Sleep Apneas

Obstructive
Central
Complex
An Overview of Sleep Apnea
And Non-Surgical Treatments
Terry Mark Himes D.O., AOBNP,
ABPN
Subspecialty Certification
In Sleep Medicine
www.SleepCenterOTR.com
LEARNING OBJECTIVES
Upon completion, the participant should be able to:
Understand pathology and prevalence of Obstructive Sleep
Apnea (OSA) , Central and Complex Apnea
Discuss potential consequences and economic impact of
untreated or under-treated OSA
Identify risks and co-morbidities associated with OSA
Recommend appropriate diagnosis and screening procedures
used to identify OSA , Central and Complex Apnea
Discuss various treatment options and long-term
management of patients with OSA and CSAs
DEFINITION OF OSA
OSA (Obstructive Sleep Apnea) occurs when the upper airway repeatedly
collapses during sleep, causing cessation of breathing (apnea) or inadequate
breathing (hypopnea) and sleep fragmentation.
Normal
Obstructed
PREVALENCE OF OSA IN THE U.S.
5% of population is estimated to have undiagnosed OSA
1
As common as adult asthma
1
Obstructive Sleep Apnea/Hypopnea (OSA/H) prevalence:
Wisconsin study
2,3
:
> 24% of men, 9% of women: Apnea/Hypopnea Index (AHI) > 5
> 9% of men, 4% of women: AHI >15
> 4% of middle-aged men, 2% of middle-aged women: AHI > 5 and
daytime sleepiness
Pennsylvania study
4
:
> 17% of men AHI >5
> 7% of men, 2% of women: AHI >15
1
Young, et al., AJRCCM 2002
2
Young, et al., NEJM 1993
3
Redline, et al., AJRCCM 1997
4
Bixler, et al., AJRCCM 1998 & 2001
POTENTIAL HEALTH CONSEQUENCES IF UNTREATED
Short-Term
Automotive accidents
Excessive sleepiness
Decreased quality of life
Neurocognitive and
performance deficits
Long-Term
Hypertension
Heart disease
Heart attack
Arrhythmias
Stroke
Impaired glucose tolerance
CONSEQUENCES OF UNTREATED OSA
Motor vehicle crashes are
leading cause of injury,
morbidity, and mortality
In US, more than 40,000
deaths and 6 million injuries
occur from motor vehicle
accidents every year
1
Sleep-related accidents
comprise 15-20% of all
motor vehicle crashes
2
1
US Census Bureau. Statistical Abstract of the United States. 119
th
end. 1999, No. 225 (146) and No. 1041 (645)
2
Young, T., Blustein, J., Finn, L., et al. Sleep Apnea, Sleepiness, and Driving Risk. Am J Respir Crit Care Med 1994:150:1463-73
Kryger, M., et al. Utilization of Health Care Services in Patients with Severe Obstructive Sleep Apnea. Sleep 1996:19(9):S111-S116
$100,000
$80,000
$60,000
$40,000
$20,000
$0
300
240
180
120
60
0
OSA
GROUP
NON-OSA
GROUP
OSA
GROUP
NON-OSA
GROUP
251
90
$82,000
$41,100
Kryger, et al. OSA Patients Use More Health Care Resources Ten Years Prior to Diagnosis. Sleep Research Online 1998:1(1):71-74
$5,000
$4,000
$3,000
$2,000
$1,000
$0
$7,500
$6,000
$4,500
$3,000
$1,500
0
. .
