Transcript 2-Phillips-Apnea

Understanding and Recognizing
Obstructive Sleep Apnea
Barbara Phillips, MD, MSPH,
FCCP
August 9, 2008
Disclosures
• Consulting, speaking
–
–
–
–
–
–
Boehringer Ingelheim
Department of Transportation, FMCSA
GSK
Jefferson County Metro Government
TempurPedic
Ventus
• Leadership position
– American College of Chest Physicians
– National Sleep Foundation
Pre-Test Questions
Meet Mr S Nora
• A 55 year old man complains that his wife
will no longer sleep with him because he is
too noisy and it is disrupting her sleep.
• This has been going on for several years,
but has worsened in the past 18 months
as he has gained weight.
• Last year, he ran off the road while driving
back from a sales meeting in the evening.
Mr S Nora
• Past Medical History
– Hypertension
– Glucose intolerance
• Medications
– Metoprolol
– HCTZ
• Examination: bp 146/94, BMI 33 Kg/m2
• Neck circumference=18.5 inches
The Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in
contrast to just feeling tired? This refers to your usual way of life in recent
times. Even if you have not done some of these things recently, try to work
out how they would have affected you. Use the following scale to chose the
most appropriate number for each situation:
0=would never doze
1=slight chance of dozing
2= moderate chance of dozing
3=high chance of dozing
Situation
Sitting and reading
Watching TV
Sitting, inactive, in a public place
As a passenger in a car for an hour
Lying down in the afternoon
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Chance of Dozing
_____
_____
_____
_____
_____
_____
_____
_____
Risk Factors for Obstructive Sleep
Apnea
•
•
•
•
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Obesity (Kripke DF 1997; Tsai WH 2003)
Male Gender (until about age 50)
Postmenopausal state (Young T, 2003)
Upper airway anatomic obstruction
African-American, Asian, or Hispanic
ethnicity (Kripke DF 1997; Young T 2003; Stepanski E 1999; Li
KK 1999)
• Being a football player (George CF 2003) or truck
driver (Howard, 2005)
Clinical Practice
Recommendation
•
Practice Recommendation:
The risk for obstructive sleep apnea correlates on a continuum with
obesity, large neck circumference, and hypertension. Combinations of
these factors increase the risk for OSAHS in a non-linear manner.
•
Evidence-Based Source:
Institute for Clinical Systems Improvement
•
Web Site of Supporting Evidence:
http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_o
f_obstructive_.html
•
•
Strength of Evidence:
Class A: Randomized, controlled trial; Class B: Cohort study; Class C: Nonrandomized trial with concurrent or historical controls, Case-control study,
Study of sensitivity and specificity of a diagnostic test, Population-based
descriptive study; Class D: Cross-sectional study, Case series, Case report;
Class R: Consensus statement, Consensus report, Narrative review
Clinical Practice
Recommendation
•
Practice Recommendation:
Polysomnography is the accepted standard test for the diagnosis of
obstructive sleep apnea syndrome. The benefit of using attended
polysomnography for diagnosis is the ability to establish a diagnosis and
ascertain an effective CPAP treatment pressure.
•
Evidence-Based Source:
Institute for Clinical Systems Improvement
•
Web Site of Supporting Evidence:
http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obs
tructive_.html
•
•
Strength of Evidence:
Class C: Non-randomized trial with concurrent or historical controls, Case-control
study, Study of sensitivity and specificity of a diagnostic test, Population-based
descriptive study; Class D: Cross-sectional study, Case series, Case report;
Class M: Meta-analysis, Systematic review, Decision analysis, Cost-effectiveness
analysis; Class R: Consensus statement, Consensus report, Narrative review
Weight Loss for OSA
• Modest (10%) weight loss results in
significant improvement in AHI
(Yee BJ, Int J Obes 2006)
• Bariatric Surgery results in 75-88% cure
rate at 1 year, independent of approach.
