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Obstructive Sleep Apnea A Serious Epidemic M.A.Hamadeh,M.D,FCCP,FAAM Assoc. Clinical Professor, Med. University of Illinois School of Medicine Director, Sleep Disorders Centers, Christ Hospital & Medical Center Sleep Apnea Sleep Apnea is: • Common • Dangerous • Easily recognized • Treatable Types of Sleep Disordered Breathing • Apnea – Cessation of airflow > 10 seconds • Hypopnea – Decreased airflow 30% from baseline lasting > 10 seconds associated with > 4% oxyhemoglobin desaturation Apnea Patterns Obstructive Airflow Respiratory effort Mixed Central Obstructive Apnea Central Apnea Mixed Apnea Obstructive Hypopnea Respiratory Effort-related Arousals RERA: Respiratory Effortrelated Arousal (Guilleminault, 1993) A sequence of breaths characterized by increasing respiratory effort leading to an arousal from sleep which does not meet criteria for an apnea or hypopnea. These events must fulfill both of the following criteria: 1. Pattern of progressively more negative esophageal pressure, terminated by a sudden change in pressure to a less negative level and an arousal 2. The event lasts 10 seconds or longer. UARS (Upper Airway Resistance Syndrome): > 5 RERA’s per hour of sleep What About “Simple Snoring?” • Snoring in pregnancy is associated with • increased hypertension and growth retardation, controlling for weight, age, smoking (Franklin, Chest, 2000) Snoring is associated with cognitive decline (Quesnot, J Am Geriatric Soc, 1999) • Snoring medical students are more likely to fail • • exams, controlling for BMI, age, sex (Ficker, Sleep, 1999). Snoring is a risk factor for cardiovascular disease in women. (Hu, J Am Coll Cardiol 2000). Snoring is a risk for type II diabetes (Al-Delaimy, Am J Epidemiol 2002). • Snoring women have faster progression of CAD (Leineweber C. Sleep 2004) Measures of Sleep Apnea Frequency • Apnea Index – # apneas per hour of sleep • Apnea / Hypopnea Index (AHI) – # apneas + hypopneas per hour of sleep • Respiratory Disturbance Index – # apneas + hypopneas + RERAs per hour of sleep Severity Criteria Based on PSG From the American Academy of Sleep Medicine (Sleep, 1999) • “Mild” sleep apnea is 5-15 events/hr • “Moderate” sleep apnea is 15-30 events/hr • “Severe” sleep apnea is over 30 events/hr • (“Events” includes apneas, hypopneas, and RERA’s) One Definition of Obstructive Sleep Apnea (OSA) CPAP will be covered for adults with sleepdisordered breathing if: – AHI (or RDI) > 15 OR – AHI (or RDI) > 5 with (“mild, symptomatic”) • Hypertension • Stroke • Sleepiness • Ischemic heart disease • Insomnia • Mood disorders Sleep-Disordered Breathing is a Spectrum Prevalence of Sleep Apnea 30-60 year olds 25 20 Percent of Population 15 Male Female 10 U.S. Pop 5 0 AHI > 5 Adapted from Young T et al. N Engl J Med 1993;328. SAS Asthma Why Sleep Apnea Isn’t Going Away….. SDB with Aging Sleep Apnea vs Sleep Disorders • Prevalence of common sleep disorders – Insomnia: 10-30% – Sleep Apnea: 5% – RLS: 10% – Narcolepsy: 0.05% • Diagnoses of patients presenting to sleep centers (Coleman II, 2000) – Sleep apnea: 67.8 – RLS: 4.9% – Narcolepsy 3.2% The Upper Airway 2 1 9 3 6 4 7 5 8 Control of Dilator Muscles Effects On Pharyngeal Muscle Activity Awake Genioglossus EMG Normal Subject Tensor Palatini EMG Airflow Genioglossus EMG OSA Patient Tensor Palatini EMG Airflow NREM Pathophysiology of Apnea Wakefulness Sleep Pathophysiology of Sleep Apnea Awake: Small airway + neuromuscular compensation Sleep Onset Hyperventilate: connect hypoxia & hypercapnia Loss of neuromuscular compensation + Airway opens Decreased pharyngeal muscle activity Pharyngeal muscle activity restored Airway collapses Arousal from sleep Apnea Hypoxia & Hypercapnia Increased ventilatory effort Clinical Consequences Sleep Apnea Sleep Fragmentation Hypoxia/ Hypercapnia Cardiovascular