Snoring Is No Laughing Matter

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Snoring Is No Laughing Matter

• A Primary Care Perspective On
• Obstructive Sleep Apnea
• Andrew Okas, D.O.

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Case Presentation

• CC Wife made me come!!
• HPI A 32 y.o. stubborn male doctor presents to
  his PCP for the first time in 15 years because
  his wife (a doctor) threatens to suture his mouth
  shut because of earth shaking snoring.
• Past Medical/Snoring History
• Gets Kicked Out of Medical School Library for
  snoring and slobering on text books.
• In Residency, He Fell Asleep daily on Neurology
  rotation (while standing)
• Residents ban him from ICU call rooms because of
  sonic boom snoring.
• The Diagnosis A FREAK OF NATURE

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I Am A Snorer
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Is Snoring Destroying Your Children?
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Is Snoring Destroying Your Marriage?

• "Stop snoring week aims to restore happy sex
  lives" (Telegraph.co.uk)
• "It's snore fun when you have to sleep all alone"
  (Scotsman)
• "SEX IS A REAL SNORE POINT" (Glasgow Daily
  Record)
• "Snoring can be the cause of divorce" (Pravda,
  Russia)
• "World Snoring ruins your sex life!"
  (Keralanext, India)
• "You snore? Don't score?" (Sydney Morning
  Herald, Australia)

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Is Snoring Destroying The World?

• OSA is also associated with a variety of
  disasters, such as Three Mile Island and
  Chernobyl. (Research Review, February 2006)

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Is Snoring Destroying Lives?

• "It's scary as hell when it happens to you,"
  Tosti said.
• OSA caused him to doze off sometimes in the
  middle of a conversation, at work and, on two
  occasions, in the car.
• "We had three of our grandchildren in the back
  seat. They were singing and the radio was
  blasting and he went off the road," said his
  wife, Irene.

• Reverend Reggie White (43yo) most likely had a
  condition (Sarcoidosis and Obstructive Sleep
  Apnea) resulting in "fatal cardiac arrhythmia,"
  said Dr. Mike Sullivan, the medical examiner for
  Mecklenburg County and a forensic pathologist

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Is Snoring Going To Destroy You?

• The vast majority of these Americans with
  sleep apnea have not been diagnosed.

• Sleep apnea
• affects more than twelve million Americans,
  according to the National Institutes of Health

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Overview of Sleep Disorders100 million
AmericansOver 84 Disorders

• American Academy of Sleep Medicine

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Definition

• Obstructive Sleep Apnea syndrome is daytime
  sleepiness in conjunction with 5 or more episodes
  of apnea or hypopnea per hour of sleep.

• 24 of men and 9 of women (30-60 years of age)
  have excessive snoring (an apnea/hypopnea index gt
  5) without daytime hypersomnolence. (Flemons,
  NEJM 2002).
• In Sleep 2003 Punjabi discovered that 20-25 of
  the general population screened with Epworth
  sleepiness scale had excessive daytime
  hypersomnolence.
• According to these criteria, 4 of men and 2 of
  women who are 30-60 years of age have OSA.
  (Flemons, NEJM 2002).

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The Consequences of Sleep Apnea
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Ischemic Events

• CVA A large observational cohort study published
  in November 2005 in the New England Journal of
  Medicine reported that obstructive sleep apnea
  greatly increases the risk of stroke by a factor
  of 2-3, regardless of whether a person has high
  blood pressure.
• Coronary Artery Disease - A 2-3 times increased
  risk of heart attack in patients with OSA. There
  is speculation that OSA may be one factor in the
  higher frequency of heart attacks in the early
  morning hours.

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Sudden Cardiac Death

• Gami, et al, NEJM,March 2005 Observed that people
  with OSA have a peak in sudden death from cardiac
  causes during sleeping hours which is
  significantly higher than the normal population.
  Severe OSA patients had a 40 higher relative
  risk.

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Driving

• The Wisconsin Sleep Cohort Study reported that
• Drivers with Mild OSA were 3 times as likely to
  be involved in a car accident as those without
  OSA,
• Drivers with Moderately Severe OSA were 7 times
  as likely to be involved in a car accident as
  those without OSA.

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When Is Snoring More Than Just A Snore Point?

