Obstructive Sleep Apnea:Obstructive Sleep Apnea:A Serious EpidemicA Serious Epidemic

Obstructive Sleep Apnea Obstructive Sleep Apnea A Serious EpidemicA Serious Epidemic

M.A.Hamadeh,M.D,FCCP,FAAMAssoc. Clinical Professor, Med.University of Illinois School of

MedicineDirector, Sleep Disorders Centers, Christ Hospital &

Medical Center

Sleep ApneaSleep Apnea

Sleep Apnea is:Sleep Apnea is:

•CommonCommon

•DangerousDangerous

•Easily recognizedEasily recognized

•TreatableTreatable

Types of Sleep Disordered Types of Sleep Disordered BreathingBreathing

•ApneaApnea– Cessation of airflow Cessation of airflow >> 10 seconds 10 seconds

•HypopneaHypopnea– Decreased airflow Decreased airflow 30% from 30% from

baseline lasting baseline lasting >> 10 seconds 10 seconds associated with associated with >> 4% 4% oxyhemoglobin desaturationoxyhemoglobin desaturation

Apnea PatternsApnea Patterns

ObstructiveObstructive MixedMixed CentralCentral

Airflow

Respiratoryeffort

Obstructive ApneaObstructive Apnea

Central ApneaCentral Apnea

Mixed ApneaMixed Apnea

Obstructive HypopneaObstructive Hypopnea

Respiratory Effort-related Respiratory Effort-related ArousalsArousals

RERA: Respiratory Effort-RERA: Respiratory Effort-related Arousal related Arousal (Guilleminault, 1993)(Guilleminault, 1993)

A sequence of breaths characterized by A sequence of breaths characterized by increasing respiratory effort leading to an increasing respiratory effort leading to an arousal from sleep which does not meet arousal from sleep which does not meet criteria for an apnea or hypopnea. These criteria for an apnea or hypopnea. These events must fulfill both of the following events must fulfill both of the following criteria:criteria: 1. Pattern of progressively more negative 1. Pattern of progressively more negative

esophageal pressure, terminated by a sudden esophageal pressure, terminated by a sudden change in pressure to a less negative level change in pressure to a less negative level and an arousaland an arousal

2. The event lasts 10 seconds or longer.2. The event lasts 10 seconds or longer.UARS (Upper Airway Resistance Syndrome):UARS (Upper Airway Resistance Syndrome):

>> 5 RERA’s per hour of sleep 5 RERA’s per hour of sleep

What About “Simple Snoring?”What About “Simple Snoring?”• Snoring in pregnancy is associated with Snoring in pregnancy is associated with

increased hypertension and growth retardation, increased hypertension and growth retardation, controlling for weight, age, smoking controlling for weight, age, smoking (Franklin, Chest, (Franklin, Chest, 2000)2000)

• Snoring is associated with cognitive decline Snoring is associated with cognitive decline (Quesnot, J Am Geriatric Soc, 1999)(Quesnot, J Am Geriatric Soc, 1999)

• Snoring medical students are more likely to fail Snoring medical students are more likely to fail exams, controlling for BMI, age, sex exams, controlling for BMI, age, sex (Ficker, Sleep, (Ficker, Sleep, 1999).1999).

• Snoring is a risk factor for cardiovascular Snoring is a risk factor for cardiovascular disease in women. disease in women. (Hu, J Am Coll Cardiol 2000).(Hu, J Am Coll Cardiol 2000).

• Snoring is a risk for type II diabetes Snoring is a risk for type II diabetes (Al-Delaimy, Am J (Al-Delaimy, Am J Epidemiol 2002).Epidemiol 2002).

• Snoring women have faster progression of CAD Snoring women have faster progression of CAD ((Leineweber C. Sleep 2004)Leineweber C. Sleep 2004)

Measures of Sleep Apnea Measures of Sleep Apnea FrequencyFrequency

• Apnea IndexApnea Index

– # apneas per hour of sleep# apneas per hour of sleep

• Apnea / Hypopnea Index (AHI)Apnea / Hypopnea Index (AHI)

– # apneas + hypopneas per hour # apneas + hypopneas per hour of sleepof sleep

• Respiratory Disturbance IndexRespiratory Disturbance Index

– # apneas + hypopneas + RERAs per hour of # apneas + hypopneas + RERAs per hour of sleepsleep

