sleep apnea pre-test questions. 1. bmi only 2. large neck circumference only 3. bmi and allergies...
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Sleep Apnea
Pre-Test Questions
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Understanding, Recognizing and Managing Obstructive
Sleep Apnea
Federico Cerrone, MD,FCCP,DASSM
Director, Center for Sleep Disorders
Overlook Hospital, Summit, NJ
Sleep Disorders - Socioeconomic Consequences
40 million Americans suffer from chronic disorders of sleep and wakefulness.
95% of these remain unidentified and undiagnosed.
The annual direct cost of sleep-related problems is $16 billion, with an additional $50-$100 billion in indirect costs (accidents, litigation, property destruction, hospitalization, and death).
Sleep Apnea
Patient # 1
• 52 year old male with history of borderline hypertension
• Wife complains of his snoring
• His weight has increased 10 pounds over the last year
• Feels tired, but states he is very busy with work and the kids
Sleep Apnea is:
• Common
• Dangerous
• Easily recognized
• Treatable
Sleep Apnea
•Definition
•Pathophysiology
•Clinical Features
•Risk Factors
•Methods of Diagnosis
•Treatment
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Types of Sleep Disordered Breathing
• Apnea–Cessation of airflow > 10 seconds
• Hypopnea–At least 30% reduction airflow > 10
seconds associated with:• Arousal• Oxyhemoglobin desaturation
Apnea Patterns
ObstructiveObstructive MixedMixed CentralCentral
Airflow
Respiratoryeffort
Upper Airway Resistance Syndrome
EEG
10 sec
Arousal
Airflow
Effort(Pes)
SaO2
Effort(Abdomen)
Effort(Rib Cage)
Measures of Sleep Apnea Frequency
• Apnea Index
– # apneas per hour of sleep
• Apnea / Hypopnea Index (AHI)
– # apneas + hypopneas per hour of sleep
Severity Criteria
•Mild: 5-15 events per hour
•Moderate: 15-30 events per hour
•Severe: more than 30 events per hour
Limitations to Criteria
•Does not incorporate severity of oxygen desaturation
•Does not consider non-apneic respiratory events
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Prevalence of Sleep Apnea
0
5
10
15
20
25
AHI > 5 SAS Asthma
Male
Female
U.S. Pop
30-60 year olds
Percent ofPopulation
Adapted from Young T et al. N Engl J Med 1993;328.
Patient # 1
• Patient tells you that a couple of drinks increases the snoring
• He also grinds his teeth per his dentist
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1
2
3
4
5
6
7
8
9
The Upper Airway
Anatomical Factors
•Collapsible tube
•Changes in upper airway anatomy
•There are increased parapharyngeal fat pads
•Obesity can reduce lung volumes
•Dilator muscles
Control of Dilator MusclesEffects On Pharyngeal Muscle Activity
Normal Subject
Awake
OSA Patient
NREM
Genioglosus EMG
Tensor Palatini EMG
Airflow
Genioglosus EMG
Tensor Palatini EMG
Airflow
Pathophysiology of Apnea
Pathophysiology of Sleep ApneaAwake: Small airway + neuromuscular compensation
Loss of neuromuscular compensation
+Decreased pharyngeal
muscle activity
Sleep Onset
Hyperventilate: connect hypoxia & hypercapnia
Airway opens
Airway collapsesPharyngeal muscle
activity restored
Apnea Arousal from sleep
Hypoxia & Hypercapnia
Increased ventilatory effort
Patient # 1
• The patient upon further questioning
does get tired when driving more than
one hour
• He is on medication for depression
• Sleep study reveals AHI=55 with lowest
oxygen saturation of 80%
Clinical Consequences
Cardiovascular Complications
Morbidity
Mortality
Sleep FragmentationHypoxia/ Hypercapnia
Excessive Daytime Sleepiness
Sleep Apnea
Consequences: Excessive Daytime Sleepiness
• Increased motor vehicle crashes
• Increased work-related accidents
• Poor job performance
• Depression
• Family discord
• Decreased quality of life
Consequences: Automobile Accidents
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
No Apnea Sleep Apnea All Drivers
Accident / driver / 5 yrs
Adapted from Findley LJ et al. Am Rev Respir Dis 1988;138.
Consequences: Automobile Accidents
Odds Ratio
0
2
4
6
8
10
12
NO ETOH + ETOH
ETOH On Day of Accident
Risk of Traffic Accident: OSA + ETOH
Adapted from Teran-Santos J et al.
N Engl J Med 1999;340.
