Transcript Future - North East Sleep Society

The Future of Sleep
Medicine
Barbara Phillips, MD, MSPH,
FCCP
April 2, 2011
Disclosures
• Consulting, speaking
– Cephalon
– Department of Transportation, FMCSA
– PriMed funding from ResMed, Respironics
• Leadership position
– American College of Chest Physicians
– National Sleep Foundation
– National Board of Respiratory Care
Sleep Medicine in the Future
• The prevalence and importance of
sleep apnea are attracting attention
• Training and credentialing have
changed
• Diagnostic approaches are simplifying
and multiplying
• Reimbursement will continue to fall.
• Treatment approaches are changing
• The field is vulnerable
Sleep Apnea vs Sleep Disorders
• Prevalence of common sleep
disorders
– Insomnia: 10-30%
– Sleep Apnea: 5%
– RLS: 10%
– Narcolepsy: 0.05%
• Diagnoses of patients presenting
to sleep centers (Coleman II, 2000)
– Sleep apnea: 67.8
– RLS: 4.9%
– Narcolepsy 3.2%
One Definition of Obstructive Sleep
Apnea (OSA)
CPAP will be covered for adults with sleepdisordered breathing if:
– AHI (or RDI) > 15
OR
– AHI (or RDI) > 5 with (“mild, symptomatic”)
• Hypertension
• Stroke
• Sleepiness
• Ischemic heart disease
• Insomnia
• Mood disorders
Apnea + Hypopnea Index (AHI), AKA
Respiratory Disturbance Index (RDI)
And Oxygen Desaturation Index (ODI)
• AHI =
• RDI =
Apneas + Hypopneas
Total Sleep Time, in Hours
AHI, more or less
(may include RERA’s)
• ODI =
• SDB =
Number of 4% desats/hr
Sleep-Disordered Breathing
(What you say when you are not sure what you are
including. May include snoring, RERA’s, oxygen
desaturation)
SHHS’s AHI is really an ODI
• All events (apneas and hypopneas)
required a 4% oxygen desaturation to
be counted because
• It was not otherwise possible to
achieve acceptable inter-rater reliability
based on flow rate or arousals.
RERA: Respiratory Effortrelated Arousal (Guilleminault, 1993)
A sequence of breaths characterized by
increasing respiratory effort leading to an
arousal from sleep which does not meet
criteria for an apnea or hypopnea. These
events must fulfill both of the following
criteria:
1. Pattern of progressively more negative
esophageal pressure, terminated by a sudden
change in pressure to a less negative level and
an arousal
2. The event lasts 10 seconds or longer.
UARS (Upper Airway Resistance Syndrome):
> 5 RERA’s per hour of sleep
What About “Simple Snoring?”
• Snoring in pregnancy is associated with increased
hypertension and growth retardation, controlling
for weight, age, smoking (Franklin, Chest, 2000)
• Snoring is associated with cognitive decline (Quesnot,
J Am Geriatric Soc, 1999)
• Snoring medical students are more likely to fail
exams, controlling for BMI, age, sex (Ficker, Sleep, 1999).
• Snoring is a risk factor for cardiovascular disease
in women. (Hu, J Am Coll Cardiol 2000).
• Snoring is a risk for type II diabetes (Al-Delaimy, Am J
Epidemiol 2002).
• Snoring women have faster progression of CAD
(Leineweber C. Sleep 2004)
Severity Criteria Based on PSG
From the American Academy of
Sleep Medicine (Sleep, 1999)
• “Mild” sleep apnea is 5-15 events/hr
• “Moderate” sleep apnea is 15-30
events/hr
• “Severe” sleep apnea is over 30
events/hr
• (“Events” includes apneas, hypopneas,
and RERA’s)
Which Patient Has “Mild” OSA?
Patient 1
Patient 2
AHI (events/hr)
40
10
Apnea duration (secs)
10-22
10-90
Lowest Sa02 (%)
90
71
% REM on study
18
0
Arousals/hr
8
80
Cardiac arrhythmias
none
v tach
Disease is a Spectrum…
Sleep-Disordered Breathing is a
Spectrum
Why Sleep Apnea Isn’t Going Away…..
