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xiii
Part 1 Monitoring Positive Pressure Therapy in Sleep-Related Breathing
Disorders: Advanced Analysis of Respiratory Flow
Curves/Fundamentals
1 Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Sleep and Its Characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.2 Respiration While Sleeping . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.3 Respiratory Sleep Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
1.4 Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2 Positive Airway Pressure Treatment and Monitoring . . . . . . . . . . . . . 13
2.1 Positive Airway Pressure Treatment . . . . . . . . . . . . . . . . . . . . . . . . 13
2.2 Positive Airway Pressure Adherence . . . . . . . . . . . . . . . . . . . . . . . . 16
2.3 Patient Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.4 Telemonitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
2.5 Ethical Concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.6 Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3 Respiratory Flow Curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.1 The Importance of Assessing Respiratory Flow Patterns During
Sleep . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.2 How Flow Curves Are Generated . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.3 Downloading Airow Curves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.4 Important Tips for Managing Flow Curve Analysis Software . . . . . 30
3.5 Working with Detailed Graphs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
3.6 How to Share Detailed Graph Data . . . . . . . . . . . . . . . . . . . . . . . . . 44
3.6.1 Sending Data to Healthcare Professionals . . . . . . . . . . . . . . 44
3.6.2 Receiving Data from Another Healthcare Professional . . . . 44
3.6.3 Instructing the Patient and Receiving the Data . . . . . . . . . . 45
Contents
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3.7 Procedure when Respiratory Flow Curve Is Not Displayed . . . . . . 50
3.7.1 First Options for Showing the Flow Curve . . . . . . . . . . . . . 50
3.7.2 Second Option for Viewing the Flow Curve . . . . . . . . . . . . 53
3.8 Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
4 Assessment of the Respiratory Flow Curve . . . . . . . . . . . . . . . . . . . . . 57
4.1 Understanding of Algorithms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
4.1.1 Obstructive or Central Apneas . . . . . . . . . . . . . . . . . . . . . . . 58
4.1.2 Mixed Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
4.1.3 Obstructive or Central Hypopnea . . . . . . . . . . . . . . . . . . . . 62
4.1.4 Respiratory Effort-Related Arousal . . . . . . . . . . . . . . . . . . . 65
4.1.5 Periodic Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
4.1.6 Snore Index (Vibrating Airway) . . . . . . . . . . . . . . . . . . . . . . 74
4.2 Other Information from the Detailed Graphs . . . . . . . . . . . . . . . . . . 77
4.2.1 Unintentional Leak. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.2.2 Pressure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
4.2.3 Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
4.3 Oximeter Adapter Coupled to the PAP Device . . . . . . . . . . . . . . . . 79
4.3.1 Wireless High-Resolution Oximeter . . . . . . . . . . . . . . . . . . 79
4.4 Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
5 Examples of Flow Curves and Other Advanced Graphics . . . . . . . . . 83
5.1 Obstructive Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
5.2 Central Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
5.3 Central Apnea with Cheyne-Stokes Breathing Due to Hearth
Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
5.4 Central Apnea with Non-Cheyne-Stokes Periodic Pattern . . . . . . . 87
5.5 Mixed Apneas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
5.6 Treatment-Emergent Central Sleep Apnea . . . . . . . . . . . . . . . . . . . . 90
5.7 Obstructive and Central Hypopnea . . . . . . . . . . . . . . . . . . . . . . . . . 91
5.8 RERA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
5.9 Snore Index (Vibration Level) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
5.10 Breathing Pattern According to the Sleep Phase . . . . . . . . . . . . . . . 96
5.11 Loop Gain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
5.12 Unintentional Leak . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
5.13 Palatal Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
5.14 Epiglottic Collapse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
5.15 Equipment Turns On and Off Several Times During Sleep . . . . . . . 103
5.16 Unknown Apneas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
