Treatment-emergent Central Sleep Apnea Research Articles

False High Respiratory Distress Index Due to Mask Leak During Continuous Positive Airway Pressure Titration

ABSTRACT The treatment of choice for moderate-to-severe obstructive sleep apnea (OSA) is continuous positive airway pressure therapy (CPAP), and the optimal pressure for the elimination of obstructive events is set on the basis of titration study. Treatment-emergent central sleep apnea (TECSA) is characterized by new onset of central apneas in a patient with OSA, while on CPAP therapy. Many risk factors, including some polysomnographic parameters, have an association with TECSA. One such easily correctable factor is mask leak. Mask fitting during CPAP titration is a very important consideration and loose masks can lead to air leaks, causing redness of the eyes, and in some cases, arousal and even central sleep apneas.

Treatment-Emergent Central Sleep Apnea (TECSA) with Chronic Use of Mandibular Advancement Device (MAD): A Case Series

Treatment-Emergent Central Sleep Apnea (TECSA) with Chronic Use of Mandibular Advancement Device (MAD): A Case Series

1191 A Pediatric Case of Treatment Emergent Central Sleep Apnea During High Flow Nasal Cannula Polysomnography

1191 A Pediatric Case of Treatment Emergent Central Sleep Apnea During High Flow Nasal Cannula Polysomnography

The prevalence and polysomnographic characteristics of treatment-emergent central sleep apnea with obstructive sleep apnea.

To investigate the prevalence of treatment-emergent central sleep apnea (TECSA) in individuals with obstructive sleep apnea syndrome (OSAS) during continuous positive airway pressure (CPAP) titration and assess their polysomnographic characteristics. A total of 116 patients with OSAS who underwent full-night CPAP titration at the Sleep Laboratory of Adana City Research and Education Hospital from September 2017 to January 2018 were recruited for the study. The patients' polysomnographic data related to respiratory events and sleep stages were reviewed in a retrospective manner. While on CPAP titration, 20 of the 116 patients developed central sleep apnea (CSA). The prevalence of TECSA in the patients with OSAS was 17.2%, being separately determined as 16.3% and 2.2% for the male and female patients, respectively. In the baseline PSG, the groups did not statistically significantly differ in relation to the apnea hypopnea index (AHI), central apnea index (CAI), arousal index (AI), or oxygen desaturation index (ODI). However, the TECSA group had a significantly higher mean oxygen saturation value compared to the non-TECSA group (p = 0.01). The total AHI, CAI, and AI values of the TECSA group were significantly higher during the whole CPAP titration compared to the non-TECSA group. No significant difference was observed in the comparison of the two groups in relation to the titration pressure and ODI. TECSA is a phenomenon that can occur with obstructive sleep apnea treatment and mostly regress spontaneously following appropriate CPAP treatment. TECSA is observed at different rates of prevalence. In this study, the prevalence of TECSA was higher than previously reported.

Treatment-emergent central sleep apnea (TECSA) with chronic use of mandibular advancement devices (MADs): Case series study

Treatment-emergent central sleep apnea (TECSA) with chronic use of mandibular advancement devices (MADs): Case series study

The prevalence of treatment-emergent central sleep apnea with mandibular advancement device therapy.

Treatment-emergent central sleep apnea (TECSA) describes the appearance or persistence of central sleep apnea while undergoing treatment for obstructive sleep apnea. TECSA is well studied in continuous positive airway pressure therapy with an estimated prevalence of 8%. Based on a few case reports, mandibular advancement devices (MAD) may also provoke TECSA. This study aims to gain insight into the prevalence of TECSA with MAD therapy. This retrospective study includes a total of 129 patients with moderate to severe obstructive sleep apnea who were treated with a custom-made titratable MAD. Baseline and follow-up sleep studies were compared to identify patients with TECSA. Since different diagnostic criteria to define TECSA are used in literature, prevalence was calculated according to three definitions (TECSA-1, -2, and -3). Demographics, MAD treatment variables, and findings of the diagnostic polysomnography were compared between TECSA and non-TECSA patients to identify possible predictors. Depending on the definition used, TECSA was found in 3.1%-7.8% of patients undergoing MAD therapy. TECSA patients had a higher apnea index (9.2 vs 2.0 events/h, P = .042), central apnea-hypopnea index (4.1 vs 0.2 events/h, P = .045) and oxygen desaturation index (23.9 vs 16.3 events/h, P = .018) at baseline compared to non-TECSA patients. No differences were found in demographics and treatment variables. These findings demonstrate that TECSA also occurs in patients starting MAD treatment. Patients with TECSA had a higher apnea index, central apnea-hypopnea index, and oxygen desaturation index at baseline compared to non-TECSA patients. Hellemans S, Van de Perck E, Braem MJ, Verbraecken J, Dieltjens M, Vanderveken OM. The prevalence of treatment-emergent central sleep apnea with mandibular advancement device therapy. J Clin Sleep Med. 2023;19(12):2035-2041.

