Apnee Si Boli Asociate

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Apnee Si Boli Asociate

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Spitalul Clinic de Pneumologie Iasi D.Boisteanu

SINDROMUL DE APNEE IN SOMN (SAS)

AFECTIUNI ASOCIATEAPNEEA DE SOMN - DEFINITIIApneea de somn este oprirea repetata a fluxului aerian naso-bucal > 10sec insotita de sforait, hipoxie si somnolenta diurna excesiva (treziri frecvente).

Aceasta terminologie implica 2 probleme distincte apneea obstructiva (colapsul CRS la nivelul faringelui); cea mai frecventa forma de apnee de somn; persista efortul respirator - apneea centrala este determinata de alterarea controlului respiratiei oprirea efortului ventilator si a fluxului aerian se asociaza cu insuficienta cardiaca si respiratia periodica Cheyne-Stokes - apneea mixta incepe ca fenomen central si se termina obstructiv APNEEA DE SOMN - DEFINITIIHipopneea = scaderea fluxului aerian cu 30-50% din valoarea initiala, asociata cu desaturare de min. 3%Indexul de apnei-hipopnei (IAH sau RDI)SAS = IAH > 5 /ora de somnAprecierea severitii SAS uor: IAH = 5- 15/or moderat: IAH = 15 30/or sever > 30/or de somnRERA (respiratory event related arousal) = scaderea fluxului aerian la nivelul nasului si gurii mai mult de 10 sec. insotita intotdeauna de o microtrezire.

OBEZITATEA Ample studii populaionale au evideniat corelarea SAS cu obezitatea, dovedind o relaie direct ntre severitatea SAS (apreciat prin indexul de apneehipopnee) i indicele de mas corporal (BMI).

Asocierea ntre obezitate i apneea obstructiv de somn este mai frecvent la pacienii care prezint creteri ale circumferinei taliei i gtului, nsoite de sforit.

Obezitatea este principalul predictor al apneei de somn.

OBEZITATEAObezitate majoritate cazuriCircumferinta gatului > 44cmAnomalii cranio-faciale (micro/retrognatie, acromegalie, bolta palatina ogivala)Malocluzie maxilo-mandibulara

APNEEA DE SOMN (SAS) SI SDR. PICKWICK (SOH)Majoritatea dar nu toti pacientii cu SOH au SASPerez de Llano (Chest, 2005): 87% cu ambele afectiuni.Prevalenta Sdr.Pickwck la pacientii cu apnee - 8 10% cand IMC = 30-34 kg/m- 18 25% cand IMC = 40 kg/m

Mokhlesi B, Kryger M, Grunstein R. Assessment and management of patients with Obesity Hypoventilation Syndrome. Proc Am Thorac.Soc 2008;5:218-225.

Mark Anthony Powers.The Obesity Hypoventilation Syndrome. Respir Care 2008;53(12):17231730.

ROLUL LEPTINEILeptina = proteina endogena derivata din adipociteParticipa la reglarea metabolica a greutatii corporaleFeed-back negativ care activeaza receptorii ce suprima apetitul.Stimuleaza centrii respiratori si pare sa aiba un rol protector impotriva complicatiilor respiratorii la obezi;La obezi, nivelul leptinei este mult , ceea ce implica o posibila rezistenta la leptina.Nivelul seric al leptinei este un predictor mai bun al SOH decat IMC, independent de IAH.VNI reduce nivelul leptinei in SOH.ROLUL LEPTINEI

Claudio Rabec. Leptin, obesity and control of breathing : the new aventures of mr pickwick Rev Electron Biomed / Electron J Biomed 2006;1:3-7

TRATAMENT

Mark Anthony Powers.The Obesity Hypoventilation Syndrome. Respir Care 2008;53(12):17231730.

