SLEEP APNEA

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SLEEP APNEA

• WHOUA Betsy
  R. Sears MSM, MT(ASCP)
• Executive Vice President
• ExamOne

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SLEEP APNEA

• Description
• Risk factors
• Diagnosis
• Complications
• Treatment

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SLEEP APNEA

• WHAT IS IT?
• Treatable disorder in
  which a person
  stops breathing during sleep, often
  hundreds of times during the
  night Gestaut 1965
• U.S. - 18 million (1 in 15/ 6.62)
• Canada 2.1 million
• NIH 2006 estimates

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SLEEP APNEA

• JUST THE FACTS
• Apnea (Greek) without breath
• 10 second cessation
• Hypopnea reduction in airflow
• Throat closes no air to lungs
• Disruptions reduced REM
• OXYGEN LEVEL DROPS !

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SLEEP APNEA

• PREVALENCE
• Children 1-2
• Male 4-9
• Female 2-4 (menopause)
• Elderly 20
• 2-4 of Americans go undiagnosed
• 5-10 million in the U.S.

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SLEEP APNEA

• TYPES
• Obstructive (OSA) blockage of airway
• Central brain fails to signal breathing
• Mixed combination of two
• ALL EQUAL FRAGMENTED, POOR QUALITY SLEEP

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SLEEP APNEA

• PHYSICAL EXAMINATION

Enlarged uvula
Elongated soft palate
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SLEEP APNEA

• Normal airway

Abnormal airway during sleep
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SLEEP APNEA

• RISK FACTORS - OSA
• Excess weight
• Age
• Male sex
• Family history
• Hypertension

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SLEEP APNEA

• RISK FACTORS - OSA
• Large neck, recessed chin
• Narrowed airway
• Enlarged tongue, tonsils, adenoids
• Smoking alcohol use
• Ethnicity (African-Americans,
• Pacific Islanders and Mexicans)

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SLEEP APNEA

• RISK FACTORS - CSA
• Being male
• Heart disease
• Stroke or brain tumor

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SLEEP APNEA

• WHEN TO SEE A DOCTOR
• Snoring loud enough to disturb the sleep of
  others or yourself
• Shortness of breath that awakens you from sleep
• Intermittent pauses in your breathing during
  sleep
• Excessive daytime drowsiness, which may cause you
  to fall asleep while you're working, watching
  television or even driving

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SLEEP APNEA

• Diagnosis
• SPOUSE (or partner) FIRST TO SUSPECT!
• Sleep Study
• Pulmonologist, otolaryngologist, neurologist,
  psychiatrist
• ABSM certified
• 2x health care resources in 10 years prior to
  diagnosis

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SLEEP APNEA

• Diagnosis Night Sleep Studies
• Polysomnography
• Brain activity
• Eye movement
• Muscle activity
• Heart rate
• Respiration effort
• Air flow
• Blood oxygen levels
• Chest wall movement

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SLEEP APNEA

• Diagnosis Instrumentation used
• EEG - brain waves
• EOG - eye/chin movement
• EKG - heart rate/rhythm
• Chest bands breathing movements
• Oxygen CO2 levels

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SLEEP APNEANational Commission on Sleep
Disorders Research

• SEVERITY
• AHI - apnea-hypopnea index
• aka RDI respiratory disturbance index
• Number of obstructive events/hour
• Mild OSA 5-15 events (7-18 M)
• Moderate - 15-30 events (1.8 4 M)
• Severe gt 30 events occur in REM
• Negative study doesnt exclude mild OSA

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SLEEP APNEA

• Diagnosis
• Multiple Sleep Latency Test (MSLT)
• Level of daytime sleepiness
• Measures speed of falling asleep
• -Without sleep problems 10-20 min.
• -With sleep disorders - lt 5 min.
• High MSLT, Low AHI test again!

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SLEEP APNEA

• Consequences
• of Sleep Apnea. . .
• range from annoying to
• life threatening

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SLEEP APNEA

• DAYTIME SYMPTOMS
• 70 billion lost productivity, lost wages,
  property damage
• Excessive sleepiness
• Impaired concentration
• Early morning headache
• Memory loss
• Irritability
• Depression

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SLEEP APNEA

• NOCTURNAL SYMPTOMS
• Heavy snoring 38 ( male, bp, diabetes)
• Restless sleep
• Nocturnal choking
• Sweating
• Impotence
• Witnessed apnea
• National Sleep Foundation

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SLEEP APNEA

• POTENTIAL COMPLICATIONS
• Motor vehicle crashes
• High BP
• CV problems
• Stroke
• Job impairment

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SLEEP APNEA

• According to Divided Attention Driving Task
  individuals with sleep apnea perform, on average,
  as poorly as individuals whose levels of blood
  alcohol concentration exceed the legal limit
  (More fatalities per accident)

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SLEEP APNEA

• RISKS OF UNTREATED SLEEP APNEA
• 100 million sleepy drivers (2 in 10 sleepers!)
• Car crashes 6x more likely
• Drowsy driving 180,000 accidents, 40,000
  injuries, 1,550 fatalities, costing 15.9 billion
• National Journal of Sleep May 2001
• NHTSA 2000