(Guardiano SA Chest 2003, Crooks, PF,
Annu Rev Med 2006)
Change in Weight and BMI over 4 Yrs
Mean Change in AHI, Events/h
(Peppard PE, JAMA 2000, WSCS, n=690)
-20% to
< -10%
(n = 22)
-10% to
< - 5%
(n = 39)
- 5% to
< + 5%
(n = 371)
+ 5% to
< + 10%
(n = 179)
Change in Body Weight
+ 10% to
+ 20%
(n = 79)
From JNC7…
Refractory HTN in OSA
(Logan J Hypertension 2001)
• N = 41
• BP > 140/90 on  3 antiHTN meds
• Excluded causes of secondary HTN, poor
compliance
• Prevalence of 95% in men and 65% of
women
Effect of CPAP on Blood Pressure in
Hypertensive Patients
(Becker HF, Circ, 2003)
Polysomnography Results
• AHI 42 events/hour
• Sa02 lowest 76%; 26 minutes with Sa02
below 85%
• Sleep Efficiency 64%, TST 4.8 hours
• No Stage 3 sleep, 5% REM sleep
CMS’s 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 = Number of 4% desats/hr
• SDB = Sleep-Disordered Breathing
(What you say when you are not sure what you are
including. May include snoring, RERA’s, oxygen
desaturation)
Sleep Heart Health Study: Apneas and
Hypopneas
 Decrease in airflow or chest wall
movement to an amplitude smaller
than approximately 25% (apnea) or
70% (hypopnea) of baseline
 At least 10 seconds
 Associated with oxyhemoglobin
desaturation of 4% or greater as
compared with baseline
L EOG
Arousal
from sleep
R EOG
O1 A2
C3 A2
Chin EMG
ECG
Leg EMG
NC AF
Th AF
Chest
Abd
SaO2
Apnea
L EOG
R EOG
O1 A2
C3 A2
Chin EMG
ECG
Leg EMG
NC AF
Th AF
Chest
Abd
SaO2
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
Increased Risk of Crash with
OSA (FMCSA, 2007)
Howard
ME,
AJRCCM
2004
N=3268
Crashes and CPAP
(n=210, with OSA, 210 controls)
George, C F P Thorax 2001;56:508-512
BMI and OSA Predict Atrial Fibrillation
(Gami AS, JACC 2007)
Association of nocturnal arrhythmias with sleepdisordered breathing. The Sleep Heart Health
Study
(Mehra et al, AJRCCM 2006)
(N= 228 with RDI > 30 c/w n=338 with RDI < 5)
OR Adjusted for Age, Sex,
BMI, CHD
NSVT
3.4 (1.03-11.2)
CVE
1.74 (1.11-2.74)
Atrial Fibrillation
4.02 (1.03-15.74)
Recurrence of Atrial Fibrillation Following
Cardioversion Is Higher in Patients with
Untreated Obstructive Sleep Apnea
(Kanagala et al, Circ, 2003)
100
90
80
70
60
% Recurrence
50
at 12 Months
40
30
20
10
0
*,**
Controls (n=79)
*p<0.009 compared to controls
**p<0.013 compared to treated OSA
Treated OSA
(n=12)
Untreated Osa
(n=27)
Stroke or Death
(Yaggi HK NEJM 2005)
Hazard Ratios for Death by RDI
Adjusted for BMI
(Lavie P, Eur Respir J 2005)
Relative Mortality RDI > 50/hr
(Lavie Eur Respir J 2005)
CPAP, OSA, and Death
(Doherty LS, Chest 2005)
Clinical Practice
Recommendation
•
Practice Recommendation:
Lifestyle modifications, particularly weight loss and reduced alcohol
consumption can play a significant role in the reduction of severity of
sleep apnea
•
Evidence-Based Source:
Institute for Clinical Systems Improvement
•
Web Site of Supporting Evidence:
http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_
of_obstructive_.html
•
•
Strength of Evidence:
Class A: Randomized, controlled trial; Class B: Cohort study; Class C:
Non-randomized trial with concurrent or historical controls, Case-control
study, Study of sensitivity and specificity of a diagnostic test, Populationbased descriptive study; Class D: Cross-sectional study, Case series,
Case report; Class R: Consensus statement, Consensus report, Narrative
review
Alcohol and OSA
• “Most but not all studies … have
demonstrated harmful effects on nocturnal
respiration, including increased number
and duration of hypopnea and apnea
events.”
(Young T, AJRCCM 2002)
• Alcohol may not change CPAP pressure
needed
(Wessendorf TW, Sleep Med Rev 2002)
Cigarette Smoking and OSA
• Most data indicates relationship
– OR 2.05 (Khoo SM, Respir Med 2004, n=2298)
– OR 2.5 (Kashyap R, Sleep Breath 2001, n=108)
– OR 4.4 (Wetter D, Arch Intern Med 1994, n=811)
• Some does not
– No diff (Casasola, Sleep Breath 2002, n=38)
• Ex-smokers do NOT appear to have increased
risk of OSA
• Parental smoking appears to be a risk for SDB in
children (Kadatis AG, Pediatr Pulmonol 2004,
n=3680)
Cigarette Smoking and Other
Problems
• Reduced CPAP compliance
(Russo-Magno P, J Am Geriatr Soc 2001,
n=33)
• Greater oxygen desaturation
(Casasola, Sleep Breath 2002, n=38)
Exercise for OSA?
(Quan SF, Sleep Breath 2007)
• 4275 SHHS participants
• Logistic regression analysis
• > 3 hrs/week of self-reported vigorous exercise
reduced risk of AHI > 15 (Adjusted OR, 0.68;
95%CI, 0.51-0.91 )
• Similar but weaker associations for less vigorous
exercise or different definitions of OSA
Oral Appliance Reviews
• Cochrane Database Review (Lim, 2004)
– OA improved sleepiness and SDB compared to controls, but
CPAP is the more effective of the two treatment modalities
• Ferguson KA, Sleep 2006
– 52% chance of control of sleep apnea with OA
– Successful treatment more likely in mild-to-moderate sleep
apnea
– Greater degrees of mandibular protrusion more successful.
