Sleep Apnea. ACP Oct 26, Bashir Chaudhary, MD Sleep Institute of Augusta, Augusta GA

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1 Sleep Apnea ACP Oct 26, 2014 Bashir Chaudhary, MD Sleep Institute of Augusta, Augusta GA Emeritus Professor of Medicine and Assistant Dean of Clinical Affairs, CAHS Medical College of Georgia, Georgia Health Sciences University

2 Future of Sleep Medicine? Main sleep problem will continue to be OSA In-lab studies are going to decrease Home studies are going to increase Shift of studies to PCPs Shift to studies to commercial companies Type of patients are going to be different New therapeutic modalities

3 Outcome Studies Equivalence between HST and in-lab PSG Patient satisfaction Quality of Life Epworth and other sleep measurement tools CPAP adherence (one study home)

4 Multi-Center Studies of HST Rosen CL, et al, Sleep 35:757, 2012 CPAP compliance (3months) 219 mins 281 mins p=0.001 Change in Epworth score p=0.65 Change in FOSQ p=0.38 Improved CPAP compliance but no difference in changes in other outcomes between two pathways

5 Sleep Apnea Snoring Sleepiness / tiredness Disturbed sleep

6

7

8

9

10 Clinical Features of OSA Awakenings / gasping or choking Awakenings for uncertain reasons Restless sleep Non-refreshing sleep Poor memory / intellectual function Irritability / personality change Morning headache / confusion

11 Obesity and OSA BMI kg/m 2 % OSA Neck size (inches) 30 Men: 17 Women: 16

12 Prevalence of OSA in obese patients % OSA Obese Severe Morbid Super obesity

13 Obesity and sleep apnea A majority of patients undergoing bariatric surgery have sleep apnea.

14 Percentage of OSA in bariatric surgery ( 7 studies, N: 1547) Total 1. Frey (2003) 2. O Keefe (04) 3. Lopez (08) 4. Hallowell (07)5. Sarelli (09) 6. Lee (09) 7. Ravesloot (2012)

15 % OSA in Men according to BMI and Age Age Age BMI < BMI >40 Young at el, J Apple Physiol 2005; 99 :1592-9

16 % OSA in Women according to BMI and Age Age: Age: BMI < BMI >40 Young et al, J Apple Physiol 2005; 99 :1592-9

17 Dietary Weight Loss and Sleep Apnea Meta analysis of 9 studies about dietary weight loss 5 Kg weight loss is associated with 48% reduction in AHI Anandam A et al. Sleep Breath 2012

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19 Obstructive sleep apnea Obstructive apneas 60 seconds (60 seconds) recording

20 Hypopnea

21

22 Severity of sleep apnea AHI Severity <5 Normal 5-15 Mild Moderate >30 Severe

23

24 Pickwickian Syndrome

25 Which of the following are true? (Select all that apply) 1. Majority of men with habitual snoring do not have OSA. 2. Majority of persons with OSA are sleepy. 3. Majority of persons with OSA are obese. 4. Complaint of insomnia makes the presence of OSA unlikely. 5. Dr. Fincher and Dr. Moore are members at Augusta National Golf Club. 40% 38% 11% 7% 4%

26 Majority of men with habitual snoring do not have OSA. 84% 1. True 2. False 16% 1. 2.

27 Snoring and sleep apnea Do most habitual snores have sleep apnea?

28 Prevalence of habitual snoring in adults Co Kara Kulak BurunBogas lhtis Derg. 2005;14(1-2):18-24 Males Females Habitual snoring 30% 9% Roommates unwilling to share room 9% 2% Willing to have medical attention 3% 1%

29 Prevalence of Sleep Apnea Hypersomnolence and AHI > 5: Men 4% Women 2% AHI > 5: Men 24% Women 9%

30 Most persons with sleep apnea are sleepy during the day. 86% 1. True 2. False 14% 1. 2.

31 Sleepiness Epworth Sleepiness Score

32 Sleepiness and OSA Sleepiness is considered a cardinal symptom of sleep apnea. However not all patients with sleep apnea are sleepy. What percent of the patients with severe sleep apnea are sleepy?