0485 The clinical utility of echocardiography in identifying patients with heart failure at a single academic sleep center

Abstract Introduction Heart failure and sleep disordered breathing are prevalent in the United States and often co-exist; diagnostic strategy and management for sleep disordered breathing may change based on the presence, absence and type of heart failure. The goal of this study was to evaluate how many additional patients would be identified with either heart failure with reduced (HFrEF) or preserved (HFpEF) ejection fraction through existing echocardiogram results when this diagnosis is not explicitly stated in the medical records for patients evaluated at a single academic sleep center. Methods A retrospective chart review was performed for all patients undergoing for a sleep study and/or a PAP device from February 2012 through September 2019 at the University of Arizona. Sleep disordered breathing was identified through either polysomnography (PSG) or home sleep apnea testing (HSAT). Patients were identified with heart failure with reduced ejection fraction if an echocardiogram (TTE) listed ejection fraction Results 2,817 patients were evaluated (age 57 (±16 years), 53% male and 77% Caucasian). Ninety-nine patients (3.51%) were noted to have HFrEF based on past medical history and an additional 38 patients were identified through TTE. One hundred and fifteen patients (4.08%) were noted to have HFpEF based on past medical history and an additional 265 patients were identified through TTE. Among these, a majority had OSA (77% HFrEF and 83% HFpEF), followed by combined OSA and CSA (7% HFrEF and 5% HFpEF), and primary CSA (5% HFrEF and 3% HFpEF). Of the patients identified after having reviewed TTE results, 6 (16%) with HFrEF and 42 (16%) with HFpEF developed treatment emergent central sleep apnea. Conclusion Existing echocardiography data in the electronic medical record can identify additional patients with HFrEF and HFpEF which may impact clinical diagnosis and management of sleep disordered breathing. Support (if any) AASM Foundation (203-JF-18), NIH (HL126140, 2L30HL154400-023), University of Arizona (5299903; 5833261; 4258021)

1003 Immediate Improvement of Second Degree Heart Block With Effective Treatment of Sleep-Disordered Breathing

Abstract Introduction Cardiac arrhythmia and heart block in particular is commonly found in association with obstructive sleep apnea (OSA). Here we describe real-time responsivity of 2nd degree heart block to treatment of OSA with positive airway pressure (PAP) during a titration study. Report of case(s) Our patient is a 70-year old man without significant cardiovascular disease. He presented with loud snoring and excessive daytime sleepiness. A home sleep apnea test in July 2020 revealed obstructive sleep apnea (respiratory event index 20, oxygen saturation nadir 86%). The patient was treated with auto-adjusting continuous positive airway pressure (APAP) and had symptomatic benefit. His most recent machine data download suggested an elevated residual respiratory event index (REI) of 19.6, 16.5 of which were central. A split-night study was performed to re-characterize the nature of the patient’s obstructive sleep apnea and treatment needs. The baseline portion of the study (AHI 50.8, oxygen saturation nadir 86%) was notable for the presence of frequent 2nd degree heart block (171.0 events/hour of recording). During the titration portion of the study, frequent central sleep apneas emerged with the addition of PAP therapy, consistent with treatment-emergent central sleep apnea. The patient was transitioned to bilevel positive airway pressure spontaneous timed mode (BPAP ST), and a pressure setting of 13/6 cm of water with backup rate of 14 breaths per minute effectively controlled his sleep-disordered breathing. The heart block that had been observed during the baseline portion of the study dramatically improved with the start of BPAP ST. Once the patient’s sleep-disordered breathing was controlled, the patient’s heart block occurred at a rate of only 12.1 events/hour of recording. Conclusion Treatment of sleep apnea has been established to be beneficial for the improvement of cardiac arrhythmias. This case is remarkably instructive in that attainment of an effective treatment setting for sleep-disordered breathing resulted in an almost immediate improvement of heart block. Support (if any)

Average Volume-assured Pressure Support as Rescue Therapy after CPAP Failure in Pediatric Obstructive Sleep Apnea: A Retrospective Case Series Study.