Severity Criteria Based on PSG Severity Criteria Based on PSG From the American Academy of From the American Academy of Sleep Medicine Sleep Medicine (Sleep, 1999)(Sleep, 1999)

• ““Mild” sleep apnea is 5-15 events/hrMild” sleep apnea is 5-15 events/hr

• ““Moderate” sleep apnea is 15-30 Moderate” sleep apnea is 15-30 events/hrevents/hr

• ““Severe” sleep apnea is over 30 Severe” sleep apnea is over 30 events/hrevents/hr

• (“Events” includes apneas, (“Events” includes apneas, hypopneas, and RERA’s)hypopneas, and RERA’s)

One Definition of Obstructive One Definition of Obstructive Sleep Apnea (OSA)Sleep Apnea (OSA)

CPAP will be covered for adults with sleep-CPAP will be covered for adults with sleep-disordered breathing if:disordered breathing if:– AHI (or RDI) AHI (or RDI) >> 15 15 OROR– AHI (or RDI) AHI (or RDI) >> 5 with (“mild, symptomatic”) 5 with (“mild, symptomatic”)

•HypertensionHypertension•StrokeStroke•SleepinessSleepiness•Ischemic heart diseaseIschemic heart disease•InsomniaInsomnia•Mood disordersMood disorders

Sleep-Disordered Breathing is Sleep-Disordered Breathing is a Spectruma Spectrum

Prevalence of Sleep ApneaPrevalence 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.

Why Sleep Apnea Isn’t Going Away…..Why Sleep Apnea Isn’t Going Away…..

SDB with AgingSDB with Aging

Sleep Apnea vs Sleep Sleep Apnea vs Sleep DisordersDisorders•Prevalence of common sleep Prevalence of common sleep

disordersdisorders– Insomnia: 10-30%Insomnia: 10-30%– Sleep Apnea: 5%Sleep Apnea: 5%– RLS: 10%RLS: 10%– Narcolepsy: 0.05%Narcolepsy: 0.05%

•Diagnoses of patients presenting Diagnoses of patients presenting to sleep centers to sleep centers (Coleman II, 2000)(Coleman II, 2000)

– Sleep apnea: 67.8Sleep apnea: 67.8– RLS: 4.9%RLS: 4.9%– Narcolepsy 3.2%Narcolepsy 3.2%

1

2

3

4

5

6

7

8

9

The Upper AirwayThe Upper Airway

Control of Dilator MusclesControl of Dilator MusclesEffects On Pharyngeal Muscle Activity

Normal Subject

Awake

OSA Patient

NREM

Genioglossus EMG

Tensor Palatini EMG

Airflow

Genioglossus EMG

Tensor Palatini EMG

Airflow

Pathophysiology of ApneaPathophysiology of Apnea

Wakefulness Sleep

Pathophysiology of Sleep Pathophysiology of Sleep ApneaApneaAwake: 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

Clinical ConsequencesClinical Consequences

Cardiovascular Complications

Morbidity

Mortality

Sleep FragmentationHypoxia/ Hypercapnia

Excessive Daytime Sleepiness

Sleep Apnea

Consequences: Consequences: Excessive Daytime SleepinessExcessive Daytime Sleepiness

• Increased motor vehicle crashesIncreased motor vehicle crashes

• Increased work-related accidentsIncreased work-related accidents

• Poor job performancePoor job performance

• DepressionDepression

• Family discordFamily discord

• Decreased quality of lifeDecreased quality of life

Consequences: Consequences: Automobile AccidentsAutomobile Accidents

Sassani, et al., Sleep 2004; 27:453

Consequences: Consequences: Automobile AccidentsAutomobile 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: Consequences: CardiovascularCardiovascular• Systemic hypertensionSystemic hypertension

• Cardiac arrhythmiasCardiac arrhythmias

• Cardiovascular disease Cardiovascular disease

– Myocardial ischemiaMyocardial ischemia

– Congestive heart failureCongestive heart failure

• Cerebrovascular diseaseCerebrovascular disease

Consequences: MortalityConsequences: Mortality

Marshall et al. Sleep 2008; 31:1079-1085Young et al. Sleep 2008; 31:1071-1078

Busselton, AustraliaWisconsin Cohort

RDI > 15

RDI < 5

RDI 5-15

Years of follow-up

Consequences: Consequences: HypertensionHypertension

Shepard JW Jr. Med Clin North Am 1985;69.

