Home Sleep Testing (Portable Monitoring) Kevin Shilling, MD

Transcription

1 Home Sleep Testing Kevin C. Shilling, MD President-Elect Utah Sleep Society; Sleep, Pulmonary, and Critical Care Staff Physician, LDS and Intermountain Medical Center Hospitals, Intermountain Medical Group, Intermountain Healthcare; Salt Lake City, Utah Objectives: Identify appropriate patients for home sleep studies Describe the components of the STOP BANG Questionnaire Identify patients not appropriate for a home sleep study Use the care process model for sleep apnea

2 Home Sleep Testing (Portable Monitoring) Kevin Shilling, MD

3 Disclosures No funding from industry I do not own or have an interest in a sleep laboratory or home testing company Employed physician at Intermountain Healthcare

4 OSA Epidemiology North America 20% of population have AHI>=5/hour 2 9% prevalence of AHI>=5/hour and a modifiable symptom Age Prevalence increases from 18 45; plateau after Ethnicity higher prevalence in African Americans<35 compared to caucasians Gender 3 4% women vs. 6 9% men have AHI>=5/hour with EDS or cardiovascular morbidity

5 Goal of Diagnosis and Treatment Stroke Hypertension Heart Failure Diabetes CAD Atrial arrhythmias X OSA Treatment PAP MAD Side Sleep Nasal Valves Weight Loss Excessive Daytime Sleepiness Work place errors Cognitive Deficits Traffic Accidents X With the least amount of pain, suffering, and dollars coupled with highest accuracy

6 Consequences HTN Stroke CAD Heart Failure Atrial Fibrillation DM Death

7 It is not about what test is ordered

8 Who Will Manage These Patients?

9 Why Do a HST? Study patients in home environment Less expensive? Over what time frame? Decrease time to diagnosis and treatment? Study patients who cannot come to laboratory Assure adequate treatment with MAD.

10 Why Not Do a HST? Screening asymptomatic population Patient is incapable of using device Other Respiratory Diseases Present Neuromuscular disease COPD Chronic Respiratory Failure Obesity Hypoventilation Narcotics Other Sleep Disorders May be Present Narcolepsy RLS/PLMD Insomnia Heart Failure or other central apnea

11 AASM Guidelines for HST An unattended HST should only be performed in conjunction with a comprehensive clinical evaluation by a board certified sleep medicine specialist.

12 HST What could go wrong? False Negative: TRT does not = TST Patient may drop out. False sense of security False negative rate as high as 17% False Positive: Less likely Inadequate recorded data: Repeat Study Device not turned on Leads fall off or pulled off Inadequate teaching Misses events such as Respiratory Event Related Arousals

13 AASM Guidelines for HST Limited to patients with a high pre test probability of moderate to severe OSA.

14 Data from Flemmons, WW

15 STOP Questionnaire: A Tool to Screen Patients for Obstructive Sleep Apnea. Chung F, Yegneswaran B, Liao P, et al. Anesthesiology 2008;108: Snoring Do you snore loudly (louder than talking or loud enough to be heard though closed doors)? Tired or sleepy Do you often feel tired, fatigued, or sleepy during daytime? Observed apneas Has anyone observed you stop breathing during your sleep? Pressure Do you have or are you being treated for high blood pressure? High Risk of OSA: Answering yes to 3 or more items. Yes No Yes No Yes No Yes No

16 STOP Questionnaire: A Tool to Screen Patients for Obstructive Sleep Apnea. Chung F, Yegneswaran B, Liao P, et al. Anesthesiology 2008;108: BMI BMI more than 35 kg/m 2? Yes No Age Age over 50 yr old? Yes No Neck Circumference Neck circumference greater than 40 cm? Yes No Gender Gender Male? Yes No High Risk of OSA: Answering yes to 3 or more items.

17 The STOP-Bang Equivalent Model and Prediction of Severity of OSA: Relation to Polysomnographic Measurements of the Apnea/Hypopnea Index. RJ Farney J Clin Sleep Med 2011;7(5): HYPOTHESIS: Categories of OSA severity can be predicted by the number of affirmative responses using the STOP-Bang Model.

18 SYNOPSIS OF STUDY: Retrospective analysis of 1426 cases studied by polysomnography. Inclusion criteria: Any patient referred for diagnostic or split night polysomnography for any reason from Jan 06 to Dec 08. Exclusion criteria: Incomplete questionnaire or demographic data, previously diagnosed or treated for OSA, or tested while breathing O 2 or CPAP.

