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- 1. Understanding the Severe Patient What to do when CPAP fails!
- 2. 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
- 3. 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) or lack of adequate tidal volume requiring ventilation at night
- 4. Continuum of Sleep Disordered Breathing Least Mechanical Severity Chemical Most Neuromuscular
- 5. Continuum of Sleep Disordered Breathing: Treatment Least Severity Most Mechanical Chemical Neuromuscular Oral Appliances CPAP Combination Surgery Tracheostomy Cpap Vpap Oral Appliances Combination Oxygen Ventilator Tracheotomy Combination
- 6. Continuum of Sleep Disordered Breathing: Treatment Success Severity Least Mechanical Chemical CPAP <50% ? OA’s >50% TAP-PAP > 95% Tracheotomy 100% ? Most Neuromuscular Ventilator + Tracheotomy = 100%? TAP-PAP = 100%?
- 7. Why is the Passive Pharynx So Important??? • Pharyngeal muscles are hypotonic during sleep • REM sleep causes atonia of pharyngeal muscles. • Allows the airway to collapse © W. Keith Thornton D.D.S.
- 8. Sleep Eliminates Pharyngeal Reflexes © W. Keith Thornton DDS
- 9. 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.
- 10. Neuromuscular Factors P mus –P lum > atmosphere Pharynx Open © W. Keith Thornton DDS
- 11. Neuromuscular Factors P mus - P lumin < atmospheric Pharynx closed © W. Keith Thornton DDS
- 12. Genioglossal EMG in OSA © W. Keith Thornton DDS
- 13. No Mandibular Protrusion (Oshima et al.) © W. Keith Thornton D.D.S.
- 14. Mandibular Protrusion (Oshima et al.) © W. Keith Thornton D.D.S.
- 15. Inspiratory Flow Limitation © W. Keith Thornton DDS
- 16. Inspiratory Flow Limitation : IFL Airflow Normal Esophageal pressure IFL Normal © W. Keith Thornton DDS
- 17. Severe IFL, no OSA 90% 5 Minutes, RDI 0, T90 = approx. 80%, Severe Hypoventilation Severe Inspiratory Flow Limitation, No heart rate variability
- 18. 10 Minutes, Severe, RDI=96 16 events, RDI = 96 T90 = approx 20% Little heart rate variability, 50-67
- 19. 2 Minutes, Severe, RDI=96 90% 67 bpm 50bpm 16 events, RDI = 96 T90 = approx 20% Little heart rate variablity 50to 67 Lowest desat 83%
- 20. 2 Minutes, Severe, RDI=96 90% 67 bpm 50bpm 16 events, RDI = 96 T90 = approx 20% Little heart rate variablity 50to 67 Lowest desat 83%
- 21. 10 minutes, severe osa, RDI=66 90% 80bpm 40bpm RDI = 66, T90= 75%, heart rate variability = 40-80 Lowest desat= 63
- 22. 2 minutes, severe osa, RDI=66 90% 80bpm 40bpm RDI = 66, T90= 75%, heart rate variability = 40-80 Lowest desat= 63
- 23. 2 minutes, severe osa, RDI=66 90% 80bpm 40bpm RDI = 66, T90= 70%, heart rate variability = 40-80 Lowest desat= 63
- 25. Dose dependent improvement of pharyngeal collapsibility in response to mandibular advancement Velopharynx Oropharynx 5 5 0 0 P’close (cmH2O) -5 -5 -10 -15 -10 Kato et© W. Keith Thornton D.D.S. al., (2000, Chest)
- 26. Preliminary results Patient #1 No IFL at 4mm advancement Patient #2 No IFL at 10 mm advancement 0.20 0.15 10 mm 8 mm 6 mm 4 mm 2 mm 0 mm 0.15 Airflow (L/s) 0.10 0.10 0.05 0.05 0.00 0.00 0 2 4 6 0 2 4 6 Oropharyngeal pressure (cmH2O) （unpublished） © W. Keith Thornton D.D.S.
- 27. Conclusions • Protrusion increases the cross-sectional area • Protrusion produces a hypotonic genioglossus • Efficacy is dose dependant © W. Keith Thornton D.D.S.
- 28. Maximum Protrusion Voluntary Induced Stretched © W. Keith Thornton D.D.S.
- 29. Treatment Position Maximum protrusion: MP Maximum passive protrusion: MPP
- 30. 17 mm Original Maximum protrusion 8mm Present Maximum portrusion 17mm 170% of original maximum
- 31. 23mm 23mm 185%
- 32. Macroglossia, Maxillary Hypoplasia Severe IFL Immediate TAP CS Increase vertical
- 33. 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
- 35. After therapy
- 36. Macroglossia, Maxillary Hypoplasia Lateral view, Patient in occlusion Centric Occlusion
- 37. 5. Macroglossia, Maxillary Hypoplasia Narrow arch, High palate without room for tongue Normal mandibular arch size
- 38. Macroglossia, Maxillary Hypoplasia Size of tongue Normal posture of tongue
- 39. Macroglossia, Maxillary Hypoplasia Normal lip posture Freeway space
- 40. 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
- 42. TAP III from lab Not enough vertical or protrusive Encroachment on tongue
- 43. Final TAP III appliance 6mm 17mm Initial vertical 8mm Added 6mm to plate, 3mm to bar Total vertical, 17mm
- 44. Neuromuscular Patients • • • • • • Post Polio ALS Muscular dystrophy Brain tumors affecting motor function Congenital Spinal Cord Injuries
- 45. Neuromuscular Patients • Generally need ventilatory assistance during the day • Paralysis of diaphragm • Intercostal muscle deterioration • Limited function of limbs • Adequate dentition for retention
- 46. Neuromuscular Patients: Treatment • Tracheotomy (medical) • Custom mask, oral appliance combination (dental) • No other choices except iron lung
- 47. 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
- 48. Neuromuscular Patients: History Problems: Fabrication techniques Retention Leakage Reparability Bulk Technique sensitivity Caregiver issues
- 57. Treatment of the Severe Sleep Apnic An eight year history 2002- 2010
- 58. Patient: Ron Doe
- 59. HPI 2003 • • • • • Hx of loud snoring starting in dental school Recent weight gain of 100 lbs (300 lbs) Hypersomnolence Acid reflux Htn
- 60. HPI 2003 • • • • • Fibromyalgia Night sweats Joint aches Numb feet Nocturia
- 61. 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
- 62. 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
- 63. Results Before TAP After TAP © 2010 Airway Management, Inc.
- 64. TAP III 2010 Plate anterior to upper incisors
- 65. 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
- 66. TAP-PAP 2010 • TAP-PAP custom mask (TPCM)
- 67. 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% 0% 0% 0% 12-13 cmw 9 to 10 cmw 10 to 11 cmw 4.8% CPAP pressure Comments Inadequately treated alone Mask leak, Mask was not attached correctly Sealed well, Preferred by patient