Cardiovascular Cardiovascular Consequences: Consequences: HypertensionHypertension

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: ArrhythmiasConsequences: Arrhythmias

Consequences: Consequences: Cardiovascular DiseaseCardiovascular 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.

OSA and StrokeOSA and Stroke

00.5

11.5

22.5

33.5

44.5

Unadjusted A/ GAdjusted

A/ G/ BMIAdjusted

AHI<5AHI 5-20AHI>20

* *

Arzt, et al., AJRCCM 2005; 172:1447.

Sleep Apnea Risk FactorsSleep Apnea Risk Factors• ObesityObesity

• Increasing ageIncreasing age

• Male genderMale gender

• Anatomic abnormalities of upper Anatomic abnormalities of upper airwayairway

• Family historyFamily history

• Alcohol or sedative useAlcohol or sedative use

• SmokingSmoking

• Associated conditionsAssociated conditions

Risk Factor: ObesityRisk 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: AgeRisk 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.

Risk Factor: GenderRisk 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 Risk Factor: Anatomic AbnormalityAbnormality

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 HistoryRisk 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: SedativesRisk 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: AlcoholRisk 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: SmokingRisk 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

Diagnosis: HistoryDiagnosis: History• Snoring (loud, chronic)Snoring (loud, chronic)

• Nocturnal gasping and chokingNocturnal gasping and choking– Ask bed partner (witnessed apneas)Ask bed partner (witnessed apneas)

• Automobile or work related accidentsAutomobile or work related accidents

• Personality changes or cognitive Personality changes or cognitive problemsproblems

• Risk factorsRisk factors

• Excessive daytime sleepinessExcessive daytime sleepinessSleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.

Diagnosis: Diagnosis: Assessing Daytime SleepinessAssessing Daytime Sleepiness

• Often unrecognized by patientOften unrecognized by patient

– Ask family membersAsk family members

• Must ask specific questionsMust ask specific questions

– Fatigue vs. sleepinessFatigue vs. sleepiness

– Auto crashes or near missesAuto crashes or near misses

– Sleep in inappropriate settingsSleep in inappropriate settings

•WorkWork

•Social situationsSocial situations

Diagnosis: Physical Diagnosis: Physical ExaminationExamination• Upper body obesity / thick neckUpper body obesity / thick neck

>> 17” males 17” males

>> 16” females 16” females

• HypertensionHypertension

• Obvious upperObvious upper airway abnormalityairway abnormality

Exam: Tonsillar HypertrophyExam: Tonsillar Hypertrophy

Shepard JW Jr et al. Mayo Clin Proc 1990;65.

Oropharynx With Tonsillar HypertrophyNormal Oropharynx

Exam: OropharynxExam: OropharynxPatient With the Crowded Oropharynx

Exam: OropharynxExam: OropharynxClass I

Class III

Class II

Class IV

Physical ExaminationPhysical Examination

Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978.

Structural Abnormalities

Diagnosis: Pediatric ApneaDiagnosis: Pediatric Apnea

• PresentationPresentation– Behavioral problems / irritabilityBehavioral problems / irritability– Poor school performancePoor school performance– EnuresisEnuresis– SnoringSnoring

• CauseCause– Adenotonsillar hypertrophyAdenotonsillar hypertrophy– Craniofacial abnormalityCraniofacial abnormality– Frequently not obeseFrequently not obese

Pediatric Sleep ApneaPediatric Sleep ApneaChild with Sleep Apnea Child’s Enlarged Palatine & Adenoidal

Tonsils

Why Get a Sleep Study?Why Get a Sleep Study?• Signs and symptoms poorly predict Signs and symptoms poorly predict

disease severitydisease severity

• Appropriate therapy dependent on Appropriate therapy dependent on severityseverity

• Failure to treat leads to:Failure to treat leads to:– Increased morbidityIncreased morbidity– Motor vehicle crashesMotor vehicle crashes– MortalityMortality

• Other causes of daytime sleepinessOther causes of daytime sleepiness

What Test Should be Used?What Test Should be Used?