COMORBIDITATI HTA (risc x 2) Boala coronariana (risc x 3) Tulburari de ritm cardiac Insuficienta cardiaca Accidente ischemice cerebrale (risc x 4) Trombembolism pulmonar Sdr. metabolic (diabet, dislipidemie, hiperuricemie) Hipotiroidie, acromegalie Afectiuni in sfera ORL

APNEEA DE SOMN POATE DETERMINA APARITIA URMATOARELOR AFECTIUNI Hipertensiune arteriala Boala coronariana Tulburari de ritm cardiac Accidente ischemice cerebrale Embolie pulmonaraSpitalul Clinic de Pneumologie Iasi D.BoisteanuSe poate asocia cu sindromul metabolic: diabet zaharat, dislipidemie, hiperuricemie, obezitate, HTAAPNEEA DE SOMN SI HTASAS factor de risc independent pt. HTA

la pacientii cu SAOS, TA nocturna profil non-dipper

la bolnavii cu HTA rezistenta la trat. se recomanda screening pt. apnee de somn

la aceasta categorie de pacienti (cu HTA rezistenta la trat. si SAS), folosirea nCPAP min. 5 ore/noapte duce la imbunatatirea controlului TAAPNEEA DE SOMN SI HTAWisconsin Sleep Cohort Study: SAOS factor de risc independent pt. HTA TA nocturna profil non-dipper TA diurna, sistolica si diastolica, > la cei cu SAOS

Efectul tratamentului nCPAP (Becker, 2003)

nCPAP timp de 9 sapt. scade TA (sist.+diast.) la pacienti cu HTA rezistenta la trat. si SAOS, folosirea nCPAP min. 5 ore/noapte duce la TA

CONSECINTELE CARDIOVASCULARE ALE APNEEI DE SOMN

PREVALENTA TULBURARILOR RESPIRATORII DE SOMN LA PACIENTII CU BOLI CARDIOVASCULARE30% din pacientii cu boli cardiovasculareSchafer, et al. Cardiology 199950% din bolnavii cu insuficienta cardiaca cronicaJavaheri, Circulation 199860% dintre supravietuitorii unui AVCBassetti, et al. Sleep 199983% din pacientii cu HTA rezistenta la tratamentLogan, et al. J Hypertension, 2001

SAS SI MORBIDITATEA CARDIOVASCULARA MECANISME BIOLOGICEAlterarea endoteliului vascular, aterogeneza

Cresterea activarii plachetareActivarea factorilor proinflamatori Stres oxidativ

Legatura intre aceste modificari biologice si datele clinico-experimentale nu este complet stabilita

Boala coronarianaApneea de somnHipoxieHipertensiune (nocturna)TreziriObezitateHipercolesterolemieHiperuricemieDiabet zaharatHipertensiune (diurna)PROFILUL FACTORILOR DE RISC+Spitalul Clinic de Pneumologie Iasi D.BoisteanuAPNEEA DE SOMN SI BOALA CORONARIANAMODIFICARI CARDIACE IN TIMPUL APNEEI DE SOMN

Spitalul Clinic de Pneumologie Iasi D.Boisteanu

EFECTELE MECANICE ALE APNEEIHipoventilatia(CO2) determina efortului inspirator impotriva cailor aeriene inchise (manevra Mueller) => activare vagala => bradiaritmie.

Dupa 10-60 sec respiratia se reia, manevra Mueller inceteaza, scade tonusul vagal si creste activitatea simpatica => potentand efectul aritmic.

compliantei VS = disfunctie diastolica,

dimensiunea ADJournal of Cardiovascular Electrophysiology Vol. 18, No. 9, September 2007Sleep Medicine Reviews, Vol, 2, No. 1, pp 45-60, 1998(7)26RESPIRAIA CHEYNE-STOKES ASOCIATA IC

DIAGNOSTIC SAS : SINTEZAApneea de somn este subdiagnosticataSuspiciunea de diagnostic poate fi emisa de pacient, familie sau medic.Confirmarea SAS se poate face in etapa actuala numai de catre pneumolog prin polisomnografie sau poligrafie.Screeningul preliminar poate fi realizat prin chestionar Epworth si o anamneza orientata pe tulburarile somnului.La pacientii obezi cu afectiuni cardiovasculare, poligrafia de somn pentru depistarea SAS ar trebui sa devina un test de rutina.TRATAMENTUL CU PRESIUNE POZITIVA NAZALA (CPAP)

Cea mai eficienta metoda terapeutica pentru apneea desomn moderata si severa

Titrarea polisomnografica a presiunii CPAP

Spitalul Clinic de Pneumologie Iai nCPAP elimina OA & CA si reduce postsarcina ventricolului stang prin scaderea presiunii arteriale.INFLUENTA CPAP ASUPRA APNEILOR (OBSTRUCTIVE SI CENTRALE)

