Can we do it? Yes we can!

Managing Obstructive Sleep Apnea

in Primary Care

Dr Andrea Loewen MD, FRCPC, DABIM (Sleep)

Financial disclosures

• No conflict of interest

Objectives

• When and how to order home sleep apnea testing (HSAT) for diagnosis of obstructive sleep apnea?

• What is the evidence for treatment of OSA? • Current standards in Alberta • CPAP machine coverage

WHEN AND HOW TO ORDER HOME SLEEP APNEA TESTING?

Case 1: Albert

• 45M accountant, lives with wife and 2 children • PMHx: Hypertension (controlled with HCTZ) • Chief complaint: Daytime sleepiness, snoring

– Fights sleep at desk, dozes off watching TV in evenings – Not convinced he needs to do anything about this

• Non-smoker; 3 beers on weekend • Physical Exam: BMI 34 kg/m2, BP 128/74

What is the Differential Diagnosis?

Assessing Probability of OSA • Do you Snore Loudly? (loud enough to be heard through

closed doors or your bed partner elbows you for snoring at night)

• Do you often feel Tired, Fatigued or Sleepy during the daytime? (such as falling asleep during driving or talking to someone)

• Has anyone Observed you Stop Breathing or Choking/Gasping during sleep?

• Do you have or are being treated for High Blood Pressure?

• BMI > 35 kg/m2?

• Age > 50 years old? • Neck size ≥ 17 inches/43 cm (M) or 16 inches/41 cm (F)? • Gender = Male?

Risk of OSA Low = 0-2 Intermediate = 3-4 High Risk = 5-8 OR

2 of STOP + Male 2 of STOP + BMI 2 of STOP + Neck

www.stopbang.ca

Assessing Probability of OSA • Do you Snore Loudly? (loud enough to be heard through

closed doors or your bed partner elbows you for snoring at night)

• Do you often feel Tired, Fatigued or Sleepy during the daytime? (such as falling asleep during driving or talking to someone)

• Has anyone Observed you Stop Breathing or Choking/Gasping during sleep?

• Do you have or are being treated for High Blood Pressure?

• BMI > 35 kg/m2?

• Age > 50 years old? • Neck size ≥ 17 inches/43 cm (M) or 16 inches/41 cm (F)? • Gender = Male?

Risk of OSA Low = 0-2 Intermediate = 3-4 High Risk = 5-8 OR

2 of STOP + Male 2 of STOP + BMI 2 of STOP + Neck

www.stopbang.ca

STOP-BANG

Nagappa 2015

Albert (continued)

• Unrefreshed after 7-8 hours of sleep per night – More on weekends, with no relief

• Non-smoker, no significant alcohol or sedative use

• No restless legs, no features of narcolepsy, mood OK

• STOP-BANG – 6

What would you do next?

Diagnostic Sleep Testing

• L1 (Polysomnography) – Gold standard – Resource constrained – May be inconvenient

• L3 (Home Sleep Apnea Test) – Cardiorespiratory channels – Performed in the home – Avoid if:

• Cardiopulmonary • Neuromuscular disease • Other sleep disorder

suspected • Asymptomatic

Home Sleep Apnea Test (HSAT)

Polysomnogram

WHAT IS OSA ANYWAY?

What is OSA? • Intermittent airflow

cessation (apnea) or reduction (hypopnea) during sleep (≥ 5/hr)

• Severity measured by Apnea-Hypopnea Index (AHI) – AHI 5-15/hr = mild – AHI ≥ 15/hr = moderate – AHI ≥ 30/hr = severe

Arnardottir ES et al. Eur Respir J. 2016 Jan;47(1):194-202.

