Terapia pneumologica attuale Centro di Medicina del Sonno ad Indirizzo Respiratorio Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Divisione di Pneumologia Riabilitativa

Prevenzione cardiovascolare secondaria

CPAP - Titolazione Eliminazione di eventi respiratori, russamento, arousals in tutte le posizioni e tutti gli stadi del sonno Eliminazione della limitazione di flusso Gold standard: sleep lab Alternativa: autoCPAP (almeno due notti di valutazione) con successiva validazione

Titolazione in laboratorio (Trial and error protocol) Split – night Utilizzare protocolli standardizzati: apnee:1 cm H2O ogni 5 m’, ipopnee 1 cm H2O ogni 10 m’

AutoCPAP Sviluppata nei primi anni 90 L’AutoCPAP è un dispositivo che regola automaticamente la pressione fornita in base alle necessità (resistenza) delle vie aeree del paziente Per erogare la pressione necessaria, le AutoCPAP utilizzano sofisticati algoritmi di rilevazione, diversi per ogni casa produttrice Ha guadagnato una buona porzione del mercato ( ca. 10% in Italia) Pressione Tempo Purpose: To explain how an AutoCPAP operates In response to variable pressure requirements auto-adjusting CPAP was developed in the early 1990s. An AutoCPAP is a device which automatically adjusts the delivered pressure, in response to the upper airway needs of the patient. Refer to diagram: This represents a typical pressure profile of an auto-adjusting device over a one night period. As you can see the pressure varies between a minimum and maximum pressure (which are set by the doctor) over the whole night. The device responds to events (apneas, hyoponeas, flow limitations and snoring) by increasing the pressure. When there are no events detected the machine will decrease the pressure. In order to predict the pressure needs of an individual patient, auto-adjusting devices use sophisticated algorithms. An algorithm is a piece of software in a machine that tells the machine how to respond to a certain situation. Each algorithm is unique to the manufacturer. Since their introduction in the 1990s, auto-adjusting devices have gained a substantial proportion of the market. 7 7

8

Paziente quasi sempre sveglio Guantiera 11

Respiro periodico in cardiopatico che la macchina cerca di correggere giovanni zaetta 12

B.A.

B.A.

B.A.

B.A.

B.A.

B.A.

B.A.

B.E.

B.E.

B.E.

B.E.

B.E.

25

CPAP adherence A team effort is needed to enhance CPAP adherence. The team may consist of the patient , family/bed partner, medical-equipment provider, respiratory therapist, sleep center staff, sleep center physician, primary care physician, and a home nursing service if applicable. Adherence is dependent on layers of information providing the patient with ongoing education, written instructions, demonstration of equipment, and the timely addressing and troubleshooting of the patient’s concerns and problems. Adherence of patients are clear indicators of the quality of the service.

Meccanismo d’azione della CPAP Pressione a monte 0.0 cm/H2O 5 cm/H2O Starling resistor 10 cm/H2O 15 cm/H2O Pressione a valle

32

EBT images from posterior nasal spine to epiglottis obtained during inspiration in sleep with the mandible in normal position (A) and in advanced position (B). The orpharyngeal lumina were increased and obstructions were relieved with mandibular advancement.

B) Sample excluding 126 CPAP treated participants A) Total sample B) Sample excluding 126 CPAP treated participants N=1522 AHI<5 n=1157 AHI>5 - <15 n=220 AHI>15 - <30 n=82 AHI>30 n=63 N=1396 Sleep 2008;31:1071-8 38

Courtesy of Giuseppe Insalaco

alberto.braghiroli@fsm.it Centro di Medicina del Sonno ad Indirizzo Respiratorio Fondazione Salvatore Maugeri, IRCCS, Istituto Scientifico di Veruno, Divisione di Pneumologia 44