(Yan AT. Et al. Chest 2001;120:1675-1685)32Congestive heart failure (CHF) is a serious medical condition frequently associated with sleep-related breathing disorders, which remain underdiagnosed and undertreated. Recent studies have provided important insight into the pathophysiology of sleep apnea syndrome in patients with CHF, with potential therapeutic implications. In addition to abolition of sleep apnea, continuous positive airway pressure (CPAP) treatment can improve cardiac function and relieve symptoms of CHF. Postulated mechanisms include beneficial hemodynamic effects on ventricular remodeling, unloading of fatigued respiratory muscles, and neurohormonal modulation. Although medium-term studies using CPAP to treat sleep-related breathing disorders associated with CHF have been encouraging, more definitive data from ongoing large clinical trials are necessary to clarify its therapeutic role AUTO-CPAP ESTE FOLOSIT ATAT PENTRU TRATAMENT CAT SI PENTRU TITRAREA PRESIUNII EFICIENTEAvantajele auto-CPAP fata de CPAP cu presiune fixa:Evita titrarea.Poate face titrarea automat.Simplifica modul de aplicare a tratamentului, economisind o noapte de polisomnografie astfel incat pot fi tratati mai multi pacienti.4. Detecteaza deficientele de complianta, defectele mastii si apneile reziduale.Ca eficienta, auto-CPAP nu este mai bun decat CPAP cu presiune fixa. 33INFLUENTA AUTO-CPAP ASUPRA RESPIRATIEI PERIODICE CHEYNE-STOKES DIN INSUFICIENTA CARDIACA

(Teschler H. et al. AJRCCM 2001;164:614-619)34Ref 45

Figure 1. (A) Typical 5-min polygraph recording on the diagnostic night. EMG =submental electromyogram; Thorax =rib cage movement strain gauge (uncalibrated). Abdomen =abdominal movement strain gauge (uncalibrated); Thermistor =oronasal airflow (uncalibrated); SaO2 =pulse oximetry. The subject is in stage 1sleep. Note five central apneas and associated desaturations and arousals. (B) Typical 5-min polygraph recording on the adaptive servo-ventilation night. Same subject as (A). Pressure =mask pressure. Other abbreviations as for (A). Note the transient increase in pressure modulation amplitude within 1to 2breaths of the onset of a central hypopnea early in the trace, and the absence of desaturation or arousal. [Thermistor, rib cage, and abdominal movement signal gains were chosen for visual clarity, are uncalibrated, and therefore differ from (A).]

Figure 1. (A) Typical 5-min polygraph recording on the diagnostic night. EMG =submental electromyogram; Thorax =rib cage movement strain gauge (uncalibrated). Abdomen =abdominal movement strain gauge (uncalibrated); Thermistor =oronasal airflow (uncalibrated); SaO2 =pulse oximetry. The subject is in stage 1sleep. Note five central apneas and associated desaturations and arousals. (B) Typical 5-min polygraph recording on the adaptive servo-ventilation night. Same subject as (A). Pressure =mask pressure. Other abbreviations as for (A). Note the transient increase in pressure modulation amplitude within 1to 2breaths of the onset of a central hypopnea early in the trace, and the absence of desaturation or arousal. [Thermistor, rib cage, and abdominal movement signal gains were chosen for visual clarity, are uncalibrated, and therefore differ from (A).]

Figure 1. (A) Typical 5-min polygraph recording on the diagnostic night. EMG =submental electromyogram; Thorax =rib cage movement strain gauge (uncalibrated). Abdomen =abdominal movement strain gauge (uncalibrated); Thermistor =oronasal airflow (uncalibrated); SaO2 =pulse oximetry. The subject is in stage 1sleep. Note five central apneas and associated desaturations and arousals. (B) Typical 5-min polygraph recording on the adaptive servo-ventilation night. Same subject as (A). Pressure =mask pressure. Other abbreviations as for (A). Note the transient increase in pressure modulation amplitude within 1to 2breaths of the onset of a central hypopnea early in the trace, and the absence of desaturation or arousal. [Thermistor, rib cage, and abdominal movement signal gains were chosen for visual clarity, are uncalibrated, and therefore differ from (A).]

