spreecast with mytap video
TRANSCRIPT
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Understanding the Severe Patient
What to do when CPAP fails!
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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
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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
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Continuum of Sleep Disordered Breathing
Mechanical
SeverityLeast MostChemical Neuromuscular
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Continuum of Sleep Disordered Breathing:Treatment
SeverityLeast Most
ChemicalCpapVpapOral AppliancesCombinationOxygen
NeuromuscularVentilatorTracheotomyCombination
MechanicalOral AppliancesCPAPCombinationSurgeryTracheostomy
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Continuum of Sleep Disordered Breathing:
Treatment Success
SeverityLeast Most
Chemical?
NeuromuscularVentilator +Tracheotomy = 100%?TAP-PAP = 100%?
MechanicalCPAP <50%OA’s >50%TAP-PAP > 95%Tracheotomy 100% ?
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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
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Sleep Eliminates Pharyngeal Reflexes
© W. Keith Thornton DDS
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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.
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Neuromuscular Factors
© W. Keith Thornton DDS
P mus –P lum > atmosphere
Pharynx Open
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Neuromuscular Factors
Pharynx closed
P mus - P lumin < atmospheric
© W. Keith Thornton DDS
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Genioglossal EMG in OSA
© W. Keith Thornton DDS
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No Mandibular Protrusion (Oshima et al.)
© W. Keith Thornton D.D.S.
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Mandibular Protrusion (Oshima et al.)
© W. Keith Thornton D.D.S.
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Inspiratory Flow Limitation
© W. Keith Thornton DDS
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Esophagealpressure
Inspiratory Flow Limitation : IFL
© W. Keith Thornton DDS
NormalAirflow
Normal
IFL
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5 Minutes, RDI 0, T90 = approx. 80%, Severe HypoventilationSevere Inspiratory Flow Limitation, No heart rate variability
Severe IFL, no OSA90%
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10 Minutes, Severe, RDI=96
16 events, RDI = 96T90 = approx 20%Little heart rate variability, 50-67
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90%
67 bpm
50bpm
2 Minutes, Severe, RDI=96
16 events, RDI = 96T90 = approx 20%Little heart rate variablity 50to 67Lowest desat 83%
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90%
67 bpm
50bpm
2 Minutes, Severe, RDI=96
16 events, RDI = 96T90 = approx 20%Little heart rate variablity 50to 67Lowest desat 83%
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10 minutes, severe osa, RDI=66
80bpm
40bpm
90%
RDI = 66, T90= 75%, heart rate variability = 40-80Lowest desat= 63
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2 minutes, severe osa, RDI=66
80bpm
40bpm
90%
RDI = 66, T90= 75%, heart rate variability = 40-80Lowest desat= 63
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RDI = 66, T90= 70%, heart rate variability = 40-80Lowest desat= 63
2 minutes, severe osa, RDI=66
80bpm
40bpm
90%
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Patient controlled protrusion
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Dose dependent improvement of pharyngeal
collapsibility in response to mandibular advancement
-10
-5
0
5
P’close
(cmH2O)
Velopharynx
-15
-10
-5
0
5
Oropharynx
Kato et al., (2000, Chest)© W. Keith Thornton D.D.S.
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0 2 4 6
0.00
0.05
0.10
0.15
0.2010 mm
8 mm
6 mm
4 mm
2 mm
0 mm
0 2 4 6
0.00
0.05
0.10
0.15
Airflow
(L/s)
Preliminary results
Oropharyngeal pressure (cmH2O)
Patient #1
No IFL at 4mm advancementPatient #2
No IFL at 10 mm advancement
(unpublished)
© W. Keith Thornton D.D.S.
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Conclusions
© W. Keith Thornton D.D.S.
• Protrusion increases the cross-sectional area
• Protrusion produces a hypotonic genioglossus
• Efficacy is dose dependant
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Maximum Protrusion
© W. Keith Thornton D.D.S.
Voluntary
Induced
Stretched
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Treatment Position
Maximum protrusion: MP
Maximum passive protrusion: MPP
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Original Maximum protrusion 8mm
Present Maximum portrusion 17mm
170% of original maximum
17 mm
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23mm 185%
23mm
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Macroglossia, Maxillary HypoplasiaSevere IFL
Immediate TAP CS
Increase vertical
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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
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Before appliance therapy
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After therapy
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Macroglossia, Maxillary Hypoplasia
Lateral view,Patient in occlusion
Centric Occlusion
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5. Macroglossia, Maxillary Hypoplasia
Narrow arch,High palate without room for tongue
Normal mandibular arch size
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Macroglossia, Maxillary Hypoplasia
Size of tongueNormal posture of tongue
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Macroglossia, Maxillary Hypoplasia
Normal lip posture Freeway space
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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
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Immediate TAP CS
15mm
5mm
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TAP III from lab
Not enough vertical or protrusive Encroachment on tongue
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Final TAP III appliance
Initial vertical 8mmAdded 6mm to plate, 3mm to barTotal vertical, 17mm
6mm 17mm
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Neuromuscular Patients
• Post Polio
• ALS
• Muscular dystrophy
• Brain tumors affecting motor function
• Congenital
• Spinal Cord Injuries
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Neuromuscular Patients
• Generally need ventilatory assistance during the day
• Paralysis of diaphragm
• Intercostal muscle deterioration
• Limited function of limbs
• Adequate dentition for retention
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Neuromuscular Patients:Treatment
• Tracheotomy (medical)
• Custom mask, oral appliance combination (dental)
• No other choices except iron lung
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Neuromuscular Patients:History
45 yo, post polioParalyzed from neck downMask developed by DRI using “bite block”Pressure: 45 cmwVolume ventilatorCould use intercostals during dayInserted by biting into trays
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Neuromuscular Patients:History
Problems:Fabrication techniquesRetentionLeakageReparabilityBulkTechnique sensitivityCaregiver issues
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Treatment of the Severe Sleep Apnic
An eight year history
2002- 2010
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Patient: Ron Doe
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HPI2003
• Hx of loud snoring starting in dental school
• Recent weight gain of 100 lbs (300 lbs)
• Hypersomnolence
• Acid reflux
• Htn
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HPI2003
• Fibromyalgia
• Night sweats
• Joint aches
• Numb feet
• Nocturia
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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
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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
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Results
Before TAP
After TAP
© 2010 Airway Management, Inc.
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TAP III 2010
Plate anterior to upper incisors
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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 cmwCould not tolerate
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TAP-PAP 2010
• TAP-PAP custom mask (TPCM)
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PSG 12/28/2010TAP TAP-PAP
CustomTAP-PAPUniversal
TAP-PAPNasal
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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