Complications Excessive Daytime Sleepiness Morbidity Mortality 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 Sassani, et al., Sleep 2004; 27:453 Consequences: Automobile Accidents Risk of Traffic Accident: OSA + ETOH 12 10 8 Odds Ratio 6 4 2 0 NO ETOH Adapted from Teran-Santos J et al. N Engl J Med 1999;340. + ETOH ETOH On Day of Accident Consequences: Cardiovascular • Systemic hypertension • Cardiac arrhythmias • Cardiovascular disease – Myocardial ischemia – Congestive heart failure • Cerebrovascular disease Consequences: Mortality Wisconsin Cohort Busselton, Australia RDI < 5 RDI 5-15 RDI > 15 Years of follow-up Young et al. Sleep 2008; 31:1071-1078 Marshall et al. Sleep 2008; 31:1079-1085 Consequences: Hypertension Shepard JW Jr. Med Clin North Am 1985;69. Cardiovascular Consequences: Hypertension Prospective Study of Association Between OSA and Hypertension 3 2.5 2 Odds Ratio Adjusted for age, sex, BMI, neck circ., cigs., ETOH, baseline Htn 1.5 1 0.5 0 0 0.1 - 4.9 5 - 14.9 Apnea / Hypopnea Index (AHI) Adapted from Peppard PE et al. N Engl J Med 2000;342. > 15 Consequences: Arrhythmias Consequences: Cardiovascular Disease Cross Sectional Study of Association Between OSA and CVD 2.5 2 Odds Ratio AHI 0 - 1.3 1.5 1.4 - 4.4 1 4.5 - 11.0 > 11.0 0.5 0 CAD HF CVA Adjusted for age, sex, race, BMI, Htn, cigs., chol. Adapted from Shahar E et al. Am J Respir Crit Care Med 2001;163. OSA and Stroke 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 * * AHI<5 AHI 5-20 AHI>20 Unadjusted Arzt, et al., AJRCCM 2005; 172:1447. A/G Adjusted A/G/BMI Adjusted Sleep Apnea Risk Factors • Obesity • Increasing age • Male gender • Anatomic abnormalities of upper airway Family history • • Alcohol or sedative use • Smoking • Associated conditions Risk Factor: Obesity >4% Arterial saturation dipa h-1 80 70 60 50 40 30 20 10 0 70 80 90 100 110 120 % Predicted normal neck circumference Davies RJ et al. Eur Respir J 1990;3. 130 140 Risk Factor: Age 35 30 25 % with AHI > 5 20 Female 15 Male 10 5 0 30-39 Yrs Adapted from Young T et al. N Engl J Med 1993;328. 40-49 Yrs 50-60 Yrs Risk Factor: Gender Apnea/Hypopnea Index 120 100 80 60 Male Female 40 20 0 0 20 40 60 80 100 Skinfold Sum (mm) Millman RP et al. Chest 1995;107. 120 140 Apneas & Hypopneas per hour of sleep Risk Factor: Anatomic Abnormality 6 75 4 8 5 50 45 40 3 35 7 30 2 25 1 20 15 10 5 0 Nose Open Suratt PM et al. Chest 1986;90. Nose Occluded Risk Factor: Family History Likelihood of Sleep Apnea as Function of Family Prevalence 4 3.5 Odds Ratio 3 2.5 (Adjusted for age, race, sex, BMI) 2 1.5 1 0.5 0 1 Relative Adapted from Redline S et al. Am J Resp Crit Care Med 1995;151. 2 Relatives 3 Relatives Risk Factor: Sedatives 150 100 (% control) Peak Integrated activity Phrenic Nerve Hypoglossal Nerve 50 Diazepam Injection 0 0 5 15 30 Minutes after injection 60 Sanders MH. In: Principles and Practice of Sleep Medicine. Philadelphia: W.B. Saunders Company, 1994. Risk Factor: Alcohol Before Alcohol Phrenic Hypoglossal Blood Alcohol = 83 mg/dl Phrenic Hypoglossal Blood Alcohol = 134 mg/dl Phrenic Hypoglossal Bonara M et al. Am Rev Respir Dis 1984;130 © American Lung Association. Risk Factor: Smoking Adjusted Odds Ratio for Sleep Apnea (AHI > 15) in Former & Current Smokers vs Nonsmokers 5 4 Odds Ratio 3 (Adjusted for age, race, sex, BMI) 2 1 0 Former Smokers Current Smokers Adapted from Wetter DW et al. Arch Intern Med 1994:154 ©1994 American Medical Association. 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 Diagnosis: Physical Examination • Upper body obesity / thick neck > 17” males > 16” females • Hypertension • Obvious upper airway abnormality Exam: Tonsillar Hypertrophy Normal Oropharynx Shepard JW Jr et al. Mayo Clin Proc 1990;65. Oropharynx With Tonsillar Hypertrophy Exam: Oropharynx Patient With the Crowded Oropharynx Exam: Oropharynx Class I Class II Class III Class IV Physical Examination Structural Abnormalities Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978. 