Learning Objectives At the end of this session, the learner should be able to: Obstructive Sleep Apnea: The Under Recognized Killer

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1 Obstructive Sleep Apnea: The Under Recognized Killer Sleep Apnea: A Common Mechanism for the Deadly Triad---- Cardiovascular Disease, Diabetes, and Cancer? Susan Redline and Stuart Quan Am J Respir Crit Care Med Vol 186, July 2012 Learning Objectives At the end of this session, the learner should be able to: Describe and distinguish the physiologic characteristics of an apnea and hypopnea. List the major risk factors for sleep apnea in adults. Recognize the evidence-based link between sleep apnea, hypertension, cardiovascular disease, and mortality. Understand the treatment options available for OSA Airway Collapse: Repeated Asphyxia Visual Representation of an Apnea: Cessation of Airflow State Shift to Sleep Respiratory Effort Related Arousal Upper Airway Collapse Hypoxia + Obstruction L EOG R EOG O1 A2 C3 A2 Chin EMG ECG Leg EMG NC AF Th AF Chest Abd SaO 2 Arousal from sleep Apnea Courtesy of Phillips BA, personal communication, July 13, 2009.

2 Visual Representation of Hypopneas: Reduction of Airflow Physiologic Consequences of OSA L EOG R EOG O1 A2 C3 A2 Chin EMG ECG Leg EMG NC AF Th AF Chest Abd SaO 2 Repetitive Arousal Daytime Sleepiness Sleep Disruption Courtesy of Phillips BA, personal communication, July 13, Physiologic Consequences of OSA Common Terms AHI = Apnea hypopnea index Number of apneas and hypopneas per hour of sleep Hypoxia Hypercapnia Sympathetic Nervous System Activation RDI = Respiratory disturbance index Number of apneas, hypopneas and respiratory effort-related arousals (RERAs) per hour of sleep SDB = Sleep-disordered breathing May include these terms: sleep apnea, upper airway resistance syndrome, sleep-related hypoventilation, and sleep-related hypoxemia Arousal UARS = Upper airway resistance syndrome > 5 RERAs per hour of sleep without significant apnea/hypopnea

3 Severity of Sleep Apnea Severity criteria (adults) Mild: 5-14 Moderate: Severe: > 30 Judging severity also depends on: Degree of sleep disturbance Degree of hypoxemia Associated arrhythmias Duration of respiratory events UARS Sleep apnea without the apnea Hypersomnia due to arousals and sleep disruption caused by attempts to breathe through narrowed airway No measurable apnea, hypopnea, or hypoxemia, but frequent RERAs (Respiratory Effort Related Arousals) Younger, healthier patients Mildest form of sleep-disordered breathing UARS Symptoms out of proportion to polysomnogram (PSG) findings May be as pathologically sleepy as OSA or narcolepsy patients with same consequences: Falling asleep driving Poor school performance Poor judgment Management options same as that for mild OSA Epidemiology and Risk Factors: Characteristics The most serious common sleep disorder More recent estimates: 5% to 9% of adults in Western countries Incidence is about 2% per year for AHI > 15 Approximately the same prevalence as asthma in the general population 26% to 32% of patients in primary care medical offices have sleep apnea Information from Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17): ; Tishler PV, Larkin EK, Schluchter MD, et al. Incidence of sleepdisordered breathing in an urban adult population: the relative importance of risk factors in the development of sleepdisordered breathing. JAMA. 2003;289(17): ; Hiestand DM, Britz P, Goldman M, et al. Prevelance of symptoms and risk factors of sleep apnea in the US population: Results from the National Sleep Foundation Sleep in America 2005 poll. Chest. 2006;130(3): ; Netzer NC, Hoegel JJ, Loube D, et al; Sleep in Primary Care International Study Group. Prevalance of symptoms and risk of sleep apnea in primary care. Chest. 2003;124(4):

