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Episode 111 - Dr. Ana Luisa Vieira-Women with OSA and Central Sleep Apnea Causes & Treatment Options


Hey there, it's Emma Cooksey here and I'm your host, so I feel like you guys need a little bit of an update on some things I've been doing.


I'd kind of mentioned in one of the episodes that I was looking at adding an oral appliance to my CPAP.

So I've been a CPAP user for 16 years, but last year my sleep apnea definitely took a turn and I think part partly because of a weight gain I had.


And when I started perimenopause, I went from moderate sleep apnea to severe sleep apnea.

And I definitely know it's a difference.

And my doctor went ahead and changed my CPAP pressure so that it went up and just to make sure that it was treating, you know, like all my events properly.


So that was fine.

But I definitely noticed that I wasn't sleeping as well and I was having much more, you know, disturbances, waking up more.

I was getting more mask leaks, just like the increased pressure was just less comfortable to me.


So I started reading some research articles about people who were combining CPAP therapy with oral appliance therapy.

So remember, when we're talking about oral appliances, I know it's very confusing because there's so many different, you know, oral appliances out there that do different things.


But what we're talking about is mandibular advancement devices where you wear them every night and they hold your lower jaw slightly forward so that it takes the tongue and the soft tissue out of your airway and helps you to breathe better.


So that's what we're talking about.

Just because I think sometimes people get confused, They think that it's the same as a night guard, which stops people from damaging their teeth from bronxism or it's like, you know, one of the orthotics that people use to treat TMJ.


And so that's not what we're talking about.

We're talking about oral appliance therapy, also known as a mandibular advancement device.

So it's worth saying, I think the biggest thing anybody looking to get an oral appliance should do is just spend time finding the best dentist in their area that does this.


So I've talked before on the program about going to the website for the A ADSM, which is and that's the American Academy of Dental Sleep Medicine.

And they have an area where you can find a provider and what you're looking for is either a member or better still a diplomat of the A ADSM, which means that they've completed the highest level of training in this area.


So I went to Doctor Krantz who's here in Jacksonville, FL and and this is all he does and he works, you know, all the time with and sleep doctors to get, you know, like the diagnosis and they work back and forth and that's really what you want.


And so you want somebody who does this a lot, right?

Because I mean, any dentist can make you one of these devices and.

But I think with my experience with Doctor Krantz has been, you know that he's super knowledgeable about this, right.


So a couple of people had asked me which appliance I got and and what I ended up getting fitted for was a Prosomnus Evo Evo and and it has space for my tongue and it's really comfortable because they use like digital scans and precision engineering so that it fits super well.


I would say that it's too early to say for sure because we haven't had the sleep test yet, right?

So if you've listened to the podcast, you know that I'm always talking about and probably annoyingly always talking about because I mentioned it so often and that people should really have a followup sleep study after you get fit for an oral appliance and it's titrated.


And because you can't really rely on just the fact that you stop snoring or you feel a bit better, you really need to have that followup sleep study to check that your oral appliance is treating your sleep apnea adequately, right.


So we are, we already know like with me that I'm already on CPAP, so we know that my sleep apnea is being well treated, but we just want to look at like what effect is having.

But I can tell you subjectively that I feel a lot better.


I have had a couple of weeks now with the appliance and I've noticed just waking up feeling rested, which I've never really felt before.

And so this whole time I know the aura rings aren't diagnostic tools, but they tend to, you know, give you some guide of what stage of sleep you're in.


And so for years and years that I've been on CPAP by itself, it's shown on my aura ring data that I had like, you know, anywhere from zero to about 8 minutes of deep sleep per night, which is not ideal.


And and so this last week I've been seeing, you know, an hour or 45 minutes or, you know, like a lot of significantly more deep sleep.

So yeah, I'm interested to see what the sleep study shows and I'll share with you guys when we do that, which probably quite soon.


And the other thing to say that I've had going on, which has affected my sleep is yesterday I went and had a weird mole from the side of my face removed.

And it they reckon it's like a sort of cyst thing and but they're obviously, you know, not taking any chances in case it's cancerous.


So they're sending it away and everything.

But it ended up being like a bit more like a bit of a bigger incision than I thought it was going to be.

So it's a bit like, oh gosh, and the dressing is quite big.

