Transcript Slide 1

Disease State Crossover
Managing the Complex OSA
Patient
Peter Allen, BSRC, RST, RPSGT
RRT-NPS-SDS
Conflicts of Interest
 Philips
Respironics
 ResMed Corp
 Fisher & Paykel
 DeVilbiss
 MVAP
 Natus
 NovaSom
 Watermark
Content
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Co-Morbid disease state descriptions and the
workflow of those disease states as they pass
through the sleep disorders center.
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COPD
Diabetes
Morbid Obesity
Cardiovascular
Stroke
Gastroesophageal Reflux/Gerd
Metabolic Syndrome
 Intake, Clinical and Marketing Aspects
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Learning Objectives
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1. Attendee will have a better understanding of
the underlying physiology of the co-morbid OSA
patient and various aspects of overlap syndrome
between disease states.
 2. Attendee will be better able to plan and cope
with the complex patients in their sleep labs.
 3. Attendee will learn to grow clinically while
realizing the financial opportunity that these
patients represent to their sleep centers.
Attendees
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Night Technologists
EEG Background
Respiratory Background
Home Care DME
Home Sleep Testing
Lab Managers
Lab Owners
Hospital Administrators
Nursing
Physician Assistants
Co-Morbid Condition off Your Wing
Introduction
 Since
1970 when Stanford opened the first
sleep center and Dr. Guilleminault later
described Obstructive Sleep Apnea(OSA),
many studies have been conducted
regarding associated disease states.
Introduction Cont’d
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Many studies have linked OSA to co-morbid disease
states and conditions such as:
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Cardiovascular and Pulmonary Disease
Congestive Heart Failure – 76%
A-Fib, - 49%
Diabetes – 48%
Obesity - 77%
Stroke
Spinal Cord Injury
Reflux/Gerd
End Stage Renal – 10 times Greater than General Population
Headaches, COPD, Cancer, Metabolic Syndrome
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Medicare Readmissions Policy
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Many Co-Morbid disease states that are
associated with OSA are being targeted by
Medicare as criteria, for financial penalties to
Medical Centers where readmissions occurs,
within 30 days of discharge.
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This puts a spotlight on Diagnosis and
Treatment of OSA and its associated co-morbid
disease states as an integral part of a medical
centers financial integrity plan.
COPD
 Chronic
Obstructive Pulmonary Disease
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Two Components
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Chronic Bronchitis – Productive cough, three months of
the year, two or more successive years.
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Emphysema - Abnormal enlargement of the airspaces
in the lungs with destruction to the cell walls.
Primarily caused by cigarette smoking.
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COPD Medications
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Oxygen – Physician’s Orders
Theophylline
Ipratropium bromide
Advair’
Symbicort
Daliresp
Theophylline
Atrovert
Serevent
Salmeterol
Formeterol
Proventol/Ventolin/Abuterol - Nebulizers
COPD Referral Sources
 Pulmonologists
 Hospitalists
 Internal
 Family
 Internal
Medicine
 Oncologists
COPD Intake Concerns
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Oxygen ?
Liter Flow ? Hypoxic Drive Candidate
Mobility ?
Additional Caretakers?
Medications?
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Nebulizers
Short Acting Acute
Long Acting Maintenance
Recent Hospitalizations??
COPD Night of Study
 Shortness
of Breath (SOB)
 Ambulation
 Oxygen Protocols
 Emergency Protocols
 Detailed H&P in Chart
 Medication Schedules
 Thorough Chart Review Early!!!!!
COPD and the Record
CO2 – 35 Normal>>>50+
 Low Spo2 – 90% to 97%>>>>88% or less
 Hypoventilation
 Centrals During Titration
 Supplemental Oxygen as needed
 PVCs, PACs, Uni and Multi-Focal, V-Tach
 High Heart Rates
 A-Fib
 High
COPD OSA “Overlap Syndrome”
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Impaired Lungs plus OSA
 2. COPD and OSA jointly contribute
 3. More nocturnal desaturations
 4. Reduction in respiratory drive-HV
 5. Chest wall hyperinflation causes muscle
fatigue in these patients.