NON-OSA
GROUP
OSA
GROUP
NON-OSA
GROUP
$6,176
$3,734
OSA
GROUP
$3,972
$1,969
RISKS AND
CO-
MORBIDITIES
THE LINK BETWEEN OSA AND HYPERTENSION
> 40% of patients presenting with OSA have daytime hypertension (HTN)
1
30 to 50% of patients with HTN have OSA
2
Even mild OSA is a risk factor for HTN
3, 6
Patients with untreated OSA may be resistant to their anti-hypertensive
medications
4
Even small decreases in blood pressure may help to decrease the risk of heart
attack and stroke
5
Silverberg, et al., Curr Hypertens R 2001
2
Kraicze, et al., AJRCCM 2000
3
Bixler, et al., Arch Intern Med 2000
4
Logan, et al., J Hypertens 2001
5
Heinrich, et al., Circulation 2002
6
Neito, et al., Jama 2000
The Joint National
Committee on
Prevention, Detection,
Evaluation and
Treatment of High
Blood Pressure (JNC 7)
recommends screening
patients for OSA when
they have:
New onset
hypertension
OR
Refractory
hypertension
1
1
Chobanian, A., et al., Hypertension 2003; 42:1206-1252
THE LINK BETWEEN OSA AND HEART FAILURE
Congestive Heart Failure
(CHF) affects 1.5-2% of
population
Annual direct cost
estimated $20-40 billion
There is high prevalence of
sleep-disordered breathing
in patients with CHF (~40-
50%)
1
Many of mechanisms in
OSA may play a role in
patients with heart failure
2, 3,
4, 5
1
Shara, E., Am J Resp Crit Care Med 2001
2
Peker, Y., Am J Resp Crit Care Med 2002
3
Bradley, T., New England Journal of Medicine; 349. Sin, D., Circulation 2000. 4
Bradley, T., Leung, R., Am J Resp Crit Care Med 2001.
5
Yokoe, T., Circulation 2003
THE LINK BETWEEN OSA AND ATRIAL FIBRILLATION
OSA is commonly seen in patients with Atrial
Fibrillation (AF)
The adjusted odds ratio for the association between AF
and OSA is 2.19
1
Patients with untreated OSA have a higher recurrence
of AF after cardioversion than patients without a
polysomnographic diagnosis of sleep apnea
Appropriate treatment with continuous positive airway
pressure (CPAP) in OSA patients is associated with lower
recurrence of AF
> 82% recurrence in untreated OSA
> 42% recurrence in treated OSA with CPAP
2
1
Gami, A.S., et al., Association of Atrial Fibrillation and Obstructive Sleep Apnea. Circulation 2004:110::364-367
2
Kanangala, R., et al. Obstructive Sleep Apnea and the Recurrence of Atrial Fibrillation. Circulation 2003:107:2589-2594
THE LINK BETWEEN OSA AND DIABETES
Diabetes affects nearly 21 million
Americans (7% of population)
Diabetes is the 6
th
leading cause of death
in US
2/3 of people with diabetes die from a
heart attack or stroke
1
Effective treatment of SDB led to
improved glycemic control in
subjects with Type II diabetes*
In subjects who used CPAP > 4
hrs/day, in HbA1c significantly
correlated with days of CPAP use
2
1
Centers for Disease Control and Prevention, National Diabetes Fact Sheet, 2005
2
Babu, Ambika, R., et al. Type 2 Diabetes, Glycemic Control, and Continuous Positive Airway Pressure in Obstructive Sleep Apnea. Arch Intern Med 2005:165:447-452
Glucose Values Pre/Post CPAP TX
0
50
100
150
200
250
Breakfast Lunch Dinner
Pre-Tx
Post-Tx
*Mean CPAP treatment period of 83 days
THE LINK BETWEEN OSA AND ANESTHESIA
OSA patients may be at risk of
complications related to anesthesia
due to
Significant co-morbidities
1, 2
Susceptible to airway collapse and sleep
deprivation
1
OSA can effect all phases of
perioperative period
1, 2, 3
Guidelines established for all levels of care
to address specific concerns
Anesthesiologists role in
identification of OSA
Likely that majority of patients have not
yet been diagnosed
1, 3
1
Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea. Anestheiol 2006;104:1081-1093.
2
Upper Airway Management of the Adult Patient with Obstructive Sleep Apnea in the Perioperative Period-Avoiding Complications. Sleep 2003;26(8):1060-5.
3
Young, et al. The Ocurrence of Sleep Disordered Breathing Among Middle Aged Adults. N Eng J Med 1993; 328:1230-1235.