Continuous positive airway pressure (CPAP) is frequently prescribed for patients with residual obstructive sleep apnea (OSA) following adenotonsillectomy. The goal was to examine the efficacy of noninvasive ventilation with average volume-assured pressure support (AVAPS) as a potential option for children with failed CPAP titration. In a single-center retrospective study, we included children aged 1-17 years, with polysomnographically confirmed OSA who underwent AVAPS titration following failed CPAP titration. In addition to describing the clinical characteristics of the included patients, we compared polysomnographic parameters before and after AVAPS. Nine patients met the inclusion criteria; out of them, 8 (89%) were males with an age range of 6.7 ± 3.9 years and a body mass index percentile of 81.0 ± 28.9. Reasons for failed CPAP titration were: 3 (33%) patients due to inability to control apnea-hypopnea index (AHI), 3 (33%) patients due to sleep-related hypoventilation, 2 (22%) patients due to treatment-emergent central sleep apnea, and 1 (11%) patient due to intolerance to CPAP. AVAPS resulted in a greater reduction in AHI than CPAP (reduction following CPAP = 24.6 ± 29.3, reduction following AVAPS = 42.5 ± 37.6, p = 0.008). All patients had resolution of the problems which caused CPAP failure. In this case a series of children with OSA and with failed CPAP titration, AVAPS resulted in a greater reduction in AHI compared with CPAP as well as resolution of the problems which caused CPAP failure.

Persistent Treatment-Emergent Central Sleep Apnea (TECSA) Following Hypoglossal Nerve Stimulation.

Since 2001, hypoglossal nerve stimulators (HNS) have been used worldwide to treat patients with obstructive sleep apnea (OSA). Recently, a few studies reported treatment-emergent central sleep apnea (TECSA) with spontaneous resolution following HNS. However, the evidence of persistent development of TECSA during long-term care visits was lacking. As a result, this study first report two patients with persistent TECSA and describe their development phenotype during more than two years of follow-up visits to help explore the influencing factors and underlying mechanisms. This retrospective study included twenty-seven patients who underwent HNS implantation from 2016 to 2021. Their demographic data, pre- and postoperative sleep study characteristics, and device use settings were collected. The possible factors associated with post-operative elevated CSA (central apnea index ≥5) were evaluated. Moreover, the development phenotype of the TECSA was observed and followed up with a titration trial study. Among overall 27 patients with OSA, 3 patients with an increased preoperative Epworth Sleepiness Score (ESS) got an elevated CSA (CAI ≥ 5). Two of these 3 patients developed a persistent TECSA with a significant negative correlation between obstructive apnea index (OAI) and central and mixed sleep apnea index (CMAI) (R = -0.745, P = 0.021). These development phenotypes might be associated with different stimulation amplitudes of the HNS device. Furthermore, the following titration trial study also suggested that different amplitudes would influence the development of TECSA following HNS. OSA patients with severe daytime sleepiness are more likely to have elevated CSA following HNS. An inappropriate stimulation amplitude might influence the development course of TECSA in such patients.

Treatment Emergent Central Sleep Apnea Evaluation in Patients Treated with Mandibular Advancement Device

The aim of the present cohort study was to evaluate the possible occurrence of central sleep apnea (CSA) in patients with obstructive sleep apnea (OSA) after treatment with a mandibular advancement device (MAD). In this case, 56 patients with OSA treated with MAD were enrolled. Inclusion criteria were age over 20 years, body mass index (BMI) less than 34 kg/m2, diagnosis of OSA confirmed by polysomnography (PSG), and MAD therapy for OSA. Exclusion criteria were smoking, medications for neurological disorders or a history of cervical head injury, and comorbidities (arrhythmias, congenital heart disease, stroke, heart failure or lung disease). Apnea-Hypopnea Index (AHI), Oxygen Desaturation Index (ODI), Obstructive Sleep Apnea (OSA), Central Sleep Apnea (CSA) and Mixed Apnea were extracted from the PSGs before (T0) and after three months of treatment (T1). Paired-sample t-tests and the Wilcoxon Signature Rank test were performed to evaluate differences in PSG indices at T1 and T0. OSA, CSA, AHI, ODI showed a noticeable reduction after MAD therapy, but a limited number of patients showed a dramatic increase in TCSA. The presence of TECSA in the course of MAD treatment is a condition that should be taken into consideration when needing to treat an OSA patient.