Pathophysiology of OSA

Eckert 2015; Edwards 2017

Upper Airway Collapsibility “Anatomic”

Upper Airway Dilators “Neural”

Obstructive Sleep Apnea

Ventilatory Sensitivity

“Drive”

Arousal Threshold “Cortical”

Intermittent Hypoxemia

Sleep Disruption

OSA and Cardiovascular Disease - Mechanisms

Dewan 2015; Ayas 2016

Arousal

Sleep Fragmentation

…and has Important Consequences

• All severities of OSA – Quality of life – Depression – Motor vehicle collisions – Workplace productivity – Post-op complications – Healthcare utilization

• Severe OSA – Hypertension – Diabetes – Cardiovascular events – Stroke – Atrial fibrillation (new

and recurrent)

EVIDENCE FOR OSA TREATMENT

MOSAIC Trial

Craig 2012

• Multicentre, open-label RCT of CPAP vs. no CPAP for moderate to severe OSA – 2717 patients – Australia, USA, China, India, Brazil, Spain – Pre-existing cardiovascular disease – Moderate-severe OSA on ambulatory testing – Excluded: severe sleepiness or hypoxemia, safety-critical

occ.

McEvoy 2016

SAVE Trial

• Summary – No difference in any

cardiovascular outcomes – Sleepiness, HRQOL, HADS

all improved with CPAP – Fewer work days missed

• Issues – Adherence: 3.3 hrs/night – Variable OSA care – Secondary prevention

McEvoy 2016

OSA Treatment – Does it reduce CV risk?

• Great question! • Strong biological basis for risk reduction • CPAP and oral appliance both improve BP • Other risk reduction may depend on other

factors – Disease severity and control – Primary vs. secondary prevention – Treatment adherence – CPAP in isolation vs. chronic disease management

Back to Albert

• He has severe OSA (RDI 45/hr, mean SpO2 87%), you recommend CPAP and Albert agrees

• You refer him for a CPAP setup and early feedback suggests he is feeling much better

• 2 months later, he returns with complaints of sleepiness – “My CPAP just isn’t working anymore!”

Now what?

Why CPAP “Doesn’t Work” • Nonadherence/intolerance

– Minimum use 4 hours/night on 70% of nights

• Mask leak – Facial hair, weight gain

• Sub-therapeutic pressure – Weight gain,

alcohol/sedative use • Equipment failure

– Mask replacement annually • Another sleep disorder

– 25-30% of OSA patients

CPAP Intolerance

Sample Download

Sample Download (2)

Motor Vehicle Safety & Reporting • Requirement to report varies by jurisdiction

– Alberta: Patient responsible for self-reporting • Commercial drivers: periodic medical required • http://www.transportation.alberta.ca/1929.htm

• But, general principles are similar – Symptoms/risk not a function of severity – Efficacy includes adequate compliance, improvement

in objective measure of OSA and symptoms • Compliance: ≥ 4 hours/night on 70% of nights over 30 days • Treatment effectiveness: AHI < 20/hr • Reduced daytime sleepiness

Ayas 2014

Case: Gerald

• 57M, admitted to hospital with anasarca – BMI 56 kg/m2 – Sleepy and snores loudly – ABG: PaCO2 49 mmHg, PaO2 54 mmHg

Hypoventilation

• Elevation in arterial CO2 – Abnormal increase during sleep or awake hypercapnia

• Pathophysiology – Inability to clear CO2 – COPD, neuromuscular disease – Derangement in central control of breathing –

narcotics, obesity hypoventilation syndrome • CPAP or oxygen started in an unmonitored setting

may lead to acute respiratory failure – Refer for polysomnographic PAP titration – May require bilevel PAP +/- supplemental oxygen

Case: Cecile

• 68F, recent admission for CHF – Noted by nursing staff to have intermittent

breathing pauses and hypoxemia at night – BMI 22 kg/m2 – Not sleepy

Central Sleep Apnea • Intermittent ↓ in airflow without UA obstruction

– No ventilatory effort • Pathophysiology

– Chemoreceptor hyperresponsiveness (↑ loop gain) – Circulatory delay (Cheyne-Stokes Respiration) - CHF – Disruption in respiratory pacemaker – narcotics, stroke

• Goal of treatment is to address underlying problem – Consider PAP if symptomatic – usually not CPAP – Oxygen can stabilize breathing – Specialist consultation may be warranted

SLEEP CARE IN ALBERTA

Current Landscape – A Mix!

