances Combination Oxygen Neuromuscular Ventilator Tracheotomy Combination Mechanical Oral Appliances CPAP Combination Surgery Tracheostomy
  • Continuum of Sleep Disordered Breathing: Treatment Success SeverityLeast Most Chemical ? Neuromuscular Ventilator + Tracheotomy = 100%? TAP-PAP = 100%? Mechanical CPAP <50% OA’s >50% TAP-PAP > 95% Tracheotomy 100% ?
  • Continuum of Mechanical Sleep Disordered Breathing Treatment Normal Non-sleepy snorer OSA Uars Mild Moderate Severe Medical : CPAP TreatDon’t treat < 50% success
  • Continuum of Mechanical Sleep Disordered Breathing Treatment Normal Non-sleepy snorer OSA Uars Mild Moderate Severe Dentistry: Home monitor + oral appliance + tap-pap TreatDon’t treat > 90% success
  • Patient controlled protrusion
  • Treatment Position Maximum protrusion: MP Maximum passive protrusion: MPP
  • Original Maximum protrusion 8mm Present Maximum portrusion 17mm 170% of original maximum 17 mm
  • 17+3mm 170%
  • 23mm 185% 23mm
  • 25mm 195%
  • Floppy Lid Syndrome
  • Macroglossia, Maxillary Hypoplasia Immediate TAP CS Increase vertical
  • 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
  • Macroglossia, Maxillary Hypoplasia Lateral view, Patient in occlusion Centric Occlusion
  • 5. Macroglossia, Maxillary Hypoplasia Narrow arch, High palate without room for tongue Normal mandibular arch size
  • Macroglossia, Maxillary Hypoplasia Size of tongue Normal posture of tongue
  • Macroglossia, Maxillary Hypoplasia Normal lip posture Freeway space
  • 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
  • Immediate TAP CS 15mm 5mm
  • TAP III from lab Not enough vertical or protrusive Encroachment on tongue
  • Increase protrusive and vertical Moved bar back 4mm Moved bar up 3mm
  • Final TAP III appliance Initial vertical 8mm Added 6mm to plate, 3mm to bar Total 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 polio Paralyzed from neck down Mask developed by DRI using “bite block” Pressure: 45 cmw Volume ventilator Could use intercostals during day Inserted by biting into trays
  • Neuromuscular Patients: History Problems: Fabrication techniques Retention Leakage Reparability Bulk Technique sensitivity Caregiver issues
  • Treatment of the Severe Sleep Apnic An eight year history 2002- 2010
  • Patient: Ron Doe
  • Patient: Ron Doe • History • Diagnostic Studies • Xrays • Therapy – Models – Appliances – Masks
  • HPI 2003 • Hx of loud snoring starting in dental school • Recent weight gain of 100 lbs (300 lbs) • Hypersomnolence • Acid reflux • Htn
  • HPI 2003 • Fibromyalgia • Night sweats • Joint aches • Numb feet • Nocturia
  • 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
  • Results Before TAP After TAP © 2010 Airway Management, Inc.
  • TAP III 2010 Plate anterior to upper incisors
  • 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 cmw Could not tolerate
  • TAP-PAP 2010 • TAP-PAP custom mask (TPCM)
  • TAP-PAP 2010 • TAP-PAP universal mask(TPUM)
  • TAP-PAP 2010 • TAP-PAP universal mask(TPUM)
  • PSG 12/28/2010 TAP TAP-PAP Custom TAP-PAP Universal TAP-PAP Nasal 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