Adaptive Adaptive Servo-VentilationServo-Ventilation
CasesCasesGeoffrey S Gilmartin, MDGeoffrey S Gilmartin, MD
Beth Israel Deaconess Medical CenterBeth Israel Deaconess Medical Center
Harvard Medical SchoolHarvard Medical School
Boston, MABoston, MA
OutlineOutline
Case BasedCase Based Ventilatory Control During NREM SleepVentilatory Control During NREM Sleep
Conceptual frameworkConceptual framework Specific componentsSpecific components
Lessons LearnedLessons Learned CasesCases SnapshotsSnapshots LiteratureLiterature
ConclusionsConclusions
Case #1Case #1
SHSH37 yo male37 yo maleArnold Chiari malformation, spinal Arnold Chiari malformation, spinal
stenosis, syringomyeliastenosis, syringomyeliaShunt failure in cervical regionShunt failure in cervical regionHerniation, quadriplegia, PEG and TrachHerniation, quadriplegia, PEG and TrachSnoring converted to witnessed apneasSnoring converted to witnessed apneasEDS and extended sleep timesEDS and extended sleep times
Case #1Case #1
Previous PSGPrevious PSGFailed CPAP/BI-level titrationFailed CPAP/BI-level titrationResidual diseaseResidual disease
624 central and 121 obstructive events624 central and 121 obstructive events
CPAP=7, BI-level=11/7 with RDI-22CPAP=7, BI-level=11/7 with RDI-22Treated at home and intolerantTreated at home and intolerantCurrent treatment with O2 2 lpmCurrent treatment with O2 2 lpm
Referred for evaluationReferred for evaluation
Case #1Case #1
Case #1Case #1
Case #1Case #1
Case #1Case #1
Case #1Case #1
Sleep Disordered BreathingSleep Disordered Breathing
Obstructive Sleep ApneaObstructive Sleep ApneaCPAPCPAPCardiovascular, metabolic riskCardiovascular, metabolic risk
Central Sleep ApneaCentral Sleep ApneaCheyne-Stokes RespirationCheyne-Stokes RespirationComplex Sleep ApneaComplex Sleep ApneaMixed Sleep ApneaMixed Sleep Apnea
Cheyne Stokes RespirationCheyne Stokes Respiration
The SystemThe System
NREM
Loss of wakefulness drive
Ventilatory Pattern
Generator
Medulla (pH)
Carotid Body (PCO2, PO2)
Upper Motor Neuron
Lower Motor Neuron
Respiratory Muscle/Chest Wall
Adapted From: Malhotra, Berry and White, “Central Sleep Apnea”
CSDB-TreatmentCSDB-Treatment
Body Position-Body Position- Ventilatory Reserves/ObstructionVentilatory Reserves/Obstruction
Sleep Consolidation-Sleep Consolidation- Ventilatory Overshoot/Sleep Wake InstabilityVentilatory Overshoot/Sleep Wake Instability
Supplemental O2-Supplemental O2- Stabilize ChemoreceptorsStabilize Chemoreceptors
CPAP/BI-level Pressures-CPAP/BI-level Pressures- Plant GainPlant Gain
Stabilize Ventilation- “Adaptive Ventilation”Stabilize Ventilation- “Adaptive Ventilation” Stabilize Plant GainStabilize Plant Gain
Adaptive Servo-VentilationAdaptive Servo-Ventilation
Determine Target VentilationDetermine Target Ventilation Monitors recent average minute ventilation (ie.~3 min Monitors recent average minute ventilation (ie.~3 min
window)window) Calculates a target ventilation (ie. 90% of recent Calculates a target ventilation (ie. 90% of recent
average ventilation)average ventilation)
Ventilates to the TargetVentilates to the Target Algorithm monitors patient ventilation and compares it Algorithm monitors patient ventilation and compares it
to the target ventilationto the target ventilation Adjusts pressure support up or down as needed to Adjusts pressure support up or down as needed to
achieve targetachieve target Back-up rate when neededBack-up rate when needed
End Expiratory PressureEnd Expiratory Pressure
EEP = CPAP level EEP = CPAP level FixedFixed
May adjust to improve upper airway May adjust to improve upper airway obstructionobstruction
EEP: manually titrate like CPAP to hold airway patent
Time
Pressure (cm H20)
Pressure Support (PS)Pressure Support (PS)
Pressure support = Pressure support =
(Peak Inspiratory Pressure – End Expiratory Pressure)(Peak Inspiratory Pressure – End Expiratory Pressure)
Pressure support varies between limitsPressure support varies between limits minPSminPS maxPSmaxPS
Can vary the range Can vary the range Device determines the levelDevice determines the level
maxPS
Time
Pressure (cm H20) minPS
ResponseResponse
The device “automatically” adjusts the magnitude of The device “automatically” adjusts the magnitude of pressure support breath by breath to:pressure support breath by breath to:
Provide minimal support during hyperpnea or stable Provide minimal support during hyperpnea or stable breathingbreathing
Increase support during hypopnea or apnea Increase support during hypopnea or apnea Assumption is all is centralAssumption is all is central
Time
Pressure (cm H20)
Central apneaNormalbreathing effort
Cautions-HypoventilationCautions-Hypoventilation
Chronic hypoventilationChronic hypoventilationModerate to severe COPDModerate to severe COPDChronically elevated PCOChronically elevated PCO22 on ABG (> 45 on ABG (> 45
mm Hg)mm Hg) Restrictive thoracic or neuromuscular Restrictive thoracic or neuromuscular
diseasedisease
BaselineBaseline
Effort
Flow
SpO2
Central even, no effort
Desaturations after Central apneas
One CSR/CSA cycle, ~1min
Support When NeededSupport When Needed
Effort
Flow
SpO2
FG
Continued AdaptationContinued Adaptation
Response to remaining eventsResponse to remaining events
Effort
Flow
SpO2
FG
Stability?Stability?