And so last night when I was trying to sleep with my, you know, oral appliance and my CPAP, it was like kind of pushing on where they just made the incision.


So yeah, I didn't sleep very well last night, but I'm hoping that tonight will be better because the dressing will be smaller.

But so that's a bit about what's happening with me combining sleep at with my oral appliance.

So it's going well is mainly what I'd say.


And and whenever I do that sleep study, I'm going to share with you guys what that says.

And I always feel like a Guinea pig because I just like to try everything out right to see how I feel.

So on to today's guest.


So today I'm joined by Doctor Anna Luisa Vieira, who I connected with on Instagram a little while ago.

I feel like I I kept kind of posting about different things with questions and she would always, you know, answer everything and just seem to know so much about Sleep, Medicine and that I decided that it would be great to have her on the podcast and just to pick her brain a little bit.


And originally we connected because I posted something about the ResMed for her and CPAP machine because I didn't realize that that actually has a different algorithm.

It's not just that it looks more feminine because it's white with like butterflies or whatever.


That pattern is, and it's actually got differences in the machine and the way that it delivers therapy.

So she kind of answered, you know, a whole thing about the algorithm being different.

And I just thought, I've got to get her on the podcast and pick her brain.


So Doctor Anna Louisa Vieira is a respiratory and Sleep Medicine physician.

She's double board certified and practicing at Hospital de Braga in Portugal.

When she's not providing care to her patients, she enjoys exploring nature along with her husband and two children, so you can find Doctor Vieira on social media.


She's pretty active on Instagram, Facebook and LinkedIn.

So I'm going to put links to those in the show notes.

And please enjoy my conversation with Doctor Vieira.

Dr. Vieira, thank you so much for joining me.

I really appreciate it.


It's my pleasure to be here with you, Emma, and I'm a regular listener of your podcast.

It is extremely important for me as a sleep physician and a respiratory physician to listen to to patients doubts and fears and difficulties in this sleep apnea journey and path.


It's extremely valuable for me to listen to you, so thank you and thank you for being here, so share my knowledge.

Thank you so much for listening.

I really appreciate it.

I love it when doctors listen.

It's like the ultimate compliment.

Start off by telling people you're in Portugal.


Do you want to explain where exactly you are in Portugal, what your work involves, where you work, that kind of thing?


So I live in, I'm Portuguese, I live in Portugal, which is a western country in in Europe.


It's located between the Atlantic Ocean and Spain, in the western tip of the European continent.

I work in Braga, which is the third biggest city in Portugal.

And here I am, a respiratory physician and the sleep physician, also working in a public hospital.


Hospital Braga and my practice is about chronic respiratory failure patients and also sleep respiratory disturbances patients and I also go run sleep lab here with the in lab BSG.


So we first connected on Instagram.

I think I had done a post about SO ResMed have a machine.

Which is called, I think the Air Sense.


I think it was the Air Sense 10 and they had a for her version of it.

And I always mistakenly thought that it was just that they were trying to appeal more to women with a sort of white, you know, like aesthetically, like they were trying to make the regular machine look more appealing to women.


So they just made it white and more feminine.

But actually that that post was saying that there was a different algorithm and it had been set up to address the needs of women specifically and some of the patterns they see more with women with sleep apnea.


And I was just like what like.

I had never heard that before and so you had responded that.

Yes, that that you were familiar with that machine.

And so I wondered if you could just, maybe, I know it's such a huge topic, we could talk about this for three hours.


But I just wonder in your clinic, like in the hospital, what kind of things are you aware of and the differences between how men tend to have sleep apnea and women?

Like do you see differences there?


And what are those?

And I know that we're at a very early stage in the research about this, but just to give listeners an idea of what kind of differences there might be.

Yes, I I remember when you posted that thing about the the the auto set for her being so lovely and white and with all that with a female style, right.


And then I answered well it's not just the, the design of it, it is really different.

And in that time you you said you were surprised because you didn't really know it had a different algorithm.

And yes, you're right, it was back then with the Airstens auto set for her Airstens then I guess.


Now ResMed has developed the Air Stands 11 and with the same positive air pressure machine they have these different modes.

The CPAP mode, the the the auto adjusting PAP mode and then the the sub feature with the for her.


Pack mode, which is which has some different differences based on the female phenotype of obstructive sleep apnea, but not just female.

I guess they they evolved this pack device and incorporated before her in the same device because sometimes there may be also men that have these.