• In-laboratory full night In-laboratory full night polysomnographypolysomnography

– Split night studiesSplit night studies

• Home diagnostic systemsHome diagnostic systems

– Oximetry to full polysomnography Oximetry to full polysomnography

PolysomnographyPolysomnography

PolysomnogramPolysomnogram

Full-Night In-Laboratory Full-Night In-Laboratory PolysomnographyPolysomnography

• ProPro

– Full set of variables obtainedFull set of variables obtained

– Equipment problems can be repairedEquipment problems can be repaired

– Technician can address patient problemsTechnician can address patient problems

• ConCon

– CostCost

– AccessibilityAccessibility

– Patient sleeps away from home Patient sleeps away from home

• ProPro– Reduced costReduced cost– Patient Patient maymay be studied only once be studied only once– Reduces time to treatment initiationReduces time to treatment initiation

• ConCon– Diagnostic time may be inadequateDiagnostic time may be inadequate– Treatment time limitedTreatment time limited– Protocol decisions to start CPAP may be difficult Protocol decisions to start CPAP may be difficult

to make during data acquisition to make during data acquisition

Split-Night In-Laboratory Split-Night In-Laboratory PolysomnographyPolysomnography

Home Study TracingHome Study Tracing

Home StudyHome Study• ProPro

– Potentially less expensivePotentially less expensive

– Patient sleeps at homePatient sleeps at home

• ConCon

– Generally fewer signals are recordedGenerally fewer signals are recorded

– Equipment cannot be adjustedEquipment cannot be adjusted

– Technician cannot assist patient Technician cannot assist patient

Diagnostic ConclusionsDiagnostic Conclusions• Signs and symptomsSigns and symptoms

– Excessive daytime sleepinessExcessive daytime sleepiness

– Hypertension and other cardiovascular Hypertension and other cardiovascular sequelaesequelae

• Sleep study resultsSleep study results– Apnea / hypopnea frequencyApnea / hypopnea frequency

– Sleep fragmentationSleep fragmentation

– Oxyhemoglobin desaturation Oxyhemoglobin desaturation

Treatment ObjectivesTreatment Objectives

• Reduce morbidity and mortalityReduce morbidity and mortality

– Reduce sleepinessReduce sleepiness

– Decrease cardiovascular consequencesDecrease cardiovascular consequences

• Improve quality of life Improve quality of life

Therapeutic ApproachTherapeutic Approach• Risk counselingRisk counseling

– Motor vehicle crashesMotor vehicle crashes

– Job-related hazardsJob-related hazards

– Judgment impairmentJudgment impairment

• Apnea and co-morbidity treatmentApnea and co-morbidity treatment– BehavioralBehavioral

– MedicalMedical

– Surgical Surgical

The High-Risk DriverThe High-Risk Driver• Educate patientEducate patient

• Document warningDocument warning

• Resolve apnea quicklyResolve apnea quickly

• Follow-upFollow-up

– EffectivenessEffectiveness

– ComplianceCompliance

Behavioral InterventionsBehavioral Interventions• Encourage patients to:Encourage patients to:

– Lose weightLose weight

– Avoid alcohol and sedativesAvoid alcohol and sedatives

– Avoid sleep deprivationAvoid sleep deprivation

– Avoid supine sleep positionAvoid supine sleep position

– Stop smokingStop smoking

Weight LossWeight Loss• Should be prescribed for all obese Should be prescribed for all obese

patientspatients

• Can be curative but has low success Can be curative but has low success raterate

• Other treatment is required until Other treatment is required until optimal weight loss is achievedoptimal weight loss is achieved

Weight Loss and Sleep Weight Loss and Sleep ApneaApnea

-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 WeightAdapted from Peppard PE et al. JAMA 2000;284.

Mean Change in AHI, Events/hr

Weight Loss and Sleep Weight Loss and Sleep ApneaApnea

Smith PL et al. Ann Intern Med 1985;103.