33 Sleepiness in OSA (Sleep Heart Health Study n:6440) n AHI ESS> < 5 21% % % 400 > 30 40% Kapur Sleep 2005;28:

34 Kapur Sleep 2005;28: % Sleepiness in Community OSA n: ESS >10 Sleepiness Unrested Any of AHI < >30

35 Sleepiness in OSA (Wisconsin sleep cohort n:1522) AHI ESS>10 <5 23% % % >30 37% Young Sleep 2008;3:

36 ESS>10 (sleepiness) and AHI SHHS Wisconsin % < >30 AHI

37 SLEEPINESS Most patients diagnosed to have sleep apnea are sleepy. However, most persons with sleep apnea do not complain of sleepiness.

38 Most persons with sleep apnea obese. 65% 1. True 2. False 35% 1. 2.

39 Effect of surgical weight loss on OSA Meta-analysis of 12 studies, n: Pre Post 10 0 BMI AHI Greenburg et al. Am J Med 2009; :

40 Effect of surgical weight loss on OSA Meta-analysis of 12 studies, n: 342 There was significant improvement in BMI and in AHI after surgery. Cure of sleep apnea (AHI of less than 5) was achieved in only 25% of the cases. Greenburg et al. Am J Med 2009; 122:

41 % prevalence of sleep apnea Men Women 0 USA USA Australia India China Korea n: Young Bixler Bearpark Udwalia Ip Kim

42 AHI AHI and weights in Asians and Caucasians Asians Caucasians < >31 Ong KC,, Clerk AA Resp Med 1998; 92: 843-8:

43 BMI in Asian OSA patients AHI<5 AHI>5 0 Korean Chinese- M Chinese- F Indian Kim Ip Ip Udwadia

44 29 28 BMI in a Spanish Community Study n: 2148 Men Women AHI < 5 AHI > 5 Duran et al. AJRCCM 2001; 163:685-9

45 % OSA OSA attributable to weight in men (community estimates) BMI > 25 BMI < Age: Age: Young at el, J Apple Physiol 2005; 99 :1592-9

46 OSA attributable to obesity ages % of adults have mild or worse SDB (AHI 5 ) 41% (7% of the total population) of those have OSA attributable to having a BMI of 25 kg/m2 or more. 5.7% of adults have moderate or worse SDB (AHI 15) and that 58% (3.3% of the total population) of those adults have SDB attributable to excess weight. Young at el, J Apple Physiol 2005; 99 :1592-9

47 Obesity and OSA Most patients diagnosed to have sleep apnea are obese. Most persons with sleep apnea are not obese.

48 Complaint of insomnia makes the 1. True 2. False presence of OSA unlikely. 89% 11% 1. 2.

49 Insomnia and OSA Sleep studies are not recommended for evaluation of insomnia. Many insurance companies do not approve sleep studies if a patient has a complaint of insomnia.

50 OSA and insomnia The presence of sleep onset insomnia does not rule out concomitant sleep apnea particularly in a patient with excessive caffeine intake. Sleep maintenance insomnia is common in patients with sleep apnea.

51 OSA and insomnia Prevalence of insomnia : 42% Sleep onset: 6% Maintenance: 26% Early morning: 19% Chung. Respiration 2005;72:460-5

52 Oral Pressure Therapy

53 Theravent

54 Upper Airway Stimulator

55 Dr. Fincher and Dr. Moore are members at Augusta National Golf Club. 1. True 2. False 0% 0% 1. 2.

56

57

58 The overall performance of the speaker: 1. Poor 2. Fair 3. Average 4. Good 5. Excellent 18% 76% 0% 6% 0%

59 Overall quality of this session: 1. Poor 86% 2. Fair 3. Average 4. Good 5. Excellent 0% 0% 9% 5% Poor Fair Average Good Excellent

60 How well were the learning objectives met? 1. Poor 64% 2. Fair 3. Average 36% 4. Good 5. Excellent 0% 0% 0% Poor Fair Average Good Excellent

61 Did speaker present a balanced view of therapeutic options? 1. Yes 2. No 3. N/A 95% 0% 5% Yes No N/A

62 Were relationships between grantor and speaker announced prior to the presentation? 95% 1. Yes 5% 2. No

63 How useful will this session be in your practice? 78% 1. Poor 2. Fair 3. Average 4. Good 17% 5. Excellent 0% 0% 6% Poor Fair Average Good Excellent

64 Yes No As a result of this program, do you intend to change your patient care? 1. Yes 93% 2. No 7%

65

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