Produção Nacional
Body Position May Influence Oronasal CPAP Effectiveness to Treat OSA
2016; American Academy of Sleep Medicine; Volume: 12; Issue: 03 Linguagem: Inglês
10.5664/jcsm.5602
ISSN1550-9397
AutoresJuliana Araújo Nascimento, Tômas de Santana Carvalho, Henrique Takachi Moriya, Paulo Henrique Sousa Fernandes, Rafaela Garcia Santos de Andrade, Pedro R. Genta, Geraldo Lorenzi‐Filho, Naomi Kondo Nakagawa,
Tópico(s)Sleep and Wakefulness Research
ResumoFree AccessCPAPBody Position May Influence Oronasal CPAP Effectiveness to Treat OSA Juliana Araújo Nascimento, BSc, Tômas de Santana Carvalho, BSc, Henrique Takachi Moriya, PhD, Paulo Henrique Sousa Fernandes, Rafaela Garcia Santos de Andrade, BSc, Pedro Rodrigues Genta, MD, PhD, Geraldo Lorenzi-Filho, MD, PhD, Naomi Kondo Nakagawa, PhD Juliana Araújo Nascimento, BSc Department of Physiotherapy, Communication Science and Disorders and Occupational Therapy, Faculdade de Medicina da Universidade de São Paulo, Brazil Sleep Laboratory, Pulmonary Division, Heart Institute, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil , Tômas de Santana Carvalho, BSc Department of Physiotherapy, Communication Science and Disorders and Occupational Therapy, Faculdade de Medicina da Universidade de São Paulo, Brazil Sleep Laboratory, Pulmonary Division, Heart Institute, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil , Henrique Takachi Moriya, PhD Biomedical Engineering Laboratory, Telecommunication and Control Engineering Department, Escola Politécnica da Universidade de São Paulo, Brazil , Paulo Henrique Sousa Fernandes Sleep Laboratory, Pulmonary Division, Heart Institute, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil , Rafaela Garcia Santos de Andrade, BSc Sleep Laboratory, Pulmonary Division, Heart Institute, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil , Pedro Rodrigues Genta, MD, PhD Sleep Laboratory, Pulmonary Division, Heart Institute, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil , Geraldo Lorenzi-Filho, MD, PhD Sleep Laboratory, Pulmonary Division, Heart Institute, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil , Naomi Kondo Nakagawa, PhD Address correspondence to: Naomi Kondo Nakagawa, Faculdade de Medicina da Universidade de São Paulo, Av. Dr Arnaldo, 455 room 1150, Sumaré, São Paulo, SP, Brazil - CEP 01246-930+ 55 11 3061-8529+ 55 11 3068-0072 E-mail Address: [email protected] Department of Physiotherapy, Communication Science and Disorders and Occupational Therapy, Faculdade de Medicina da Universidade de São Paulo, Brazil Sleep Laboratory, Pulmonary Division, Heart Institute, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, Brazil Published Online:March 15, 2016https://doi.org/10.5664/jcsm.5602Cited by:9SectionsAbstractPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutABSTRACTCPAP applied by a nasal mask is the gold standard treatment of obstructive sleep apnea. Oronasal masks are an alternative interface that can be used, especially in subjects with predominant oral breathing. However, oronasal masks have higher costs, are associated with larger leaks and higher residual apnea-hypopnea index, and in some cases may be ineffective.Citation:Nascimento JA, Carvalho TS, Moriya HT, Fernandes PH, Andrade RG, Genta PR, Lorenzi-Filho G, Nakagawa NK. Body position may influence oronasal CPAP effectiveness to treat OSA. J Clin Sleep Med 2016;12(3):447–448.INTRODUCTIONCPAP applied by a nasal mask is the gold standard treatment of obstructive sleep apnea (OSA). Oronasal masks are an alternative interface that can be used, especially in subjects with predominant oral breathing.1,2 However, oronasal masks have higher costs, are associated with larger leaks and higher residual apnea-hypopnea index (AHI), and in some cases may be ineffective. This case report was approved by the local ethics committee (CEP-FMUSP 102/13).REPORT OF CASEA 60-year-old female had loud snoring with suspected OSA and was referred to the sleep outpatient clinic. She complained of excessive diurnal somnolence (Epworth Sleepiness Scale score = 20). On physical examination, her body mass index was 31 kg/m2. She presented a narrow oral cavity (modified Mallampati class IV) with no significant facial anatomy abnormalities. The patient reported difficulty with nasal breathing; however, nasoendoscopy showed no significant nasal obstruction. A full baseline polysomnography (PSG) showed severe OSA (AHI = 80 events/h, minimal oxygen saturation: MinO2Sat = 58%) that was not dependent on supine position (supine and non-supine AHI = 71 and 88 events/h, respectively). A second PSG for continuous positive airway pressure (CPAP) titration was performed using an oronasal mask. CPAP was titrated up to 16 cm H2O with persistent residual events (residual AHI = 10 events/h and MinO2Sat = 84%), which were present at all CPAP levels tested. All obstructive events occurred at the supine position (Figure 1A). A third PSG study for CPAP titration was performed using a nasal mask and showed abolishment of respiratory events with CPAP at 7 cm H2O (residual AHI = 2 events/h and MinO2Sat = 90%) (Figure 1B). CPAP titration was performed manually by a sleep technician on both CPAP titration nights.Figure 1 (A) CPAP titration up to 16 cm H2O showed a residual AHI of 10 events/h. The patient slept