SDB with Aging
Positive Berlin Scores
(Heistand et al, Chest 2006)
Percentage at high risk by age category
35
30
25
20
15
10
5
0
18-29
30-49
50-64
> 65
CPAP for OSA: Benefits
•
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•
•
•
•
•
•
•
Improved cognitive function
Improved quality of life
Reduced daytime sleepiness
Reduced risk of automobile accidents
Reduced health care costs
Reduced blood pressure
Reduced cardiac arrhythmias
Improved glucose tolerance
Reduced mortality rate
Reversal of impotence
From JNC7…
Marin J
Lancet
2005
N=1751
Controlling for:
Smoking
ETOH
Weight
Pre-existing heart
disease
Age
Hypertension
Lipid-lowering
agents
Diabetes
Marin J
Lancet
2005
SDB and Death in a PopulationBased Study (Young T, Sleep 2008)
Left: Total sample of1522 SHHS participants and 18 year survival
Right: Sample excluding 126 participants who used CPAP
Increased Risk of Crash with
OSA (FMCSA, 2007)
CPAP Treatment Reduces
Crash Risk (FMCSA 2007)
Sleep Medicine in the Future
• The prevalence and importance of
sleep apnea are attracting attention
• Training and credentialing have
changed
• Diagnostic approaches are simplifying,
and multiplying
• Reimbursement will fall. A lot.
• Treatment approaches are changing
• The field is vulnerable
Two Issues for MD’s:
Training and Credentialing
• Training (Fellowships)
– More than 70 ACGME-accredited Sleep
Fellowships exist (www.acgme.org)
• Credentialing (Board Certification)
– Two rounds of ABIM-recognized sleep
board examinations have been given
(November 2007 and 2009)
– There is one more “grandfathering” round
in 2011
– Then ACGME fellowship training will be
required
Who is Eligible?
(www.abim.org)
• The examination is open to diplomates in
internal medicine, pediatrics, neurology,
family medicine, psychiatry, or
otolaryngology.
• CMS is establishing a physician specialty
code for Sleep Medicine.
Training and Credentialing for
Sleep Techs
• Currently, there is a chronic shortage of
qualified sleep techs.
• Sleep tech licensing bills that require a
RPSGT or RT credential have proliferated.
• Competition and acrimony have escalated
between accrediting bodies
– The NBRC now offers a Sleep Disorders
Specialist tech examination for RT’s (SDS).
– AASM has announced a plan for a certifying
exam for techs.
How is the NBRC examination different than
the RPSGT examination?
• The Specialty Examination for Respiratory
Therapists Performing Sleep Disorders
Testing and Therapeutic Intervention is for
respiratory therapists already having earned
the CRT or RRT credentials.
• Content of this specialty examination is
focused on sleep focused testing and
intervention conducted by respiratory
therapists and requires respiratory therapy
education for eligibility.
Comparison of the SDS and RPSGT Exam
What the Future Holds
• The NBRC has been accredited by the
National Commission of Certifying
Agencies (NCCA).
• This opens the door to acceptance as a
credential for sleep laboratory
accreditation through the AASM and the
Joint Commission.
• The AASM’s entry on the scene will shake
things up.
35
• This may help reduce the tech shortage.
Sleep Medicine in the Future
• The prevalence and importance of
sleep apnea are attracting attention
• Training and credentialing have
changed
• Diagnostic approaches are simplifying,
and multiplying
• Reimbursement will continue to fall.
• Treatment approaches are changing
• The field is vulnerable
How does this sound to YOU?
• “You have a life-threatening condition that
can cause car crash, hypertension, stroke,
cognitive dysfunction and many other
consequences. Effective treatment is
available. And, after several weeks, a
couple of nights in the sleep laboratory,
and several thousand dollars, we may be
able to get you started on that treatment.”