5.17 Sighs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
5.18 Catathrenia or Artifact at Exhalation Flow Curve . . . . . . . . . . . . . . 108
5.19 Oximetry Module . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Contents
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5.20 Isometric Airway Flow Curve Trace . . . . . . . . . . . . . . . . . . . . . . . . 112
5.21 Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Part 2 Monitoring Positive Pressure Therapy in Sleep-Related Breathing
Disorders: Advanced Analysis of Respiratory Flow
Curves/Case Reports
6 Case Report: Obstructive Sleep Apnea Developed into Central Sleep
Apnea After a Stroke . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
6.1 Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
6.2 Therapeutic Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
7 Case Report: Microarousals Due to Respiratory Effort . . . . . . . . . . . 127
7.1 Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127
7.2 Therapeutic Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
8 Case Report: Positional Sleep Apnea . . . . . . . . . . . . . . . . . . . . . . . . . . 137
8.1 Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
8.2 Therapeutic Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
9 Case Report: Leaking Through the Mouth . . . . . . . . . . . . . . . . . . . . . 143
9.1 Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
9.2 Therapeutic Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
10 Case Report: Obstructive Sleep Apnea and Obesity Hypoventilation
Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
10.1 Patient Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
10.2 Therapeutic Intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
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Abbreviations and Acronyms
AASM American Academy of Sleep Medicine
AC Alternating current
CSA Central sleep apnea
TECSA Treatment-emergent central sleep apnea
OSA Obstructive sleep apnea
AutoSet™ Trade name for ResMed's algorithm for automated continuous
positive airway pressure equipment
cmH
2
O Centimeters of water
CO
2
Carbon dioxide
CPAP Continuous positive airway pressure
DC Direct current
SRBD Sleep-related breathing disorder
EPAP Expiratory positive airway pressure
EtCO
2
End-tidal of carbon dioxide
HR Heart rate
Hz Hertz
AHI Apnea-hypopnea index
ICSD International Classication of Sleep Disorders
IPAP Inspiratory positive airway pressure
L/min Liters per minute
LG Loop gain
lpm Liters per minute
NREM Non-rapid eye movement
O
2
Oxygen
PAP Positive airway pressure
PaCO
2
Partial pressure of carbon dioxide in arterial blood
PaO
2
Partial pressure of oxygen in arterial blood
REM Rapid eye movement
RERA Respiratory effort-related arousals
ResScan™ Trade name for ResMed´s data management software for positive
pressure equipment
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SaO
2
Oxygen saturation
Sec Second
OHS Obesity hypoventilation syndrome
SmartStart™ Trade name for ResMed's system for automatic CPAP activation
and deactivation (automatically turns on the device when the patient
breathes through the mask and automatically turns off the
equipment when the patient removes the mask)
UARS Upper airway resistance syndrome (also known as RERA:
respiratory effort-related arousal)
UA Upper airway
Abbreviations and Acronyms
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In this section of the book, we present normal sleep and sleep-disordered breathing
and aspects of the treatment and monitoring of positive airway pressure. We present
respiratory ow curves (how to analyze these curves) and important aspects of posi-
tive airway pressure device algorithms, used for the treatment of sleep- disordered
breathing. Also provided in this section are examples of ow curves and other
advanced graphics.
Part 1
Monitoring Positive Pressure Therapy in
Sleep-Related Breathing Disorders:
Advanced Analysis of Respiratory Flow
Curves/Fundamentals
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3© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
V. S. Piccin, Monitoring Positive Pressure Therapy in Sleep-Related Breathing
Disorders, https://doi.org/10.1007/978-3-031-50292-7_1
Chapter 1
Sleep
1.1 Sleep andIts Characteristics
Humans exhibit circadian rhythms of approximately 24h that are self-sustaining in
physiology and behavior, which are regulated by a central clock in the hypothala-
mus [1]. This system plays a role in the regulation of diverse physiological functions
such as central body temperature, hormone release, and sleep. The sleep-wake cycle
is the most evident circadian rhythm in men and women, and its main stimulus is
ambient light.