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SLEEP APNEA Commercial Drivers

• RISKS OF UNTREATED SLEEP APNEA
• 33 of commercial drivers - OSA
• Sleepiness 31-41 major crashes
• 1,550 fatalities, costing 15.9 billion
• 2001- 429,000 crashes, 5,000 fatal (trucks)
• Costs - 75,637/crash
  3.57 M/ fatal crash
• Legislation?
• American Journal of Respiratory and Critical
  Care, August 15, 2004

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SLEEP APNEA

• If all drivers suffering from sleep apnea were
  treated, 11.1 billion in damages could be saved,
  along with 980 lives, each year
• National Journal of Sleep May 2005

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SLEEP APNEA

• RISKS OF UNTREATED SLEEP APNEA
• Stroke 4x more likely
• Heart disease 4x more likely
• 3 risk of heart attack and stroke
• 50 have hypertension
• Because OSA occur in obese with co-morbid
  conditions, individual contribution difficult to
  discern
• National Sleep Foundation 2003
• Lancet 2002 359 204-210

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SLEEP APNEA

• CARDIOVASCULAR COMPLICATIONS
• Systemic Hypertension
• Left Ventricular Dysfunction
• Arrhythmia
• Pulmonary Hypertension
• Myocardial Ischemia
• Cerebrovascular Events
• Congestive Heart Failure
• Prolonged low 02 angina, heart attacks
• Increased norepinephrine high BP, arrhythmias
• ESTIMATED 38,000 deaths a year

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SLEEP APNEA

• CARDIOVASCULAR COMPLICATIONS
• Episode O2 drops, CO2 high. . .
• Releases catecholamines. . . arousal
• Adrenalin surge increases
• Heart rate
• Stroke volume
• Peripheral vascular resistance Heart on OT!
• Can elevate systolic BP to gt 200 mm Hg

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SLEEP APNEA

• CV COMPLICATIONS - TIMING
• Cardiac workload increases with each
  oxygen-demand episode
• Multiple episodes throughout night. No
  recovery time! Heart worn out
• MANY CV DEATHS between 12 6am
• Hmmmmmmmm. . . .

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SLEEP APNEA

• CV COMPLICATIONS STUDY
• Day-Night Pattern of Sudden CV Death in OSA
• 112 Minnesota residents 1987 2003 (CV deaths)
• 4 daytime/3 nighttime intervals compared for rate
  of sudden cardiac death
• Midnight 6am 46 death with OSA
• 21 without OSA
• Gami, Howard, Olson Somers, MD SLEEP APNEA
  Volume 3521206-1214 March 24, 2005

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SLEEP APNEA

• GENERAL COMMUNITY STUDY
• AUSTRALIA
• 380 men and women
• 40 65 yrs old
• Severe OSA 3, moderate 18, mild -77
• Deaths (14 year followup) 33 moderate to
  severe died
• 6.5 mild
• 7.7 without
• "Our findings ... remove any reasonable doubt
  that sleep apnea is a fatal disease" Researcher
  Nathaniel Marshall, a postdoctoral fellow
  at the Woolcock Institute of Medical Research in
  Sydney

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SLEEP APNEA

• Influence of OSA on Mortality in Patients
  with Heart Failure
• 164 patients LVEF lt 45
• Comparison death rates
• AHI lt 15
• AHI gt 15 (untreated OSA)
• Followup 2.9 7.3 years
• Results 8.7 vs. 4.2 deaths per 100 patient/yrs
• Hanqiao Wang, MD,1, John D. Parker, MD, FACC,,2,
  Gary E. Newton, MD, FACC, John S. Floras, MD,
  DPhil, FACC,,3, Susanna Mak, MD, PhD December
  19, 2006
  

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SLEEP APNEA

• TREATMENT OPTIONS
• Conservative
• Positional
• Avoid alcohol
• Weight loss

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SLEEP APNEA

• TREATMENT OPTIONS
• Positional therapy
• -Stay off back
• -FDA approved pillow
• -Positional alarms (too noisy, disrupt sleep!)

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SLEEP APNEA

• TREATMENT OPTIONS (behavioral)
• -Avoid alcohol/CNS depressants
• -relax airway muscles
• -reduce respiratory drive

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SLEEP APNEA

• TREATMENT OPTIONS (behavioral)
• Weight loss (10)
• -fat around neck
• -total resolution pressurelt4 cm H20
• -3 weight off for 5 years
• STUDY 216 patients, 24 (11.1) resolution
• -94 mos. 13 maintained, 11 regained
• - 3 yrs only 3 maintained resolution

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SLEEP APNEA Gastric Bypass

• 90 OSA severely overweight
• 1999 10-15,000 per yr
• 2002 75,000 per yr
• VBG or Roux-en-Y gastric bypass
• CPAP

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SLEEP APNEA Gastric Bypass
HG horizontal gastroplasty EBM
evidence-based medicine Retro retrospective
study. Mean SD. Only studies presenting
BMI data.
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SLEEP APNEA

