OSA OBSTRUCTIVE SLEEP APNEA

Transcription

1 OSA OBSTRUCTIVE SLEEP APNEA Anna-Marie Wellins DNP, ANP-C Objectives Describe consequences of Obstructive Sleep Apnea Outline sleep facts/stages Define OSA and clinical symptoms Describe Pathophysiology and risk factors for OSA List/describe screening tools Outline OSA treatment Describe benefits of OSA treatment Describe CPAP Troubleshooting problems with CPAP Describe strategies to promote treatment adherence 1

2 OSA Overview- THE PROBLEM OSA is an underdiagnosed and common disorder that is treated most commonly with Continuous Positive Airway Pressure (CPAP). OSA is associated the significant morbidity and mortality. Screening for OSA is needed for sleep studies and diagnosis. CPAP is a challenging modality with less than optimal adherence rates. Untreated OSA is associated with increased CV risks and neurocognitive impairment. OSA increases the risk of vehicular and workplace injuries and death. Education and support early in CPAP use increases adherence. Public health problem-high risk driving populations-commercial Truck Drivers Vehicular Accidents- 10% related to sleep disorders cost in billion in US 2

3 Common disorder underdiagnosed male>female increased in obese patients. Associated with adverse CV events and neurocognitive impairment. Repetitive episodes of upper airway obstruction- apnea/hypopnea- sleep fragmentation and deprivation. Hypoxia- ischemic/oxidative stress on CV system increased risk MI, CVA, arrhythmias, heart failure, sudden death. Increased anesthesia surgery/procedures Bariatric surgeries-osa screening OSA INCIDENCE In the US it is estimated to be at 4% in adult men 2 % in adult woman Gap narrows in woman after menopause Most likely underestimated due to soaring rates of obesity and morbid obesity 3

4 Why Sleep Matters Sleep researchers are discovering how sleep is vital for learning and memory, and how lack of sleep impacts health, safety, and longevity. Life sustaining activity similar to hunger. Needed for repair, rejuvenation. Necessary for tissue repair, muscle growth, protein synthesis, Growth Hormone release, immune function. Cognitive function/brain plasticity- critical for brain development (infants & children) Allows for the ability to learn and perform tasks. Role of adenosine at cellular level. Importance of Sleep Sleep and Disease Risk The price of insufficient sleep may be poor health. Studies support that people who sleep poorly are at greater risk for a number of diseases and health problems. Sleep, Performance, and Public Safety Lack of sleep exacts a toll on perception and judgment. In the workplace, its effects can be seen in reduced efficiency and productivity, errors, and accidents. Sometimes the effects can even be deadly, as in the case of drowsy driving fatalities. 4

5 SLEEP DISORDERS/PARASOMNIAS Sleep Apnea- Obstructive and Central/COMBO Insomnia Narcolepsy Restless Leg Syndrome Sleep terrors Sleep walking Process for OSA Management Screen high risk pts for OSA Refer to Sleep Specialist /Sleep Study Diagnosis OSA Treatment for OSA CPAP set up dƌžƶďůğɛśžžɵŷőї ^ƵƉƉŽƌƚї ĚŚĞƌĞŶĐĞї ї Improved outcomes! 5

6 Clinical Features of OSA Loud cyclic snoring Nocturnal choking/gasping Apnea Restless sleep/repetitive awakening/ thrashing body movements Excessive daytime sleepiness/unintentional sleeping Fatigue Nocturia Impaired concentration/memory Irritability, moodiness, depression, Deceased libido/sexual dysfunction Morning headache Difficulty with weight loss, leptin resistance 6

7 Obstructive Sleep Apnea Sleep Loss of airway tone Airway obstruction Hypoxia Arousal CV stress, arrhythmias, HTN, insulin resistance, weight gain Fragmented sleep, hyper somnolence, impaired cognition Increased airway tone Patent airway Repeatedepisodes SLEEP FRAGMENTATION/ DEPRIVATION OSA RISK FACTORS 7

8 HYPOXIA Endothelial damage/oxidative stress Stress response- cortisol dysfunction Increased free radicals, CRP, platelet activation Atherosclerosis, formation of thrombus 8

9 Obstructive Sleep Apnea When to refer patients for sleep studies? STOPBANG inventory -screening tool S- snoring T- tired O- observed episodes of apnea P- high blood pressure B- BMI> 25 A- age- >50 N- neck circumference: male >17 female >16 G- gender- male 3 or more = positive screen for OSA EPWORTH SLEEPINESS SCALE (ESS) 9

10 Mallampati Score PSG Polysomnography, also called a sleep study, is a test used to diagnose sleep disorders. Polysomnography records brain waves (EEG), blood oxygen level, heart rate and breathing, as well as eye and leg movements during the study. Home or portable studies do not include all parameters such as brain waves, eye and leg movements. In lab -Split night study for OSA diagnosis and CPAP titration PAP nap return to lab for troubleshooting problems 10