Have this kind of features that will answer better to this to this treatment algorithm.

So it's all about one size does not fit all.

We have to to know the kind of patient we have and the kind of sleep study the patient has and then adapt the treatment.


So what you told me about female obstructive sleep apnea is really a complex.

Topic Well, we know obstructive sleep apnea is most common form of sleep disorders.

Breathing the prevalence is increasing and historically obstructive sleep apnea has been considered like a male disease as apparently male are more often affected than women.


However, research challenges that.

Recent research challenges those facts, and we now know.

That women interrupt you, but I I also think.

That the more women I talk to you with sleep apnea, the more the, you know what I think we're realizing that all of the research started with men because it was very much seen as a a male issue.


But I think maybe, you know, there have been women dealing with this as well, but we just have not been aware because.

Nobody's been looking at them.

Yeah, for sure.

We now know that also it's just as important for women as it is for men.


But diagnosing obstructive sleep apnea in women can be challenging and it can be because of several factors.


On the one hand, women often present with some more generalized daytime symptoms, and not only those witness apneas and and extensive snoring through through the night.


They might have insomnia, they might have restless legs, they might complain of depression palpitations for example, rather than those symptoms such snoring or apnea.

Besides that, women may also under.


Support their symptoms and we as women most of the time we feel tired because of all our social and cultural roles so and it's kind of tricky when to know it's too much tired or when this tiredness is is abnormal, right?


Our threshold for feeling sleepy or for feeling tired is different, and besides of that, women tend to go to regular appointments alone, so they're.

Their best partners won't be there in the consultation to say, well, my wife snores and I listen to her snore during the night and she well, she stops breathing during the night.


I know this bed.

So this is these are the main symptoms and the challenges that women with sleep apnea face regarding to symptoms.

But women also have different a different type of sleep, apnea and sleep.


That woman make are different and the sleep study findings and I can talk to you.

For example, we know that women have a lower apnea epochne index versus men.



And we also know that the apneas in women are more focused, are more centered on the REM, on the REM, sleep, on this stage, on this stage of of sleep.

And men for for instance, they suffer more from supine related structive sleep apnea.


So positional, the positional author.

Yeah, besides that, women also have a shorter apnea duration and less severe oxygen saturations.

This is a problem because think with me, we know women tend to to to to perform short apneas and less apneas epophneas well, and in women we might have symptoms.


With a lower AHI, but that's because the home sleep studies will measure apnea and ipopnea.

But in women we know there are there is this concept of respiratory effort.

And we have in in Sleep Medicine we have the the, the concept that we call respiratory effort related arousals which is a feature is a feature is a respiratory event during the night.


It does not meet the criteria for apnea or hypopnea.

But it is still a respiratory event.

There's, there are, there is respiratory effort and there is a flattening of the of the curve.



And if a person is in, you know, a deeper sleep level and they have one of those events, it's going to bring them out of you know, it's going to like, you know.

Wake them up, they will.

They will have.

Or not wake them up in the sense that they, they, they understand, they they work, right.


They're not.

But they have this arousal.

Yeah, yeah, yeah.

A change in the EEG frequency which meets the criteria for an arousal.

So they don't.

They will not have.

High AHI, but they will have this event that will will make the score for the respiratory disturbance in it.


But we we only get to know this better with a inlapse sleep study or a level 2 sleep study.

Those Psg's done at home with the EEG monitoring.

So this is another challenge for for for women.


Besides that, there are other differences between women and men in sleep apnea anatomy.

For example, the anatomy of the upper Airways, the upper airway anatomy is different.

The obesity also plays here a role and we also have a difference in the distribution of facts, for example, whether it's in the posterial tone or or no.


And then we have the hormonal issues about menopause and what we believe is the loss of the hormonal protective effect.

And also in pregnancy where we have increased rates of obstructive sleep apnea that go completely under diagnosed with risks for the the woman, the pregnant woman and for the baby.


And we really know that from from research the risks of and diagnosed and treated sleep apnea in pregnancy and outcomes for the for for the child.

So I think obstructed sleep apnea has consequences in women, has severe consequences with associated with our other comorbidities and with also with mortality.


But women are different and they have to be looked as different with unique symptoms and unique specificities.

And that was the rational for developing the treatment, a specific treatment and a specific algorithm for positive area pressure.