– High BMI predicts failure
• Hoekema, Crit Rev Oral Biol Med, 2004
– OA are more effective than controls for treating OSA, and
possibly more effective than UPPP
– OA are less effective than CPAP, but patients generally
preferred OA therapy to CPAP
– OA are a viable treatment for mild-moderate OSA
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 apnea (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.”
Indications for Oral Appliances
(Kushida C, Sleep 2006)
– Primary snoring
– Mild to moderate OSA patients who:
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•
•
•
Prefer OAs to CPAP
Do not respond to CPAP
Are not appropriate candidates for CPAP
Fail treatment attempts with CPAP or behavioral changes
– Patients with severe OSA should have an initial trial of
nasal CPAP [before considering OAs]
– Upper airway surgery may also supersede use of OAs in
patients for whom these operations are predicted to be
highly effective in treating sleep apnea
Types of Oral Appliances (OA)
• There > 50 different OAs commercially available;
only about 30 have been approved by the FDA for
OSA
• Two basic types:
– Mandibular repositioners (MRD); reposition and
maintain the mandible and tongue in a forward
position
– Tongue retainers (TRD); engage and hold only
the tongue in a forward position without affecting
the mandible or teeth (not FDA approved for
OSA)
Consequences of Sleep Apnea
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Sleepiness
Impaired quality of life
Decreased cognitive function
Increased hospitalizations and health care
costs
Increased car accidents
Impaired glucose control
Hypertension
Increased cardiac risk
Increased mortality rate
Impotence
Effectiveness of Nasal CPAP
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Decreases sleepiness
Improves quality of life
Improves cognitive function
Decreases hospitalizations and health care
costs
Decreases car accidents
Improves glucose control
Lowers blood pressure
Reduces cardiac risk
Reduces mortality rate
Reverses impotence
Meet Ms S Nora
• Mr Nora’s 52 year-old wife presents with a
complaint of sleep onset insomnia.
• This started at about the time of
menopause, but has gotten worse; she
blames her husband’s snoring
• She notes that she has gained weight
recently, and wonders if her poor sleep is
related
Ms S Nora
• Past Medical History
– Hypothyroidism
– Depression
• Medications
– Thyroxin
– Buproprion
• Examination: bp 128/74, BMI 28 Kg/m2
The effects of gender
and BMI change with
aging
AFTER THE AGE OF
50, GENDER
BECOMES AN
UNIMPORTANT
VARIABLE
AFTER THE AGE OF
60, BMI BECOMES AN
UNIMPORTANT
VARIABLE
Tischler PV. JAMA. 2003
Menopause and Sleep Apnea
(Young T, AJRRC, 2003, n=589)
Changes in Airway Age MRI findings
• Soft palate gets longer
• Pharyngeal fat pads
increase in size
• Shape of bony
structures around
pharyngeal airway
change
• Response of
genioglossus muscle to
negative pressure
stimulation diminishes
Malhotra et al. Am J. Med, 2006. 119:72.e9-e14
Midsagittal magnetic resonance image
illustrating anatomic structures of interest
Women with Sleep Apnea Are Different
from Men
Women with OSA are more likely to
– present with insomnia
– be depressed
– have thyroid disease
– report nightmares, palpitation, and hallucinations
– have comorbid Restless Legs Syndrome
They are less likely to have snoring and
witnessed apneas
Valipour A. Sleep 2007
Shepertycky and Kryger, Sleep 2005
Women Are Under-diagnosed
• Symptoms of insomnia, chronic fatigue or
depression may not be recognized as
attributable to OSA
– delay in diagnosis and treatment
• Severe cases of OSA are more likely to be
referred; UARS may not be diagnosed or
treated
• Women are less likely to be accompanied to
clinic by a bed partner, whose complementary
sleep history is often important in identifying
sleep symptoms
The Stereotype….
The
Reality.
Ms S Nora: Polysomnography
Results
• AHI 18 events/hour
• Sa02 lowest 86%
• Sleep Efficiency 54%, TST 4.1 hours
• No Stage 3 sleep, 15% REM sleep
Treatment of Sleep Apnea
• Behavioral Therapy
– Avoid alcohol, nicotine and
sleep medications
– Lose weight if overweight
• Physical or Mechanical
Treatment
– CPAP (Continuous Positive
Airway Pressure)
– Oral appliance
• Surgery in very rare cases
Understanding and Recognizing
Obstructive Sleep Apnea
• Sleep apnea is common, treatable, and associated
with morbidity and mortality.
• The best-proven consequences of sleep apnea are
hypertension and car crashes. Which kill.
• History and physical findings differ between men
and women; PSG is the definitive test.
• CPAP treatment is safe, effective and inexpensive.
Lifestyle changes can help.
• Oral appliances are safe, somewhat effective, and
inexpensive.
Post-Test Questions