4 Major Risk Factors Major factors include: Obesity associated with adult OSA Snoring Male gender (until about age 50) Postmenopausal state Upper airway anatomic obstruction (including nose) Ethnicity: black, Asian, or Hispanic Obesity and OSA Lateral Fat Pads Information from Kripke DF, Ancoli-Israel S, Klauber MR, et al. Prevalence of sleep-disordered breathing in ages years: a population based survey. Sleep. 1997;20(1):65-76; Tsai WH, Remmers JE, Brant R, et al. A decision rule for diagnostic testing in obstructive sleep apnea. Am J Respir Crit Care Med. 2003;167(10): ; Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165(9): ; Young T, Shahar E, Nieto FJ, et al. Predictors of sleep-disordered breathing in community-dwelling adults: The Sleep Heart Health Study. Arch Intern Med. 2002;162(8): ; Stepanski E, Zayyard A, Nigro C, et al. Sleep-disordered breathing in a predominantly African-American pediatric population. J Sleep Res. 1999;8(1):65-70; Li KK, Powell NB, Kushida C, et al. A comparison of Asian and white patients with obstructive sleep apnea syndrome. Laryngoscope. 1999;109(12): Pre-Weight Loss Post-Weight Loss Reprinted with permission from Schwab RJ, Kline NS. Radiographic and endoscopic evaluation of the upper airway. In: Lee- Chiong TL. Sleep: A Comprehensive Handbook. John Wiley & Sons, Inc. 2006; Gender, Age, and Body Mass Index (BMI) The effects of gender and BMI change with age. After the age of 50, gender becomes an unimportant variable. After the age of 60, BMI becomes an unimportant variable. Tishler PV, Larkin EK, Schluchter MD, et al. Incidence of sleep-disordered breathing in an urban adult population: the relative importance of risk factors in the development of sleep-disordered breathing. JAMA. 2003;289(17): Signs and Symptoms of OSA: History Snoring Unrefreshing sleep/daytime sleepiness Witnessed apneas Insomnia Restless sleep Nocturnal heartburn Morning headache Nocturia Dry mouth, sore throat, sinus and nasal congestion Mood, memory, and learning problems Parasomnias Impotence Enuresis Many with almost no symptoms

5 STOP BANG Screening Tool for Obstructive Sleep Apnea Do you Snore loudly (louder than talking or loud enough to be heard through the closed door)? Do you often feel Tired, fatigued or sleepy during daytime? Has anyone Observed you stop breathing during your sleep? Do you have or are you being treated for high blood Pressure? BMI :Is your body mass index greater than 35 Age :Are you 50 years old or older Neck : Is your neck circumference >17 (male) or > 16 (female) Gender : Are you a male STOP: 2/4 significant chance of OSA STOP +BANG: Very likely moderate to severe OSA Sequelae in OSA The effects of sleep-disordered breathing include: Neurocognitive impairment (memory loss) Daytime sleepiness Impaired quality of life Metabolic effects Cardiovascular effects Cancer OSA and Metabolic Dysfunction OSA is associated with glucose intolerance and insulin resistance, independent of potential confounders. OSA is an independent risk factor for the metabolic syndrome. Hypoxemia may be the predisposing factor to the metabolic alterations associated with OSA. CPAP improves insulin sensitivity in some patients with OSA. Information from Tasali E, Ip MS. Obstructive sleep apnea and metabolic syndrome: alterations in glucose metabolism and inflammation. Proc Am Thorac Soc. 2008;5(2): Cardiovascular Effects of OSA These include: Systemic hypertension Pulmonary hypertension (with sustained hypoxemia) Arrhythmias, especially atrial fibrillation Coronary artery disease Congestive heart failure Stroke and transient ischemic attacks (TIA) Mortality

