Sleep Apnea Syndromes: Brown LK

Kushida CA, Chediak A, Berry RB, Brown LK, Gozal D, Iber C, Parthasarathy S, Quan SF, Rowley JA, Anonymous00026, Anonymous00027. · Stanford University Center of Excellence for Sleep Disorders, 401 Quarry Road, Suite 3301, Stanford, CA 94305-5730, USA. · J Clin Sleep Med. · Pubmed #18468315 links to  free full text

Abstract: Positive airway pressure (PAP) devices are used to treat patients with sleep related breathing disorders (SRBDs), including obstructive sleep apnea (OSA). After a patient is diagnosed with OSA, the current standard of practice involves performing attended polysomnography (PSG), during which positive airway pressure is adjusted throughout the recording period to determine the optimal pressure for maintaining upper airway patency. Continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP) represent the two forms of PAP that are manually titrated during PSG to determine the single fixed pressure of CPAP or the fixed inspiratory and expiratory positive airway pressures (IPAP and EPAP, respectively) of BPAP for subsequent nightly usage. A PAP Titration Task Force of the American Academy of Sleep Medicine reviewed the available literature. Based on this review, the Task Force developed these recommendations for conducting CPAP and BPAP titrations. Major recommendations are as follows: (1) All potential PAP titration candidates should receive adequate PAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration. (2) CPAP (IPAP and/or EPAP for patients on BPAP) should be increased until the following obstructive respiratory events are eliminated (no specific order) or the recommended maximum CPAP (IPAP for patients on BPAP) is reached: apneas, hypopneas, respiratory effort-related arousals (RERAs), and snoring. (3) The recommended minimum starting CPAP should be 4 cm H2O for pediatric and adult patients, and the recommended minimum starting IPAP and EPAP should be 8 cm H2O and 4 cm H2O, respectively, for pediatric and adult patients on BPAP. (4) The recommended maximum CPAP should be 15 cm H2O (or recommended maximum IPAP of 20 cm H2O if on BPAP) for patients < 12 years, and 20 cm H2O (or recommended maximum IPAP of 30 cm H2O if on BPAP) for patients > or = 12 years. (5) The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential is 10 cm H2O (6) CPAP (IPAP and/or EPAP for patients on BPAP depending on the type of event) should be increased by at least 1 cm H2O with an interval no shorter than 5 min, with the goal of eliminating obstructive respiratory events. (7) CPAP (IPAP and EPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 obstructive apnea is observed for patients < 12 years, or if at least 2 obstructive apneas are observed for patients > or = 12 years. (8) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 hypopnea is observed for patients < 12 years, or if at least 3 hypopneas are observed for patients > or = 12 years. (9) CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 3 RERAs are observed for patients < 12 years, or if at least 5 RERAs are observed for patients > or = 12 years. (10) CPAP (IPAP for patients on BPAP) may be increased from any CPAP (or IPAP) level if at least 1 min of loud or unambiguous snoring is observed for patients < 12 years, or if at least 3 min of loud or unambiguous snoring are observed for patients > or = 12 years. (11) The titration algorithm for split-night CPAP or BPAP titration studies should be identical to that of full-night CPAP or BPAP titration studies, respectively. (12) If the patient is uncomfortable or intolerant of high pressures on CPAP, the patient may be tried on BPAP. If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP. (13) The pressure of CPAP or BPAP selected for patient use following the titration study should reflect control of the patient's obstructive respiration by a low (preferably < 5 per hour) respiratory disturbance index (RDI) at the selected pressure, a minimum sea level SpO2 above 90% at the pressure, and with a leak within acceptable parameters at the pressure.) (14) An optimal titration reduces RDI < 5 for at least a 15-min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings. (15) A good titration reduces RDI < or = 10 or by 50% if the baseline RDI < 15 and should include supine REM sleep that is not continually interrupted by spontaneous arousals or awakenings at the selected pressure. (16) An adequate titration does not reduce the RDI < or = 10 but reduces the RDI by 75% from baseline (especially in severe OSA patients), or one in which the titration grading criteria for optimal or good are met with the exception that supine REM sleep did not occur at the selected pressure. (17) An unacceptable titration is one that does not meet any one of the above grades. (18) A repeat PAP titration study should be considered if the initial titration does not achieve a grade of optimal or good and, if it is a split-night PSG study, it fails to meet AASM criteria (i.e., titration duration should be > 3 hr).

Brown LK. · No affiliation provided · Chest. · Pubmed #18628213 links to  free full text

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Casey KR, Brown LK. · No affiliation provided · Sleep Med. · Pubmed #18482865 No free full text.

