Just When You Think You Have Heard Everything About Sleep Disordered Breathing
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1 Just When You Think You Have Heard Everything About Sleep Disordered Breathing David F Wolfe Crouse Hospital SUNY Upstate Medical University September 13, 2012
2 Outline Sleep-Disordered Breathing Case Studies CHF Anagrams Questions Tx Ghosts?
3 60 yo Diabetes Hypertension Ischemic heart disease MI -> CABG LVEF = 40% BMI = 60 Bordier et al, Chest, 2004
4 Presentation Chronic Heart Failure Respiratory Acidosis O 2 = 0.5 L/min NC ph 7.31 PaCO 2 82 mmhg PaO 2 40 mmhg HCO 3 40 mmol/l BE 10.2 O 2 Sat 67% Bordier et al, Chest, 2004
5 Home Sleep Test Found dead on morning after HST Severe CSA (AHI = 93.3) No OSA Mean O 2 sat = 58% No cardiac arrhythmias 8h of constant CSR during sleep, then Respiratory arrest 7 min later, asystole. Bordier et al, Chest, 2004
6 Cheyne Stokes Breathing Rule Score if 3 consecutive cycles of cyclical crescendo and decrescendo change in breathing amplitude and at least 1 of the following: 5 CAs or hypopneas per hour of sleep The cyclic crescendo and decrescendo change in breathing amplitude has duration of 10 consecutive minutes. AASM Scoring Manual, 2007
7 Bordier et al, Chest, 2004
8 Bordier et al, Chest, 2004
9 January yo Overweight CHF DM HTN Am I dying? Brandon Harris
10 Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults Epstein et al, J Clin Sleep Med, 2009
11 Adult OSA AASM Task Force Recommendations: OSA questions in routine health evals OSA suspicion should trigger sleep eval Diagnosis should include: Sleep-oriented H&P Objective testing Patient education Epstein et al, J Clin Sleep Med, 2009
12 Task Force Recommendations OSA presence and severity must be determined before tx. Include patient in appropriate tx. OSA should be approached as a chronic disease. With tx, describe: Appropriate outcome measures. Long-term follow-up. Epstein et al, J Clin Sleep Med, 2009
13 AASM - ICDMPPO Innovation Care Delivery and Management Program for Patients with OSA
14 Case History 67 yo A-fib & severe mitral valve regurgitation Mod-severe tricuspid regurgitation Severe CSA prolonged lung-to-finger circulation time Dilated left atrium Preserved LVEF Takahashi et al, J Clin Sleep Med, 2011
15 Case History BNP indicates mild heart failure NY Heart Association class II (symptoms w/ activity, not at rest) Mod-severe bilateral leg edema Takahashi et al, J Clin Sleep Med, 2011
16 Insert illustration Oct 2011, page 524 Takahashi et al, J Clin Sleep Med, 2011
17 Before Surgery CPAP for CSA Slight AHI improvement No mitral regurg improvement Slight improvement in daytime tiredness Continued CPAP Takahashi et al, J Clin Sleep Med, 2011
18 Surgery Mitral valvuloplasty (for HF symptoms) with Maze procedure Tricuspid annuloplasty Takahashi et al, J Clin Sleep Med, 2011
19 After Surgery NY Heart Assoc class I (no symptoms) Decreased LA dimension BNP (normal) bilateral leg edema (mild) Sinus rhythm Takahashi et al, J Clin Sleep Med, 2011
20 After Surgery Severe SDB Shorter lung-to-finger circulation time CSA converted to predominant OSA Takahashi et al, J Clin Sleep Med, 2011
21 After Surgery Insert illustration Oct 2011, page 525 Takahashi et al, J Clin Sleep Med, 2011
22 After Surgery OSA responded well to CPAP Takahashi et al, J Clin Sleep Med, 2011
23 Why? supine sleep? No. REM? No. in ventilatory drive? pulmonary congestion and chemosensitivity OSA masked by elevated ventilatory drive? Takahashi et al, J Clin Sleep Med, 2011
24 Normally During OSA: BP surges Repetitive hypoxemia CO 2 retention? Cardiac hemodynamic changes Cardiac arrhythmias? DURING SLEEP!!! Ki-Hwan et al, J Clin Sleep Med, 2009
25 Hx 46 yo BMI = 35.8 One year hx of chest discomfort and dizziness sec Mainly daytime 4-5x/week occasionally upon awakening Ki-Hwan et al, J Clin Sleep Med, 2009