6 Mortality in OSA 1,522 sample cohort with standard PSG Ages 30 to 60 years at recruitment OSA severity by AHI (a priori) 5 = mild 15 = moderate 30 = severe Three-fold all cause mortality (HR = 3.8) > Five-fold risk cardiovascular mortality (HR = 5.2) Information from Young T, Finn, L, Peppared PE, Sziko-Coxe M, Austin D et al. Sleep disordered breathing and mortality:eighteen year follow-up of the Wisconsin sleep cohort. Sleep. 2008;31(8): All-Cause Survival in Untreated SDB (p < , diff by AHI) Reprinted with permission from Young T, Finn, L, Peppared PE, Sziko-Coxe M, Austin D et al. Sleep disordered breathing and mortality:eighteen year follow-up of the Wisconsin sleep cohort. Sleep. 2008;31(8): Recurrence of Atrial Fibrillation After Cardioversion Is Higher in Patients With Untreated OSA. OSA in Patients With New York Heart Association Classification III to IV Congestive Heart Failure (CHF) Author Naughton (AJRCCM, 1995) n 74 Patients with SDB 41 (56%) Patients with OSA 5 (7%) Patients with CSA 36 (49%) Javahari (Circ, 1998) Lanfranchi (Circ, 1999) (51%) 46 (69%) 9 (11%) 4 (6%) 32 (40%) 42 (63%) Reprinted with permission from Kanagala R, Murali NS, Friedman PA, Ammash NM, et al. Obstructive sleep apnea and the recurrence of atrial fibrillation. Circulation. 2003;107(20):

7 Sleep Apnea in Newly Diagnosed Heart Failure Stroke and Mortality With OSA AmJRespCritCareMed: vol 183 July 2010 Retrospective study 31, 000 patients with newly daignosed heart failure 4% suspected of having sleep apnea while data supports incidence of over 50% 2% actually evaluated and treated Treated group had 10% mortality at 2 years Untreated group had 30% mortality at 2 years Reprinted with permission from Yaggi, HK, Araujo AB, McKinlay JB. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;353(19): International Diabetes Federation Taskforce on Epidemiology and Prevention Recommendations All health professionals caring for patients with diabetes or OSA should be educated about links between the two conditions Health professionals caring for patients with type 2 diabetes or OSA should adopt clinical practices to ensure that a patient presenting with one condition is considered for the other. Information from Shaw JE, Punjabi NM, Wilding JP, et al. Sleep-disordered breathing and type 2 diabetes: a report from the International Diabetes Federation Taskforce on Epidemiology and Prevention. Diabetes Res Clin Pract. 2008;81(1):2-12. Reprinted from Shaw JE, Punjabi NM, Wilding JP, et al. Sleep-disordered breathing and type 2 diabetes: a report from the International Diabetes Federation Taskforce on Epidemiology and Prevention. Diabetes Res Clin Pract. 2008;81(1):2-12.

8 Standard for Diagnosis: Polysomnography Image courtesy of Dr. Richard Castriotta, MD, FCCP Home Sleep Testing Bottom Line for Objective Testing for OSA Pros More like usual night s sleep More convenient for patient Less expensive? More available? Cons Quality of data/need to repeat studies A test for sleep apnea only No trained technologist present to: Correct equipment problems Directly observe any abnormalities during sleep Start treatment if necessary Provide patient education Full attended nocturnal polysomnography for diagnosis and management of sleep apnea in sleep laboratory when possible A second night may be required for titration of CPAP. CPAP may be applied after 2 hours of sleep if severe OSA is present on first night (split-night study).this should be done routinely. Unattended home sleep testing has a role in selected, uncomplicated patients. These are now accepted by CMS for the diagnosis of OSA.

9 Management of OSA Medical Therapies for OSA There are no medical therapies that are indicated as primary management options for OSA. Overweight and obese patients should be counseled on weight loss, in addition to a primary therapy. Nasal steroids and nonsedating antihistamines may be useful adjuncts. Avoid respiratory depressant drugs, benzodiazepines, and opioids. CPAP Therapy Common CPAP Interfaces: Masks Initially described by Sullivan in 1981 Currently the mainstay of therapy for OSA Full Face Masks Nasal Pillows Nasal Masks