And so how do you approach like treatment for women?

Like is it is it using things like that you know particular algorithm for women or is there anything specific that you do in treating women versus men.


Yeah so the the, the main, the main treatments are more more like the same right positive error pressure mandibular advancement devices, positional therapy, the mainstay of treatments are more or less the same.


However, regarding this positive area pressure devices, there are really a few differences that if people, if sleep physicians are aware of these differences, they we can adjust the treatment.


So if we have an obstructive sleep apnea woman with these features in the sleep study that I mentioned, well, maybe we have to look for an algorithm that will look not not for the apneas or the Ipopneas, but for the flow limitation.


And besides the flow limitation, the algorithm has to have this quick response time because we know that events in women are short, then it remains in man.

So the algorithm has to to answer to sense what is happening in that area more quickly and to answer more quickly also.


And that's the rationale behind this.

This for her algorithm from regimed, it has an increased sensitivity to flow limitation and also it has an adaptive minimum pressure setting.


So this means that the algorithm adjusts the minimum expiratory pressure based on the patient's breathing patterns and the presence of limitations.

So it tailors the pressure to individual needs.


Also it has this response game I was talking to you about.

It's kind of optimized so the positive airway pressure device responds more quickly to the change in airflow.

So it seems like this algorithm is more responsive to flow limitation rather than to apneas which is usual in the in the other devices.


And comparison studies have demonstrated that results are equivalent and the pressures the pressures used during the night are lower than it would have been with the regular algorithm.

So by using lower pressures patient gets more more comfort and treatment is enhanced and and there is more difference to treatment.


So I I kind of like this female algorithm but I don't really think it's just female because they are also men with with this phenotype of upper airway resistance syndrome which is based on rarest and not on not only on apnea and hypopnea because sleep apnea has different faces, right?


We have to know it and and to adjust the treatment to the patient we have in front of us.

I'm just, I'm just quiet because I'm like astonished like I like I didn't know any of this.


I'm totally like learning.

It's great.

And so for people who are tuning in who are like, what are they talking about?

Could you just explain a little bit about, just take it back to the basic level of.




How an apnea is defined, right?

So how long of a pause and and all of that how a hypopnea is defined?

And then a little bit more about this respiratory effort.


So this respiratory sleep disturbances are based on some features from the sleep studies that might be at home or might be at in lab in the hospital.

And we have several respiratory in this we are going to use when a patient is performing a sleep study.


The patient has something in the nose that will measure the pressure and and the floor that goes around a canal that see it.

A camera in the nose that will measure the flow of the air in and out and they will have two bends, A thoracic belt and abdominal bed belt that will measure if we are breathing or not or if we stop this historical abdominal movements.


And plus we have an oximeter in the finger that will check the the the the U2 saturation during the night and based on these four things we'll score an an hypopnia or a rare earth.


But in case of respiratory effort related arousal, we we have to have EE G monitoring to check.

The electrodes on your head Electrodes on our head and they will monitor a change in the EEG frequencies during the night to see if the person has an arousal or an awakening, even though the person is not aware that he or she awakes.


But there is a change in the EEG frequency during the night.

So for the most conventional homes with studies we will measure apnea and hypopnia.

Then this this event might might be obstructive or central.


But regarding the obstructive event, we have an obstructive apnea.

When we have a complete cessation of flow for more than 10 seconds, this is an apnea.

Well, we stopped breathing for more than 10 seconds and I pop.


Yeah, we don't stop reading for 10 seconds, but we have a reduction in the airflow during this period with or not associated desaturation.

That's why we need the oximeter in the finger.


Obstructive apnea, obstructive obstructive ipopnea and then the respiratory effort which does not accomplish the criteria for apnea or apopnea.


But there is still flow limitation.

There are not the saturations there.

The the the partial flow limitation does not meet the criteria for Ipopnea but it is associated with an arousal and the person is sleeping in a deep sleep stage for example or in the RAM stage or in N two stage and it there is an abrupt change in EEG frequency and this leads to the feeling of non repairing sleep when a person wakes up.


That was an extremely good description.

Thank you.

It's because I think sometimes people have listened to a lot of podcast episodes and they're right there with us and then other times.

People have only just find out they have sleep apnea and then they're like what are they talking about?


And I just want to make sure everybody is on the same page.