26 Hx BP WNL with calcium channel blocker 1-2 ppd smoker Social drinker 24 hr Holter monitor Symptomatic sinus pauses (2 7.1 sec) Chest discomfort Dizziness Day and night Ki-Hwan et al, J Clin Sleep Med, 2009
27 Ki-Hwan et al, J Clin Sleep Med, 2009
28 Dx/Tx Sick Sinus Syndrome Implanted cardiac pacemaker Atrial single chamber pacing Symptoms persisted F/U Holter Monitoring Occasional 2:1 and 3:1 AV block Wake and sleep Ki-Hwan et al, J Clin Sleep Med, 2009
29 Ki-Hwan et al, J Clin Sleep Med, 2009
30 More Hx C/O snoring every night EDS (ESS=12) Ki-Hwan et al, J Clin Sleep Med, 2009
31 More Dx PSG -> severe OSA AHI = 55.5 Min SpO 2 = 67% ECG frequent atrial pacing 2:1 AV block (REM & NREM) Ki-Hwan et al, J Clin Sleep Med, 2009
32 Ki-Hwan et al, J Clin Sleep Med, 2009
33 CPAP the night after PSG CPAP 15 cmh 2 O resolved Obstructive breathing Atrial pacing AV block Ki-Hwan et al, J Clin Sleep Med, 2009
34 With CPAP Avg usage 6 hrs AHI = 6.3 Ø chest discomfort EDS improved (ESS = 7) Holter monitor Ø atrial pacing Ø AV block Ki-Hwan et al, J Clin Sleep Med, 2009
35 Ki-Hwan et al, J Clin Sleep Med, 2009
36 Central SA Rare in general population Sometimes with opioid usage Common: High altitude Systolic HF Javaheri et al, J Clin Sleep Med, 2009
37 CPAP-emergent CSA Of 1286 patients, 6.5% had complex sleep apnea Mostly transitory with resolution within 8 weeks CPAP-persistent CSA ~1.5% Javaheri et al, J Clin Sleep Med, 2009
38 Potential Risk Factors for Complex SA Increased severity of OSA CAI 5/hr Opioid usage Javaheri et al, J Clin Sleep Med, 2009
39 ASV vs CPAP in HF with CSA and OSA 12 month period Both CPAP and ASV improved respiratory disturbances O 2 desaturations arousals Randerath et al, Chest, 2012
40 ASV vs CPAP ASV more effectively improved: CSA/CSR (central AHI) BNP No difference: Exercise performance Echocardiographic parameters Randerath et al, Chest, 2012
41 Case History 52 yo BMI = 29 Former smoker Ø pulmonary disease Past MI, leading to CHF Meds: bisoprolol, losartan, furosemide, spironolactone Biventricular pacemaker Vermes et al, J Clin Sleep Med, 2009
42 Case History Still had severe symptoms; NYHA class IV EF = 20% LV dilation Severe systolic pulm HTN Listed for heart transplant Vermes et al, J Clin Sleep Med, 2009
43 Pretransplant PSG CAs with CSR OAs Inspiratory flow limitation Occasional snoring AHI and ODI = 21/h (moderate SA) 193 min O 2 sat < 90% (mean 72%) EDS (ESS 13) ASV initiated Vermes et al, J Clin Sleep Med, 2009
44 Treatment for SDB ASV initiated CSA-CSR and OAs improved AHI < 5/h Vermes et al, J Clin Sleep Med, 2009
45 Few Weeks Later Biventricular external assist device implanted ASV D/C d Vermes et al, J Clin Sleep Med, 2009
46 Biventricular Assist Device National Heart Lung and Blood Institute, 2012
47 Biventricular Assist Device LV dilation improved (70 -> 55 mm) EF = no change PSG AHI = 5/h BMI same (29) Two months later... Vermes et al, J Clin Sleep Med, 2009
48 Heart Transplant EF 60% BMI 23.6 PSG AHI = 13/h (mild obstructive SA) Vermes et al, J Clin Sleep Med, 2009
49 One Year Later... BMI 28.1 EF 50% AHI = 29/h (mod obstructive SA) ODI = 28/h SpO 2 < 90% - 2 minutes Min SpO 2 = 87% Refused PAP Dental device offered Vermes et al, J Clin Sleep Med, 2009
50 MATRx SomnoMed, 2012
51 Apnea Guard Advanced Brain Monitoring, Inc, 2012
52 Case Study 39 yo BMI ~ 21 Symptoms of narcolepsy at 16 yo EDS Cataplexy Frequent hypnagogic hallucinations Hartley et al, J Clin Sleep Med, 2011
53 Case Study Narcolepsy Diagnosed in 1999 PSG (#1) and MSLT mean sleep latency 2 SOREM Initial tx: modafinil fluoxetine Hartley et al, J Clin Sleep Med, 2011
54 Case Study Cataplexy and sleepiness (ESS 13) persisted fluoxetine d/c d venlafaxine started Cont d to work and drive Hartley et al, J Clin Sleep Med, 2011