Consequences: Cardiovascular
• Systemic hypertension
• Cardiac arrhythmias
• Myocardial ischemia
• Cerebrovascular disease
• Pulmonary hypertension / cor pulmonale
Consequences: MortalityEffect of Al on Mortality
He J et al. Chest 1988;94.
(Untreated, age<50)
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Entry 1 2 3 4 5 6 7 8 9
AI < 20
AI > 20
Cu
mu
lati
ve S
urv
ival
Interval (Years)
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Consequences: Hypertension
Shepard JW Jr. Med Clin North Am 1985;69.
Cardiovascular Consequences: Hypertension
Odds Ratio
0
0.5
1
1.5
2
2.5
3
0 0.1 - 4.9 5 - 14.9 > 15
Apnea / Hypopnea Index (AHI)
Prospective Study of Association Between OSA and Hypertension
Adjusted
for age, sex, BMI, neck circ., cigs., ETOH, baseline Htn
Adapted from Peppard PE et al. N Engl J Med 2000;342.
Consequences: Arrhythmias
Shepard JW Jr. Clin Chest Med 1992;12.
EEG
LOC
EMG
CHIN
EKG
SAO2
FLOW
PNT
EFFABDEFF
SUM
EFFRC
Atrial Fibrillation
•Decrease in oxygen saturation may be the best predictor of risk
Gami,JACC,2007
Stroke
•Increased severity of obstructive sleep apnea increases risk of stroke
Yaggi et al: NEJM 2005
Consequences: Cardiovascular Disease
Odds Ratio
Cross Sectional Study of Association Between OSA and CVD
Adjusted for age, sex, race, BMI, Htn, cigs., chol.
0
0.5
1
1.5
2
2.5
CAD HF CVA
0 - 1.3
1.4 - 4.4
4.5 - 11.0
> 11.0
AHI
Adapted from Shahar E et al.Am J Respir Crit Care Med 2001;163.
Metabolic Consequences
•OSA is linked to glucose intolerance and increased leptin levels
•Leptin mediates appetite suppression
•Obese patients have increased leptin levels but are resistant to the appetite suppressant effects
•OSA patients have higher leptin levels than similarly obese pts without OSA
•CPAP reduces leptin levels and improves glucose tolerance
Barkoukis: Review of Sleep Medicine,2007
Patient # 2
• 55 year old female post-menopause complains of insomnia
• Extreme fatigue during the day
• Interrupted sleep at night
• Normal blood pressure
• BMI 24 (normal)
• Moderate overbite
• Sleep study with AHI=8, RDI=30, oxygen saturation low 94%
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Sleep Apnea Risk Factors-Patient # 1
• Obesity
• Increasing age
• Male gender
• Anatomic abnormalities of upper airway
• Family history
• Alcohol or sedative use
• Smoking
• Associated conditions
Risk Factor: Obesity
Davies RJ et al. Eur Respir J 1990;3.
0
10
20
30
40
50
60
70
80
70 80 90 100 110 120 130 140
>4%
Art
eria
l sat
ura
tio
n d
ipa
h-1
% Predicted normal neck circumference
Risk Factor: Age
0
5
10
15
20
25
30
35
30-39 Yrs 40-49 Yrs 50-60 Yrs
Female
Male
% with AHI > 5
Adapted from Young T et al. N Engl J Med 1993;328.
Age
•Prevalence plateaus after age 65
•Is sleep apnea different in older people?
Young; 2002 Arch Intern Med
Risk Factor: Gender
Millman RP et al. Chest 1995;107.
0
20
40
60
80
100
120
0 20 40 60 80 100 120 140
Ap
nea
/Hyp
op
nea
Ind
ex
Skinfold Sum (mm)
Male
Female
Risk Factor: Anatomic Abnormality
Suratt PM et al. Chest 1986;90.
0
5
10
15
20
25
30
35
40
45
50
Nose Open Nose Occluded
Ap
ne
as
& H
yp
op
ne
as
pe
r h
ou
r o
f s
lee
p 75 6
4
8
5
1
2
7
3
Adapted from Redline S et al. Am J Resp Crit Care Med 1995;151.
Likelihood of Sleep Apnea as Function of Family Prevalence
Risk Factor: Family History
(Adjusted forage, race, sex,BMI)
Odds Ratio
0
0.5
1
1.5
2
2.5
3
3.5
4
1 2 3 Relative Relatives Relatives
Risk Factor: Sedatives
Sanders MH. In: Principles and Practice of Sleep Medicine. Philadelphia: W.B. Saunders Company, 1994.
