Central Sleep Apnea, An Issue of Sleep Medicine Clinics,

1. Auflage 2014
ISBN: 978-0-323-28723-4
Verlag: Elsevier Health Care - Major Reference Works
Format: PDF
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)

E-Book, Englisch, Band Volume 9-1, 153 Seiten

Reihe: The Clinics: Internal Medicine

Dr. Peter Gay has put together a team of expert authors centering on the topic of Central Sleep Apnea. Focus will include articles on CSA due to other Medical Disorders, Cheyne-Stokes Respiration, Central Sleep Apnea and Cardiovascular Disease, Complex Sleep Apnea,Adaptive servo-ventilation Treatment, Drug induced central apneas- Mechanism and Therapies, ICSD-2 and AASM Practice Parameters, Alternative approaches to treatment of Central Sleep Apnea, and Infant central apnea.

Autoren/Hrsg.

Inhaltsverzeichnis

1;Front Cover;1
2;Central Sleep Apnea;2
3;copyright
;3
4;Sleep Medicine Clinics
;5
5;Contributors;6
5.1;Consulting editor;6
5.2;Editor;6
5.3;Authors;6
6;Contents;8
7;Preface
;12
7.1;References;13
8;International Classification of Sleep Disorders 2 and American Academy of Sleep Medicine Practice Parameters for Central Sleep Apnea
;14
8.1;Key points;14
8.2;Introduction;14
8.3;Primary CSA;15
8.3.1;Definition;15
8.3.2;Features;15
8.3.3;Treatment;15
8.3.3.1;Summary of evidence;15
8.3.3.1.1;Recommendation;16
8.3.3.1.1.1;Level of recommendation;16
8.3.3.1.2;Recommendation;16
8.3.3.1.2.1;Level of recommendation;16
8.3.3.1.3;Recommendation;16
8.3.3.1.3.1;Level of recommendation;16
8.4;CSA due to Cheyne-Stokes breathing pattern;16
8.4.1;Definition;16
8.4.1.1;Cheyne-Stokes breathing pattern;16
8.4.2;Features;16
8.4.3;Treatment;17
8.4.3.1;Continuous PAP;17
8.4.3.1.1;Summary of evidence;17
8.4.3.1.2;Discussion;18
8.4.3.1.3;Recommendation;18
8.4.3.1.3.1;Level of recommendation;18
8.4.3.2;Bilevel PAP;18
8.4.3.2.1;Summary of evidence;18
8.4.3.2.2;Discussion;18
8.4.3.2.3;Recommendation;18
8.4.3.2.3.1;Level of recommendation;18
8.4.3.3;ASV;18
8.4.3.3.1;Summary of evidence;18
8.4.3.3.2;Discussion;18
8.4.3.3.3;Recommendation;18
8.4.3.3.3.1;Level of recommendation;18
8.4.3.4;Oxygen;19
8.4.3.4.1;Summary of evidence;19
8.4.3.4.2;Discussion;19
8.4.3.4.3;Recommendation;19
8.4.3.4.3.1;Level of recommendation;19
8.4.3.5;Treatment comparison studies;19
8.4.3.5.1;Summary of evidence;19
8.4.3.6;Cardiac interventions;19
8.4.3.6.1;Summary of evidence;19
8.4.3.6.2;Discussion;19
8.4.3.7;Alternate therapies;19
8.4.3.7.1;Summary of evidence;19
8.4.3.7.2;Discussion;19
8.4.3.7.3;Recommendation;19
8.4.3.7.3.1;Level of recommendation;19
8.5;CSA due to high-altitude periodic breathing;19
8.5.1;Definition;19
8.5.2;Features;20
8.5.3;Treatment;20
8.5.3.1;Summary of evidence;20
8.5.3.2;Discussion;20
8.6;CSA caused by medical conditions other than Cheyne-Stokes;20
8.6.1;Treatment;20
8.6.1.1;Summary of evidence;20
8.6.1.2;Discussion;20
8.6.1.3;Recommendation;20
8.6.1.3.1;Level of recommendation;20
8.7;CSA caused by a drug or substance;20
8.7.1;Definition;20
8.7.2;Features;20
8.7.3;Treatment;22
8.7.3.1;Summary of evidence;22