55 Case Study PSG (#2) PLMS Sleep fragmentation Satisfactory MWT sleep latency (23 min) Fe = normal No 2 o PLM cause (except antidepressant) Hartley et al, J Clin Sleep Med, 2011
56 Case Study modafinil dosage increased Added clonazepam for LMs Venlafaxine d/c d, replaced by clomipramine Trial of ropinirole poorly tolerated Thyroidectomy (2009) -> Began levothyroxine Hartley et al, J Clin Sleep Med, 2011
57 Case Study BMI d 23.5 (was 21) cataplexy Antidepressants d/c d Na oxybate started Sleep and EDS improved (although ESS stable) -> stopped clonazepam Hartley et al, J Clin Sleep Med, 2011
58 Case Study PSG (#3) LMs improved Cont d fragmented sleep Non-desaturating central and obstructive hypopneas (AHI = 19.7/h) Arousals MWT = mean sleep latency (8 min) Hartley et al, J Clin Sleep Med, 2011
59 Case Study Na oxybate d/c d PSG (#4) LMs worse Ø sleep apnea (AHI < 5/h) (Continues modafinil and levothyroxine) Hartley et al, J Clin Sleep Med, 2011
60 2013 CPT Codebook Subject to Change
61
62 Osama bin Laden s Residential Compound Howell et al, J Clin Sleep Med, 2011
63 Health Problems Associated With Untreated SDB prevalence of nonalcoholic fatty liver disease (severe OSA) 1 risk of postoperative hypoxemia, transfer to ICU, longer hospital stay 2 cancer mortality (community-based sample: Wisconsin Sleep Cohort Study) 3 1. Türkay et al, Respir Care, Kaw et al, Chest, Nieto et al, Am J Respir Crit Care Med, 2012
64 Health Problems Associated With Untreated SDB risk for delirium after surgery 1 risk of diabetic peripheral neuropathy in those with T2DM 2 likelihood of depression 3 1. Kwatra et al, Anesthesiology, Tahrani et al, Am J Respir Crit Care Med, Wheaton et al, Sleep, 2012
65 SA -> Stroke > 5 SA episodes/night associated w/silent strokes > 1/3 of patients with white matter lesions had severe SA > ½ of silent stroke patients had SA 91% of patients who had a stroke had SA Kepplinger et al, Am Stroke Assoc Intern Stroke Conf, 2012
66 CPAP 1 st Night After Stroke Experimental Group Rec d CPAP 3 nights 4 additional nights when AHI >10/hour Conclusions: Feasible (workload did not differ) Not associated with neurological deterioration Minnerup et al, Stroke, 2011
67 CPAP Impact Moderate-Severe OSA Structural and functional changes in LV function (comparable to HTN) Significantly improve following 6 months of CPAP Butt et al, Circ Heart Fail, 2012
68 CPAP Effective in Mild OSA! First placebo-controlled study Multi-site, double-blind, randomized Large and small facilities Used sham CPAP CPAP in mild and moderate SA: symptoms Improves QOL Improves ESS and mood Weaver et al, Am J Respir Crit Care Med, 2012
69 3 months PAP Children w/osa Improvement in: Attention deficits Behavior Sleepiness (correlated with adherence) Caregiver QOL Child-reported QOL *Suboptimal adherence (3 hours) still improved outcomes Marcus et al, Am J Respir Crit Care Med, 2012
70 SoClean CPAP Machine Activated oxygen cleans and sanitizes Cleans CPAP reservoir, hose, and mask
71 Transcend Transcend
72
73 SleepSense EZ-Talk Speak/Yawn Cough Sip of water
74 Provent Estimated >4 million US veterans have OSA 61% increase in OSA from US Department of Veterans Affairs expands access to Provent
75 Oral Pressure Therapy ApniCure, Winx Sleep Therapy System, 2012
76 OPT Negative pressure to the oral cavity Increases retropalatal airway Pulls soft palate forward Stabilizes tongue base
77
78 OPT Significantly Improves: AHI ODI Sleep architecture ESS Malhotra et al, Abstract
79
80 Treat OSA with Temperature? In untreated OSA patients: AHI with colder temp More severe OSA at 16 o C (61 o F) & 20 o C (68 o F) than 24 o C (75 o F). Valham et al, Sleep, 2012
81 OSA & HTN No association between OSA and systemic HTN in the middle-aged population (Spain) Cano-Pumarega et al, Am J Respir Crit Care Med, 2012
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