So one of the things I did want to ask you about is just the differences in how things are dealt with in Portugal versus.

I mean, my personal experience is with growing up in the UK and having the National Health Service and then being in.


America for the last 16 years and the health system here, and I'm wondering if you can explain to people listening a little bit about the Portuguese system and whether and people are paying for their health care.

How that works like sure.


Well, in Portugal we also have the National Health Service, So we we have public hospitals, we also have private hospitals and private medical practice based mentally on insurances.

But the public health hospitals, they work with National Health services and they are conditionally free regarding sleep apnea services.


While patients, patients to the consultations, they perform sleep study, they get diagnosis of obstructive sleep apnea and then we as sleep physicians, as a respiratory physicians prescribe the treatment in Portugal positive area pressures therapies are completely reimbursed by the state.


So National Health Service as like a contract with different home care providers companies and those home care providers kind of rent the devices to the patient at 0 cost.

Patient does doesn't pay anything, it's the National Health Service that's copays to the this home care companies, that's the the contract which is really nice for the patients because we have access to all kind of Pap machines.


We have access to all kind of interfaces and masks without the patient really have to buy it from a retail store or something like that.

The main ventilator companies to these home care providers and then the home care providers deliver the therapies and the equipments in patients home.


Besides doing this, they support all the maintenance of the equipments and the interfaces and all the Tele monitoring and the communication and supplies and the telemonitoring platforms to contact and communicate with us in the hospital with the respiratory or the sleep physician.


So I think it works really well.

We don't really have constraints regarding equipment or devices.

That's this main.

There is there is here some two issues which is well this is free but it we have some norms, some rules for prescribing.


So we have national guidelines that recommend which which kind of thing we must prescribe, how to prescribe and we have like an audit about that.

We have to comply with those rules and the reimbursement is complete, is is total, but it does not take into account if the patient is adherent or not to the therapy.


So it's an ongoing debate if it's if it should, if it should have here some adjustments or no.

But in the end I think it works really well and this works for sleep apnea but also for chronic respiratory failure devices.


There are some things that are not reimbursed, for example mandibular advancement devices.

Are that was going to be my next question.

Positional therapy, yeah, it's it's, I don't know if it will be reimbursed sometime, but nowadays it is not.


Positional therapy is also not reimbursed and the the implant, the type of muscle nerve stimulation is not reimbursed yet and it is really expensive here.


So there's some way we have.


So somebody in Portugal wanted to try a mandibular advancement.

Appliance like you do have them available, but they would have to pay a dentist privately to do that and then similarly with the Inspire implant, they would find a surgeon and privately go and have that treatment.


OK, got it.

Yes, that is the, the current situation.

There are some exceptions.

There are some hospitals that manage to include these mandible advancement devices in their budget, but it's for extremely selective patients.


But this is a work in progress.

And Oh yeah, I don't.

I don't think there's anybody.

That pretends like they've sorted, like they've figured it all out, like I feel like everything's a work in progress and.

Especially as new treatments come like you know, there's just a period where you know, they're trying to figure usually I feel like things come in America quite quickly just because all of us pay so much for healthcare and that we're kind of almost like conditioned to be okay with paying for things, you know, whereas I think like in Europe like where there is free healthcare.


I mean I think understandably people, you know don't necessarily want to pay on top of you know whatever like treatment they're getting.

So that was super helpful.

Thank you for explaining that.

And and so do you have similar challenges in I think CPAP can be or PAP therapy can be a very challenging therapy for a lot of people to get used to especially in the beginning?


And do you have like certain patients where they just are having problems or they don't want to use it or any of those things?

Is that like a universal issue?

And cuz I know in America that seems to be quite a challenge for a lot of doctors, yes it is here also because well, we I understand because we can solve the respiratory events with the back therapy, but we might worsen the sleep symptoms.


So it's like my my my approach is like to solve the respiratory events.

I don't want the patient to have apneas or apopneas or rarest, but I want the patient to sleep well and I want the patient to sleep well under CPAP because CPAP is important for the respiratory episodes and I want them solved because of all the problems related to that.


But I also want to pay.

I will also want the patient to sleep with it.

So this this thing of respiratory Sleep Medicine, it's also Sleep Medicine.

So I don't really want just to prescribe the CPAP and to solve the respiratory issues without solving the sleep issues, that's that sometimes previous.


