Common Sleep Disorders

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Managing Hypertension through the Patient
Centered Medical Home
Web Conference Series
12 1 p.m., June 17, 2009
Hypertension Obstructive Sleep Apnea Jacalyn A.
Nelson, MD, Dean Health System
Sponsored by
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Agenda

• Obstructive sleep apnea
• Hypertension
• Patient Centered Medical Home

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Definitions

• Obstructive Apnea
• Cessation of airflow at least ten seconds in
  duration
• With or without an oxygen desaturation or arousal
• Central Apnea
• No airflow
• No effort to breathe
• At least ten seconds in duration
• Hypopnea
• No universally accepted definition
• Commonly a 30 or greater airflow reduction
  accompanied by a 3 to 4 oxygen desaturation and
  arousal
• At least ten seconds in duration

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Definitions

• RERA (Respiratory Effort-Related Arousal)
• Increased respiratory effort leading to an
  arousal
• Does not meet the criteria for apnea or hypopnea
• At least ten seconds in duration

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Definitions

• Apnea/Hypopnea Index (AHI)
• The number of apneas plus hypopneas per hour of
  sleep
• Respiratory Disturbance Index (RDI)
• The AHI plus RERAs per hour of sleep
• Obstructive Sleep Apnea
• RDI (or sometimes AHI) 5

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Anatomy

• Pharyngeal Airway Patency
• Balance between upper airway muscles and
  intraluminal pressure

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Craniofacial Abnormalities

• Low-lying Soft Palate
• Elongated or Widened Uvula
• Tonsillar Hypertrophy
• Macroglossia
• Micrognathia
• Retrognathia
• Nasal Pathology
• Deviated Septum
• Turbinate Hypertrophy

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Craniofacial Abnormalities

• Low-lying Soft Palate
• Elongated or Widened Uvula
• Tonsillar Hypertrophy
• Macroglossia
• Micrognathia
• Retrognathia
• Nasal Pathology
• Deviated Septum
• Turbinate Hypertrophy

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Common Presenting Symptoms - Daytime

• Somnolence and/or fatigue
• Napping
• Drowsiness during daytime activities
• Falling asleep at the wheel
• Nodding off during meetings
• High caffeine intake
• Impaired memory and concentration
• Irritability
• Morning headaches

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Common Presenting Symptoms - Nocturnal

• Loud snoring
• Witnessed apneas
• Respiratory disturbances
• Sleep maintenance difficulties
• Diaphoresis
• Sensation of choking or dyspnea
• Nocturnal reflux
• Nocturia

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Risk Factors

• Obesity
• BMI gt 25
• Android-type fat deposition
• Age
• gt 65
• Craniofacial Abnormalities
• Behavioral Factors
• Alcohol and Sedatives
• Smoking

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Risk Factors

• Genetic Influences
• Positive family history
• African-American, Asian, Hispanic ethnicity
• Associated Medical Conditions

• Trisomy 21
• Achondroplasia
• Arnold-Chiari
• Klippel-Feil

• Pierre Robin
• Marfans Syndrome
• Hypothyroidism

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Diagnosis

• Quick Assessment Tool
• Epworth Sleepiness Scale (Sleep, 1999)
• Validated tool
• Overnight Polysomnography

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Epworth Sleepiness Scale (ESS)
Use the following scale to choose the most
appropriate number for each situation 0 would
never doze or sleep 1 slight chance of dozing
or sleeping 2 moderate chance of dozing or
sleeping 3 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 up
all scores) _____
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Adverse Associations

• Causes hypertension
• Associated with
• Stroke
• Myocardial infarction
• Sudden death at night
• Right-sided heart failure
• Cor pulmonale
• Atrial fibrillation
• Diabetes mellitus
• Depression

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Epidemiology of Sleep Apnea

• Current prevalence data inaccurate
• Wisconsin Sleep Cohort Study (1993)
• AHI gt 5
• 2 of women
• 4 of men
• Sleep Heart Health Study (1997)
• RDI gt 15
• In this study, RDI AHI
• 22 of 1824 people

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Epidemiology of Sleep Apnea Hypertension

• 45 of patients with hypertension have sleep
  apnea
• 80 of patients with drug resistant hypertension
  have sleep apnea

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Pathophysiology of Sleep Apnea Hypertension