The prevalence of treatment-emergent central sleep apnea in mandibular advancement device therapy

The prevalence of treatment-emergent central sleep apnea in mandibular advancement device therapy

Positional therapy in a patient with refractory treatment-emergent central sleep apnea

Positional therapy in a patient with refractory treatment-emergent central sleep apnea

Treatment-Emergent Central Sleep Apnea - Detection and Treatment

Treatment-Emergent Central Sleep Apnea - Detection and Treatment Abstract. In treatment-emergent central sleep apnea (TECSA), affected patients with obstructive sleep apnea newly develop central sleep apnea (AHI central ≥5/h) under therapy with positive pressure ventilation which cannot be explained by other causes. The pathophysiology of TECSA is incompletely understood. PaCO2 and the associated apnea threshold seem to play a central role. The incidence of TECSA varies (1.8-20%), and in about 2/3 of cases it is self-limiting in the course of the therapy. If persistence or new onset occurs later in the course of positive pressure therapy, a further evaluation (e.g., echocardiography, neurologic examination, medication history) is indicated. Effective treatment options include a change in ventilation therapy (adaptive servoventilation or bilevel ventilation with back-up frequency) or additional nocturnal oxygen supplementation; these options should be decided case by case.

Average volume-assured pressure support for patients with obstructive sleep apnea with failed CPAP titration.

ObjectivesObstructive sleep apnea (OSA) is a common disease, often treated using continuous positive airway pressure (CPAP) therapy. In many cases, patients fail a CPAP titration study due to inadequate control of the apnea-hypopnea index (AHI, events/hour) or due to treatment-emergent central sleep apnea (TE-CSA). We report our experience using a mode of non-invasive ventilation for alternative treatment of these patients.Material and MethodsWe reviewed records of adults who had OSA with AHI≥15 diagnosed on polysomnography (PSG) with failed CPAP titration and in whom titrations with average volume-assured pressure support (AVAPS) with auto-titrating expiratory positive airway pressure were performed.ResultsForty-five patients, age 57.9±13.1 y, 26 males, body mass index (BMI) 40.2±8.7kg/m2. Reasons for CPAP titration failure included: TE-CSA (25, 55.6%) and inadequate control of AHI at maximum CPAP of 20cm H2O (20, 44.4%). Changes noted from baseline PSG to AVAPS titration: AHI: 65.3±29.3 decreased to 22.3±16.1 (p<0.001). Median time SpO2 ≤88%: 63.7 to 6.9min (p<0.001). In 16 patients the AHI was reduced to <15 and in 16 additional patients the AHI was reduced to <30. Improvement in AHI was not related to gender, age, or opioid use, but was correlated with BMI: ∆AHI=12.2 - (1.4 * BMI); p=0.05. AVAPS resulted in improved sleep architecture: median N3 sleep increased: 1.4% to 19.6% total sleep time (TST) (p<0.001), and median R sleep increased: 6.4% to 13.6% TST (p<0.01).DiscussionFor patients with OSA for whom CPAP titration failed, titration with AVAPS may be an effective treatment.

0792 Exploring Symptomatic Relief of Patients with Central Sleep Apnea when using CPAP or BiPAP Therapy

Abstract Introduction About 0.9% of peoples over the age of 40 in the United States have Central Sleep Apnea (CSA). The key to treating CSA is to address any underlying health issues causing the condition as there are no clear, established treatment guidelines. For example, approaches will be made to mitigrate congestive heart failure. Often, patients may require the use of CPAP or BiPAP device to decrease cessations in respiration during sleep. Methods We investigated those patients diagnosed with CSA who use CPAP or BiPAP therapy and it's potential therapeutic effects through a retrospective chart review over a three-year period. We excluded those who were diagnosed with treatment emergent CSA and those using ASV. Data was collected from each patient's chart about patient demographics, modality of PAP therapy, and information pertaining to symptomatic relief. Results 42 patients were identified who had a diagnosis of CSA. 25 of 42 (59.5%) were excluded as they were using alternative therapies. Of the 17 patients, 14 (82.4%) were male with an average age of 70.7 and 3 (17.6%) were females with an average age of 50. 15 of the 17 (88.2%) used CPAP therapy and the 2 (11.8%) patients used BiPAP.Prior to PAP therapy, the average Epworth Sleepiness Scale was 8.08 which improved to 3.79 post therapy. 9 out of the 17 (52.9%) patients reported improvement in nocturnal gasping while 2 (11.8%) did not report relief and 6 (35.3%) patients we were unable to determine through chart review. 9 out of 17 (52.9%) patients reported unrefreshed sleep and later 6 of the 9 (66.7%) patients reported refreshed sleep with initiation of PAP therapy while 1 patient reported no improvement and 2 (22%) we were unable to determine. 15 of the 17 (88.2%) patients complained of waking up multiple times throughout the night before PAP therapy. 5 (33.3%) patients had improvement of the frequency of nighttime awakenings while we were unable to determine the remaining 10 patients. Conclusion When central sleep apnea persists despite adequate treatment of the primary cause, CPAP or BiPAP may be used for symptomatic relief. Support (If Any)