 6. COPD has systemic consequences
 7. CO2 High(Retainers), Spo2 Low
Overlap Syndrome Conclusions
 Overlap
syndrome increases risk of death
and hospitalization due to COPD.
 PAP
treatment with or without oxygen is
associated with better patient outcomes
along with decreased hospitalizations.
 Less
readmissions for these patients
Diabetes
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Impairment of the body’s ability to use blood
sugar for energy.
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Type 1- Insulin producing Beta cells in pancreas destroyed.
 Type 2- Most common 90% to 95%, Weight, Food
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Insulin resistance by body, so pancreas overproduces
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Gestational - during pregnancy- Usually Temp
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Over 6 million in the US alone
Diabetes Medications
 Type
I Insulin – Oral or Injection
 Type
II
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Metformin
Victoza
Glucophage
Amaryl
Glucotrol
Januvia
Novolin
Diabetes Referral Sources
 Family
 Internal
Medicine
 Endocrinologist
 Bariatric Medicine
Diabetes Intake Concerns
 Type
1:
 When do they take their meds?
 Reinforce that patient needs to bring
meds.
 Type II:
 When do they take their meds?
 Labs
are Out-Patient Facilities, So…
Diabetes Night of Study
 Tech
needs to establish med routine
 Patient will always self-administer
 Refrigeration for meds
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not let patients “Take a Night Off”
 Call
to Physician if need be to
clarify/safety concerns/patient coherent?
Diabetes Sleep Loss Effects
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Frequent urination common during PSG
Sleep loss leads to:
Altered glucose and metabolism
Reduced Leptin/Increased Ghrelin
Up regulation of appetite/weight gain
Lower energy = Weight Gain(OSA Factor)
Insulin resistance = Type 2
Increased Risk for Diabetes
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Adapted from Parker, K.P. (2011) Sleep disorders and sleep promotion in nursing practice; p. 180
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Morbid Obesity
 Co-Mobidities
within a Co-Morbidity
BMI > 32 – Doubles risk of death
 High Blood Pressure
 Heart Disease – Left and Right side - Lymphedema
 High Cholesterol Levels
 Diabetes- 10 times- 60% to 80%
 Gastroesophageal Reflux
 Urinary Stress Incontinence
 Degenerative Arthritis-Fall Risk
 Skin Infections, Fluid Retention
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Morbid Obesity Medications
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1. Metformin – Type II
2. Diuretics - Lasix
3. Hypertensive Meds – Lisinopril
4. Pillows, Pillows, Pillows,- Orthopnea
5. Insulin – Type 1
6. Lymphedema Meds
7. Oxygen
8. Lipitor
9. Vaso…….Cardio Meds
Morbid Obesity Referrals
 Family
 Internal
Medicine
 Endocrinologist – Metabolic Syndrome
 Bariatric Medicine – Pre and Post Surgical
 Nephrologist- Renal Disease
 Perioperative Referrals
Morbid Obesity Intake
 Weight
 Bed
Limits
 Toilet Limits
 Chairs
 Ambulation?
 Medications?
 Drs to be copied?
 Special Needs?
Morbid Obesity Night of Study
PSG Set-Up – Belts, leads, sensors…
 Titration Night Mask Fitting Concerns
 Headgear Big Enough?- Call Reps
 Does your lab have a weight limit?
 Bariatric Approved Beds?
 Fall Risk?
 Culture of Safety Concerns all Around
 Meds
 Frequent bathroom breaks
 Possible Incontinence
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Morbid Obesity Record
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1. Loud Snoring
2. Deep Desaturations
3. Irregular EKG
4. Usually Severe OSA
5. CPAP to BI-Level Protocols?
6. Frequent breaks in recording
7. Artifact, movement, sweat
8. Speaking
Morbid Obesity OSA Overlap
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1. OSA Influence on other conditions, high
 2. Cardio
 3. Pulmonary
 4. High Blood Pressure
 5. Fluid Retention
 6. Bariatric Surgery or Intensive Lifestyle Changes
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Metabolic Syndrome, Insulin Resistance – Type 2
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Haines et al. Surgery 2007; 141: 354-8
Look Ahead Research Group, Diabetes Care 2007
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Cardiovascular
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1. 70% of patients admitted to the hospital for coronary
artery disease were found to have sleep Apnea
2. Patients with OSA have a 50% risk of hypertension
3. OSA starves heart of oxygen while making it work
harder leading to higher blood pressures through the
night.