• Sympathetic activation is probably causal
• Increased hypoxia and hypercapnea act through
  chemoreflexes to activate the sympathetic nervous
  system and vasoconstriction
• When breathing resumes, there is an inspiratory
  increase in ventricular filling leading to
  increase in stroke volume
• Vagolytic effects of inspiration cause
  tachycardia
• Increased stroke volume and heart rate lead to
  increased cardiac output which enters
  vasoconstricted circulation
• (Fletcher, J Sleep Res, 1995)

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Pathophysiology of Sleep Apnea Hypertension

• Other candidate mechanisms include
• Modification of the cardiovascular system in
  response to the large change in intra-thoracic
  pressure (Ehlenz, J Sleep Res, 1995)
• Increased stress from sleep disruption
  (Guilleminault, J Sleep Res, 1995)
• Endothelial dysfunction (Ip, Am J Respir Cri Care
  Med, 2004)

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Treatment

• CPAP is the most efficacious treatment for sleep
  apnea
• CPAP may lower blood pressure
• Approximate 10 mmHg drop in systolic and
  diastolic BP (Becker, et al., 2003)

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Composite Patient

• 55 year old female w/ CC of snoring, restless
  sleep, fatigue and daytime sleepiness
• Started antidepressants three years ago
• Has gained 20 pounds
• Past medical history
• Impaired glucose
• Depression
• Hypothyroidism

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Composite Patient

• Exam
• BP 136/82
• Weight 170 pounds on a 55 frame
• Oropharyngeal exam
• Low-lying palate
• Mild retrognathia
• Otherwise unremarkable
• Sleep schedule
• Bedtime 1030 or 11 PM
• Wake time 530 AM
• Awakening three to four times per night
• Has difficulty getting back to sleep one to two
  times per week
• ESS 12

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Composite Patient

• Polysomnography
• RDI 18
• Low oxygen saturation 83
• CPAP titration
• Titrated to 9 cmH2O
• Patient returns to clinic
• Feeling better
• BP 126/78

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Conclusion

• Sleep apnea is fairly common
• Large impact on overall health
• Causal role in the development of hypertension
• Compelling evidence that treating sleep apnea
  lowers blood pressure
• Patient Centered Medical Home
• Identifying sleep apnea in patients
• Monitoring CPAP compliance

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Patient Centered Medical Home Overview

• In a Patient Centered Medical Home
• Patients have a relationship with a personal
  physician.
• A practice-based care team takes collective
  responsibility for the patients ongoing care.
• The care team is responsible for providing or
  arranging all the patients health care needs.
• The results are
• ? Better health outcomes
• ? Lower costs
• ? Greater equity in health

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12 Components of the Patient Centered Medical Home

• ? After Hours Coverage
• ? Chronic Care Model
• ? Disease Registry
• ? Electronic Health Records
• ? Email with Patients
• E-Prescribing

• ? Evidence-Based Clinical Guidelines
• ? Group Visits
• ? Office Redesign
• ? Open Access Scheduling
• Quality Outcomes Measurements
• ? Team Approach

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Managing Hypertension through the Patient
Centered Medical Home
Hypertension Obstructive Sleep Apnea
CME Credit

• This activity has been reviewed and is acceptable
  for up to 1 Prescribed credit by the American
  Academy of Family Physicians. To receive CME
  credit you must complete the pre- and post-test.
  The link for the post-test will be sent to your
  email address following the webinar.
• If you do not receive the link by June 20, please
  contact Wisconsin Academy of Family Physicians
  Project Coordinator Sheri Urban at 262/512-0606
  or email academy_at_wafp.org.

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Managing Hypertension through the Patient
Centered Medical Home
Thank you for joining us for Hypertension
Obstructive Sleep Apnea. The next presentation in
the series will be   Hypertension Chronic
Kidney Disease Paul S. Kellerman, MD, FACP 12-1
p.m., July 16, 2009 Explore the relationship
between hypertension and chronic kidney disease
with Paul S. Kellerman, MD, FACP, an Associate
Professor of Medicine in the UW School of
Medicine and Public Health Nephrology Division,
the Director of ESRD and the Director of the UW
Hypertension Clinic.
For more information on the Patient Centered
Medical Home in Wisconsin, visit
www.wafp.org/pcmh.
Thank you to Fred Petillo, Julie Shinefield,
Cindy Huber and David Eitrheim, MD for their
assistance in developing the webinar series.