Doctor Vieira, that makes you.

Very unusual among among sleep, we have obstructive sleep apnea symptoms and and at the same time we might have other sleep symptoms related to other sleep pathologies.



And then we might have a person that all only has obstructive sleep apnea and start positive air pressure therapy.

And then some sleep symptoms emerge that didn't exist before.


And we need to treat these these two kinds of patients, the the sleep apnea patient with other sleep things like insomnia for example, you have the example of Camisa which is which is a problematic thing.

And also sleep apnea patients that started PAP therapy and have these sleep symptoms to solve under PAP therapy.


And that's why we as sleep physicians have to really be aware of all these these things and to have a deep knowledge about respiratory Sleep Medicine, but also about Sleep Medicine because they are connected and we cannot disconnect them.


Yes, I think sometimes there's a sort of disconnect just, I mean in my own experience, but also talking to a lot of other people where understandably right, the the sleep doctor is looking at the machine's data and saying well, this is great because your AHI has reduced right down and and your you know apnea is the hypotenuse are well treated.


And I think that there's this disconnect because the patient really wants.

You know, restorative sleep, they want to wake up and feel well rested.

And so I think sometimes, I mean I kind of feel for sleep doctors, right, because they they're kind of like, well, we've done really well, like you know, we're treating that part.


But I think that this overall sleep, health and especially people that have insomnia at the same time or other things going on, it can be a really challenging puzzle, yeah.


Insomnia, restless legs, leg movements during the night that were not that people were not aware or just sleep, fragmentation because of because of CPAP and we need to understand how that works during the sleep and what we can do to fine to fine tune these settings or to fine adjust.


These things, in order for the patient to do the path therapy and stop the HI, but also to sleep well, right?


Oh yeah.

So the other thing we might not have a lot of time to get to everything I want to ask you, but I did want to just ask a little bit about the thing I get asked most by my followers and my listeners is to do more on central sleep apnea and complex or mixed sleep apnea as well.


And so I think that we talk a lot about obstructive sleep apnea because it's more common.

And so I guess I just kind of wanted to ask a little bit about any patients that you have with central sleep apnea and and the treatment options available for that?



So let's move to another topic.


Yeah, huge topic.

So then International Classification of Sleep Disorder Disorders has these different classifications of central sleep apnea, and these classifications vary.


This is International Classification.

But then it varies from article to article and from statement to statement.

So the International Classification?

Central sleep apnea with shine Stokes breathing or periodic breathing.

This term has been replaced by periodic breathing central sleep apnea due to a medical desire that without periodic breathing.


The shine Stokes breathing central sleep apnea due to high altitude for people that go high in the mountains.

Central sleep apnea due to medication, for example, primary central sleep apnea, which is rare.


And then these two things of childhood primal primary central sleep apnea, of income and of prematurity.

And then this I don't understand what?

Taxa means yeah.

What does taxa means?




Central sleep apnea or the term complex sleep apnea that was has been introduced for this, this, this thing, this treatment diversions, central sleep apnea.

There are some terms that relate to the same thing and I I think it is important for us to to to use uniform terms and diagnosis because otherwise it's it is really very, very complicated, very complicated, very quickly.


And, and in a quick way, my my most favorite article and recommendation on central sleep apnea is the European Respiratory Society Task Force from 2017.

It was written by Professor Vinfred Randeradt and other colleagues and it's really simple to read.


It has some statements and it's.

I can link to that in the show as well.

Yes, and it bails into the different kinds of central sleep apnea and talks about the the relationship between central sleep apnea, heart failure, neurological disorders, emergent to treatment and several treatments modalities.


It is really, really nice to read about central sleep apnea.

What is the main things I see in my daily practice we have central sleep apnea related to heart failure.

It is.

It is an important topic.

We have central sleep apnea related to medication, namely opioids.


Opioids, yeah, opioids for opioids for chronic pain or methadone for drug addicts and it is common.

And we we also have the text, the treatment immersion central sleep apnea, which is and I'll talk about that later, it's a phenomenon of obstructive sleep apnea and we have to have this in mind.


So this all started, has obstructive and then.

For some reasons I'll talk later, it will go to central sleep apnea, but it was primary primarily A phenomenon of obstructive sleep apnea.


So it is kind of different from the other central sleep apnea diagnosis.

So regarding the heart failure thing.