Baseline

20

40

60

80

100

5

10

15

20

40

Weight Loss Baseline Weight Loss

Apnea Frequency(EPISODES/HOUR)

Mean Fall Sa02(PERCENT)

Sleep-Position TrainingSleep-Position Training

Medical InterventionsMedical Interventions• Positive airway pressurePositive airway pressure

– Continuous positive airway pressure Continuous positive airway pressure (CPAP)(CPAP)

– Bi-level positive airway pressureBi-level positive airway pressure

• Oral appliancesOral appliances

• Other (limited role)Other (limited role)– MedicationsMedications

– OxygenOxygen

Positive Airway PressurePositive Airway Pressure

Positive Airway PressurePositive Airway Pressure

Benefits of CPAP: MortalityBenefits of CPAP: Mortality96%

91%86%

Campos-Rodriguez, et al., Chest 2005; 128:624

Benefits of CPAP: SleepinessBenefits 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: Benefits of CPAP: PerformancePerformance

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: Positive Airway Pressure: ProblemsProblems

Patient Acceptance Claustrophobia Aerophagia Chest Discomfort

Mask Discomfort

CPAP for OSA: BenefitsCPAP for OSA: Benefits

• Improved cognitive functionImproved cognitive function• Improved quality of lifeImproved quality of life• Reduced daytime sleepinessReduced daytime sleepiness• Reduced risk of automobile accidentsReduced risk of automobile accidents• Reduced health care costsReduced health care costs• Reduced blood pressureReduced blood pressure• Reduced cardiac arrhythmiasReduced cardiac arrhythmias• Improved glucose toleranceImproved glucose tolerance• Reduced mortality rateReduced mortality rate• Reversal of impotenceReversal of impotence

Positive Airway Pressure: Positive Airway Pressure: ProblemsProblems

CPAP ComplianceCPAP Compliance• Patient report: 75%Patient report: 75%

• Objectively measured useObjectively measured use

>> 4 hrs for 4 hrs for >> 5 nights / week: 5 nights / week: 46%46%

• Asthma-medicine compliance: Asthma-medicine compliance: 30%30%

Mea

n p

erce

nta

ge

day

s C

PA

P u

sed

Adapted from Kribbs NB et al. Am Rev Respir Dis 1993;147.

CPAP ComplianceCPAP Compliance

Time CPAP used

CPAP Compliance: CPAP Compliance: PredictorsPredictors• Predict Good Predict Good

ComplianceCompliance– Increased AHIIncreased AHI– Increased daytime Increased daytime

sleepinesssleepiness– Perception of Perception of

benefitbenefit

• Predict Poor Predict Poor ComplianceCompliance– Lack of EDSLack of EDS– Lack of perceived Lack of perceived

benefitbenefit– Nasal obstructionNasal obstruction– Side effectsSide effects– ClaustrophobiaClaustrophobia

Strategies to Improve Strategies to Improve ComplianceCompliance

• Patient EducationPatient Education• Frequent and early follow-upFrequent and early follow-up• Machine-patient interfacesMachine-patient interfaces

– MasksMasks– Nasal pillowsNasal pillows– Chin strapsChin straps

• HumidifiersHumidifiers• RampRamp• DesensitizationDesensitization• Pressure relief CPAP or Bi-level pressurePressure relief CPAP or Bi-level pressure

CPAP MasksCPAP Masks

CPAP RampingCPAP Ramping

Pressman MR et al. Am J Respir Crit Care 1995;151 © American Lung Association.

Effect of Recurrent Use of Ramping on Nocturnal Saturation

Bi-level Positive Airway Bi-level Positive Airway PressurePressure

Positive Pressure Therapy

15

CPAP Bi-level

10

5

0

Pressure

FlowInsp

Exp

Compliance: CPAP Vs. Bi-Compliance: CPAP Vs. Bi-Level PAPLevel 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

Monitoring ComplianceMonitoring Compliance

• Most PAP units measure ‘mask-on’ Most PAP units measure ‘mask-on’ timestimes

• Adherence data can be downloaded Adherence data can be downloaded into compliance reportsinto compliance reports

• Objective monitoring recommended in Objective monitoring recommended in treatment guidelinestreatment guidelines

• Objective monitoring required by CMSObjective monitoring required by CMS

Monitoring ComplianceMonitoring Compliance

Oral AppliancesOral Appliances• IndicationsIndications

– Snoring and apnea (not severe)Snoring and apnea (not severe)

• EfficacyEfficacy

– Variable with 52% of patients with Variable with 52% of patients with AHI<10/hr on treatmentAHI<10/hr on treatment

• Side effectsSide effects

– TMJ discomfort, dental TMJ discomfort, dental misalignment, and salivationmisalignment, and salivation

Oral AppliancesOral AppliancesVariables that Effect EfficacyVariables that Effect Efficacy