• Mix of providers – Primary care, specialists (sleep/non-sleep), RRTs, NPs,

RNs. – RCPSC AFC Sleep Disorders Medicine July 2018

• Mix of funding for sleep diagnostic testing – Limited public funding for sleep laboratories (PSG) – Privately funded PSG laboratories (independent

centres) – No funding for HSAT (hospitals, homecare companies)

• Mix of regulations – CPSA standards (PSG update, new for HSAT) Jan 2018

Cost of Treatment (Alberta)

• Out-of-pocket or private insurance for most therapies – CPAP ~ $1500-2800

• Online purchase ~$600 but no service provided – OA ~ $300-3000

• Less expensive options compromise efficacy

• Surgery – maxillomandibular advancement covered – Other procedures offered privately (limited evidence)

• Special groups receive government funding – AISH, AB Works, low-income seniors (Special Needs

Assistance for Seniors Program – SNAP), NIHB – AADL: severe sleep-disordered breathing – bilevel PAP, O2

Patient Pathways

• Referral options (testing and treatment) – Respiratory homecare company – for OSA

• HSAT (+/- cost), CPAP if prescribed • May or may not see physician (sleep, resp, general)

– Independent sleep centres • Usually sleep trained physicians (or supervision) • Affiliated with polysomnography lab (cost) +/- HSAT

– Public sleep centres – Edmonton, Lethbridge – Public sleep centres - Foothills Medical Centre

• Sleep physician (mostly respirologists) +/- sleep-trained RRT • HSAT and/or polysomongraphy

Considerations for referral

• Pre-test probability of OSA – Is HSAT appropriate?

• Requirement for clinical review – Is a Sleep Physician assessment needed?

• Choice of treatment – CPAP provided by respiratory homecare companies – Dental referral for oral appliance – Upper airway surgery – suggest sleep physician

consult, and ENT or oromaxillofacial surgeon consult

New Initiatives

• FMC Sleep Centre – Delegation of follow-up for uncomplicated OSA

requiring therapy to primary care physician and homecare company

• Have met with many companies to lay out expectations – Return of non-urgent mild/moderate OSA referrals

(after review of patient questionnaire and HSAT by clinician) to referring physician, usually primary care MD

• Accompanying information package

http://www.albertahealthservices.ca/info/Page5037.aspx

Can we do it? Yes we can!

• OSA is prevalent • Like hypertension, Family MDs have the tools available

in Alberta to – Diagnose OSA – Discuss and advise treatment options for mild/moderate

obstructive sleep apnea with their patients – Consider behaviour modification, driving safety in all – Refer for all patients with suspected sleep disorders to

sleep physician – Have severe OSA/OHS, complex and non-respiratory sleep-

disorders managed by a sleep specialist

NEW INITIATIVES

New Initiatives

• Sleep Disorders Working Group – Part of the Respiratory Health Strategic Clinical

Network – Clinicians, researchers, policy-makers interested in

improving sleep care for Albertans • Projects

– Regulations for HSAT (CPSA to implement late 2018) – Defining practice competencies for sleep providers – Improve integration of primary/specialty sleep care

http://www.albertahealthservices.ca/scns/Page9823.aspx

Progress to Date • Needs Assessment

– Primary care survey – summer 2016 – Patient focus groups & interviews - spring 2017 – Provider workshops – May 29 (Calgary), June 1 (Edmonton)

• Partnerships – AHS Primary Healthcare Integration Office – Toward Optimized Practice (guideline scheduled for 2018) – AMA – Physician Learning Program, Respiratory Medicine – Alberta College of Family Physicians – Respiratory Home Care Association of Alberta

• Initial conversations with Calgary Zone Secretariat – Health Systems Support Task Force

Questions? andrea.loewen@ahs.ca