This is important because of the treatments and some clinical trials that that we we we get got chance to to learn.


So we know that central sleep apnea is a prevalent comorbidity in heart failure patients which might have a preserved cardiac function, reduced cardiac functions or a moderate midrange.

Midrange is action fraction, that's what the the the echocardiogram.


When a patient performs this, this exam and we know that this central sleep apnea in heart failure patients is really heterogeneous and some studies found that there are different phenotypes in heart failure patients with obstructive sleep apnea or with central sleep apnea and the response to treatment and the prognosis of these patients is different.


I'll try to talk about that in a way that that people can.

Understand it is important to mention that both obstructive sleep apnea, a central sleep apnea most of the time go under recognized in heart failure patients and it has huge consequences.


It has increased hospitalization rates and and it has.

Increased mortality also we have we had in 2015 this trial called CERF HF before this year heart failure patients with central sleep apnea.


One of the main treatments besides medical treatment organization was positive.

Every pressure that could be with FIPA or Bilevel Pack or Servo ventilation, which is a different kind of information.

A different algorithm ASV that's right and and this trial served HF in 2015 showed that patients with heart failure and a reduced.


Ejection fraction under a SV or having higher mortality rates and this clinical trial was interrupted because of that finding back there.

I hear some some some details we need to to explore.


On one hand, there are two modalities of a SV well.

There is the modality of a SV based on minutes ventilation.

And there is the modality of ASV based on peak flow and both modalities have different windows times for the adjustments.


And the third HF was performed with the the minute ventilation algorithm and it had the pressure support that was not zero.

So it had a minimum pressure support beside the the exploratory pressure.


Because of the results from search HF, this kind of device is no longer used after the trial it was in.

It was about SO they're no longer using ASV machines for patients that have.


So it's mainly heart failure patients.


ASD machines have two treatments modalities.

The treatments or the treatment algorithm based on the peak flow has these negative effects.


Based on server HF, that kind of machine is no longer used.

We have newer machines.

That kind of surpassed these limitations of the clinical trial.

And then and then we have several clinical trials from these 2015 like Advent HA that was a nice clinical trial but was also prematurely interrupted because of Phillips recall and because of Pandemic because the device was from Phillip.


But the its main findings seem seem nice and we also have the last trial.

That was for heart failure patients and their ASD.

And we with that last trial, we understood that there are several phenol for heart failure patients and the impact on prognosis and the impact on mortality is determined by phenotypes and not by the use of servo ventilation.


So nowadays, for heart failure patients with central sleep apnea, we have several treatments.

Medical treatment and this kind of patients are extremely sensitive to to optimize medical treatment and we have newer drugs for heart failure and we also have PAP therapy, CPAP and also servoventilation if events, if respiratory events are not solved under under CPAP, so nowadays only.


Only heart failure patients with.

Yes, there are options and only heart failure patients with extremely reduced ejection fraction and those are the patients we tend to get more cautious about the SERVE of the a three prescription.

But in the other patients, we now have clear evidence that is not as deleterious as it looks in the SERVE HF trial in 2000 and.


So it's regarding sleep apnea and respiratory sleep disturbances.

I think it is important to find a doctor that really understands the the pathophysiology of things of sleep and also breathing and the the interconnection of breathing, ventilation and airway anatomy and so.


Because we breathe based on our lungs, right?

But also based on our brain.

So I think I had kind of asked you and I don't think it is available there.

But one of the things I get asked by Americans here is there is a frantic nerve stimulator.


I think it's called, I want to say it's called Remedy by Zol it tomorrow.

Like, is that something that's available privately in Portugal or it's just not available?

I don't know.

For now we for now we don't have it available.


I know it.

But for now we we still I was talking about the other the other things from central sleep apnea.

So about the the medication central sleep apnea.

Well, it's central sleep events can be placed by medication use.


We know that the central apnea index, apnea and apopnea index is related to, for example, the use of methadone, the use of opioids and benzodiazepine.

So it is frequently for us to see in chronic addicts or in chronic pain people who use this this medication for chronic pain management, so.


Regarding treatment, we have several kinds of treatment.

We might have PAP therapies modalities, whether CPAP or a SP.

And we we might also have use acetosolamide, which is a drug, a drug used to stimulate breathing and it's also used in central sleep apnea related to to drugs about the text, which is the treatment emergence.