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 Apnea Child’s Enlarged Palatine & Adenoidal Tonsils 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 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 Split-Night In-Laboratory Polysomnography • Pro – Reduced cost – Patient may be studied only once – Reduces time to treatment initiation • Con – Diagnostic time may be inadequate – Treatment time limited – Protocol decisions to start CPAP may be difficult to make during data acquisition Home Study Tracing Home Study • Pro – Potentially less expensive – Patient sleeps at home • Con – Generally fewer signals are recorded – Equipment cannot be adjusted – Technician cannot assist patient 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 morbidity and mortality – Reduce sleepiness – Decrease cardiovascular consequences • Improve quality of life Therapeutic Approach • Risk counseling – Motor vehicle crashes – Job-related hazards – Judgment impairment • Apnea and co-morbidity 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 6 5 4 3 Mean Change in AHI, Events/hr 2 1 0 -1 -2 -3 -4 -20 to <-10% Adapted from Peppard PE et al. JAMA 2000;284. -10 to <5% -5% to <+5 +5 to +10% Change in Body Weight +10% to +20 Weight Loss and Sleep Apnea 100 40 80 20 60 15 40 10 20 5 Baseline Smith PL et al. Ann Intern Med 1985;103. Weight Loss Baseline Weight Loss Apnea Frequency Mean Fall Sa02 (EPISODES/HOUR) (PERCENT) 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 Positive Airway Pressure Positive Airway Pressure Benefits of CPAP: Mortality 96% 86% Campos-Rodriguez, et al., Chest 2005; 128:624 91% Benefits of CPAP: Sleepiness CPAP Treatment Latency to Sleep (min) 15 12 9 1 night 14 nights 42 nights 6 3 0 Pre Adapted from Lamphere J et al. Chest 1989;96. Post Benefits of CPAP: Performance 35 Obstacles hit in 30 min. 30 25 20 15 10 5 0 Before CPAP (n=6) Adapted from Findley L et al. Clin Chest Med 1992;13. After CPAP (n=6) No Apnea (n=12) Positive Airway Pressure: Problems Mask Discomfort Patient Acceptance Claustrophobia Aerophagia Chest Discomfort CPAP for OSA: Benefits • • • • • • • • • • Improved cognitive function Improved quality of life Reduced daytime sleepiness Reduced risk of automobile accidents Reduced health care costs Reduced blood pressure Reduced cardiac arrhythmias Improved glucose tolerance Reduced mortality rate Reversal of impotence 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 70 1 month 3 month Mean percentage days CPAP used 60 50 40 30 20 10 0 20 Minutes 4 Hours Time CPAP used Adapted from Kribbs NB et al. Am Rev Respir Dis 1993;147. 7 hours CPAP Compliance: Predictors • Predict Good Compliance – Increased AHI – Increased daytime sleepiness – Perception of benefit • Predict Poor Compliance – Lack of EDS – Lack of perceived benefit – Nasal obstruction – Side effects – Claustrophobia Strategies to Improve Compliance • Patient Education • Frequent and early follow-up • Machine-patient interfaces • • • • – Masks – Nasal pillows – Chin straps Humidifiers Ramp Desensitization Pressure relief CPAP or Bi-level pressure CPAP Masks CPAP Ramping Effect of Recurrent Use of Ramping on Nocturnal Saturation Pressman MR et al. Am J Respir Crit Care 1995;151 © American Lung Association. Bi-level Positive Airway Pressure Positive Pressure Therapy CPAP 15 10 Pressure 5 0 Insp Flow Exp Bi-level Compliance: CPAP Vs. Bi-Level PAP Compliance: CPAP vs Bi-level Positive Pressure CPAP Bi-level Mean hours of use 86 75 64 53 42 31 20 Visit 1 2 weeks Visit 1 2 4-8 weeks Visit 23 8-12 weeks Visit 34 24-28 weeks Visit 45 52 weeks Reeves-Hoché MK et al. Am J Respir Crit Care Med 1995;151 © American Lung Association. Monitoring Compliance • Most PAP units measure ‘mask-on’ times • Adherence data can be downloaded into compliance reports • Objective monitoring recommended in treatment guidelines • Objective monitoring required by CMS Monitoring Compliance Oral Appliances • Indications – Snoring and apnea (not severe) • Efficacy – Variable with 52% of patients with AHI<10/hr on treatment • Side effects – TMJ discomfort, dental misalignment, and salivation Oral Appliances Variables that Effect Efficacy • Severity of OSA: higher success with mild to • • • moderate disease (AHI <30-40) Degree of protrusion: more effective with increased protrusion Positionality of SDB: more effective in patients with supine-dependent OSA BMI: more effective in patients with lower BMI Sleep 2006;29:244 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) Radiofrequency tissue volume reduction Genioglossal advancement Nasal reconstruction Tonsillectomy • Bypass upper airway – Tracheostomy Sites of Airway Narrowing 18% 82% Adapted from Morrison DL et al. Am Rev Respir Dis 1993;148. Collapse at soft palate only Multiple sites of collapse 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) 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 Medicine in the Future • The prevalence and importance of • • • • • sleep apnea are attracting attention Training and credentialing have changed Diagnostic approaches are simplifying, and multiplying Reimbursement will continue to fall. Treatment approaches are changing The field is vulnerable Portable Monitoring (or oximetry) is to in-lab PSG as… • CXR is to CT scan (lung cancer) • Pre-post spirometry is to methacholine challenge (asthma) • Fasting glucose is to oral glucose challenge test (diabetes) Outcomes of Home-Based Diagnosis and Treatment of Obstructive Sleep Apnea Chest 2010; 138: 257-263 • Home testing and autoCPAP resulted in the same results in sleepiness, adherence, blood pressure and QoL as in-lab testing. • “It is really not about the technology; it is about the initial and then chronic care of the patient….” (Dr N Collop, editorial) CPAP as a Therapeutic Trial (Senn O Chest 2006, n= 33) • Autotitrating CPAP, 4-15 cm H20, was used as • the therapeutic trial A successful trial was “yes” to – Are you willing to continue CPAP treatment? – Was objective CPAP use > 2 hours/night? • All underwent PSG; sleep apnea was • • considered an AHI of > 10 Excluded were those with CHF, OHS, underlying lung disease, prior CPAP Rx, psych or illness, language problems Those who were diagnosed with OSA on basis of TT had same outcomes as in-lab diagnosed. Autotitrating CPAP (Ayas N, Sleep 2004) • Most commonly, increases pressure to eliminate • • • • • vibration of palate and soft tissue. Now costs about the same as “straight” CPAP. May improve compliance. Results in lower pressure over all. Can obviate the need for in-lab titration, in many cases. Is supplanting in-lab titration Oral Appliances (Kushida C, Sleep 2006) Indicated for patients with mild-to-moderate obstructive sleep apnea who prefer oral appliances to CPAP do not respond to CPAP are not appropriate candidates for CPAP fail treatment attempts with CPAP (Kushida Sleep 2006) Not as effective as CPAP Lower blood pressure 3-4 mmHg (Otsuka Sleep Breath 2006) Outperformed surgery in the only head-to head trial. Preferred to CPAP in head-to-head trials. Do Oral Appliances Work? Cochrane Database Syst Rev. 2006 Jan 25;(1):CD001106. “CPAP is effective in reducing symptoms of sleepiness and improving quality of life measures in people with moderate and severe obstructive sleep apnoea (OSA). It is more effective than oral appliances in reducing respiratory disturbances in these people but subjective outcomes are more equivocal. Certain people tend to prefer oral appliances to CPAP where both are effective. This could be because they offer a more convenient way of controlling OSA.” Sleep Apnea Questions?