THE LINK BETWEEN OSA AND BARIATRIC SURGERY
Clinically severe obesity
BMI > 40kg/m
2
or BMI 35-40 kg/m
2
with comorbid conditions
Obesity well known risk factor for
OSA
1
71% of patients evaluated for bariatric
surgery were identified as having OSA
1
Death following bariatric surgery is rare
(< 1%)
Post-op deaths may be linked to
cardiac arrhythmias due to OSA
2
Initiate CPAP therapy and continuous
monitoring for at-risk patients
1, 2
Research supports referring bariatric
candidates for sleep study as part of
preoperative evaluation
1, 2
1
Frey WC and Pilcher J. Obstructive Sleep-Related Breathing Disorders in Patients Evaluated for Bariatric Surgery. Obes Surg 2003;13:676-683.
2
McGlinch B.P, Que F.G, and et al. Perioperative Care of Patients Undergoing Bariatric Surgery. Mayo Clin Proc 2006; 81(10, suppl):525-533.
THE LINK BETWEEN OSA AND PAIN MANAGEMENT
People suffering from chronic pain
often require around-the-clock
opioid therapy
In recent study, AHI was abnormal
in 75% of patients who participated
39% OSA
Disturbances were predominant
during NREM sleep, contrary to what
is normally seen with OSA
1
Direct relationship found between
AHI and daily dosage of methadone
1
1
Webster and et al. Sleep Disordered Breathing and Chronic Opioid Therapy. American Academy of Pain Medicine 2007
OTHER RISK FACTORS
Hypothyroidism
Acromegaly
Amyloidosis
Vocal cord paralysis
Marfan syndrome
Down syndrome
Neuromuscular disorders
DIAGNOSIS AND
SCREENING
PROCEDURES
FOR IDENTIFICATION OF OSA
DIAGNOSIS OF SLEEP APNEA
Physical exam and history
Asking questions about sleep or
symptoms that may occur during the
day, indicating a problem with sleep
Diagnosed by having a
polysomnogram or sleep study
performed during the patients
normal sleep time
PATIENTS TO CONSIDER FOR OSA SCREENING
Complain of fatigue or unrefreshing
sleep
Hypertension (HTN)
Newly identified HTN
Resistant or refractory HTN
CHF with nocturnal angina or
Cardiovascular (CV) Disease
Bariatric patients
Patients with large necks
17 in for men, 16 in for women
Patients with small jaws
Patients with metabolic syndromes
KEY SIGNS/SYMPTOMS OF OSA
Excessive daytime sleepiness
Loud snoring
Pauses in breathing at night
Waking up gasping or
choking
Witnessed snoring or pauses
in breathing
High blood pressure
ADDITIONAL SIGNS/SYMPTOMS OF OSA
Morning headaches
Irritability
Depression
Memory loss
Lack of concentration
Frequent nighttime
urination
Sexual dysfunction
COMMON QUESTIONS USED TO IDENTIFY OSA
Do you fall asleep easily watching
TV, reading or at times when you
do not want to fall asleep?
Is your snoring louder than your
talking?
How often do you wake up
feeling un-refreshed?
Has your breathing or snoring at
night bothered other people?
Does anything unusual happen
when you are asleep?
METHODS OF SCREENING FOR OSA
Epworth Sleepiness Scale
8 questions answered on a scale of 0 3
0 = would never doze
3 = high chance of dozing
Score > 10 represents daytime sleepiness
Epworth Sleepiness Scale does not identify cause of sleepiness
May include sleep apnea, but also insomnia, lack of time to sleep, etc.