8.7.3.2;Discussion;22
8.8;Summary;22
8.9;References;22
9;Cheyne-Stokes Respiration;26
9.1;Key points;26
9.2;Introduction;26
9.3;Epidemiology;26
9.4;Pathophysiology;27
9.4.1;CO2 Reserve;27
9.4.2;Loop Gain;27
9.4.3;Vagal Afferent;29
9.4.4;Chemosensitivity;29
9.4.5;Upper Airway;29
9.4.6;Change in CSA-CSR Overnight;30
9.4.6.1;Pulmonary changes with HF;31
9.4.6.2;Body position (vertical and rotation);32
9.5;Clinical features of CSA-CSR;32
9.6;Monitoring techniques;33
9.6.1;Is CSA-CSR Detrimental?;36
9.7;Summary;36
9.8;References;36
10;Central Sleep Apnea and Cardiovascular Disease;40
10.1;Key points;40
10.2;Epidemiology: heart failure;40
10.3;Epidemiology: CSA in HF;40
10.4;Clinical implications of CSA in HF;41
10.5;Treatment of CSA;42
10.6;Medical optimization: pharmacologic intervention;42
10.7;Medical optimization: surgery/devices/cardiac pacing;42
10.8;Positive airway pressure;42
10.8.1;CPAP;42
10.8.2;Adaptive Servo-Ventilation;44
10.8.3;Nocturnal Gas (Oxygen and Carbon Dioxide) Supplementation;44
10.9;Novel drug therapy;45
10.9.1;Theophylline;45
10.9.2;Acetazolamide;45
10.9.3;CSA and Atrial Fibrillation;45
10.10;References;45
11;Central Sleep Apnea The Complex Sleep Apnea Syndrome
(CompSAS)
;50
11.1;Key points;50
11.2;Introduction;50
11.3;Evaluation;51
11.3.1;Clinical Characteristics;51
11.3.2;Polysomnographic Findings;51
11.4;Treatment;51
11.4.1;CPAP Therapy;52
11.4.2;BPAP Therapy;55
11.4.3;ASV Therapy;55
11.5;Outcomes;57
11.6;Follow up care;59
11.7;Summary;59
11.8;References;59
12;Opioid-Induced Central Sleep Apnea;62
12.1;Key points;62
12.2;Introduction;62
12.2.1;CSA Present During Initial Polysomnographic Study;63
12.2.2;Opioid-Associated Complex Sleep Apnea;64
12.3;Mechanisms of opioid-induced CSA;65
12.3.1;Suppression of Breathing Rhythm;65
12.3.1.1;Alterations in ventilatory control;65
12.4;Treatment options for opioid-induced CSA;66
12.4.1;Treatment of OSA with PAP Devices in Patients on Opioids;66
12.4.2;Treatment of CSA with PAP Devices in Patients on Opioids;67
12.5;Summary;67
12.6;References;68
13;Central Sleep Apnea due to Other Medical Disorders;70
13.1;Key points;70
13.2;Introduction;70
13.3;Physiology of control of breathing and pathophysiology of central sleep apnea;71
13.3.1;Central Control of Breathing;71
13.3.2;Changes in the Inputs to Breathing from Wakefulness to Sleep;71
13.3.3;Pathophysiology of Central Apnea/Sleep Hypoventilation;72
13.4;Medical disorders associated with central sleep apnea;72
13.4.1;Renal Failure;73
13.4.2;Brain Tumors;73
13.4.3;Chiari Type I Malformation;73
13.4.4;Stroke;74
13.4.5;Pain and Opioids;74
13.4.6;Endocrine and Hormonal Disturbances;74
13.4.6.1;Acromegaly;74
13.4.6.2;Hypothyroidism;74
13.4.6.3;Pregnancy;75
13.4.6.4;Other endocrine or hormonal disturbances;75
13.4.7;Neurodegenerative Diseases;75
13.4.7.1;Multiple sclerosis;75
13.4.7.2;Multiple-system atrophy;75
13.4.7.3;Parkinson disease;75
13.4.8;Neuromuscular Disease;76
13.4.8.1;Congenital muscular dystrophies;76
13.4.8.2;Myasthenia gravis;76
13.4.8.3;Amyotrophic lateral sclerosis;77