4. Untreated OSA is well documented as a factor in
causing heart disease
5. A patient’s chance of having OSA if they have heart
failure is very high.
AM J Respir Crit Care Med Vol. 188, P1-P2, 2013
ATS Patient Education Series 2013
Chowdhuri, S., MD, Weingarten, J., MD
Congestive Heart Failure
 Systolic
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Failure
Failure to eject/pump blood out of the heart effectively
 Diastolic
Failure
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Heart muscles have become stiff and do not fill easily
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Fluid builds up in the lungs, liver, gastrointestinal
tract, arms and legs/ankles.
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Zee, P & Naylor, E http://www.medscape.org/viewarticle/491026
CHF and Sleep
 Shortness
of Breath
 RLS Symptoms
 Diuretics = Increased Bathroom Breaks
 OSA and CSA
 Insomnia – Daytime Sleepiness
 Short Sleep Duration
Cardiovascular Medications
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1. Lisinopril
2. Atenolol
3. Diovan
4. Norvasc
5. Clonidine
6. Azor
7. Verapamil
8. Furosemide
9. Lasix
10.Coreg
11. Zestril
12. Vasotec
13. Lopressor
14. Levatol
15. ……anybody
Cardiovascular Referral
 Family
 Internal
Medicine
 Cardiology
 Surgeons - Perioperative
 Hospitalist
Cardiovascular Intake
 Oxygen?
 Get
both Family and Specialists
 Last Hospitalization?
 Medications and average BP
Cardiovascular Night of Study
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BP Pre and Post Study – Both Arms
Ask when they last took their medications
DeFib Unit Operational – Signed off on?
Room Temp Important if Sweating
Note any swelling in arms or legs
Note Pacemaker and Type – Constant/As Need
BLS, ACLS, PALS
911 , 711 depending on hospital/freestanding
Cardiovascular Record
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Irregular EKG
PVCs, PACs, V-Tach, A-Fib, Pauses
Full or Partial Heart Block
Breaks in record-Diuretics/Lazix
Insomnia from Anxiety
Cheyne Stokes Breathing Pattern – 73% in CHF patients
Left ventricular dysfunction-Hyper and Hypo ventilation
Waxing and Waning breathing pattern
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Pacing Spikes
OSA and CSA
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CSA sometimes evoked by O2 and PAP, Auto Servo Ventilation
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Cardiovascular OSA Overlap
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1. Elevated Blood Pressure during Sleep
2. Elevated Sympathetic Tone leads to HBP
3. About 30% of patients with hypertension have OSA
4. Congestive Heart Failure well documented connection
5. Left ventricle enlargement/increased workload/events
6. Effects are both acute and chronic
7. Cessation of airflow and subsequent desat starves
heart of oxygen.
8. PAP Treatment is shown to have positive effect on all
9. Heart Failure associated with Cheyne Stokes Pattern
10. OSA occurs in 50% of atrial fibrillation patients
Stroke
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Hemorrhagic-Vessel breakdown
Ischemic-transient ischemic attack (TIA) Narrowing
Embolic-Clot local or from other area blocks flow
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OSA and SDB contributes to increased risk of stroke.
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Stroke can contribute to OSA or CSA
Reduced muscle tone and control of upper airway
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Stroke Onset Symptoms
 Sudden
Slurring of Speech
 Muscle control deficit in face/body
affecting one side or bilaterally
Stroke Medications
 Anti-platelet
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Aspirin
Plavis/Clopidogrel
Ticlid/Ticiopidine
 Anti-clot
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Warfarin/Coumadin
Heparin-Hospital via IV
 Acute
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Phase
Thrombolytic Agents-”Clot Busters”
Stroke Patient Referral Sources
 Family
 Internal
Medicine
 Neurology
 Hospitalist
 Case Managers
 CRNPs
Stroke Intake
 1.