• Severity of OSA: higher success with Severity of OSA: higher success with mild to moderate disease (AHI <30-40)mild to moderate disease (AHI <30-40)

• Degree of protrusion: more effective Degree of protrusion: more effective with increased protrusionwith increased protrusion

• Positionality of SDB: more effective in Positionality of SDB: more effective in patients with supine-dependent OSApatients with supine-dependent OSA

• BMI: more effective in patients with BMI: more effective in patients with lower BMIlower BMI

Sleep 2006;29:244

Oral Appliance: MechanicsOral Appliance: Mechanics

Supplemental OxygenSupplemental Oxygen• Not a primary treatment for sleep Not a primary treatment for sleep

apneaapnea

• Does not improve daytime sleepinessDoes not improve daytime sleepiness

• May prolong apneasMay prolong apneas

• Reduces oxygen desaturation during Reduces oxygen desaturation during

apneasapneas

• Reduces arrhythmiasReduces arrhythmias

Pharmacologic TreatmentPharmacologic Treatment• Limited RoleLimited Role

– Protriptyline or fluoxetineProtriptyline or fluoxetine

– DecongestantsDecongestants

– Nasal steroidsNasal steroids

– AntihistaminesAntihistamines

– OtherOther

Surgical AlternativesSurgical Alternatives• Reconstruct upper airwayReconstruct upper airway

– Uvulopalatopharyngoplasty (UPPP)Uvulopalatopharyngoplasty (UPPP)– Radiofrequency tissue volume reductionRadiofrequency tissue volume reduction– Genioglossal advancementGenioglossal advancement– Nasal reconstructionNasal reconstruction– TonsillectomyTonsillectomy

• Bypass upper airwayBypass upper airway– TracheostomyTracheostomy

Sites of Airway NarrowingSites 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 Uvulopalatopharyngoplasty (UPPP)(UPPP)

• Usually eliminates snoringUsually eliminates snoring

• 41% chance of achieving AHI < 2041% chance of achieving AHI < 20

• No accurate method to predict surgical No accurate method to predict surgical successsuccess

• Follow-up sleep study requiredFollow-up sleep study required

Uvulopalatopharyngoplasty Uvulopalatopharyngoplasty (UPPP)(UPPP)

Primary Care ManagementPrimary Care Management• Risk counselingRisk counseling

• Behavior modificationBehavior modification

• Monitor symptoms and complianceMonitor symptoms and compliance

– Monitor weight and blood pressureMonitor weight and blood pressure

– Ask about recurrence of symptomsAsk about recurrence of symptoms

– Evaluate CPAP use and side effectsEvaluate CPAP use and side effects

Sleep Apnea: Is Your Patient at Risk? NIH Publication No.95-3803.

Primary Care ManagementPrimary Care Management• Reasons for lack of improvementReasons for lack of improvement

– NoncomplianceNoncompliance

– Alcohol and sedative useAlcohol and sedative use

– DepressionDepression

– Poor sleep habitsPoor sleep habits

– Nonapneic sleep disorderNonapneic sleep disorder

• Persistent or recurrent symptomsPersistent or recurrent symptoms– Consider referral to sleep specialistConsider referral to sleep specialist

Sleep Medicine in the Sleep Medicine in the FutureFuture• The prevalence and importance of sleep The prevalence and importance of sleep

apnea are attracting attentionapnea are attracting attention

• Training and credentialing have changedTraining and credentialing have changed

• Diagnostic approaches are simplifying, Diagnostic approaches are simplifying, and multiplyingand multiplying

• Reimbursement will continue to fall. Reimbursement will continue to fall.

• Treatment approaches are changingTreatment approaches are changing

• The field is vulnerableThe field is vulnerable

Portable Monitoring (or Portable Monitoring (or oximetry) is to in-lab PSG as…oximetry) is to in-lab PSG as…

• CXR is to CT scan (lung cancer)CXR is to CT scan (lung cancer)

• Pre-post spirometry is to Pre-post spirometry is to methacholine challenge (asthma)methacholine challenge (asthma)

• Fasting glucose is to oral glucose Fasting glucose is to oral glucose challenge test (diabetes)challenge test (diabetes)

Outcomes of Home-Based Diagnosis Outcomes of Home-Based Diagnosis and Treatment of Obstructive Sleep and Treatment of Obstructive Sleep Apnea Apnea Chest 2010; 138: 257-263Chest 2010; 138: 257-263

• Home testing and autoCPAP resulted Home testing and autoCPAP resulted in the same results in sleepiness, in the same results in sleepiness, adherence, blood pressure and QoL adherence, blood pressure and QoL as in-lab testing. as in-lab testing.