• TREATMENT OPTIONS
• Oral appliances (for mild cases)
• -pushes lower jaw forward (MAD)
• -prevent tongue blocking airway (TRD)

Mandibular Advancement Device 
Tongue Retaining Device
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SLEEP APNEA

• TREATMENT OPTIONS
• SURGERY
• Goal - to remove excess tissue from nose or
  throat that may be vibrating causing you to
  snore blocking your upper air passages and
  causing sleep apnea
• Only after other options have been eliminated
• Success rate 50 (50 reduction of
  RDI/postoperative RDI of lt 20)

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SLEEP APNEA

• TREATMENT OPTIONS
• SURGERY (minor)
• Somnoplasty radiofrequency to reduce soft
  tissue in upper airway
• Uvulopalatopharyngoplasty (UPPP) (1981) removes
  soft tissue, tonsils/palate, uvula increasing
  width of airway
• Nasal surgery deviated septum

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SLEEP APNEA

• TREATMENT OPTIONS
• SURGERY (major)
• Mandibular maxillar advancement surgery -
  corrects facial abnormalities/throat obstructions
• Tracheostomy opening in throat bypasses
  blocked air passage
• INVASIVE! Severe cases/craniofacial
  abnormalities

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SLEEP APNEA

• TREATMENT OPTIONS
• MECHANICAL THERAPY - CPAP
• Continuous Positive Airway Pressure 1981
• Blows pressurized room air Splint
• Most effective treatment
• Devices must be FDA approved
• Compliance

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SLEEP APNEA

• TREATMENT OPTIONS
• MECHANICAL THERAPY (CPAP)
• Nasal masks
• Nasal pillows
• Nasal seals
• Amount of pressure open airways expressed in
  centimeters of water
• (5-20 cm/H2O)
• CPAP titration study necessary
• DEEP SLEEP. . . finally

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SLEEP APNEA
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SLEEP APNEA
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SLEEP APNEA
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SLEEP APNEA

• TREATMENT OPTIONS
• MECHANICAL THERAPY (CPAP)
• COMPLAINTS
• Financial
• Nasal Congestion
• Dryness
• Abrasions

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SLEEP APNEA CPAP Compliance

• STUDY To determine long-term compliance rates
  to CPAP therapy in OSA patients
• 296 patients (AHI gt 20) on polysomnography 81
  males
• CPAP device with monitoring chip
• Followup 2 wks, 4 wks, 3 months, 6 months
• Mean AHI - gt 64, Mean age 51 yrs, Mean BMI
  35.2
• Mean duration CPAP use 5.7 hrs/day 5.9
  hrs/day
• Chest. 2002121430-435

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SLEEP APNEA CPAP Compliance

• Increased Use of CPAP
• Education/consistent follow-up
• Female gender
• Increased age
• Reduction of daytime sleepiness scores
• Compliance 85 over 6 month period
• Pattern determined by 4th night
• John D. Zoidis, MD RT June 2007
• Chest. 2002121430-435

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Mean ESS scores at baseline and during follow-up
Sin, D. D. et al. Chest 2002121430-435
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SLEEP APNEA
 
Cassel W, Ploch T, Becker C, et al. Risk of
traffic accidents in patients with
sleep-disordered breathing reduction with nasal
CPAP. Eur Respir J 1996 92606-2611. Krieger J,
Meslier N, Lebrun T. Accidents in obstructive
sleep apnea patients treated with nasal CPAP a
prospective study. Chest 1997 1121561-1566
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SLEEP APNEA ASV

• Recently approved airflow device
• Adaptive servo-ventilation (ASV)
• Learns normal breathing pattern, stores
  information in a built-in computer
• After falling asleep, machine uses pressure to
  normalize breathing pattern and prevent pauses in
  breathing
• May be more successful than CPAP at treating
  central sleep apnea.

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SLEEP APNEA Summary

• Negative Consequences of OSA increase as severity
  increases. Untreated OSA progressively
  worsens and sooner or later will result in
  partial or complete disability or death

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SLEEP APNEA
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SLEEP APNEA

• References
• Cartwright RD, Samelson CF. The effects of a
  nonsurgical treatment for obstructive sleep
  apnea. JAMA 1982248705-9.
• J Insur Med 200537272-282
• Hung J, Whitford EG, Parsons RW, Hillman DR.
  Association of sleep apnea with myocardial
  infarction in men. Lancet 1990336261-4.
• Partinen M, Guilleminault C. Daytime sleepiness
  and vascular morbidity at seven-year follow-up in
  obstructive sleep apnea patients. Chest 199097
  27-32.
• Aldrich MS. Automobile accidents in patients with
  sleep disorders. Sleep 198912487-94.
• Am Fam Physician 1999602279-86
• American Sleep Apnea Association website 2007
• National Sleep Foundation
• National Institute of Health www.nih 2007
• Sleep Medicine Center-Cleveland Clinic 2006

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SLEEP APNEA

• QUESTIONS?
• Betsy.sears_at_examone.com
• 913-577-1306