13.5;Summary;77
13.6;References;77
14;Adaptive Servoventilation in Central Sleep Apnea;82
14.1;Key points;82
14.2;Introduction;82
14.3;Pathophysiologic background;83
14.4;Adaptive servoventilation;83
14.4.1;Devices and Algorithms;83
14.4.2;Titration and Setting of ASV;89
14.4.3;Influence of ASV on Respiratory Disturbances and Cardiovascular Parameters;90
14.4.4;Influence of ASV on Physiologic Parameters and Sympathoadrenergic Activity;92
14.4.5;Efficacy According to Severity of SRBD or Underlying Cardiac Disease;92
14.4.6;Does ASV Influence Daytime Symptoms and Quality of Life?;93
14.4.7;Alternatives to ASV;93
14.4.8;Open Questions on ASV Therapy in HF Patients with SRBD;93
14.5;ASV in complex sleep apnea and other central disturbances;94
14.6;ASV in opioid-induced sleep apnea;94
14.7;Summary;95
14.8;References;95
15;Alternative Approaches to Treatment of Central Sleep Apnea;100
15.1;Key points;100
15.2;Introduction;100
15.3;Polysomnographic recognition of a heightened respiratory chemoreflex;101
15.4;Advanced phenotyping of chemoreflex influences on sleep respiration;101
15.5;Non–positive airway pressure treatments for central sleep apnea syndromes;102
15.5.1;Minimization of Hypocapnia;102
15.5.2;Oxygen;107
15.5.3;Sleep Stabilization;108
15.5.4;Reduction of Opioid Dose;108
15.5.5;Carbonic Anhydrase Inhibition;110
15.5.6;Clonidine;111
15.5.7;Nasal Expiratory Positive Pressure;112
15.5.8;Oral Appliances;112
15.5.9;Weight Reduction;112
15.5.10;Nerve Stimulation;114
15.5.11;Maxillomandibular Advancement;114
15.5.12;Winx/Oral (Negative) Pressure Therapy;114
15.5.13;Manipulation of Body Position;114
15.6;Summary;114
15.7;References;114
16;Central Hypoventilation Syndromes;118
16.1;Key points;118
16.2;Introduction;118
16.3;Normal control of breathing;118
16.4;Congenital central hypoventilation syndrome;120
16.4.1;Background and Genetics;120
16.4.2;Clinical Presentation;120
16.4.3;Sleep Findings;121
16.4.4;Associated Conditions;121
16.4.5;Diagnostic Evaluation;122
16.4.6;Management of CCHS;122
16.5;Rapid-onset obesity with hypothalamic dysfunction, hypoventilation and autonomic dysregulation;123
16.6;Familial dysautonomia;124
16.7;Chiari malformation;124
16.7.1;Prader-Willi Syndrome;125
16.7.2;Achondroplasia;125
16.7.3;Mitochondrial Disorders;126
16.7.4;Acquired Conditions Causing Central Hypoventilation;126
16.8;Management of central hypoventilation syndromes;126
16.8.1;Ventilatory Support;126
16.8.1.1;Positive pressure ventilation;126
16.8.1.2;Negative pressure ventilation;127
16.8.1.3;Diaphragmatic pacing;127
16.8.1.4;Respiratory stimulants;127
16.8.1.5;General considerations;127
16.9;Summary;127
16.10;References;128
17;Central Sleep Apnea in Infants;132
17.1;Key points;132
17.2;Introduction;132
17.3;Apnea in healthy normal infants;133
17.4;Apnea of prematurity;135
17.5;Apparent life-threatening event;136
17.6;Pathophysiology of central apnea in infants;137
17.7;Diagnosis;138
17.8;Management of central apnea in infants;138
17.9;Summary;139
17.10;References;139
18;Index;144