• ““It is really not about the It is really not about the technology; it is about the initial and technology; it is about the initial and then chronic care of the patient….” then chronic care of the patient….” (Dr N Collop, editorial)(Dr N Collop, editorial)

CPAP as a Therapeutic TrialCPAP as a Therapeutic Trial (Senn O Chest 2006, n= 33) (Senn O Chest 2006, n= 33)

• Autotitrating CPAP, 4-15 cm HAutotitrating CPAP, 4-15 cm H220, was used as the 0, was used as the therapeutic trialtherapeutic trial

• A successful trial was “yes” toA successful trial was “yes” to– Are you willing to continue CPAP treatment?Are you willing to continue CPAP treatment?– Was objective CPAP use > 2 hours/night? Was objective CPAP use > 2 hours/night?

• All underwent PSG; sleep apnea was considered an All underwent PSG; sleep apnea was considered an AHI of > 10AHI of > 10

• Excluded were those with CHF, OHS, underlying lung Excluded were those with CHF, OHS, underlying lung disease, prior CPAP Rx, psych or illness, language disease, prior CPAP Rx, psych or illness, language problemsproblems

• Those who were diagnosed with OSA on basis of TT Those who were diagnosed with OSA on basis of TT had same outcomes as in-lab diagnosed. had same outcomes as in-lab diagnosed.

Autotitrating CPAPAutotitrating CPAP(Ayas N, Sleep 2004)(Ayas N, Sleep 2004)

• Most commonly, increases pressure to Most commonly, increases pressure to eliminate vibration of palate and soft tissue.eliminate vibration of palate and soft tissue.

• Now costs about the same as “straight” CPAP.Now costs about the same as “straight” CPAP.

• May improve compliance.May improve compliance.

• Results in lower pressure over all.Results in lower pressure over all.

• Can obviate the need for in-lab titration, in Can obviate the need for in-lab titration, in many cases.many cases.

• Is supplanting in-lab titrationIs supplanting in-lab titration

Oral AppliancesOral Appliances(Kushida C, Sleep 2006)(Kushida C, Sleep 2006)

Indicated for patients with mild-to-Indicated for patients with mild-to-moderate obstructive sleep apnea whomoderate obstructive sleep apnea who

prefer oral appliances to CPAPprefer oral appliances to CPAP do not respond to CPAPdo not respond to CPAP are not appropriate candidates for CPAPare not appropriate candidates for CPAP fail treatment attempts with CPAP fail treatment attempts with CPAP ((Kushida Sleep Kushida Sleep

2006)2006)

Not as effective as CPAPNot as effective as CPAP Lower blood pressure 3-4 mmHg Lower blood pressure 3-4 mmHg (Otsuka Sleep (Otsuka Sleep

Breath 2006)Breath 2006)

Outperformed Outperformed surgerysurgery in the only head-to- in the only head-to-head trial.head trial.

Preferred to CPAP in head-to-head trials.Preferred to CPAP in head-to-head trials.

Do Oral Appliances Work?Do Oral Appliances Work?Cochrane Database Syst Rev. 2006 Jan 25;(1):CD001106.Cochrane Database Syst Rev. 2006 Jan 25;(1):CD001106.

““CPAP is effective in reducing symptoms of CPAP is effective in reducing symptoms of sleepiness and improving quality of life sleepiness and improving quality of life measures in people with moderate and measures in people with moderate and severe obstructive sleep apnoea (OSA). It severe obstructive sleep apnoea (OSA). It is more effective than oral appliances in is more effective than oral appliances in reducing respiratory disturbances in these reducing respiratory disturbances in these people but subjective outcomes are more people but subjective outcomes are more equivocal. Certain people tend to prefer equivocal. Certain people tend to prefer oral appliances to CPAP where both are oral appliances to CPAP where both are effective. This could be because they offer effective. This could be because they offer a more convenient way of controlling a more convenient way of controlling OSA.”OSA.”

Sleep ApneaSleep Apnea

Questions?