Effort
Flow
SpO2
FG
Variable Input = Stability?Variable Input = Stability?
20012001
Adaptive Pressure Support Servo-Adaptive Pressure Support Servo-VentilationVentilation
Teschler H, et al.Teschler H, et al.AJRCCM, 164, 614-19, 2001AJRCCM, 164, 614-19, 2001
Patients with CHF and CSR (3%, >15/hr)Patients with CHF and CSR (3%, >15/hr)Acute prospective randomized crossoverAcute prospective randomized crossover5 sequential nights5 sequential nightsN=16N=16
Teschler, et al.Teschler, et al.
Teschler, et al.Teschler, et al.
Teschler, et al.Teschler, et al.
Teschler, et al.Teschler, et al.
Single night (acute) studySingle night (acute) studyDid randomize orderDid randomize orderCovers standard interventionsCovers standard interventionsASV performs well in this population, in ASV performs well in this population, in
the labthe labPCO2 results “reassuring”PCO2 results “reassuring”
Case #2Case #2
RARA67 yo male67 yo maleAsthmaAsthmaOSA-AHI=13, RDI=43, desats to 80%OSA-AHI=13, RDI=43, desats to 80%Failed CPAP/BIPAP Titration-AHI=14.7Failed CPAP/BIPAP Titration-AHI=14.7Adapt SV- EEP 5-7, PS 2-10Adapt SV- EEP 5-7, PS 2-10PerfectionPerfection
Recent DataRecent Data
Adaptive Servoventilation Versus Adaptive Servoventilation Versus Noninvasive Positive Pressure Noninvasive Positive Pressure
Ventilation for Central, Mixed And Ventilation for Central, Mixed And Complex Sleep Apnea SyndromesComplex Sleep Apnea Syndromes
Morgenthaler T, et al.Morgenthaler T, et al. Sleep, 30(4), 2007Sleep, 30(4), 2007 Multicenter, prospective randomized crossover Multicenter, prospective randomized crossover
designdesign
Morgenthaler et al.Morgenthaler et al.
Morgenthaler, et al.Morgenthaler, et al. DEFINITITIONSDEFINITITIONS
CSA-CSRCSA-CSR CAI >5 events/hrCAI >5 events/hr CAI/AHI >50%CAI/AHI >50% CSR patternCSR pattern
SA-MixedSA-Mixed AHI >5AHI >5 >50% mixed apneas>50% mixed apneas
Complex SASComplex SAS AHI >5 (majority obstructive)AHI >5 (majority obstructive) CAI >5 or CSR during titration at best CPAPCAI >5 or CSR during titration at best CPAP
Morgenthaler et al.Morgenthaler et al.
Morgenthaler, et al.Morgenthaler, et al.
Morgenthaler, et al.Morgenthaler, et al.
Morgenthaler et. al.Morgenthaler et. al.