Leseproben

International Classification of Sleep Disorders 2 and American Academy of Sleep Medicine Practice Parameters for Central Sleep Apnea
Meghna P. Mansukhani, MDa, Bhanu Prakash Kolla, MD, MRCPsychb and Kannan Ramar, MDc*,     aSleep Medicine, Affiliated Communities Medical Center, 101 Willmar Avenue Southwest, Willmar, MN 56201, USA; bPsychiatry and Sleep Medicine, Affiliated Communities Medical Center, 101 Willmar Avenue Southwest, Willmar, MN 56201, USA; cDivision of Pulmonary and Critical Care Medicine, Center for Sleep Medicine, Mayo College of Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA. Email: [e-mail] *Corresponding author. This review summarizes the main features of the different central sleep apnea syndromes (CSASs) based on the International Classification of Sleep Disorders, 2nd edition, and provides a management overview of the different CSASs in the adult population based on the current recommendations from the American Academy of Sleep Medicine practice parameters. Keywords Central sleep apnea Cheyne-Stokes breathing pattern Congestive heart failure Periodic breathing Sleep apnea of infancy Adaptive servoventilator Key points
• Though central sleep apnea syndromes are treated with positive airway pressure therapies, further long-term studies are required to address the effects on hospital admission rates, morbidity, and mortality. • Additional studies comparing the relative cost-effectiveness, risks, and benefits of various treatment modalities are needed. • More research on multimodality titration polysomnograms that use a different device when the previous one seems to be unsuccessful may eventually help reduce testing time and health care costs. Introduction
Sleep disorders are classified into 8 main categories based on the International Classification of Sleep Disorders, Second Edition (ICSD-2).1 The ICSD-2 helps provide a consistent framework for clinicians and researchers to categorize and define sleep and arousal disorders in a structured, scientific, rational, and practical manner. It is compatible with the International Classification of Diseases, Tenth Revision (ICD-10). Central sleep apnea syndromes (CSASs) are in the category of sleep-related breathing disorders (SRBDs) and are characterized by apneas with diminished or absent respiratory effort that occur in a cyclic or intermittent pattern. These apneas may be idiopathic or secondary to environmental causes, drugs, or underlying medical conditions. The various types are listed and discussed later. The American Academy of Sleep Medicine (AASM) practice parameters are evidence-based clinical guidelines developed by the Standards of Practice Committee (SPC) for the treatment of various common sleep disorders. These parameters are approved by the Board of Directors of the AASM before publication. The practice parameters are freely accessible on the AASM Web site and are widely used by physicians engaged in treating patients with sleep disorders, and are therefore capable of influencing not only medical decision making and patient outcomes but also health care costs. A recent practice parameters article by Aurora and colleagues2 discussed the treatment recommendations for CSAS in adults. The central sleep apnea (CSA) task force under the SPC conducted a PubMed search for articles from 1966 to 2010 on the medical treatment of CSAS, defined as greater than 50% central disordered breathing events including periodic breathing (if subjects presented with both CSAS and obstructive sleep apnea). Of those that met initial criteria, 77 articles were included.2 Assessment of the quality of evidence was performed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process, which begins with clearly specifying the question to be answered, collecting and summarizing available data, using explicit criteria for rating the evidence, and then providing recommendations according to the strength of supporting evidence.3 Levels of recommendations used by the AASM based on GRADE are shown in Table 1. All practice parameter articles published after the CSA article have used the GRADE methodology. This article summarizes the various CSASs in adults based on the ICSD-2 and the treatment options and recommendations using the practice parameters as a guide (Box 1). Box 1   Summary of recommendations from the AASM practice parameters for the treatment of CSAS 1. Primary CSAS a. PAP may be considered (option) b. Acetazolamide may be considered (option) c. Zolpidem and triazolam may be considered only if the patient does not have underlying risk factors for respiratory depression (option) 2. CSAS related to CSBP a. CPAP targeted to normalize the AHI is indicated for the initial treatment (standard) b. ASV targeted to normalize the AHI is indicated (standard) c. Nocturnal oxygen therapy is indicated (standard) d. BPAP-ST targeted to normalize the AHI may be considered only if there is no response to adequate trials of CPAP, ASV, and oxygen therapies (option) e. Acetazolamide and theophylline may be considered if PAP therapy is not tolerated, after optimization of standard medical therapy, and with close clinical follow-up (option) 3. CSAS caused by medical condition caused by end-stage renal disease CPAP, supplemental oxygen, bicarbonate buffer use during dialysis, and nocturnal dialysis may be considered (option) Abbreviations: AHI, Apnea-Hypopnea Index; ASV, adaptive servoventilator; BPAP-ST, bilevel positive airway pressure in the spontaneous timed mode; CPAP, continuous positive airway pressure; CSBP, Cheyne-Stokes breathing pattern; PAP, positive airway pressure. Data from Aurora RN, Chowdhuri S, Ramar K, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep 2012;35:17–40. Table 1 AASM levels of recommendations From Aurora RN, Chowdhuri S, Ramar K, et al. The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses. Sleep 2012;35:21; with permission. Primary CSA
Definition
As per the ICSD-2, primary CSA is characterized by at least 1 of the following: excessive daytime sleepiness, frequent arousals and awakenings during sleep, insomnia complaints, awakening short of breath, and by polysomnography (PSG) showing 5 or more central apneas per hour of sleep. The disorder is not better explained by another current sleep disorder, medical or neurologic disorder, medication use, or substance use disorder.1 Features
Primary CSA is idiopathic, characterized by recurrent pauses in breathing with no ventilatory effort occurring in a repetitive manner during sleep. Studies suggest that the disorder is rare, with a male predominance, and is more commonly seen in middle-aged and older individuals.4 Increased ventilatory response to partial pressure of carbon dioxide in blood (PaCO2) leading to instability in ventilatory control seems to be the predominant predisposing factor. A low normal PaCO2 of less than 40 mm Hg is typically seen during wakefulness in patients with this disorder. Even a small increase in ventilation in these chemosensitive individuals causes the PaCO2 level to decrease to less than the apnea threshold, triggering cessation in breathing.5,6 Insomnia, nasal obstruction, and neurologic disorders with autonomic dysfunction are other reported predisposing factors.7,8 Central apneas are seen more commonly at sleep onset and during non–rapid eye movement (NREM) sleep than rapid eye movement (REM) sleep. These respiratory events are usually associated with only mild oxyhemoglobin desaturation. In general, patients with primary CSA do not develop pulmonary hypertension, cor pulmonale, or other adverse cardiovascular unless there is accompanying nocturnal hypoventilation with hypercapnia. Treatment
Summary of evidence A few small nonrandomized trials directly examining therapeutic options for primary CSA showed significant improvement in the Apnea-Hypopnea Index (AHI) with a low dose (250 mg per day) and a high dose...