Hemorrhagic
 2. Ischemia (TIA) or Embolic
 3. Left or Right Side Deficit
 4. Speech?
 5. Ambulatory ?
6. Aide or Family Member
7. Time of Day or Night –Triggers
Stroke Night of Study
 Left
side Right side?
 Full 10-20?
 Fall Risk?
 Medication Schedule?
 BP in the evening and morning
 Medical Director Parameters for BP
 Time of Day/Night-Triggers
Stroke Patient Record Aspects
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Left Side or Right Side EEG differences
 2. Non-Homologous electrodes can cause
voltage asymmetries.
 3. Measure, Measure, Measure
 4. Do not eye-ball EEG set-up
 5. Full 10/20 frequently ordered
Stroke Patient OSA Overlap
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OSA increase risk of stroke, independent of other risk
factors.
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Males with mild sleep apnea have doubled stroke risk
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Stroke patients-63% have SDB
Stroke patients w SDB have higher mortality, 1yr
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Even higher frequency of SDB in stroke patients with
high BMI and Type 2 Diabetes.
Gastroesophageal Reflux(Gerd)
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1. Human PH – 1 TO 14
2. Arterial PH – Normal 7.35 – 7.45
3. Stomach PH – 4 or less
4. Adults and Infants
5. Apnea causes Reflux or is Reflux causing Apnea?
6. Heartburn most common symptom
7. Chronic Illness 5-7% Worldwide
8. Middle Age-Esophageal Valve Weakens
9. Opening pressure of that valve?? PAP concerns?
Reflux/Gerd Medications
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1. Zantac
 2. Reglin
 3. Nexium-Purple Pill
 4. Pepto-Bismol
 5. Ranitidine
 6. Lansoprazole
 7. Famotidine
 8. Simethicone
 9. Gavison
 10. Maalox
 11. Mylanta
 12. Prevacid
 13. Pepcid
 14. Tums
Reflux/Gerd Referral Sources
 Family
 Internal
Medicine
 Cardiology
 Gastroenterologists
 Neonatologists
 Pediatricians
Reflux/Gerd Intake Concerns
 1.
Medication Schedule
 2. Physicians orders regarding meds
 3. Hospitalizations?
 4. Barrett’s esophagus or other Upper GI?
Reflux/Gerd Night of Study
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Dr’s Orders Followed?
 2. Last Meal time documented
 3. Last Med
 4. Does patient have a logbook?
 5. Flat or Raised?
 6. Document Patients Snacking/Eating
 7. Spicy, acidic, fried foods, tomato based
Reflux/Gerd Record Aspects
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1. Infant Study- Arousals, Body Posture
2. Adults- Arousals, Frequent breaks
3. Document Patient Observations
4. GERD with OSA events?
5. Choking Aspiration Risk?
6. Upright Posture
7. Left side/Right side/Recovery Position
8. Dr’s orders regarding food/meds/body
position
Reflux/Gerd OSA Overlap
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1. Not a clear causal relationship
2. Chicken/Egg or Egg/Chicken
3. Hard breathing during events?
4. Different mechanisms can cause both
5. Multifactorial Origin – Shared risk factors
6. Aspiration risk at end of apnea is of concern
to the technologists.
Metabolic What???
Metabolic Syndrome
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Systemic rather than local disorder
 2. OSA & Metabolic = Syndrome Z
 3. Causal Relationship Probable
 4. Repetitive Hypoxia
 5. Adipokines and Inflamatory Cytokines
 6. Estimated 24% of US Population
Metabolic Syndrome
 Three
of the following five variables:
 Hypertension
resistance – Type 2
 Low high-density lipoprotein cholesterol
 Elevated serum triglyceride
 Abdominal Obesity-Visceral Fat
 Insulin
Metabolic Syndrome
 Multiple
studies have shown that
association between OSA plus Metabolic
Syndrome increases as severity of the
patient’s OSA increases.