When we sleep, there is a change in our state of consciousness and we restore our
balance, preserving various functions such as immunity, metabolism, cognition,
cardiovascular activity, and humor, among many others. Several studies have
already shown that poor sleep quality increases the risk of disorders in the body
(e.g., increased blood pressure, cardiovascular diseases, diabetes, and depres-
sion) [2, 3].
Nowadays we know that sleeping well is essential for our physical and mental
health. Unfortunately, modern lifestyles often lack regular working, eating, and
sleeping patterns. And despite reports on the occurrence of sleep disorders dating
back to ancient times, this eld of medicine has only recently received greater atten-
tion [4, 5].
Sleep is physiological, necessary, temporary, reversible, and cyclical [6]. It is an
active process, with variation and duration controlled by specic structures in the
central nervous system, and can be divided into two distinct states: REM (rapid eye
movement) and NREM (non-rapid eye movement). REM sleep only has one stage,
while NREM has three different sleep stages called N1, N2, and N3 (in an increas-
ing degree of depth of sleep, respectively) [4, 5].
The sleep set in which all stages of NREM (N1, N2, and N3) and REM sleep are
completed is called a sleep cycle and in a normal individual, the sleep cycle lasts
between 70 and 110min, repeating 4–6 times throughout the night (Fig.1.1) [4].
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Adult sleep stages
W (5%)
N1 (2 to 5%)
N2 (45 to 50%)
N3 (3 to 15%)
REM (20 to 25%)
Fig. 1.1 Percentage classication of the various sleep stages in adults. Wake (W) in sleep repre-
sents less than 5% of the night. The N1 stage generally accounts for 2–5% of sleep; N2 for 45–50%
of sleep; and the N3 stage for 3–15% of sleep (NREM sleep is usually 75–80% of sleep). REM
(rapid eye movement) sleep generally accounts for 20–25% of sleep time [7]. (Figure source:
own work)
NREM and REM sleep have different characteristics regarding endocrine, respi-
ratory, cardiovascular, gastrointestinal, and genitourinary functions. Mainly, in
NREM sleep we observe regular ventilation, maintenance of effectiveness of the
proprioceptive and chemoreceptive reexes, active intercostal muscles, mainte-
nance of upper airway muscle tone, eurhythmic decrease in heart rate, and a regular
decrease in blood pressure and cardiac output. In REM sleep there is a varied range
of ventilation, the proprioceptive and chemoreceptor reexes are canceled, intercos-
tal muscles become inactive, muscle tone in the upper airways is reduced, heart rate
becomes variable, and blood pressure and cardiac output uctuate irregularly. REM
sleep is also known as paradoxical sleep just because of the paradox of being a
period when our mind is more active and muscle tone is more relaxed [4, 8].
Figure1.2 shows the relationship between human sleep, level of consciousness pat-
terns, and electroencephalogram (EEG).
The distribution of sleep stages during the night can be altered by several factors
such as age, circadian rhythm, room temperature, drug ingestion, or by certain dis-
eases. But normally, NREM sleep is more concentrated in the rst part of the night,
while REM sleep predominates in the second part [4, 8].
1 Sleep
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5
Sleep Stages
NREM REM
Electroencephalogra
m
W
N1
N2
N3
Consciousness le
vel
High
Low
Sleep cycle
(approximately 90 minutes each, throughout the night)
Fig. 1.2 Sleep stages are characterized by differences in the frequency and amplitude of the elec-
troencephalographic (EEG) waves. Stage N1 includes light sleep with low-amplitude waveforms.
Stage N2 is characterized by sleep spindles (high-frequency waves) and K complexes (not shown).