Pea
k In
teg
rate
d a
ctiv
ity
(% c
on
tro
l)
Minutes after injection
Diazepam Injection
Hypoglossal Nerve
Phrenic Nerve
0 5 15 3060
150
100
50
0
Risk Factor: Alcohol
Bonara M et al. Am Rev Respir Dis 1984;130 © American Lung Association.
Before Alcohol
Blood Alcohol = 83 mg/dl
Blood Alcohol = 134 mg/dl
Phrenic
Hypoglossal
Phrenic
Hypoglossal
Phrenic
Hypoglossal
Risk Factor: Smoking
0
1
2
3
4
5
Adjusted Odds Ratio for Sleep Apnea (AHI > 15) in Former & Current Smokers vs Nonsmokers
Adapted from Wetter DW et al. Arch Intern Med 1994:154 ©1994 American Medical Association.
Former Current Smokers Smokers
(Adjusted for age, race, sex, BMI)
Odds Ratio
Risk Factor: Associated Conditions
• Hypothyriodism
• Acromegaly
• Amyloidosis
• Vocal cord paralysis
• Marfan syndrome
• Down syndrome
• Neuromuscular disorders
Patient # 3
• 42 year old male weight lifter
• Girlfriend states he holds his breath during sleep
• He is not aware of this
• No complaints of tiredness
• Epworth Sleepiness Scale 11
Diagnosis: History
• Snoring (loud, chronic)
• Nocturnal gasping and choking
– Ask bed partner (witnessed apneas)
• Automobile or work related accidents
• Personality changes or cognitive problems
• Risk factors
• Excessive daytime sleepiness
Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.
Diagnosis: Assessing Daytime Sleepiness
• Often unrecognized by patient
– Ask family members
• Must ask specific questions
– Fatigue vs. sleepiness
– Auto crashes or near misses
– Sleep in inappropriate settings
• Work
• Social situations
0 = would never doze or sleep.1 = slight chance of dozing or sleeping2 = moderate chance of dozing or sleeping3 = high chance of dozing or sleeping
Situation Chance of Dozing or Sleeping
Sitting and reading ____
Watching TV ____
Sitting inactive in a public place ____
Being a passenger in a motor vehicle for an hour or more
____
Lying down in the afternoon ____
Sitting and talking to someone ____
Sitting quietly after lunch (no alcohol) ____
Stopped for a few minutes in traffic while driving
____
Total score (add the scores up)(This is your Epworth score)
____
Epworth Sleepiness Scale
Patient # 3
• Blood pressure 140/85
• His neck size is 18 inches
• Tonsils are 4+
• Rest of exam unremarkable
• Sleep study with AHI of 25
• Lowest oxygen saturation 92%
Diagnosis: Physical Examination
• Upper body obesity / thick neck
> 17” males
> 16” females
• Hypertension
• Obvious airway abnormality
Exam: Tonsillar Hypertrophy
Shepard JW Jr et al. Mayo Clin Proc 1990;65.
Oropharynx With Tonsillar Hypertrophy
Normal Oropharynx
Exam: Oropharynx
Patient With the Crowded Oropharynx
Physical Examination
Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978.
Structural Abnormalities
Practice Recommendation
• Practice Recommendation: The risk for obstructive sleep apnea correlates on a continuum with obesity, large neck circumference, and hypertension. Combinations of these factors increase the risk for OSAHS in a non-linear manner.
• Evidence-Based Source: Institute for Clinical Systems Improvement
• Web Site of Supporting Evidence: http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html
• Strength of Evidence: Class A: Randomized, controlled trial; Class B: Cohort study; Class C: Non-randomized trial with concurrent or historical controls, Case-control study, Study of sensitivity and specificity of a diagnostic test, Population-based descriptive study; Class D: Cross-sectional study, Case series, Case report; Class R: Consensus statement, Consensus report, Narrative review
Diagnosis: Pediatric Apnea
• Presentation– Behavioral problems / irritability– Poor school performance– Enuresis– Snoring
• Cause– Adenotonsillar hypertrophy– Craniofacial abnormality– Frequently not obese
Pediatric Sleep Apnea
Child with Sleep ApneaChild’s Enlarged Palatine &
Adenoidal Tonsils
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Why Get a Sleep Study?
• Signs and symptoms poorly predict disease severity
• Appropriate therapy dependent on severity
• Failure to treat leads to:
– Increased morbidity
– Motor vehicle crashes
– Mortality
• Other causes of daytime sleepiness
What Test Should be Used?