Development of Central Sleep Apnea After Sleep Surgery

Central sleep apnea (CSA) is defined as an absence of breathing without respiratory drive during sleep. It can occur after treatment of obstructive sleep apnea (OSA), a phenomenon known as treatment-emergent central sleep apnea (TECSA). We present a case of a 23-year-old male who developed CSA after pharyngeal and nasal surgery for severe OSA. High loop gain and increased ventilations from frequent arousal are likely explanations for our patient’s central apnea, which resolved with positive airway pressure therapy that possibly alleviated residual airway obstruction and ventilatory instability. This case suggests that effectiveness of treatment for OSA should be based on careful long-term observation with multiple follow-up polysomnography tests, especially in patients at high risk of TECSA.

Positional Therapy in a Patient With Refractory Treatment-Emergent Central Sleep Apnea

Treatment-emergent central sleep apnea (TE-CSA) is commonly encountered during the treatment for obstructive sleep apnea (OSA) with positive airway pressure (PAP) and usually remains self-limited. Persistent TE-CSA is sporadically seen with PAP therapy and has only rarely been described with hypoglossal nerve stimulation (HGNS). We report the case of a 60-year-old female patient with moderate OSA that progressed to TE-CSA with PAP therapy. A prolonged trial with PAP therapy was limited because the patient experienced recurrent aerophagia and subsequently underwent HGNS implantation. HGNS titration led to improved control of the patient’s OSA, but TE-CSA recurred and demonstrated a strong positional component. Lateral positional therapy was implemented with adequate control of respiratory events. TE-CSA can persist throughout different treatment modalities, including HGNS. The patient’s successful lateral sleep therapy for persistent and positionally exacerbated TE-CSA demonstrates the benefit of a well-known sleep apnea treatment for this poorly understood condition.

TREATMENT EMERGENT CENTRAL SLEEP APNEA IN PATIENTS TREATED WITH CPAP AND BIPAP FOR OSA

TREATMENT EMERGENT CENTRAL SLEEP APNEA IN PATIENTS TREATED WITH CPAP AND BIPAP FOR OSA

Overview of the pathogenesis, clinic, diagnostics and treatment of treatment-emergent central sleep apnea

Pijus Ruokis1, Algimantas Žaltauskas1, Gabrielė Baltrūnaitė1 1Medical Academy of the Lithuanian University of Health Sciences Abstract Background. Treatment-emergent central sleep apnea (TECSA) is a central-onset apnea that occurs during initial treatment for obstructive sleep apnea (OSA) and is diagnosed in 0.56-21.3 % of patients treated for OSA. The emergence of TECSA significantly reduces the effectiveness of OSA treatment and patient cooperation. The aim: to review the pathogenesis, clinic, diagnosis, and treatment of treatment-induced central sleep apnea. Methods: the literature and data search were performed using PubMed, SpringerLink, ScienceDirect, Lithuanian Academic Library (eLaBa), Google Scholar databases. Published research papers and articles on the pathogenesis, clinic, diagnosis, and treatment of TECSA syndrome were selected, prioritizing the literature in English and Lithuanian, that was not older than 10 years. Results. Although the exact mechanism of this disorder is unknown, TECSA pathogenesis is thought to be dominated by increased sensitivity of chemoreceptors to hypocapnia, explained by loop gain in combination with increased CO2 clearance by opening the upper airways during CPAP therapy and activating the Hering-Breuer reflex. TECSA presents with typical symptoms of sleep apnea already during treatment of a patient with first line OSA treatment and is diagnosed in a PSG study. TECSA is treated by continuing CPAP therapy at minimum effective pressure or by replacing CPAP therapy with more modern devices (BiPAP or ASV) capable of analyzing the patient’s breathing pattern and adjusting the supplied air pressure accordingly. There is currently no drug treatment for TECSA. Conclusions: 1. TECSA is a disorder in which episodes of central apnea occur during treatment with OSA due to unstable central respiratory regulation, increased CO2 clearance, and lung tissue strain during CPAP therapy. 2. TECSA presents with typical symptoms of sleep apnea syndrome in the presence of active OMA treatment with positive pressure therapy. 3. TECSA diagnosis is based on a polysomnography, where five or more episodes of central apnea per hour occur after CPAP therapy has resolved obstructive events. 4. The main treatment for TECSA is the continuation of CPAP at minimum effective pressure or the change of therapy to automatic pressure-regulating devices. Keywords: treatment-emergent central sleep apnea, complex sleep apnea, obstructive sleep apnea, central sleep apnea, CPAP, BiPAP, ASV.