Portable Monitoring (or oximetry) is
to in-lab PSG as…
• CXR is to CT scan (lung cancer)
• Pre-post spirometry is to methacholine
challenge (asthma)
• Fasting glucose is to oral glucose
challenge test (diabetes)
Counting up sleepers..?
Just how do we do it…?
Really quite simple. There’s
nothing much to it.
We find out how many, we
learn the amount
By an Audio Telly-o-Tally-o
Count.
We have a machine in a
plexiglass dome
Which listens and looks into
everyone’s home.
Theodore Geisel, 1962
Outcomes of Home-Based Diagnosis and
Treatment of Obstructive Sleep Apnea
Chest 2010; 138: 257-263
• Home testing and autoCPAP resulted in
the same results in sleepiness, adherence,
blood pressure and QoL as in-lab testing.
• “It is really not about the technology; it is
about the initial and then chronic care of
the patient….” (Dr N Collop, editorial)
The Use of Clinical Prediction Formulas in the
Evaluation of Obstructive Sleep Apnea
(Rowley J, Sleep 2000)
• Crocker et al, Am Rev Respir Dis 1990
– age, BMI, witnessed apneas, hypertension
• Maislin et al, Sleep 1995
– sex, BMI, age, snorting, snoring, witnessed
apneas
• Flemons et al, Am J Respir Crit Care Med,
1994
– Neck circumference, hypertension, habitual
snoring, choking
• Viner et al Ann Intern Med 1991
– Sex, age, snoring, BMI
The Berlin Questionnaire
(Netzer et al. Ann Intern Med 1999)
• N=100
• Multicenter trial
• Berlin questionnaire: queries about snoring,
sleepiness, obesity, hypertension
• Being identified as “high risk” predicted an
RDI > 5
– sensitivity
– specificity
– PPV
86 %
77 %
89 %
CPAP as a Therapeutic Trial
(Senn O Chest 2006, n= 33)
• Autotitrating CPAP, 4-15 cm H20, was used as
the therapeutic trial
• A successful trial was “yes” to
– Are you willing to continue CPAP treatment?
– Was objective CPAP use > 2 hours/night?
• All underwent PSG; sleep apnea was
considered an AHI of > 10
• Excluded were those with CHF, OHS, underlying
lung disease, prior CPAP Rx, psych or illness,
language problems
• Those who were diagnosed with OSA on basis
of TT had same outcomes as in-lab diagnosed.
A Few More Observations
• Most folks wind up on 10 + 2 cm H20
CPAP.
• Heavier people need more pressure
• Checking the mask may be more costeffective than repeating the titration
• There is no substitute for following the
patient clinically!
An Outrageous Premise
• The CPAP titration is a highly overrated, overpriced, overused, frequently
unsuccessful gimmick whose main
function is to keep sleep lab beds full.
• Fewer titrations will be done, and this
will be mostly for those with CSA.
Sleep Medicine in the Future
• The prevalence and importance of
sleep apnea are attracting attention
• Training and credentialing have
changed
• Diagnostic approaches are simplifying,
and multiplying
• Reimbursement will continue to fall.
• Treatment approaches are changing
• The field is vulnerable
2011 Reimbursement for
Common Sleep Codes
The PSG Gravy Train
Enjoy the ride while it lasts!
PRWestbrook
Sleep Medicine in the Future
• The prevalence and importance of
sleep apnea are attracting attention
• Training and credentialing have
changed
• Diagnostic approaches are simplifying,
and multiplying
• Reimbursement will continue to fall.
• Treatment approaches are changing,
and compliance with CPAP will improve
• The field is vulnerable
Coverage Beyond the 1st 3 Months
Continued coverage of a PAP device
beyond the first three months of therapy
requires that, no sooner than the 31st day
but no later than the 91st day after
initiating therapy, the treating physician
must conduct a clinical re-evaluation and
document that the beneficiary is benefiting
from PAP therapy.