 PAP
has been shown to improve high
blood pressure but not insulin resistance
or lipid profiles.
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Coughlin et al.
Metabolic Syndrome
 Studies
are showing that OSA and
Metabolic Syndrome are not separate comorbidities but actually linked to each
other very closely.
Metabolic Syndrome
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The Sleep Heart Health Study found a significant
association between the respiratory disturbance index
and waist to hip ratio, hypertension, and
hypercholesterolemia in men, and low HDL-C, and
hypertriglyceridemia in women.
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A matched control study found that OSA was associated
with insulin resistance, total cholesterol, HDL-C and
Leptin. A Japanese study showed that OSA may
promote metabolic dysfunction and fat maldistribution.
Metabolic Syndrome
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Linkage between OSA and Diabetes is very well
documented and appears to play a role in
Metabolic Syndrome.
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Prevalence of OSA in obese Type 2 Diabetic
patients with moderate to obstructive severe
sleep apnea has been reported as high as 70%.
Metabolic Syndrome
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Hypothalmic-pituitary-Adrenal(HPA) Axis
Cortisol – Hormone/Steroid is released – Adrenal Gland
Cortisol secretion was increased by sleep apnea
Study shows that obese men with OSA have abnormally higher
sympathetic nervous system activity and HPA.
Autonomic(ANS), Sympathetic(SNS), Parasympathetic(PNS)
OSA has inflamatory cascade component, although linkage to OSA
is still unclear.
Repetitive hypoxia and reoxygenation lead to oxidative stress
Oxidative stress appears to be a consequence of metabolic
syndrome and visceral obesity.
Oxidative stress activates an inflammatory response.
Metabolic Syndrome
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Inflammatory responses activate Cytokines.
Inflammation, metabolic syndrome ties in with atherosclerosis.
Biomarkers are used by researchers to track the bodies
inflammatory responses and associate them with OSA.
Obesity is the common factor that connects OSA TO Metabolic
syndrome.
Monocytes and Macrophages abound and increase through what is
known as the “Cascade”. Monocytes>>Macrophages eat/destroy
Adipokines-Fat derived Cytokines-One is Leptin. Leptin plays a role
in appetite and energy.
Ghrelin-Hormone that also regulates appetite. High levels after
weight loss. CPAP reduces
Monocyte Responds
Macrophage Engulphs Pathogen
Exploding Macrophages
Metabolic Syndrome
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Patients with sleep apnea have reduced Leptin levels.
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Sleep deprivation unto itself,,, alone,,, contributes to increased
levels of Ghrelin, increased appetite, higher glucose levels, insulin
resistance, and therefore a higher risk of diabetes.
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OSA compounds and contributes to most any other disease state a
patient has. (Allen, P. et al)
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Normalization of metbolic parameters often occurs after PAP tx.
Metabolic Syndrome Conclusion
 Metabolic
syndrome consists of a systemic
and complicated chain of events and
components, one of which can be the
presence of Obstructive Sleep Apnea.
 Research
is showing that Sleep Disorder
Medicine will be playing a major role in the
diagnosis and treatment of patients with
Metabolic Syndrome or Syndrome Z.
Overall Summary/Conclusions
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Sleep Technologists
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You will be seeing more complex patients
 Get as much additional training as you can
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Is your sales department, physician liaison, lab
owner, hospital focusing on these patients?
 They
Should Be For Economic Survival
of Your Sleep Lab
References
AM j Resp Crit Care Med 2010 Aug 1;182(3):325-31
Int J Chron Obstruct Pulmon Dis. Dece. 2008: 3(4): 671-682
Adaptation from Parker, K.P. (2011) Sleep disorders sleep, nursing P180
ATS J Vol; 181, Issue 5(March1, 2010) Impact of Untreated OSA on Glucose
Control in Type 2 Diabetes
Grimaldi, D. et al. Diabetes Care February 2014 vol. 37 no. 2 355-363
Glycemic Control in Type 2 Diabetes
University of Chicago, et al., Sleep Diagnosis and Therapy “Sleep Apnea Can
Worsen Blood Sugar Control in People with Type 2 Diabetes”
WebMD, Mann, Denise, Smith , Michael, MD Reviewed Jan10th 2010 “The
Sleep-Diabetes Connection
Coughlin, et al. Eur Heart J. 2004 International Diabetes Foundation Brussels
Einhorn et al. Edocr Pract. 2007
Resmed.com
Woidtke, Robyn, APSS Boston 2012
References Cont’d

Resnick HE, Redline S, Share E, Gilpin A, ET al.