in lateral-decubitus during most of the night. However, observe that obstructive events returned in supine (arrows) and were not dependent on CPAP level that was titrated up to 16 cm H2O. (B) In contrast, nasal CPAP at 7 cm H2O was effective to abolish respiratory events.Download FigureDISCUSSIONOSA treatment with CPAP was first conceived to be applied by a nasal mask because the pressure through the nose would displace the tongue forward. Early clinical observations showed that oronasal interfaces can be an effective alternative, particularly in patients with nasal issues.1,2 However, there is evidence that the use of oronasal interface is associated with higher therapeutic CPAP level, higher leak and lower effectiveness to treat OSA compared to nasal CPAP.3,4 The present clinical case describes one patient with severe OSA who was not adequately treated with CPAP via oronasal mask despite high CPAP levels, but was successfully titrated with a nasal mask to a relatively low CPAP level, independent of body position. When there was a coincidence of oronasal CPAP during supine position, obstructive events were not abolished, despite titration up to 16 cm H2O. In contrast, when lateral decubitus was adopted by the patient using an oronasal interface, a CPAP of 16 cm H2O was able to control obstructive events, probably by decreasing the collapsibility in the pharynx.5 Therefore, the interaction between supine position and the oronasal interface may have resulted in posterior tongue displacement and airway obstruction. Alternatively, the oronasal interface by itself may have led to airway narrowing through posterior mandible displacement, mouth opening, or failure to improve the trans-mural pressure gradient between nasal and oral cavities, as well as intermediate palatal position resulting from oronasal breathing.6 In conclusion, this is a unique case reporting the interaction between supine positon and CPAP for OSA treatment applied through an oronasal interface that resulted in persistency of obstructive events.DISCLOSURE STATEMENTThis was not an industry supported study. Financial support was provided by Fundação de Amparo à Pesquisa do Estado de São Paulo (2013/13598-9) and CNPq (470356/2013-8). The authors have indicated no financial conflicts of interest.ABBREVIATIONSAHIapnea-hypopnea indexCPAPcontinuous positive airway pressureOSAobstructive sleep apneaPSGpolysomnographyREFERENCES1 Prosise GL, Berry RBOral-nasal continuous positive airway pressure as a treatment for obstructive sleep apnea. Chest; 1994;106:180-6, 8020269. CrossrefGoogle Scholar2 Sanders MH, Kern NB, Stiller RA, Strollo PJ, Martin TJ, Atwood CWCPAP therapy via oronasal mask for obstructive sleep apnea. Chest; 1994;106:774-9, 8082358. CrossrefGoogle Scholar3 Kaminska M, Montpetit A, Mathieu A, Jobin V, Morisson F, Mayer PHigher effective oronasal versus nasal continuous positive airway pressure in obstructive sleep apnea: effect of mandibular stabilization. Can Respir J; 2014;21:234-8, 24791252. 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An Official American Thoracic Society Workshop ReportGenta P, Kaminska M, Edwards B, Ebben M, Krieger A, Tamisier R, Ye L, Weaver T, Vanderveken O, Lorenzi-Filho G, DeYoung P, Hevener W and Strollo P Annals of the American Thoracic Society, 10.1513/AnnalsATS.202007-864ST, Vol. 17, No. 10, (1177-1185), Online publication date: 1-Oct-2020. Use of the WatchPAT to detect occult residual sleep-disordered breathing in patients on CPAP for obstructive sleep apneaEpstein M, Musa T, Chiu S, Costanzo J, Dunne C, Cerrone F and Capone R Journal of Clinical Sleep Medicine, Vol. 16, No. 7, (1073-1080), Online publication date: 15-Jul-2020. 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Transmission of Oral Pressure Compromises Oronasal CPAP Efficacy in the Treatment of OSAMadeiro F, Andrade R, Piccin V, Pinheiro G, Moriya H, Genta P and Lorenzi-Filho G Chest, 10.1016/j.chest.2019.05.024, Vol. 156, No. 6, (1187-1194), Online publication date: 1-Dec-2019. Efficacy of the Addition of a Cervical Collar in the Treatment of Persistent Obstructive Apneas Despite Continuous Positive Airway PressurePrigent A, Grassion L, Guesdon S and Gonzalez-Bermejo J Journal of Clinical Sleep Medicine, Vol. 13, No. 12, (1473-1476), Online publication date: 15-Dec-2017. Choosing the right interface for positive airway pressure therapy in patients with obstructive sleep apneaBaHammam A, Singh T, George S, Acosta K, Barataman K and Gacuan D Sleep and Breathing, 10.1007/s11325-017-1490-9, Vol. 21, No. 3, (569-575), Online publication date: 1-Sep-2017. Oronasal mask may compromise the efficacy of continuous positive airway pressure on OSA treatmentAndrade R, Madeiro F, Genta P and Lorenzi-Filho G Current Opinion in Pulmonary Medicine, 10.1097/MCP.0000000000000318, Vol. 22, No. 6, (555-562), Online publication date: 1-Nov-2016. Volume 12 • Issue 03 • March 15, 2016ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationJuly 1, 2015Submitted in final revised formNovember 1, 2015Accepted for publicationNovember 1, 2015Published onlineMarch 15, 2016 Information© 2016 American Academy of Sleep MedicineKeywordssupinecontinuous positive airway pressuretitrationobstructive sleep apneaoral maskPDF download
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