Small studySmall studyDefinitions standard and importantDefinitions standard and importantBi-level alone poorBi-level alone poorExclusion criteria-Exclusion criteria-
CPAP >10CPAP >10HypoventilationHypoventilationUnstable CHFUnstable CHF
Beneficial, ? superiorBeneficial, ? superior
Case #3Case #3
CHCH83 yo male83 yo maleCAD-IMI, EF=55%, CRICAD-IMI, EF=55%, CRIOSA-AHI=82.5, Sat Nadir 88%OSA-AHI=82.5, Sat Nadir 88%Failed BIPAP 13/8 with 2 lpm O2Failed BIPAP 13/8 with 2 lpm O2Concern for central sleep apneaConcern for central sleep apneaASV titration-EEP 5-8, PS-3-10ASV titration-EEP 5-8, PS-3-10DisasterDisaster
Long TermLong Term
Compliance with and effectiveness of Compliance with and effectiveness of adaptive servo-ventilation versus CPAP adaptive servo-ventilation versus CPAP
in the treatment of Cheyne-Stokes in the treatment of Cheyne-Stokes respiration in heart failure over a six respiration in heart failure over a six
month periodmonth period
Philippe C, et. al.Philippe C, et. al. Heart 92, 337-42, 2006Heart 92, 337-42, 2006 Randomized, prospective trial (CSR)Randomized, prospective trial (CSR)
BackgroundBackground
CPAPCPAP Improves CSRImproves CSRDecreases SNADecreases SNA Improves ejection fractionImproves ejection fraction Improved combined mortality-cardiac Improved combined mortality-cardiac
transplantation ratestransplantation ratesBut, incomplete “in-lab” response But, incomplete “in-lab” response Relative benefit over time?Relative benefit over time?
Philippe, et al.Philippe, et al.
Subjects-Subjects- N=25N=25 18-80 yo18-80 yo Stable CHF (EF <45%), newly diagnosed CSRStable CHF (EF <45%), newly diagnosed CSR AHI >15, >80% centralAHI >15, >80% central
Design-Design- Randomized to Randomized to
Best CPAP (mean=8) or Best CPAP (mean=8) or ASV-Default settingsASV-Default settings
Philippe, et al.Philippe, et al.
Philippe, et al.Philippe, et al.
Philippe, et al.Philippe, et al.
ESS ESS Non-significant Non-significant
decreasedecrease
MWTMWT Non-significant Non-significant
increaseincrease
QOLQOL ImprovedImproved Greater in ASVGreater in ASV
Philippe, et al.Philippe, et al.
Philippe, et al.Philippe, et al.
Patients with CSR and symptomatic CHFPatients with CSR and symptomatic CHFReasonable compliance (> with ASV)Reasonable compliance (> with ASV) Improvement inImprovement in
CSR severityCSR severityQOL (greater in ASV)QOL (greater in ASV)EF (ASV only)EF (ASV only)
Hemodynamic toleranceHemodynamic tolerance
Case #4Case #4
DBDB79 yo male79 yo maleA-Fib, HTN, Spinal Stenosis, P-veraA-Fib, HTN, Spinal Stenosis, P-veraSleep Apnea-AHI=42.1, Nadir-80%Sleep Apnea-AHI=42.1, Nadir-80%CPAP poorly toleratedCPAP poorly toleratedAdapt Titration EEP 5-8, PS 3-10Adapt Titration EEP 5-8, PS 3-10Synchrony?Synchrony?
Very Recent DataVery Recent Data
Effect of Flow-Triggered Adaptive Effect of Flow-Triggered Adaptive Servo-Ventilation Compared with CPAP Servo-Ventilation Compared with CPAP in Patients with Chronic Heart Failure in Patients with Chronic Heart Failure
with Coexisting OSA and Cheyne-with Coexisting OSA and Cheyne-Stokes RespirationStokes Respiration
Kasai T, et. al.Kasai T, et. al. Circ Heart Fail. 2010:3:140-148Circ Heart Fail. 2010:3:140-148 Randomized, prospective trial Randomized, prospective trial 31 Patients31 Patients
Kasai et alKasai et al
Stable EF <50%Stable EF <50% Stable Class >/= II Heart FailureStable Class >/= II Heart Failure AHI >15AHI >15
Obstructive AHI >5Obstructive AHI >5 Cheyne-Stokes RespirationCheyne-Stokes Respiration
Not previously treatedNot previously treated Randomized to (titration) Randomized to (titration)
CPAP (4-12)CPAP (4-12) HEART PAP (flow-triggered ASV)HEART PAP (flow-triggered ASV)
Kasai et alKasai et al
Kasai et alKasai et al
Kasai et alKasai et al
Kasai et alKasai et al
ASV-TreatmentASV-Treatment
We knowWe knowPhysiologyPhysiologyPatientsPatientsLiteratureLiterature
In-labIn-labTitration process-what to controlTitration process-what to controlWhen to abandonWhen to abandonIf effective in lab, hope for long termIf effective in lab, hope for long term