• You are High Risk for OSA if you have 2 of the 4
  following criteria.
• 1. Snoring
• 2. Anyone who has daytime hypersomnolence or fall
  asleep while driving (night or day)
• 3. Obesity
• 4. Hypertension
• (78-95 sensitivity, Flemons, et al. Sleep
  Medicine Review 1997)

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THE EPWORTH SLEEPINESS SCALE (Johns, Sleep
1991)1 Slight chance of dozing 2 Moderate
chance of dozing 3 High chance of dozing

• 1. Sitting and reading     0 1 2 3
• 2. Watching TV     0 1 2 3
• 3. Sitting inactive in a public place (e.g. a
  theater or a meeting)     0 1 2 3
• 4. As a passenger in a car for an hour without a
  break     0 1 2 3
• 5. Lying down to rest in the afternoon     0 1
  2 3
• 6. Sitting quietly after a lunch without alcohol
• 0 1 2 3
• 7. Sitting and talking to someone     0 1 2 3
• 8. In a car, while stopped for a few minutes in
  the traffic     0 1 2 3

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Epworth Sleepiness Scores by Diagnosis

• Controls 6.0 2.5
• OSA 11.7 4.6
• Narcolepsy 17.5 3.5
• Insomnia 2.2 2.0
• In OSA, ESS gt 16 was only seen in patients with
  moderate to severe disease.

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Approach to a Patient with Suspected Sleep Apnea

• Adjusted Neck Circumference
• actual neck size plus
• 3cm for snoring
• 3cm for choking /gasping,
• 4cm for HTN
• If score is over 48 then high probability (over
  20 times as probable).

Respiratory Disturbance Index
Apnea/Hypopnea Index
Flemons, W. W. N Engl J Med 2002347498-504
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THE MAJORITY OF OSA PATIENTS ARE NOT OBESE

• The article "Association of Sleep-Disordered
  Breathing, Sleep Apnea, and Hypertension in a
  Large Community-Based Study" published in the
  Journal of the American Medical Association in
  April 2000 is the largest published
  population-based study to provide the breakdown
  of subjects apnea-hypopnea index (AHI) by
  body-mass index (BMI).
• According to Nieto et al, the majority of
  subjects with an AHI ³ 5 are not obese.

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Patient With Suspected Sleep Apnea

• The Future
• A large HMO in Puget Sound, Washington is already
  using home sleep monitoring as the principal
  method for diagnosing OSA.
• A Continuous Positive Airway Pressure Trial as a
  Novel Approach to the Diagnosis of the
  Obstructive Sleep Apnea Syndrome Oliver Senn, MD
  University Hospital of Zurich, Switzerland. Chest
  2006 suggests empiric trial of cpap for moderate
  to high risk patients for 2 weeks before doing
  any sleep studies

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Polysomnography (Gold Standard) (Over 16
Channels)

• 2 - 6 channels of EEG (Electroencephalogram -
  electrical activity in the brain) which allow the
  person interpreting the test to determine how the
  stages of sleep change during the night
• 2 channels of EOG (Electrooculogram - movement of
  the eye) which are used to distinguish so-called
  REM (Rapid eye movement) sleep from Non-REM sleep
• Chin EMG (Electromyography - electrical activity
  of the chin muscle) which is an indicator of
  arousal and activation of the upper airway
  muscles,
• Airflow from the nose and mouth
• Respiratory effort which is measured with elastic
  belts around the chest and the abdomen
• Body position
• 1 channel of ECG (Electrocardiogram)
• Oximetry (Recording of the oxygen saturation of
  the blood)
• 2 channels of leg EMG (the electrodes are usually
  applied to the shins) to record limb movements
  during sleep.
• Madison waiting period is 1-2 months.

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• A 4-channel home sleep study is covered by Unity
  and Physicians Plus 750.
• Madison waiting period less than 1 week

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• 6 Channel Home Sleep Monitor
• Single leg activity (Channel 1).
• Body position (Channel 2),
• Snoring (Channel 3),
• Airflow from the nose and mouth (Channel 4),
• Chest/Abdomen movement (Channel 5)
• Oxygen saturation (Channel 8)
• Heart rate (Channel 7)

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Treatment
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CONSERVATIVE TREATMENT