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Brown LK, Casey KR. · No affiliation provided · Curr Opin Pulm Med. · Pubmed #17901751 No free full text.

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Brown LK. · No affiliation provided · Chest. · Pubmed #16899825 links to  free full text

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Brown LK. · No affiliation provided · Chest. · Pubmed #12226012 links to  free full text

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Brown LK. · No affiliation provided · Chest. · Pubmed #12226009 links to  free full text

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Brown LK. · Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87102, USA. · J Clin Sleep Med. · Pubmed #17561626 No free full text.

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Brown LK. · Sleep Disorders Center, University of New Mexico, Albuquerque, NM 87102, USA. · J Clin Sleep Med. · Pubmed #17561591 links to  free full text

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Morgenthaler TI, Gay PC, Gordon N, Brown LK. · Mayo Clinic Sleep Disorders Center, 200 First Street SW, Rochester, MN 55905, USA. · Sleep. · Pubmed #17520791 No free full text.

Abstract: RATIONALE: Although continuous positive airway pressure (CPAP) is most often effective in patients with obstructive sleep apnea, optimal treatment of patients with predominantly mixed apneas, central sleep apnea syndrome/Cheyne-Stokes respiration (CSA/CSR), or complex sleep apnea (CompSAS) is less straightforward, and may require alternative ventilatory assist modalities. OBJECTIVES: To compare the efficacy of noninvasive positive pressure ventilation (NPPV) with adaptive servoventilation (ASV) in treating patients with centrally mediated breathing abnormalities. We hypothesized that NPPV and ASV would be equivalently efficacious in improving the apnea/hypopnea index (AHI) and respiratory arousal index (RAI). METHODS: Prospective randomized crossover clinical trial comparing NPPV with ASV in patients with CSA/CSR, predominantly mixed apneas, and CompSAS in an acute setting. MEASUREMENTS AND MAIN RESULTS: 21 patients (6 with CSA/CSR, 6 with predominantly mixed apneas, and 9 with CompSAS) with initial diagnostic AHI +/- standard deviation 51.9 +/- 22.8/hr and RAI 45.5 < or = 26.5/hr completed the study. Following optimal titration with CPAP (N = 15), disturbed breathing and disturbed sleep remained high with mean AHI = 34.3 +/- 25.7 and RAI = 32.1 +/- 29.7. AHI and RAI were markedly reduced with both NPPV (6.2 +/- 7.6 and 6.4 +/- 8.2) and ASV (0.8 +/- 2.4 and 2.4 +/- 4.5). Treatment AHI and RAI were both significantly lower using ASV (P < 0.01). CONCLUSION: These data confirm that in patients with CSA/CSR, mixed apneas, and CompSAS, both NPPV and ASV are effective in normalizing breathing and sleep parameters, and that ASV does so more effectively than NPPV in these types of patients.

Dedrick DL, Brown LK. · Division of Pulmonary, Allergy, and Critical Care, University of New Mexico School of Medicine, Albuquerque, NM 87109, USA. · Chest. · Pubmed #14718463 links to  free full text

Abstract: We report a 75-year-old Spanish-American woman who received a diagnosis of oculopharyngeal muscular dystrophy after presenting with ptosis and dysphagia. She also complained of snoring and daytime somnolence, and was found to have obstructive sleep apnea (OSA) syndrome attributable to her neuromuscular disorder. This is the first report of OSA syndrome complicating typical, adult-onset oculopharyngeal muscular dystrophy, and should prompt the evaluation of other such patients for sleep-disordered breathing.

Auckley DH, Schmidt-Nowara W, Brown LK. · University of New Mexico School of Medicine, Albuquerque, NM, USA. · Am J Kidney Dis. · Pubmed #10516357 No free full text.

Abstract: Sleep apnea hypopnea syndrome (SAHS) is extremely common in patients with end-stage renal disease (ESRD). Although the underlying mechanisms linking these 2 conditions remain to be better defined, it is likely that multiple factors are involved. We report an individual with ESRD with severe SAHS that resolved after kidney transplantation. The improvement in SAHS paralleling the effective treatment of ESRD suggests the pathogenesis involves an unstable breathing pattern, possibly caused by an altered metabolic state, uremia, and changes in volume status. The possibility that elevations in cytokine levels could be involved also is discussed and deserves further attention.

Brown LK. · No affiliation provided · Mt Sinai J Med. · Pubmed #10475796 links to  free full text

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