Education Improves CPAP
Adherence
• Education and visits improved adherence, but
APAP did not (Damjanovic Eur Respir J, 2009)
• Patients value education about CPAP more
than health care providers do (Brostrom A, Pat Educ
Couns, 2009)
• Education can improve adherence in
previously non-compliant patients (Ballard RD, JCSM,
2007)
• CBT can improved adherence (Richards D, Sleep 2007)
• Education improved adherence in a large
number of French patients (Meurice JC, Sleep Med,
2007)
• Video education may help! (Wiese J, Sleep Med 2005)
Autotitrating CPAP
(Ayas N, Sleep 2004)
• Most commonly, increases pressure to eliminate
vibration of palate and soft tissue.
• Now costs about the same as “straight” CPAP.
• May improve compliance.
• Results in lower pressure over all.
• Can obviate the need for in-lab titration, in many
cases.
• Is supplanting in-lab titration
Compliance: APAP = CPAP
Meurice
Series
Konerman
n
d’ Ortho
Hudgel
Teschler
Randerath
Massie
Planes
Combine
d
-2
-1
0
1
Use of APAP-CPAP (Hrs/day)
2
3
Ayas, NT et al.Sleep 2004;27:249-53
What About Blowers?
The autoadjusting, bilevel, ASV,
self-cleaning, downloadable, full
color, titratable, automatic
transmission $6000 PAP machine
has yet to prove itself, and maybe
never will.
For Blowers, Simpler May be
Better
Adjustable PM
Positioner
Oral Appliances
(Kushida C, Sleep 2006)

Indicated for patients with mild-to-moderate
obstructive sleep apnea who
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




prefer oral appliances to CPAP
do not respond to CPAP
are not appropriate candidates for CPAP
fail treatment attempts with CPAP (Kushida Sleep 2006)
Not as effective as CPAP
Lower blood pressure 3-4 mmHg (Otsuka Sleep
Breath 2006)


Outperformed surgery in the only head-tohead trial.
Preferred to CPAP in head-to-head trials.
Do Oral Appliances Work?
Cochrane Database Syst Rev. 2006 Jan 25;(1):CD001106.
“CPAP is effective in reducing symptoms of
sleepiness and improving quality of life
measures in people with moderate and
severe obstructive sleep apnoea (OSA). It is
more effective than oral appliances in
reducing respiratory disturbances in these
people but subjective outcomes are more
equivocal. Certain people tend to prefer oral
appliances to CPAP where both are effective.
This could be because they offer a more
convenient way of controlling OSA.”
• Nasal valves
– Decreased AHI from 43 to 27, improved
Epworth in a small group of CPAP “failure”
patients (Walsh JK, Sleep Med 2011)
– Reduced AHI by about 50% (compared with
10% for sham) in RCT of 250 people (Berry
RB, Sleep 2011)
Sleep Medicine in the Future
• The prevalence and importance of
sleep apnea are attracting attention
• Training and credentialing have
changed
• Diagnostic approaches are simplifying,
and multiplying
• Reimbursement will continue to fall.
• Treatment approaches are changing
• The field is vulnerable
Who Will Practice Sleep
Medicine?
• Sleep apnea is too prevalent to be
managed by specialists.
• Many other sleep disorders lack
established diagnostic criteria or treatment
outcomes.
• Sleep apnea is well-managed by
pulmonologists…who may not be
interested in psychiatry. Or another
examination.
• The field could split. Or dissipate.
The Future of Sleep Medicine?
• Sleep apnea management will become bread
and butter primary care, like COPD or
asthma.
• Portable monitoring and other tests will
become the standard.
• Titrations will be rare.
• Increasingly, the diagnosis of sleep apnea will
be made outside of sleep laboratories, maybe
empirically on clinical grounds
• We will make less money.
• Those patients who do go to the sleep center
will need precise, sophisticated testing; fewer,
more sophisticated labs will exist.
Additional Resources
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www.sleepfoundation.org
www.aarc.org
http://www.aarc.org/sections/sleep/index.asp
http://www.abim.org/cert/aqsleep.shtm
www.chestnet.org
www.acgme.org
www.aasmnet.org
https://www.cms.hhs.gov
www.dot.fmcsa.gov