• Do not drink alcoholic beverages in the evening
  as this disturbs sleep.
• Avoid cafeinated beverages after noontime, as
  caffeine disturbs sleep. Limit total caffeine
  consumption to no more than two beverages per
  day.
• Do not smoke just before bedtime or during the
  night as this disturbs sleep.
• Exercise regularly during the day, but avoid
  exercise in the evening within 3 hours of
  bedtime.
• Maintain a comfortable temperature in the
  bedroom.
• If you're overweight, lose weight. Being
  overweight is the most common cause of snoring.
  Flabby throat tissues are more likely to vibrate
  as you breathe.
• Sleep on your side. Lying on your back allows
  your tongue to fall backward into your throat,
  narrowing your airway and partially obstructing
  airflow. To prevent sleeping on your back, try
  sewing a tennis ball in the back of your pajama
  top.
• Treat nasal congestion or obstruction. Adhesive
  strips applied to your nose widen nasal passages
  and may help reduce congestion or obstruction.
• Limit or avoid alcohol and sedatives. Sedatives
  and hypnotics (sleeping pills) and alcohol
  depress your central nervous system,

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Dental Devices

• Indication Mild/Moderate OSA
• Disadvantage
• 1. Cost Over 700
• 2. Side effects Obstruct Breathing, Slober
• 3. Low compliance

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Dental Appliances

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Surgery

• Uvulopalatopharyngoplasty (UPPP). Your tonsils
  and adenoids usually are removed as well. This is
  the most common type of surgery to treat sleep
  apnea.
• Laser-assisted uvulopalatoplasty (LAUP). this
  procedure involves the use of a laser to remove
  part of your soft palate and shorten uvula.
• Radiofrequency ablation (RFA). In this office
  procedure, radiofrequency energy to remove tissue
  from your uvula, and soft palate.
• Both LAUP and RFA Are Not recommended for
  moderate to severe obstructive sleep apnea.

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Continuous positive airway pressure (CPAP)

• Some studies say that compliance is less than
  4 hours per night.

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Atrial Overdrive Pacemakers

• NEJM 2002 Atrial overdrive (15 beats above
  baseline) pacemakers improved both OSA and
  central sleep apnea

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The Future

• Researchers at the University of Pennsylvania are
  studying whether serotonin can help English
  bulldogs, whose facial structure causes them to
  snore and suffer apnea.
• Lab tests show serotonin seems to help keep the
  bulldogs' throats open during sleep.

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The Family That Snores Together Slobers Together
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Upper Airway Resistance Syndrome (UARS)

• A "typical" patient with UARS is a slender woman
  in her 20's - 30's with a small jaw and a high,
  arched palate.
• Some experts also believe that there is a group
  of patients, mostly female, who are not loud
  snorers, who do not show evidence of OSA on sleep
  monitoring, and yet suffer the symptoms of OSA.
  In these patients, there is partial airway
  collapse without detectable change in airflow
  that results in repeated awakenings during sleep.
  
• The occurrence of these partial airway collapses
  can be documented by putting a catheter into the
  esophagus to measure pressure changes in the
  chest during breathing. These patients show
  marked changes in pressure during inspiration
  that are similar to those seen in patients with
  OSA.

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• SLEEP EVALUATION
• 1) Do you sometimes experience a creeping feeling
  in your legs?     Yes No
• 2) Do you or have you ever been told that you
  kick your legs at night?     Yes No
• 3) Do you snore?     Yes No I don't know
• If "yes" please continue with 4 If "no" or "I
  dont know" please continue with 8
• 4) Your snoring is...     softer than talking
      as loud as talking     louder than talking
• 5) Your snoring occurs...     every/almost every
  night     a few times each week     once a week
  or less
• 6) Your snoring is also...     frequently
  interrupted by pauses/choking     occasionally
  interrupted by pauses/choking     not
  interrupted as far as you know
• 7) Do you snore in every body position?     Yes
  No I don't know
• 8) Do you have, or ever had a bed partner?    
  Yes No

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• The MSLT measures how easily a person can fall
  asleep when given the chance across the day.
• The MSLT is the gold standard, but this one day
  test is not an accurate view of daily life. M.
  W. Johns in The Journal of Sleep Research 2000
  showed that the ESS is a more discriminating test
  of sleepiness in daily life than either the MSLT
  or the MWT in patients with Narcolepsy.