Patient with sleep apnea may have normal value
EPWORTH SLEEPINESS SCALE
Situation
Chance of Dozing
(0 3)
Sitting and reading 0 - 1 - 2 - 3
Watching television 0 - 1 - 2 - 3
Sitting, inactive in a public place, for example, a theater or meeting 0 - 1 - 2 - 3
As a passenger in a car for an hour without a break 0 - 1 - 2 - 3
Lying down to rest in the afternoon when circumstances permit 0 - 1 - 2 - 3
Sitting and talking to someone 0 - 1 - 2 - 3
Sitting quietly after lunch without alcohol 0 - 1 - 2 - 3
In a car, while stopped for a few minutes in traffic 0 - 1 - 2 - 3
Total Score
THE BERLIN QUESTIONNAIRE
Simple, self-administered patient
questionnaire
Asks patients to report their
symptoms
Questionnaire is specific to OSA
Identifies patients at high risk for
OSA who are likely to benefit from
diagnosis
THE BERLIN QUESTIONNAIRE
Uses 10 questions to assess:
Presence & frequency of
snoring behavior
Wake-time sleepiness or
fatigue
History of HTN &/or
obesity
Persistent or frequent
symptoms in 2 of 3
categories indicates a high
likelihood of OSA
RUSLEEPING RTS
In-home objective screening device
that provides real-time results
Provides continuous apneic event
scoring
Designed to be used to supplement
other subjective screening methods
such as questionnaires and diaries
Offers solution to patients who are
on a waiting list for PSG
WHAT IS A SLEEP STUDY?
Polysomnography is a painless study that is
done in a laboratory setting to monitor
patients sleep patterns
The study may record the following during
sleep:
Brain wave activity
Respiratory pattern
Heart rate
Chest movement
Leg movement
Eye movement
Identification and treatment of the sleep
disorder may occur
POLYSOMNOGRAPHY IN OSA
POLYSOMNOGRAPHY (NREM)
EFF
/
/
/
/
POLYSOMNOGRAPHY (REM)
/
/RAT
/
SLEEP APNEA
PATTERNS
OBSTRUCTIVE SLEEP APNEA
EEG
Airflow
Effort
(Pes)
SaO
2
Effort
(Abdomen)
Effort
(Rib Cage)
Arousal
10 sec
MEASURES OF SLEEP APNEA
FREQUENCY
Apnea Index
# apneas per hour of sleep
# of obstructive apneas per hour of sleep
# of central apneas per hour of sleep
Hypopnea Index
# of reduction in patient flow per hour of sleep
# of central or obstructive hypopneas per hour of sleep
Apnea / Hypopnea Index (AHI)
# apneas + hypopneas per hour of sleep
Arousal Index (AI)
When the patient arouses from sleep or changes sleep staging that does not normally occur at night
Number of arousals in EEG activity per hour of sleep
Associated with apnea/hypopnea/desaturation events
Associated with other events (PLM, seizure, etc)
CLASSIFICATION OF
RESPIRATORY EVENTS
Mild Sleep Apnea
AHI is 5 to 15 with excessive
daytime sleepiness (EDS)
Moderate Sleep Apnea
AHI >15 to 30 with EDS
Severe Sleep Apnea
AHI > 30 with EDS
WHY GET A SLEEP STUDY?
Signs and symptoms poorly predict
disease severity
1
Appropriate therapy dependent on
severity
Failure to treat leads to:
Increased morbidity
Motor vehicle crashes
Mortality
Other causes of daytime sleepiness
1. Viner S, Szalai JP, Hoffstein V. Are history and physical examination a good screening test for sleep apnea? Ann Intern Med 1991;115(5):559-68.
TREATMENT
OPTIONS
MEDICAL INTERVENTIONS
Oral appliances
Positive airway pressure
Continuous positive airway
pressure
Bi-level positive airway
pressure (BiPAP)
Other (limited role)
Medications
Weight loss
Behavioral therapy
Oxygen
SnoreSilencer Pro
OSA THERAPY
Of those patients being
treated for OSA, 70 - 80%
utilize CPAP therapy with
a nasal mask
1
CPAP provides positive
pressure to provide a
pneumatic splint for the
patients airway
1
Frost & Sullivan, Sleep Apnea Models, 2001
PAP THERAPY FOR PATIENTS WITH OSA
CPAP
One level of pressure on inspiration and exhalation
Device may have the option to provide pressure relief in early
exhalation
Bi-level therapy
One level of pressure on inspiration and lower level of pressure on
expiration
Device may have the option to provide pressure relief in early
exhalation
Auto titration therapy
Device pressure is adjusted based on airway dynamics and device
algorithm
GOALS OF TREATING OSA WITH PAP
Short Term
Maintain open airway
Improve quality of sleep
Alleviate daytime symptoms
Sleepiness
Moodiness/Impaired
concentration/Memory loss
Morning headache
Long Term
Reduce mortality and morbidity
Decrease cardiovascular
consequences
Reduce sleepiness
Improve quality of life
Marin, JM et. al Lancet 2005: 365:1046 - 1053
LONG-TERM
MANAGEMENT
Compliance and Acceptance of OSA Therapy
CPAP THERAPY ADHERENCE
How is OSA treatment adherence
defined?