10 CPAP Acts as an Airway Stent 0 cm H cm H cm H cm H 2 0 Compliance With CPAP Definition of compliance > 4 hours/night on 70% of nights Compliance probably about 50% to 60% Patients overestimate nightly use. Compliance patterns are determined early. Few clear predictors of compliance: Daytime sleepiness More severe disease CMS requires documentation of compliance and benefit after 90 days to retain CPAP Reprinted with permission from Schwab RJ, Kline NS. Radiographic and endoscopic evaluation of the upper airway. In: Lee- Chiong TL. Sleep: A Comprehensive Handbook. John Wiley & Sons, Inc. 2006; Information from Centers for Medicare and Medicaid Services. Definition of compliance. Available at CPAP: Complications Rhinorrhea Nasal congestion or dryness Epistaxis Skin abrasions/rashes Chest discomfort Claustrophobia Air swallowing Inconvenient Not sexy Strategies to Improve CPAP Compliance Education, support, reinforcement Heated humidification Attention to patient-machine interface (mask) Get a good home care/durable medical equipment company Follow-up: Early (within first few weeks of treatment) Objective compliance monitoring

11 Strategies to Improve CPAP Compliance Oral Appliances Management of nasal congestion Nasal steroids Antihistamines Other types of positive airway pressure (PAP): Expiratory pressure relief technologies Bilevel positive airway pressure (BPAP) for pressures 17 cm H2O Autotitrating positive airway pressure (APAP) Adaptive servo-ventilation (ASV) for complex sleep apnea Adjustable devices Nonadjustable devices Images courtesy of Dr. Donald Falace CPAP Better Than Oral Appliances at Reducing AHI Practical Considerations for Prescribing Oral Appliances Identification of proper candidates Finding qualified/reputable oral surgeon or dentist Cost Insurance Adverse events Follow-up sleep study is needed Information from Kushida, CA, Littner MR, Hirshowitz M, et al. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. Sleep. 2006;29(3):

12 Surgical Management Surgical Success Depends on Definition Soft Tissue (Phase 1) Adenotonsillectomy Palatal Procedures (UPPP, RFA, Pillar) Genioglossal Advancement Hyoid Suspension Nasal Procedures Base of the Tongue Procedures Combinations Boney/Reconstructive (Phase 2) Maxillomandibular Advancement Other Tracheostomy Bariatric Surgery? Information from Elshaug, AG, Moss JR, Southcott AM, et al. Redefining success in airway surgery for obstructive sleep apnea: a meta analysis and synthesis of the evidence. Sleep. 2007;30(4): Surgical Summary Data concerning efficacy for many surgical procedures is controversial. Role of surgery must be tailored to the individual patient s needs: Adenotonsillectomy for children and adults with enlarged tonsils Nasal procedures for septal deviation in attempt to improve CPAP compliance Tracheostomy for severe disease intolerant to other treatments Role of bariatric surgery is not well-defined. Provent nasal valve One way valve FDA approved but not covered yet Effective 30% if able to learn to sleep with it

13 OSA Management Summary Signs and Symptoms of OSA Medical therapies are not supported as primary management options for any degree of OSA. CPAP is indicated for all adult patients with OSA. Compliance is improved by education and heated humidification. Follow-up: Early with objective compliance monitoring Oral appliances may be indicated for patients with mild-to-moderate OSA as an alternative to CPAP. Provent now another non-cpap alternative Efficacy and role of surgery for OSA are not welldefined and must be individualized to the patient. Children may show the following signs: Snoring, gasping, choking Mouth-breathing Obesity or failure to thrive Behavioral problems Adenotonsillar hypertrophy Nocturnal enuresis Morning headache Restless sleep OSA: Diagnosis and Management Recommendations from the American Academy of Pediatrics 2002: All children should be screened for snoring. Snoring in children is not normal! Complex high-risk patients should be referred to a subspecialist. Patients with cardiorespiratory failure cannot await elective evaluation. Diagnostic evaluation is useful in discriminating between primary snoring and OSA, the gold standard being polysomnography. OSA: Diagnosis and Management Recommendations from the American Academy of Pediatrics 2002 Adenotonsillectomy is the first-line treatment for most children, and CPAP is an option for those who are not candidates for surgery or do not respond to surgery. High-risk patients should be monitored as inpatients postoperatively. Patients should be re-evaluated postoperatively to determine whether additional treatment is required.

14 Thank You Jerrold Kram, MD, FCCP, FAASM California Center for Sleep Disorders Alameda SF Fremont Livermore Concord Daly City Sonoma Petaluma