19 Predicted Sleep Apnea severity by STOP-Bang

20 49 year old male pre-surgical knee arthroplasty Snore Y + Tired Y + Observed N Pressure Y + BMI 36 + Age 49 Neck 41 + Gender M + STOP-Bang Score = 6 Probability: Severe 53.3% Moderate 27.8% Mild 14.7%

21 75 year old female pre-surgical hip arthroplasty Snore N Tired Y + Observed N Pressure Y + BMI 27 Age 75 + Neck 35 Gender F STOP-Bang Score = 3 Probability: Severe 22.3% Moderate 29.6% Mild 33.2%

22 Limitations of the STOP-Bang Model 1. Targeted for Obstructive Sleep Apnea (i.e. not necessarily sensitive for central events associated with CHF, opioids etc.) 2. Other risk factors are not included (e.g. comorbidities such as DM, cranio-facial morphology, pharyngeal anatomy)

23 Problem=Who is high risk of moderate to severe OSA? Clinical Scales ESS STOP BANG Sleep apnea clinical score BMI? Clinical gut sense?

24 AASM Guidelines for HST Device must be placed by a trained professional or patient must be educated by said professional Raw data must be reviewable and editable by sleep professional A PSG should be performed after negative HST Follow up to review results must occur.

25 Device Classification Type I Traditional attended in lab polysomnography Type II HST with at least 7 measures EEG leads, respiratory parameters, position. Unattended. Type III Unattended. Four measures including 2 respiratory channels, heart rate, and oximetry. Type IV At least one measure. Eg. Oximetry.

26 NVision (by Nonin)- Data Output (Features: Desaturation Index, SpO2 by band, graphic output in variety of formats with good resolution)

27 Limitations of Oximetry for OSA Not reliable for mild sleep apnea or UARS Does not differentiate types various respiratory disturbances (central versus obstructive) Substantial wakefulness skews results Abnormal hemoglobins (COHb) Significantly affected by technical factors and software algorithms

28 Type III Devices At least 25 different companies each producing 1 4 different devices Most measure airflow(via thermistor), respiratory effort (belt), oximetry and HR. Embletta Apnea Link Watch PAT Peripheral artery tonometry used to assess breathing ARES device THERE ARE NO HEAD TO HEAD STUDIES COMPARING DEVICES

29 Embletta

30 Apnea Link

31 Watch PAT

32 Apnea Risk Evaluation System ARES

33 Costs(CMS data) Baseline in lab PSG Technical $ Professional $ Failure rates <4% Split night or CPAP in lab PSG Technical $ Professional $ HST Type III study Technical $ Professional $67.68 Failure rates range from 7 33%

34 Comparative Effectiveness At least 4 studies conclusively show that in patients with high probability of moderate to severe OSA, an ambulatory approach in terms of diagnosis and CPAP titration is feasible and has equivalent outcomes to in laboratory management of OSA.

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37 Study Design Age > 18 years referred to sleep center High pretest probability of moderate to severe OSA Adjusted neck circumference>=43cm 3cm for snoring 4cm for HTN 3cm for apneas ESS > 12 No exclusions

38 Study Design All patients underwent Sleep Consult HST subjects had demonstration of device and an observed trial of self application Auto CPAP=OSA and APAP education, mask fitting, and comfortable starting pressure 4 20 cm H2O. 5 7 days Patients telephoned at 3 days and 1 week after CPAP initiation. Face to face visit at 1 and 3 months

39 Adherence Outcomes ARM 1 month 3 months Average nightly Time at pressure min Nights used for at least 4 hours (%) Used CPAP for at least 70% nights Lab 224(121) 219(144) HOME 244(141) 281(126) Lab 48(31) 49(36) HOME 54(33) 63(29) Lab 30% 39% HOME 40% 50%

40 Rate of Unacceptable Studies Study Type Number Rate Split Night Lab % Full Night Lab % Home Diagnostic % Home Titration % 147(82%) had acceptable HST on 1 st attempt; 20/33 had second study; 12/20 successful

41 Study Conclusions Home based strategy for DX and Treatment of OSA, not inferior to lab based. This has not been our experience with AUTO CPAP Lower cost in short term (3 month) Fewer eligible patients than expected CPAP acceptance and continued use less than expected Patients closely monitored at all points by sleep physicians, technologists, coordinators.

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45 Uncomplicated OSA Patient does not meet exclusion criteria Epworth Sleepiness Score >=10 Patient is capable of placing HST device at home OR a family member is present who is able and willing to help. Patient is capable of keeping the device on

46 Heart Failure Neuromuscular disease COPD Chronic Respiratory Failure Narcotics Obesity Hypoventilation Central Sleep Apnea Other Sleep Disorders Narcolepsy RLS/PLMD Insomnia Asymptomatic Exclusion Criteria

47 Uncompli cated OSA no yes HST no no Dx of OSA? RDI>= 15? yes Pt. Offered CPAP? yes

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49 Notes CPM attempts to give PCP choice of involvement of Dx and treatment of OSA We are available at any time in the process, BUT usually more efficient to be involved from the beginning.

50 Conclusions Screening via clinical history key first step Choosing the test is only a small component of overall care of the sleep patient HST is appropriate in a subset of patients and will hopefully increase the number of patients who actually receive treatment for OSA. PCP plays a fundamental role in identifying patients, encouraging dx and treatment, and providing comprehensive care. Sleep physician may cover sleep care