 NM: Heart Health Study. Diabetes and Sleep Disturbances
 Diabetes Care 2003;26(3):702-9
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Meslier N, et al. Impaired glucose-insulin metabolism in males with
obstructive sleep apnoea syndrome Eur Respir J 2003;229(1):156-60

O’keeffe T, et al. “Evidence supporting routine polysomnography before
bariatric surgery” Obesity Surgery 2004; 14(1):23-6

Foster, Gary, PhD, Temple University School of Medicine Diabetes Care.
Net “Obstructive Sleep Apnea and Diabetes” 6/21/2010
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Look AHEAD Research Group Diabetes Care 2007
References Cont’d
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Hanes et al., Surgery 2007; 141:354-8“Change in OSA Following Bariatric Surgery”
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WebMD Drugs & Medications Search March 2004
Sleep Apnea and Heart Failure-ResMed Corp
Ferreira, S et al. BMC Pulm Med 2010
Lanfranchi, PA et al Ciculation 2003
Javeheri, S et al. AM Col Cardiol. 2007
Garcia-Touchard, A. et al. Chest. 2008
Joseph et al. Tex Heart Inst. 2009
SDB and Hypertension-ResMed Corp
Peppard, PE. Et al. N Eng J Med 2000
Lavie P et al. BMJ 2000
Nieto, FJ, Young TB et al. JAMA 2000
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References Cont’d
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Javaheri, Shahrokh, MD. Feb 19th 2013 “Basics of Sleep Apnea and Heart
Failure” Cardiosource.org
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Wuhl, J., MD “Obstructive Sleep Apnea’s Cardiovascular Effects” MLH
2/21/2012
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Weingarten, J MD et al., Am j Respir Crit Care Med Vol 188, P1-P2, 2013
“Obstructive Sleep Apnea and Heart Disease”
Zee, P 7 Naylor, E medscape.org/viewarticle/491026 ‘Congestive Heart
Failure”
 Mark D. Elay, MS, RST, RPSGT, RRT-NPS, RPFT “Obstructive Sleep
Apnea and Comorbidities: A Survey of Current Information” A2Zzz 23.1
March 2014
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References Cont’d
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SDB and Stroke ResMed Corp
Johnson, KG, et al. Clin Sleep Med. 2010
Martinez-Garcia MA, et al. AM J Resp Crit Care Med 2009
Wessendorf TE, et al. J Neurol 2000
Drager, LF, et al. Chest 2011
Jelic S, Trends Cardiovasc Med 2008
Kirschheimer, S. WebMD Health News “Are GERD and Sleep Apnea
Related” 2014
“Gerd and Sleep” National Sleep Foundation
 Morse ca, et al. “Is there a relationship between obstructive sleep apnea
and gastroesophageal reflux disease?” Clin Gastroenterol Hepatol 2004
Sep;2(9):761-8
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References Cont’d
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Calvin, Andrew, D., et al. “Obstructive Sleep Apnea, Inflammation, and the
Metabolic Syndrome” Mtab Syndr Relat Discord. Aug 2009; 7(4): 271-277
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Vgontzas, AN. Et al. “Sleep apnea is a manifistation of the metabolic
syndrome” Sleep Med Re. 2005 Jun;9(3):211-24. Abstract
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Obesity and Inflammation APSS 2012 Boston
Fantuzzi j All Clin Imunol 2005; 115:911-9
Christiansen, et al. Int J Obes Relat Metab Discord 2004; 29:146-50
Robker, et al. OBES Res 2004; 12:936-40
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Thank You
 Peter
Allen, BSRC, RRT-NPS-SDS,
 RST, RPSGT
 [email protected]