How to choose the right mask under long term nocturnal NIV

Transcription

1 How to choose the right mask under long term nocturnal NIV Jean Christian Borel 1 AGIRàdom. Associa-on 38- Meylan 2 Univ Grenoble Alpes, HP2, Grenoble France 3 CRIUCPQ, Université Laval, Québec, Canada

2 Oral Mask Nasal Pillows + Oral Cushion Nasal Pillows Different types of masks Oro- Nasal Mask Nasal Mask Borel JC et al. Treatment Strategies - Respiratory 2014; 5: different types of masks - Oro- nasal masks are oren used in ARF - Nasal masks are oren (but not always) preferred in pa-ents with chronic respiratory failure - RCT comparing nasal vs oro- nasal mask are only available under CPAP However: - Nasal masks can result in mouth leaks with implica-ons on sleep quality and related symptoms (dry mouth, nasal conges-on) - To overcome this problem of mouth leaks, what are the strategies: - Tape the mouth? - Use a chin strap? - Oronasal mask?

3 Mouth leaks are associated with sleep fragmentalon and persistant nocturnal hypovenllalon. Teschler et al. Eur Respir J 1999; 14:

4 In healthy subjects, mouth breathing during sleep is very limited Normal Nasal (2.0±0.3 cmh2o.l -1.s -1 ) Mouth breathing <10% Fitzpatrick F et al. J Appl Physiol 94:

5 Mouth Breathing is frequent in patients with sleep breathing disorders % of total sleep Lme spent with mouth breathing N = 30 N = 21 77% of patients with OSAS spend > 30% of TST with mouth breathing Bachour A et al. Chest 2004;126:

6 Mouth Opening during sleep is larger in patients with sleep breathing disorders than in Healthy subjects Healthy subjets : mouth opening < 5mm for more than 80% of sleep -me Pa-ents with OSA > 5mm for 70% of total sleep -me ProporLon of Lme in each mandible posilon Miyamoto et al. Archives of Oral Biology 1999; 44:

7 PAP therapy reduces the time spent in mouth breathing KH Ruhle et al. Respiration 2008; 76:40-45 Senny F et al. Open Sleep J : 1-5

8 However the persistance of mouth breathing under PAP therapy is associated with poor compliance A. Bachour, CHEST What are the potenlal factors which contribute to the persistance of mouth opening? - What are the strategies to reduce mouth leaks?

9 Mouth breathing is strongly influenced by nasal resistance Healthy subject with nasal resistance (4.6 cmh2o.l -1.s -1 ) Fitzpatrick F et al. J Appl Physiol 94:

10 1- Reducing nasal resistance Humidification, topic treatment, sugery sham humidificalon Heated humidificalon Koutsourelakis I et al. Eur Respir J 2011; 37:

11 1- Reducing nasal resistance Humidification, topic treatment, sugery Koutsourelakis I et al. Eur Respir J 2013; 42:

12 D.E. Hollowel. J.Appl.Physiol. 1991, 71: Reducing Pharyngeal resistance: obstructive events result in mouth opening

13 F. Senny et al. IEEE 2007 obstructive events result in mouth opening

14 Collabora-on with Nomics, Coupling CPAP data with mandibular mvt analysis (JAWAC) ObstrucLve events Opening/ mandible oscillalons Leaks! There is a need to set appropriate pressure to also prevent mouth opening and thus potenlal mouth leaks!!!

15 Collabora-on with Nomics, Coupling CPAP data with mandibular mvt analysis (JAWAC) ObstrucLve events Opening/ mandible oscillalons Leaks!

16 2- Reducing pharyngeal resistance In edentulous palents, sleeping with dental appliance (or at least test it..) (Posterior airway space) Bucca C et al. Respiratory Research 2006,

17 3- Using a chin Strap 15 palents with observed mouth leaks and complaining of mouth dryness Bachour A, Sleep Med 2004

18 3- Using a chin Strap Bachour A, Sleep Med 2004

19 Chin strap is not used on a long term basis Not so easy to fit, possible constraints on UA Bachour A, Sleep Med 2004

20 4- Using an oro- nasal mask

21 Clinical case: PaLent with ALS Male, 52 years old. Diagnosed 17 months before. No bulbar involvement PaCO2 = 67.9mmHg; PaO2=67.9 mmhg; ph=7.42; HCO3- =38.7mmol/L IniLated on NIV in ICU with oro- nasal mask Vrijsen B et al. JCSM 2014; 10:

22 Clinical case N 2: PAP therapy delivered by oronasal mask may not be effective for obstructive sleep apnoea Schorr F et al. Eur Respir J :

23 Physiological data Nasal CPAP 6cmH 2 O Oro-nasal Random order CPAP 8cmH 2 O Nasal + MAD CPAP 10cmH 2 O Borel JC et al. Respir Physiol and Neurobiol 2012

24 Physiological data Linear Velo-pharyngeal resistance, cmh2o.s.l p<0.05 Oro-Nasal Nasal Nasal + MAD Linear Oro-pharyngeal resistance, cmh 2 O.s.L p<0.05 Oro-Nasal Nasal Nasal + MAD 6cmH2O 8cmH2O 10cmH2O Borel JC et al. Respir Physiol and Neurobiol 2012

25 Does oro- nasal mask actually improve the control of non- intenlonal leaks compared to nasal mask? J.P Backer, Sleep Breath 2011

26 Does oro- nasal mask actually improve the tolerance of (C)PAP therapy? Ming Teo, Sleep 2011

27 French Cohort of patients with OSAS under CPAP(n=2311) Anthropometrics Age, years ± BMI, kg/m² ± 6.58 Gender, % female 29.0 Active smokers, % 15.4 Medical History COPD, % 5.00 Hypertension, % Myocardial infarction, % 4.00 Coronary artery disease, % 6.00 Heart failure, % 2.70 Arrhythmias, % 8.70 Stroke, % 3.00 Gastroesophageal reflux, % Diabetes, % Hypercholesterolemia, % Hypertriglyceridemia, % 8.20 Depression, % Sleep apnea severity AHI, events/hour ± SpO2<90%, % of recording time ± Epworth Sleepiness scale 10.6 ± 5.1 Characteristics of CPAP treatment CPAP use, hours/night 5.39 ± 1.92 Patients with 4 hours/night, % 78.8 CPAP modality, % auto-adjusted pressure Type of interface, % Nasal Facial Nasal Pillows Additional heated Humidification (%) Borel JC et al. 2013, Plos One

28 Comparison of adherence and level of pressure according to the type of mask in palents with OSAS treated with CPAP <0.05 6,0 < <0.05 <0.05 Daily Adherence, hours/day 5,5 5,0 4,5 Pressure level, cm H ,0 6 0,0 Nasal oro-nasal nasal pillows 4 Nasal oro-nasal nasal pillows Borel JC et al. 2013, Plos One

29 Does oro- nasal mask actually improve the proporlon of side effects? Borel JC et al. 2013, Plos One

30 Oro- nasal mask is an independant factor associated with the risk of non adherence. Depression Scale Mean pressure ( 9 versus < 9 cmh 2 O) Choking sensa-on under CPAP Psychological gene Oronasal versus Nasal Nasal pillows versus Nasal No risk of non- adherence Risk of non- adherence Borel JC et al. 2013, Plos One

31 AlternaLng oronasal mask and nasal mask were tested in day (2hours) and overnight sessions, then the palents returned home with the preferred mask or most efficient mask In 11 cases the ONM was preferred (38%), but actually prescribed for 14 subjects (48%), because in 3 cases (10%) the criterion of effeclveness (nocturnal SpO2) was priorilzed over comfort.

32 At 3 months no differences in terms of PaCO2, nocturnal SpO2 and Daily use. Results are difficult to interpret: mixt between the palents preference and clinician preference

33 In conclusion There is no evidence on the best strategy for choosing the mask in long term NIV: Lack of well designed studies Most of the studies comparing different type of mask concern OSAS and CPAP Further research on the effects of different interfaces on the NIV efficacy are needed However, based on these studies,

34 Prior to PAP treatment inilalon, assessment of nasal resistance No is it increased? Yes Can you use a Nasal mask? Treatment of the obstruclon Yes Can the obstruclon be treated? Yes No Reevaluate nasal resistance (Allergic rhinils or PAP side effects) Check for mouth leaks with impact (inefficiency / intolerance / noncompliance) Check for other difficulles: - mask size - skin problems, pain at mask s contact area - ocular irritalon due to leaks is it increased? Yes Mouth leaks? Yes Other dificulles? No - Add Heated Humidifier - Add anlallergic filter - Local Treatment Yes Try to adjust pressures Persistant events (obstruclve IFL) No Yes Try nasal pillows / other bands of mask Try Chinstrap Yes No No Use oronasal mask ConLnue with nasal mask close monitoring to assess the therapeulc efficacy and tolerance