Stage N3 represents slow wave sleep (SWS), with high amplitude waves and a deeper level of
unconsciousness. These three stages comprise non-rapid eye movement (NREM) sleep. The sub-
sequent stage is rapid eye movement (REM) sleep, which is associated with a higher level of
consciousness. (Modied after Bryant etal., 2004 (with permission) [8])
1.2 Respiration While Sleeping
Recalling respiratory physiology, we know that the main function of our lungs is to
exchange O2 and CO2 between blood and gas and thus maintain normal levels of
PaO
2
and PaCO
2
in arterial blood. PaO
2
and PaCO
2
values remain at adequate levels
mainly because ventilation is carefully maintained by our organism [9]. This regula-
tion of gas exchange is sustained by three basic elements of the respiratory control
system: (1) the sensors, which capture the information of circulating blood gas lev-
els and, afferently, feed the (2) central controller in the brain, which coordinates the
information and sends impulses to the (3) effectors (respiratory muscles), which
promote ventilation. By means of a complex neural network, the respiratory mus-
cles in the chest wall perform their function [9]. Figure1.3 shows these basic ele-
ments of the respiratory control system [10].
The most important factor to control ventilation under normal conditions is
PaCO
2
, which can be very sensitive to minor changes. For example, a reduction in
PaCO
2
may reduce ventilation, and even generate a central apnea or hypopnea
event, in an attempt to re-establish normal values of PaCO
2
in arterial blood (between
35 and 45mmHg), as shown in Fig.1.4 [12].
The intensity of the body’s response to PaCO
2
changes also depends on another
factor, called cyclical neuroanatomic interaction or loop gain. The stability of the
respiratory system is dictated by the magnitude of the loop gain. If the magnitude of
the ventilatory response is high (hyperpnea) about the magnitude of the disorder
(hypopnea), in other words, a high gain loop, ventilation will be unstable and will
uctuate between hyperpnea and hypopnea/apnea. In contrast, if the magnitude of
1.2 Respiration While Sleeping
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Cortex-behavioral/
voluntary control
Hypothalamus
Peripheral
chemoreceptors
Ca
rotic body
Aortic body
Central
chemoreceptors
Receptors in
joints &
muscles
Stretch
receptors
Pons
Cerebellum
Irritant recepto
rs
Medulla
O
2
CO
2
H
+
+
+
+
CO
2
H
+
(modulated by O2)
Diaphragm
Spinal cord
_
_
±
±
±
Fig. 1.3 The basic elements of respiratory control: sensors (central and peripheral chemorecep-
tors, receptors in the lung, and other receptors), which capture information and feed the central
controller; the central controller in the brain (bridge, spinal cord, and other parts of the brain),
which coordinates information and sends impulses to effectors; and effectors (respiratory muscles)
promote ventilation. (Modied after Carroll, 2010 (with permission) [11])
the response is low, i.e., a low loop gain, the ventilation will remain stable in
response to the disturbance. That is to say, the breathing pattern is the result of a
balance between “Control Gain” (represented by the sensitivity of central and
peripheral chemoreceptors to CO
2
variations) and “Plain Gain” (represented by the
effectiveness of the lungs in altering blood gases and the ability to anatomically
support the upper airway, especially during the various sleep phases) (Fig.1.5) [13].
Typically, we observe that there is a high loop gain in the occurrence of central
apnea/hypopnea at the beginning of pressure therapy to treat sleep apnea. This usu-
ally occurs because individuals with obstructive sleep apnea (particularly severe)
often have higher values of PaCO
2
in their blood, even if they are in the normal
PaCO
2
range. When these people begin to treat apnea with a positive pressure
device, the PaCO
2
values decrease due to the support of the upper respiratory tract
through the pneumatic effect of positive pressure, which normalizes ventilation.
However, the breathing control center, in the central nervous system, may not be
equalized to work with the new PaCO
2
values, and can respond with central apneas/
hypopneas in an attempt to return the usual PaCO
2
rates [13]. Likewise, depending
on the loop gain (sensitivity) of each individual, the initial stimulus (in this example,
central apnea) can generate an increased response (hyperventilation), leading to
treatment-emergent central sleep apnea (Fig.1.6) [13–16].
1 Sleep
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