>= 4 hours of use, >=70% of time
(Kribbs
1
)
Studies show patient adherence to
therapy is not ideal
Kribbs found that 54% could be
inconsistent users
1
Weaver found 47% inconsistent
users
2
1
Kribbs, et al., Objective Measurement of Patterns of Nasal CPAP Use by Patients with OSA. American Review of Respiratory Disease 1997:147 No. 4
2
Weaver, et al., Night-to-Night Variability in CPAP Use Over the First Three Months of Treatment. Sleep 1993:20(4):278-283
ENSURE PATIENTS RECEIVE EFFECTIVE THERAPY
Look for
Acceptance
Tolerance
Response
Enhance patient
education
Proactive in addressing
non-tolerance and non-
response
Therapy
Selection
Patient
Education
CPAP
Set-up
Patient
Follow-up
Helpful hints
Ramp time
Ramp start pressure
Mask-off alarm
Mask satisfaction/fit
Humidification
Flex technology
OSA Diagnosis
CPAP CLINICAL PATHWAY
Encore 1.6
Phone in
Compliance
Effective
Therapy?
Effective
Therapy
Effective Therapy
Achieved
Yes
*or Auto-Adjusting
Bi-level Therapy
No
Non-Acceptance
Non-Tolerance
Non-Response
Nasal
Symptoms
Mask
Issues
Pressure
Issues
Psychosocial
Concerns
No Perceived
Benefit
Go to
Bi-level*
Therapy
No
MONITORING FOR EFFECTIVE THERAPY
Humidification
C-Flex
Overall daily use
Quality of life with
therapy
Impact of therapy
effectiveness
Average AHI
Treat similar to sleep study
standards
If the AHI > 5 with EDS or >15
consistently you may want to
address with patient & MD
Average Vibratory Snore Index
Determines amount of snoring or
airway movement with therapy
Excessive snoring may
negatively impact therapy
Leak Information
Acceptable leak based on
pressure and mask being used
High mask leaks may cause
pressure levels to be inaccurate
Trend Dates
Data on report is based on
these dates at the top of the
report
CPAP REPORTS
TOOLS THAT MAY IMPROVE COMPLIANCE
Comfort settings on
exhalation
Provide relief during exhalation
phase to allow for improved
comfort to CPAP therapy
When to use:
Initial set up
Pressure intolerance
Difficulty with acclimation to
PAP therapy
1
Aloia, et. al. Chest, June 2005
2
Rosenthal, et. al Sleep, June, 2005
Ramp
Allows for patient to fall asleep at a
lower pressure and acclimate to
pressure over time
Can be adjusted based on pressure
drop and length of time until patient
is back at prescribed PAP pressure
while falling asleep
Side effects of ramp
Patient has apnea or hypopnea
events and overactivates the
ramp system
TOOLS THAT MAY IMPROVE COMPLIANCE
Humidification adds
moisture for patients
receiving PAP therapy
Cool humidifiers or heated
humidifiers available
Humidification may improve
compliance by decreasing
effects of:
Dry or runny nose
Nose bleeds
Mouth breathing/leak
Reimbursement provided for
humidification
TOOLS THAT MAY IMPROVE
COMPLIANCE
Nasal
A common starting mask for OSA
patients
Full
Good for mouth breathers
Claustrophobia/closed in
Pillows/Prongs
Claustrophobia
Allergic reaction
Side sleepers
Chinstrap may be used for mouth leak
with nasal interfaces
Reimbursement provided for
replacement equipment
Central Sleep
Apnea
What is the population mix
of OSA vs. CSA?