And central sleep apnea also named complex sleep apnea.

As I stated previously, it's a phenomenon of obstructive sleep apnea and we have different definitions according to.


To different articles and based on the International Classification of Sleep Disorders I spoke previously well Treatment emergence central sleep apnea is defined as having an in the in the sleep exam diagnosis.


People have more than five obstructive obstructive events or predominantly obstructive events.

Then people start on CPAP or on PAP treatment and the obstructive events are solved based on the report and central events emerge or perceived.


And this is the the, the, the tricky, the tricky part.

And they persist for a central index of more than five per hour and more than 50% central events.

And this thing is not better explained by any other explanation or or central sleep apnea disorder.


So this is the criteria from the.

International Classification of Sleep Disorders.

However, several articles including the the the ERS task force from 2017 used different kind of terms and they use the term treatment emergent treatment persistence and treatment resistance.


And we what we know now is that there are some phenotypes of people, namely heart failure.

Patients are people that are using this kind of medication that might predisposed to central apneas that in the initial sleep study study they might have obstructive sleep apnea but also central sleep apnea but in a lesser degree.


It's predominantly obstructive.

The ERS task force clearly states that we can diagnose this thing called coexistence of all the and central sleep apnea.

So we have this phenol type of people that already have some kind.


With central events and then we treat the obstructive events because they are related to the airway and the central movement events persist because they are not related to the airway, they are related to the respiratory Dr. of the patients, the brain, the brain and the brain is drive for us to breathe and this kind of patients have kind of an unstable breathing control in the brain.


So we have this phenotype.

I have so many questions but keep going.

It's OK.

We also have the the transient phenotype in which we know that obstructive sleep apnea start PAP treatment and they have this central events that probably is related to this adaptation of the brain to treat the obstructive events and we know that this is transient.


This will solve under time under PAP therapy and the main.

Treatment here is wait and see if the patient is not really symptomatic and then we have the treatment resistance central sleep apnea which are the events that don't resolve, don't solve and their Pap therapy and their continued PAP therapy and keep there.


And for these kind of patients with our which are the exception for these kind of patients, we might prescribe them on a SV for example in order for us to treat the the central events.

So people doing home tests sometimes get diagnosed with obstructive sleep apnea and they don't have an in lab study.


So they start on CPAP or whatever, just having had the home test and how does that patient know if they could have, you know, treatment emergent central apnea is is it just about that?


Would it show on their machine that they would have a higher AHI or do they just not feel better?

Like how should they know that they need to go to a doctor and talk more about that?


Well, the home sleep study makes the difference between obstructive events and central level, right.


So in the beginning of the diagnosis, we kind of get this part rate.

So you should know that of the patients okay?

Yeah, we can.

We we have to know the the portrait of the patient in the beginning and then we'll get to see what happens under Pap treatment.


So Pap devices, they have this kind of report, automated report and they kind of develop this residual AHI and its device in obstructive and in central apneas or ipognis, but this is the software that comes from the device.


So if we have any doubts the report might state that might state that there is a elevated residual AHI that we need to to to be concerned about.

But this is a derivative that comes from the software from the pack device.


So we have to rely on it but not 100% rely on it.

So if the patient has symptoms or if the machine report states there is an elevated AHI

I think we we.

Have to check what it is, if the machine is right and that's correct, or if there's here some kind of misunderstanding or misinterpretation of software.


So we might reperform the flip study and the path and try to understand what is happening and what the patient is complaining about, if he's complaining or not.

Yeah, it's it's very, it can be super complicated to pick this whole thing apart, I mean, for doctors as well as her patients.


And so listen, I could talk to you for four hours, but we're going to have to wrap up for today, but I think I'll probably need to have you come back on because you're just a wealth of knowledge.

And so thank you so much for joining me.

Is there anything else you want to share about where people can find you?


Yes, I'd like to thank you very much for the invitation.

For me it's it's a really pleasure to be here.

Your episodes help me several times when you talk with with patients and the listening to your episodes help me to to really keep on track and keep centered on patients outcomes and helping them to to sleep better to breathe better and to live better.


So thank you for for you and for your project.

It's a pleasure for me to be here and to contribute with my experience with my knowledge to people that are listening to us.

Well, people can find me in social media network and all that, but mainly in Portuguese, but I'm fluent in English so.

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