• In-laboratory full night polysomnography
–Split night studies
• Home diagnostic systems
–Oximetry to full polysomnography
Polysomnography
Polysomnogram
Polysomnography in OSA
Full-Night In-Laboratory Polysomnography
• Pro
– Full set of variables obtained
– Equipment problems can be repaired
– Technician can address patient problems
• Con
– Cost
– Accessibility
– Patient sleeps away from home
• Pro– Reduced cost– Patient may be studied only once– Reduces time to treatment initiation
• Con– Diagnostic time may be inadequate– Treatment time limited– Difficult decisions required of technicians
Split-Night In-Laboratory Polysomnography
Cases
• Some cases can be misleading and you can miss serious cases if you just use oximetry
• It is important to conduct the proper study
Oximetry
• Pro– Inexpensive–Simple to perform–Little patient discomfort–Widely available
• Con– Interpretation not standard–Poor sensitivity – missed diagnosis–Specificity controversial
Home Study Tracing
Redline S et al. Chest 1991;100.
Home Study
• Pro
– Potentially less expensive
– Patient sleeps at home
• Con
– Generally fewer signals are recorded
– Equipment cannot be adjusted
– Technician cannot assist patient
Diagnosis of Sleep Apnea
• In-laboratory polysomnography
–Gold standard
–Assess severity
– Initiate treatment
Diagnostic Conclusions
• Signs and symptoms
– Excessive daytime sleepiness
– Hypertension and other cardiovascular sequelae
• Sleep study results
– Apnea / hypopnea frequency
– Sleep fragmentation
– Oxyhemoglobin desaturation
Treatment Objectives
• Reduce mortality and morbidity
–Decrease cardiovascular consequences
–Reduce sleepiness
• Improve quality of life
Therapeutic Approach
• Risk counseling
– Motor vehicle crashes
– Job-related hazards
– Judgment impairment
• Apnea and comorbidity treatment
– Behavioral
– Medical
– Surgical
The High-Risk Driver
• Educate patient
• Document warning
• Resolve apnea quickly
• Follow-up
– Effectiveness
– Compliance
Behavioral Interventions
• Encourage patients to:
–Lose weight
–Avoid alcohol and sedatives
–Avoid sleep deprivation
–Avoid supine sleep position
–Stop smoking
Weight Loss
• Should be prescribed for all obese patients
• Can be curative but has low success rate
• Other treatment is required until optimal weight loss is achieved
Weight Loss and Sleep Apnea
-4
-20 to <-10%
-10 to <-5%
-5% to <+5
+5 to +10%
+10% to +20
-3
-2
-1
0
1
2
3
4
5
6
Change in Body Weight
Adapted from Peppard PE et al. JAMA 2000;284.
Mean Change in AHI, Events/hr
Practice Recommendation
• Practice Recommendation: Lifestyle modifications, particularly weight loss and reduced alcohol consumption can play a significant role in the reduction of severity of sleep apnea
• Evidence-Based Source:Institute for Clinical Systems Improvement
• Web Site of Supporting Evidence:http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html
• Strength of Evidence:Class A: Randomized, controlled trial; Class B: Cohort study; Class C: Non-randomized trial with concurrent or historical controls, Case-control study, Study of sensitivity and specificity of a diagnostic test, Population-based descriptive study; Class D: Cross-sectional study, Case series, Case report; Class R: Consensus statement, Consensus report, Narrative review
Sleep-Position Training
Medical Interventions
• Positive airway pressure
–Continuous positive airway pressure (CPAP)
–Bi-level positive airway pressure
• Oral appliances
• Other (limited role)
–Medications
–Oxygen
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Positive Airway Pressure
Positive Airway Pressure
Benefits of CPAP: Mortality
He J et al. Chest 1988;94.
1 2 3 4 5 6 7 8 9
CPAP
(AI > 20, All Ages)C
um
ula
tive
Su
rviv
al
Interval Years
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
** ** ** **Control
Benefits of CPAP: Sleepiness
0
3
6
9
12
15
Pre Post
1 night14 nights
42 nights
CPAP TreatmentL
aten
cy t
o S
leep
(m
in)
Adapted from Lamphere J et al. Chest 1989;96.
Benefits of CPAP: Performance
0
5
10
15
20
25
30
35
Before CPAP After CPAP No Apnea
Ob
stac
les
hit
in 3
0 m
in.
Adapted from Findley L et al. Clin Chest Med 1992;13.
