Keith thornton spreecast

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Keith thornton spreecast

  1. 1. Awake Airway Dilator Muscles © W. Keith Thornton DDS Temporalis Masseter
  2. 2. Digastric-Hyoid Sling © W. Keith Thornton D.D.S.
  3. 3. Medial Pterygoid © W. Keith Thornton D.D.S.
  4. 4. Lateral Pterygoid © W. Keith Thornton D.D.S.
  5. 5. Normal Breathing: Awake © W. Keith Thornton DDS pharynx P muscle P muscle
  6. 6. Neuromuscular Factors © W. Keith Thornton DDS P mus –P lum > atmosphere Pharynx Open
  7. 7. 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
  8. 8. © W. Keith Thornton DDS Airway Dilator Muscles During Sleep
  9. 9. Sleep Eliminates Pharyngeal Reflexes © W. Keith Thornton DDS
  10. 10. 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.
  11. 11. 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
  12. 12. 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
  13. 13. 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.
  14. 14. Bernoulli's principle © W. Keith Thornton D.D.S. S 4S -P
  15. 15. Bernoulli's principle © W. Keith Thornton D.D.S. S 4S -P - 4P - 4P
  16. 16. Neuromuscular Factors © W. Keith Thornton DDS Pharynx closed P mus - P lumin < atmospheric
  17. 17. Genioglossal EMG in OSA © W. Keith Thornton DDS
  18. 18. No Mandibular Protrusion (Oshima et al.) © W. Keith Thornton D.D.S.
  19. 19. Mandibular Protrusion (Oshima et al.) © W. Keith Thornton D.D.S.
  20. 20. Inspiratory Flow Limitation © W. Keith Thornton DDS
  21. 21. Critical (closing) Pressure is Elevated in OSA © W. Keith Thornton DDS
  22. 22. Genioglossal EMG is Elevated in Awake OSA © W. Keith Thornton DDS
  23. 23. Esophageal pressure Inspiratory Flow Limitation : IFL © W. Keith Thornton DDS Normal Airflow Normal IFL
  24. 24. 5 Minutes, RDI 6, T90 = approx. 80%, Severe Hypoventilation Severe Inspiratory Flow Limitation, No heart rate variability Mild OSA, 5 min 90%
  25. 25. 5 Minutes, RDI 6, T90 = approx. 80%, Severe Hypoventilation Severe Inspiratory Flow Limitation, No heart rate variability 2 Minutes 90%
  26. 26. 10 Minutes, Severe, RDI=96 16 events, RDI = 96 T90 = approx 20% Little heart rate variability, 50-67
  27. 27. 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%
  28. 28. 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%
  29. 29. 10 minutes, severe osa, RDI=66 80bpm 40bpm 90% RDI = 66, T90= 75%, heart rate variability = 40-80 Lowest desat= 63
  30. 30. 2 minutes, severe osa, RDI=66 80bpm 40bpm 90% RDI = 66, T90= 75%, heart rate variability = 40-80 Lowest desat= 63
  31. 31. RDI = 66, T90= 70%, heart rate variability = 40-80 Lowest desat= 63 2 minutes, severe osa, RDI=66 80bpm 40bpm 90%
  32. 32. ? • 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?
  33. 33. 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
  34. 34. 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
  35. 35. Continuum of Sleep Disordered Breathing Mechanical SeverityLeast Most Chemical Neuromuscular
  36. 36. 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
  37. 37. 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% ?
  38. 38. Continuum of Mechanical Sleep Disordered Breathing Treatment Normal Non-sleepy snorer OSA Uars Mild Moderate Severe Medical : CPAP TreatDon’t treat < 50% success
  39. 39. 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
  40. 40. Patient controlled protrusion
  41. 41. Treatment Position Maximum protrusion: MP Maximum passive protrusion: MPP
  42. 42. Original Maximum protrusion 8mm Present Maximum portrusion 17mm 170% of original maximum 17 mm
  43. 43. 17+3mm 170%
  44. 44. 23mm 185% 23mm
  45. 45. 25mm 195%
  46. 46. Floppy Lid Syndrome
  47. 47. Macroglossia, Maxillary Hypoplasia Immediate TAP CS Increase vertical
  48. 48. 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
  49. 49. Macroglossia, Maxillary Hypoplasia Lateral view, Patient in occlusion Centric Occlusion
  50. 50. 5. Macroglossia, Maxillary Hypoplasia Narrow arch, High palate without room for tongue Normal mandibular arch size
  51. 51. Macroglossia, Maxillary Hypoplasia Size of tongue Normal posture of tongue
  52. 52. Macroglossia, Maxillary Hypoplasia Normal lip posture Freeway space
  53. 53. 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
  54. 54. Immediate TAP CS 15mm 5mm
  55. 55. TAP III from lab Not enough vertical or protrusive Encroachment on tongue
  56. 56. Increase protrusive and vertical Moved bar back 4mm Moved bar up 3mm
  57. 57. Final TAP III appliance Initial vertical 8mm Added 6mm to plate, 3mm to bar Total vertical, 17mm 6mm 17mm
  58. 58. Neuromuscular Patients • Post Polio • ALS • Muscular dystrophy • Brain tumors affecting motor function • Congenital • Spinal Cord Injuries
  59. 59. Neuromuscular Patients • Generally need ventilatory assistance during the day • Paralysis of diaphragm • Intercostal muscle deterioration • Limited function of limbs • Adequate dentition for retention
  60. 60. Neuromuscular Patients: Treatment • Tracheotomy (medical) • Custom mask, oral appliance combination (dental) • No other choices except iron lung
  61. 61. 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
  62. 62. Neuromuscular Patients: History Problems: Fabrication techniques Retention Leakage Reparability Bulk Technique sensitivity Caregiver issues
  63. 63. Treatment of the Severe Sleep Apnic An eight year history 2002- 2010
  64. 64. Patient: Ron Doe
  65. 65. Patient: Ron Doe • History • Diagnostic Studies • Xrays • Therapy – Models – Appliances – Masks
  66. 66. HPI 2003 • Hx of loud snoring starting in dental school • Recent weight gain of 100 lbs (300 lbs) • Hypersomnolence • Acid reflux • Htn
  67. 67. HPI 2003 • Fibromyalgia • Night sweats • Joint aches • Numb feet • Nocturia
  68. 68. 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
  69. 69. 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
  70. 70. Results Before TAP After TAP © 2010 Airway Management, Inc.
  71. 71. TAP III 2010 Plate anterior to upper incisors
  72. 72. 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
  73. 73. TAP-PAP 2010 • TAP-PAP custom mask (TPCM)
  74. 74. TAP-PAP 2010 • TAP-PAP universal mask(TPUM)
  75. 75. TAP-PAP 2010 • TAP-PAP universal mask(TPUM)
  76. 76. 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

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