What are the various forms of
Central Sleep Apnea?
Identification of various forms of Central Sleep Apnea
(CSA)
Idiopathic Central Sleep Apnea (ICSA)
Complex Sleep Apnea (CSA)
Cheyne-Stokes Respiration (CSR)
PSG Findings of CSA/ISCA/CSR
Treatment suggestions
Reimbursement requirements for reimbursement of
treatment strategy
Sleep-Disordered Breathing (SDB): Patient Population / Mix
Vast majority of SDB patients typical OSA profile
80 90% OSA
Apnea/Hypopnea Index (AHI) controlled by CPAP
therapy
3 main forms of Central Sleep Apnea
Idiopathic Central Sleep Apnea
Brain issue with control of respiration
Complex Sleep Apnea
CPAP Emergent events
Chemoreceptor issue
Periodic Breathing
Heart Failure vs. Non Heart Failure populations
Chemoreceptor issue/CO
2
issue
Treatment of Central Sleep Apnea is by alternative
pathways discussed in this presentation
OSA
CSA
Complex
OSA vs. Central vs. Complex
OSA starts with airway collapse
CSR : Pulmonary congestion/chemoreceptors/
circulation
Diagnosis of Central Sleep Apnea
Central Sleep Apnea
Apnea index > 5
Central apneas / hypopneas >50% of the total apneas /
hypopneas
Central apneas or hypopneas > 5 times per hour
Idiopathic Central Sleep
Apnea
What is Idiopathic Central Sleep Apnea?
What does it look like on PSG?
What is the treatment for CSA?
Treatment Recommendations for
Idiopathic Central Apnea
Oxygen Therapy **
Must have desaturation below 88% for 5 minutes or longer to qualify for oxygen
therapy (CMS guidelines) OR 89% for 5 minutes with history of either CHF, Pulm.
HTN, Cor Pulmonale or Increased RBC count
Oxygen Therapy and CPAP Therapy
Must have desaturation + AHI >5 with EDS or AHI>15 without EDS (CMS guidelines)
Medications:
Theophylline
1, 3
Acetazolamide
2, 3
Gradual reduction of opioid medications may improve
narcotic-induced CSA
3
1 Orth, et al. Resp. Med. 2005;99:471-476
2 Javahari, S. AJRCCM: 2006:173(2) 234-237
3 Eckert, et al. Chest. 2007; 131:595-607
Remember:
<2% of SDB
Cheyne-Stokes
Respiration
What is the population mix?
What does it look like on PSG?
What is the treatment strategy for CSR?
Cheyne-Stokes Respiration
Characteristics of CSR: waxing and waning breathing pattern
CSR length is based on disease process causing the breathing pattern
Longer events for patients in heart failure
1
(Picture A)
50-70 second events of CSR then followed by normal respiration (waxing
and waning of respiration) in patients with heart failure
1
Shorter events in those with preserved heart function
1
(Picture B)
20 40 seconds on length with those with preserved heart function
1
~60
sec
1
Thomas, et. al. Curr. Opin Pulm Med. 2005
A
B
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70
Servo Ventilation Algorithm
4 Minutes
On a breath by breath basis peak flow is captured
Peak flow is monitored over a moving 4 minute window
As 1 breath is added, the initial breath falls off
At every point within this 4 minute period an Average Peak Flow is calculated
The Peak flow target is established around that average and is based on the patients needs (95% peak flow average)
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71
IF: Peak flow is at target
THEN: autoSV Advanced delivers CPAP pressure
Servo Ventilation Algorithm:
Normal Breathing
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72
IF: Peak flow falls below target
THEN: autoSV Advanced increases pressure support
Servo Ventilation Algorithm:
Decreased Flow
IN SUMMARY
Pathology and prevalence of OSA
Risks and co-morbidities associated with OSA
Potential consequences and economic impact of untreated or
undertreated OSA
Diagnosis and screening procedures used to identify OSA
Various treatment options and long-term management of
patients with OSA
Any questions?
THANK YOU!