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• If "yes" please continue with 9 If "no" please
  continue with 12
• 9) Has your bed partner ever said that you have
  pauses in your breathing or periods of stopped
  breathing during your sleep?     Yes No
• 10) Has your bed partner ever commented that you
  snore?     Yes, loud snoring Yes, soft snoring
  No
• 11) If you snore, is it loud enough to bother
  her/him?     Yes No
• 12) Has anyone besides a bed partner ever
  commented on your snoring (roommate, neighbor,
  family, etc.)?     Yes, loud snoring Yes, soft
  snoring No
• 13) Do you feel fatigued or exhausted or tired or
  not up to par?     nearly every day     3 to 4
  times a week     once or twice a week     once
  or twice a month     never or hardly ever
• 14) Do you feel that in some way your sleep is
  not refreshing or restful?     nearly every day
      3 to 4 times a week     once or twice a
  week     once or twice a month     never or
  hardly ever
• 15) Do you have periods of the day when you have
  trouble paying attention, remembering things or
  staying awake?     nearly every day     3 to 4
  times a week     once or twice a week     once
  or twice a month     never or hardly ever
• 16) Do you have high blood pressure?     Yes No
• If "yes" are you being treated for high blood
  pressure?     Yes No
• 17) Do you wake up during the night or in the
  morning with headaches?     Yes No
• 18) Are you a shift worker?     Yes No
• 19) Do you have trouble initiating and/or
  maintaining sleep?     nearly every day     3
  to 4 times a week     once or twice a week    
  once or twice a month     never or hardly ever
• 20) What do you feel is your ideal amount of
  sleep per day?     2-4 5 6 7 8 9 10
• 21) Estimate the average number of hours of sleep
  you had per day during the last week.     2-4 5
  6 7 8 9 10

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• A number of studies have shown that The number of
  transient arousal periods and the severity of
  hypoxia correlate with the severity of
  hypersomnolence. (Newman et al., Journal of
  Epidemiology 2001)

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• OSA may be more common in certain ethnic groups
  such as Black Americans, and Hispanics. It is our
  impression that the prevalence will be quite high
  in Sikhs, in certain South Asian populations, and
  in Coastal Indians.

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• Sleep is usually in a Biphasic circadian pattern
  with the maximal sleepiness occurring between 2AM
  and 6AM and from 2 PM and 4PM.

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• In Sleep 2002 Drake and Roehrs discovered that
  the prevalence of excessive daytime sleepiness in
  the general population was 13 to 25 if a
  Multiple Sleep Latency Test (gold standard was
  used)

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• A Continuous Positive Airway Pressure Trial as a
  Novel Approach to the Diagnosis of the
  Obstructive Sleep Apnea Syndrome
• Oliver Senn, MD University Hospital of Zurich,
  Switzerland. Chest 2006
• Abstract
• Objectives Treatment of obstructive sleep apnea
  syndrome (OSA) is often delayed because
  polysomnography, the recommended standard
  diagnostic test, is not readily available. We
  evaluated whether the diagnosis of sleep apnea
  could be inferred from the response to a
  treatment trial with nasal continuous positive
  airway pressure (CPAP).
• Patients Seventy-six sleepy snorers
  consecutively referred for sleep apnea
  evaluation.
• Interventions CPAP treatment trial over 2 weeks
  as an initial diagnostic test in comparison with
  polysomnography, and treatment success over 4
  months.
• Measurements and results The main outcome was
  diagnostic accuracy of the CPAP trial. The trial
  result was positive if the patient had used CPAP
  for gt 2 h per night and wished to continue
  therapy. This suggested sleep apnea. The trial
  was evaluated in terms of predicting an
  obstructive apnea/hypopnea index (AHI) gt 10/h
  during polysomnography performed for validation,
  and in terms of identifying sleep apnea patients
  treated successfully over 4 months. Forty-four
  of 76 patients (58) had sleep apnea as confirmed
  by an AHI gt 10/h. The CPAP trial predicted sleep
  apnea with a sensitivity of 80, a specificity of
  97, and positive and negative predictive values
  of 97 and 78, respectively. In 35 of 76 sleep
  apnea patients (46) with positive CPAP trial
  results, polysomnography could have been avoided.
  These patients were prescribed long-term CPAP
  therapy. After 4 months, 33 of 35 patients (94)
  still used CPAP, and their symptoms remained
  improved. These patients were identified by the
  CPAP trial with positive and negative predictive
  values of 92 and 100, respectively.
• Conclusions In a selected population, a CPAP
  trial may help to diagnose OSA, to identify
  patients who benefit from CPAP, and to reduce the
  need for polysomnography.

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• Patient not wearing a dental appliance

• Same patient wearing a dental appliance

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