Adaptive servo-ventilation (ASV) is a novel method of ventilatory support designed for Cheyne-Stokes respiration (CSR) in heart failure. The aim of our study was to compare the effect of one night of ASV on sleep and breathing with the effect of other treatments. Fourteen subjects with stable cardiac failure and receiving optimal medical treatment were tested untreated and on four treatment nights in random order: nasal oxygen (2 L/min), continuous positive airway pressure (CPAP) (mean 9.25 cm H(2)O), bilevel (mean 13.5/5.2 cm H(2)O), or ASV largely at the default settings (mean pressure 7 to 9 cm H(2)O) during polysomnography. Thermistor apnea + hypopnea index (AHI) declined from 44.5 +/- 3.4/h (SEM) untreated to 28.2 +/- 3.4/h oxygen and 26.8 +/- 4.6/h CPAP (both p < 0.001 versus control), 14.8 +/- 2.3/h bilevel, and 6.3 +/- 0.9/h ASV (p < 0.001 versus bilevel). Effort band AHI behaved similarly. Arousal index decreased from 65.1 +/- 3.9/h untreated to 29.8 +/- 2.8/h oxygen and 29.9 +/- 3.2/h CPAP, to 16.0 +/- 1.3/h bilevel and 14.7 +/- 1.8/h ASV (p < 0.01 versus all except bilevel). There were large increases in slow-wave and rapid eye movement (REM) sleep with ASV but not with oxygen or CPAP. All subjects preferred ASV to CPAP. One night ASV suppresses central sleep apnea and/or CSR (CSA/CSR) in heart failure and improves sleep quality better than CPAP or 2 L/min oxygen

CPAP ASOCIAT CU OXIGENAdaugarea oxigenului la CPAP sau BiPAP la pacienti cu SAS care sunt hipoxemici in stare de veghe (ex. sdr.Pickwick) - boli coronariene-accidente vasculare cerebrale- trombembolism pulmonarVPAP : ADAPT SERVO-VENTILATIA

Trateaza toate formele de apnee centrala, mixta si respiratie periodica.Este dotat cu un sistem inteligent de calcul care determina continuu suportul de presiune necesar pentru a aduce ventilatia pacientului la un nivel-target.In ansamblu, realizeaza sincronizarea intre presiunea furnizata de aparat si respiratia pacientului.CORECTIA CHIRURGICALA A FARINGELUIUvulo-palato-faringoplastie (UPPP)

Laser-UPPP

Rigidizarea valului palatin cu radiofrecventa

AVANSAREA MAXILO-MANDIBULARA Obiective Cresterea diametrului caii aeriene superioare

Diminuarea tendintei la colaps al faringelui

PROTEZELE MANDIBULARE Dispozitivele pot fi:neajustabilepartial ajustabile total ajustabile mandibula este avansata progresiv pana ajunge in pozitia utila terapeutic.

KLEARWAYOVERLAP SYNDROMEConcomitena BPOC i SAS

Frecvena apneilor la bolnavii cu BPOC ~ 4%

Frecvena BPOC la bolnavii cu apnee n somn ~ 11% Prezena celor dou afeciuni la acelai bolnav duce la: Agravarea desaturrilor nocturne Permanentizarea hipoxemiei Instalarea HTAP PAP se coreleaz cu PaO2 i nu cu severitatea SASPATOGENIA OVERLAP SYNDROMERolul hipoxemiei diurne prin obstrucie bronic este primordial n determinismul HTAP permanente.

Hipoxemia nocturn datorat apneilor are un rol secundar n instalarea HTAP permanente i apariia cordului pulmonar cronic.

HTAP este corelat cu severitatea obezitii i consecinele ei asupra ventilaiei.PATOGENIA OVERLAP SYNDROME Factori predictivi pentru hipercapnie n overlap sdr. PaO2 (38%) - VEMS (15%) - BMI (12%)

Hipercapnia din overlap sdr. are etiologie plurifactorial, fiind numai parial explicat de asocierea obezitii cu apneea de somn i cu deteriorarea funciei respiratorii.TESTE PRELIMINARE DE DEPISTARE A APNEILOR NOCTURNE LA BOLNAVII CU BPOC Asociaz simptomele/semnele BPOC i ale SAS nregistrarea nocturn continu a saturaiei arteriale a O2 nregistrarea zgomotelor respiratorii traheale Chestionare (evaluarea somnolenei diurne: scala Stanford sau Epworth)TRATAMENTUL OVERLAP SYNDROMEOxigenoterapia la domiciliu SpO2 < 88%Crete durata de viaAmelioreaz calitatea somnuluiPrevine creterea PAP n somnul paradoxal

Ventilaia nocturna pe masc nazal:- cu auto-ti...