(n=6) (n=6)
(n=12)
Positive Airway Pressure: Problems
Patient Acceptance Claustrophobia Aerophagia Chest Discomfort
Mask Discomfort
Positive Airway Pressure: Problems
CPAP Compliance
• Patient report: 75%
• Objectively measured use
> 4 hrs for > 5 nights / week: 46%
• Asthma-medicine compliance: 30%
CPAP Compliance: Apnea Severity
Engleman HM et al. SLEEP 1993;16.
0
2
4
6
8
10
12
14
CP
AP
Ru
n H
ou
rs/N
igh
t
Apneas and Hypopneas/Hr.
20 40 60 80 100 120
Practice Recommendation
• Practice Recommendation:Polysomnography is the accepted standard test for the diagnosis of obstructive sleep apnea syndrome. The benefit of using attended polysomnography for diagnosis is the ability to establish a diagnosis and ascertain an effective CPAP treatment pressure.
• Evidence-Based Source:Institute for Clinical Systems Improvement
• Web Site of Supporting Evidence: http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html
• Strength of Evidence: Class C: Non-randomized trial with concurrent or historical controls, Case-control study, Study of sensitivity and specificity of a diagnostic test, Population-based descriptive study; Class D: Cross-sectional study, Case series, Case report; Class M: Meta-analysis, Systematic review, Decision analysis, Cost-effectiveness analysis; Class R: Consensus statement, Consensus report, Narrative review
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Strategies to Improve Compliance
• Machine-patient interfaces–Masks–Nasal pillows–Chin straps
• Humidifiers• Ramp• Desensitization• Bi-level pressure
CPAP Masks
Bi-level Positive Airway Pressure
Positive Pressure Therapy
15
CPAP Bi-level
10
5
0
Pressure
FlowInsp
Exp
Compliance: CPAP Vs. Bi-Level PAP
Reeves-Hoché MK et al. Am J Respir Crit Care Med 1995;151 © American Lung Association.
0
1
2
3
4
5
6
1 2 3 4
Compliance: CPAP vs Bi-level Positive Pressure
CPAP Bi-level
Mean hours of
use
8
7
6
5
4
3
2Visit
12 weeks
Visit 2
4-8 weeks
Visit 4
24-28 weeks
Visit 3
8-12 weeks
Visit 5
52 weeks
Oral Appliances
• Indications
–Snoring and apnea (not severe)
• Efficacy
–Variable
• Side effects
–TMJ discomfort, dental misalignment, and salivation
Oral Appliance: Mechanics
Supplemental Oxygen
• Not a primary treatment for sleep apnea
• Does not improve daytime sleepiness
• May prolong apneas
• Reduces oxygen desaturation during apneas
• Reduces arrhythmias
Pharmacologic Treatment
• Limited Role
–Protriptyline or fluoxetine
–Decongestants
–Nasal steroids
–Antihistamines
–Other
Surgical Alternatives• Reconstruct upper airway
– Uvulopalatopharyngoplasty (UPPP)– Laser-assisted uvulopalatopharyngoplasty
(LAUP)– Radiofrequency tissue volume reduction– Genioglossal advancement– Nasal reconstruction– Tonsillectomy
• Bypass upper airway– Tracheostomy
Sites of Airway Narrowing
Adapted from Morrison DL et al. Am Rev Respir Dis 1993;148.
Collapse at softpalate only
Multiple sites ofcollapse
18%
82%
Uvulopalatopharyngoplasty (UPPP)
• Usually eliminates snoring
• 41% chance of achieving AHI < 20
• No accurate method to predict surgical success
• Follow-up sleep study required
Uvulopalatopharyngoplasty (UPPP)
Radiofrequency Tissue Volume Reduction
• Radiofrequency energy delivered to palate or tongue
• Causes tissue scarring / retraction
• Relatively painless
• Office vs O.R. procedure
• FDA approved for snoring and sleep apnea
• Role unclear - limited efficacy data
Staged Surgical Procedures
Primary Care Management
• Risk counseling
• Behavior modification
• Monitor symptoms and compliance
– Monitor weight and blood pressure
– Ask about recurrence of symptoms
– Evaluate CPAP use and side effects
Sleep Apnea: Is Your Patient at Risk? NIH Publication No.95-3803.
Primary Care Management
• Reasons for lack of improvement
– Noncompliance
– Alcohol and sedative use
– Depression
– Poor sleep habits
– Nonapneic sleep disorder
• Persistent or recurrent symptoms
– Consider referral to sleep specialist
Sleep Apnea
• Common
• Dangerous
• Easily recognized
• Treatable
Sleep Apnea
Sleep Apnea
Post-Test Questions
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