Generally, auto PAP makes central apnea worse which is not present in REM Sleep. I would recommend performing a CPAP titration study in such patients.

Thank you for your reply. Manual titration sounds reasonable to determine the pressure; however, the problem is prescribing optimal device. CPAP or Auto PAP. What would you do if the required pressure showed huge variation during sleep?

Hello Metin,

Was there a great variability in the pressure needed during the night - i.e., effect of REM  only or REM and posture observed? pressure intolerance?

What was the machine- determined average Apnea-Hypopnea for each night (events and time at pressure) for your patient?  did you observe problems with high leak?

Tatyana

Hello and Thank you Tatyana,

It is not only case but a common problem we observe. The most common problem is observing  a great variability in the pressure needed between REM and Non-REM sleep in supine position. 

Because we could not prescribe any device, we had no chance to see machine-determined average Apnea-Hypopnea for each night. 

Metin

Hello Metin,

there may be benefits to prescribe a more narrow pressure range then, as failure of the device algorithms is possible, leading to over titration and as a result appearance of central events, high leaka and frequent awakenings- you can modify the pressure later based on clinical assessment. The increase in AHI you observed with APAP can also be due to residual or transitional events when the patient may have been awake, and the machine responded to the awaken breathing pattern. 

Kind regards, Tatyana

I recommend surgeries to these patients. CGL（correction of Glosso-Larynx） and EVO (Expansion of Vestibular Oris) are surgery for choice. Please refer references. (1-5) 1. Mukai S, Mukai C, Asaoka K. Congenital ankyloglossia with deviation of the epiglottis and larynx. Annals of Otolaryngol. 1991;100, supple 153:1-20. 2. Mukai S, Mukai C, Asaoka K. Congenital ankyloglossia with deviation of the epiglottis and larynx: symptoms and respiratory function in adult. Annals of Otolaryngol. 1993;102(102):620-4. 3. Nitta M, Mukai S, Mukai C. The expansion of the hypopharynx by correction of glosso-larynx. Psychiatry and Clinical Neurosciences. 2000;54:344-5. 4. Mukai S. Expansion of the Vestibular Oris (EVO) --- Esthetic Facial Changes and Expansion of the Nasal Cavity --. Nihon Zetuychakusho Gakkai Kaishi (Annals ADEL). 2010;16:32-41. 5. Mukai S. Dilatation of the nasal valve by expansion of the vestibular oris (EVO) http://dxdoiorg/104236/health201358A2004, Health. 2013;5:21-5.

First assess history of patient. If he complaints about SPBA (supine position based apnea) i.e. cannot ly on back and breath normally, feeling a joking sensation, when lying supine, sometimes impossibility to find sleep in supine position.

Then, please perform somnoscopy in Propofol induced sleep with and without NCPAP and look if you note an aSGO (adult supraglottic obstruction, abstract: schedler, supraglottic obstruction) regarding base of tongue and/or epiglottis. In case of aSGO avoid APAP, since the ventilationpressure will steadily increase with rising upper airway resistance. Settle then for a lower range Bilevel therapy, which can be titrated in Propofol sleep, sneaking a thin endoscope under the mask, while setting the pressure level so that no obstruction (e.g. bending down epiglottis by airflow) is induced. Or refer to airway surgeon, who can address the problem surgically. I have personally performed about 520 laser epiglottis partial resections (EPR), close to 300 HPPs (Hyoidpharyngoplasty) and 3 Supraglottoplasties; simultaneous Laser EPR/HPP procedure.

I can give access to my Dropbox to learn more about the issue, if desired. Best regards Mike

sorry , I meant of course "choking sensation" ! Here the corrected version:

First assess history of patient. If he/she complaints about SPBA (supine position based apnea) i.e. cannot ly on back and breath normally, feeling a choking sensation, when lying supine, sometimes impossibility to find sleep in supine position.

Then, please perform somnoscopy in Propofol induced sleep with and without NCPAP and look if you note an aSGO (adult supraglottic obstruction, abstract: schedler, supraglottic obstruction) regarding base of tongue and/or epiglottis. In case of aSGO avoid APAP, since the ventilationpressure will steadily increase with rising upper airway resistance. Settle then for a lower range Bilevel therapy, which can be titrated in Propofol sleep, sneaking a thin endoscope under the mask, while setting the pressure level so that no obstruction (e.g. bending down epiglottis by airflow) is induced. Or refer to airway surgeon, who can address the problem surgically. I have personally performed about 520 laser epiglottis partial resections (EPR), close to 300 HPPs (Hyoidpharyngoplasty) and 3 Supraglottoplasties; simultaneous Laser EPR/HPP procedure.

I can give access to my Dropbox to learn more about the issue, if desired. Best regards Mike

I agree about seeing the patient under sedation, the problem with propofol is that it doesn't reproduce REM sleep: it's abolished, but maybe you can have an idea about what is going on just by watching the UA under sedation, although the patient has a predominate REM sleep apnea, he will have also apneas during N-REM and that ones are easily seen during DISE (Drug induced sedation endoscopy). 

If you want to see the patient under REM sleep, the the drug should be midazolam, but be prepared to be patient and wait about and hour and a half or two hours with the endoscope inside the pharynx...

Check about the position too, and check the lingual tonsils, if they are hypertrophic, patients cannot tolerate supine .... other times is the trapdoor phenomena of the epiglotis ...

The european position paper on DISE can help you to see how to perform the sedation.

Good luck with the patient and please tell the results

Article Critical closing pressure during midazolam-induced sleep

Article Polysomnographic evaluation of propofol-induced sleep in pat...

Article European position paper on drug-induced sedation endoscopy (DISE)

In my opinion base of tongue tonsils only play a minor roll in SPBA. If it wasn't so, we would have a big UARS/OSA problem with post tonsillectomy hypertrophy of base of tongue tonsils in the population. My view is supported by experience of average 12-15 videodocumented somnoscopies per week since about 18 years, not counted the fewer numbers during my 11 years consultant at an University hospital. Unfortunately I have started publication late and so far only in abstract form. Sorry about that!

REM sleep related apnea is present in individuals, who have a sufficient tone in NREM sleep to keep airway open and prevent UARS or OSA, but  loss of tone in REM sleep causes the airway to collapse. Loss of tone is also present in Propofol induced sleep, even though it is usually NREM  sleep. It therefore can be used to assess loss of tone induced apnea.

Thanks for all answers. It was very useful discussion for me.

my pleasure dear colleague!

Dear Colleague,

Is your patient a child?

in this case you can treat him by Rapid Maxillary Expansion.

if your patient is adult I can suggest different options but I need more info.

if you need,call me.

i give you my contact: [email protected]

happy new year!

paola

You might want to consider Myofunctional Therapy, particularly if the tongue level at resting is low, abnormal, if tongue tied or a mouth breather.   By toning the muscles of the airway it only makes sense that there would be less muscle relaxation in REM.  Also, verify that the patient is a nasal breather while sleeping since the research shows mouth breathing causes upper and lower airway instability as compared to nasal breathing.

Rem related sleep apnea is significantly associated with central sleep apnea, parkinsons, temporomandibular dysfunction, depression, and a number of other pathologies.  Before recommending surgery, would it not be prudent to engage in a multidisciplinary evaluation to ascertain the most likely contributor to the REM sleep apnea?  If your subject, for example, has limited mouth opening of only 1 cm enlarging the oropharynx is not likely to be of great benefit - is it?

attached is a reference study for my example

Article The Relationship Between Mouth Opening and Sleep Stage-Relat...

 There are too many variables that are left out for this to have any real validity.  What is the head position, tongue level, malampatti, swallow pattern,degree of mouth breathing, protrusive capability etc.  This may be a variable, but I doubt seriously it is the variable.