11 Sleep Studies-POLYSOMNOGRAPHY (PSG) IN LAB STUDY Historical standard Wired up like an astronaut Unfamiliar environment Accurate and reproducible method for dx OSA Can add split night study to start CPAP (titration) HOME STUDY Technical difficulties Less instrumentation More natural sleeping environment Cannot dx other sleep disorders Increased risk of inaccurate readings SLEEP STUDIES IN LAB 7 Parameters EEG EOG Electromyogram HR Airflow sensor Respiratory Effort Pulse Oximeter HOME 3-4 Parameters Ventilation/Airflow Respiratory Movement HR Pulse Oximeter POLYSOMNOGRAM- IN LAB SLEEP STUDY 11

12 TYPICAL PATIENT 12

13 HOME SLEEP STUDY AHI INDEX/events per hour Apnea cessation of breathing for at least 10 seconds with drop in O2 sat by 4% Hypopnea- drop of respiratory flow by 30% of baseline lasting for at least 10 seconds with drop in O2 sat by 4% Similar to RDI (Respiratory Disturbance Index) 13

14 APNEA/HYPOPNEA INDEX (AHI) FOR OSA Mild: AHI of 5-15 events per hour Moderate: AHI of events per hour Severe: AHI of greater than 30 events per hour OSA TREATMENT PAP/CPAP for moderate to severe OSA is the Gold Standard Promote lifestyle changes, heart healthy diet, smoking cessation, exercise and weight loss, avoid excessive ETOH Surgery may be needed for CROWDED AIRWAY tonsils, adenoids, nasal polyps and craniofacial abnormalities- micrognathia, retognathia, macroglossia, pendulous uvula MANDIBULAR ADVACEMENT DEVICES (MAD) -mild to moderate OSA NASAL STRIPS mild OSA 14

15 CPAP Pressurized room air which provides pneumatic splinting of upper airway to counter the tendency to collapse CPAP APAP Bi PAP TYPES OF MASK INTERFACES 15

16 Promoting CPAP Adherence Education about CPAP Emphasizing benefits of use Dispelling myths/embarrassment Partner support Acclimation/desensitization Lifestyle changes- 10 % weight loss can reduce AHI by 26% Reduction in daytime sleepiness Early intervention for problems Encouragement Habit formation 21 days Challenges CPAP is a complex and demanding therapy which requires a high level of input and support Early intervention improves adherence Increased hours of CPAP use more likely to further improve symptoms Non adherence/therapy abandonment results in diminished benefit and recurrence of OSA Adherence rate mirrors other chronic diseases 16

17 SLEEP HYGEINE Treatment Goals Minimum use of CPAP 4 hours night 70 % nights Improvement in day time sleepiness (ESS) Weight loss Improvement in BP, blood sugar, LDL Improvement in QOL Improved cognitive function CPAP Troubleshooting Mask fit Claustrophobia Air swallowing Air leaks Adjustment to device Skin irritation Noise Nasal dryness 17

18 Other options for OSA treatment Lifestyle changes- weight loss takes time Positional changes Sleep Etiquette Mandibular Advancement Device (MAD) best for mild to moderate OSA Nasal strips- Provent one way valve adhesive to each nares Surgery (at best 50% effective) 18

19 Surgical Options UPP (uvulopalatopharyngoplasty) Soft Palate Pillar Procedure Hyoid Advancement Tongue Base Reduction Lower Jaw Advancement Tracheostomy 19

20 UPP procedure 20

21 8/11/2015 Benefits of CPAP adherence Reduced morbidity and mortality Cardiovascular risk reduction of MI and stroke, hypertension and diabetes Decreased depression and neurocognitive impairment Improved sleep quality and quality of life Weight control Improvement in daytime sleepiness and fatigue enhances weight loss Alertness as the result of restorative sleep Improved safety by reducing risk of injury Positive impact on public health and safety. CONCLUSION- TAKE AWAYS Identify patients at risk Refer for sleep study Educate patients Encourage lifestyle changes CPAP Support Promote adherence Improve outcomes 21

22 8/11/2015 REFERENCES Budhiraja. (2007). Early CPAP use identifies subsequent adherence to CPAP therapy. Sleep (New York, N.Y.), 30(3). Caple, C., & Schub, T. (2011). Obstructive Sleep Apnea in Adults. In D. Pravikoff (Ed.), (pp. 2p). Glendale, California: Cinahl Information Systems. Catcheside, P. G. (2010). Predictors of continuous positive airway pressure adherence. F1000 medicine reports. doi: /m2-70 Doghramji, P. (2011). The evaluation and management of obstructive sleep apnea. Primary Issues. Johnson. (2008). Patient education increases CPAP compliance. Focus Journal. Kapur. (2010). Obstructive sleep apnea: Diagnosis, epidemiology, and economics. Respiratory Care, 55(9). Mc Doniel, S. O., & Hammond, R. S. (2010). A comprehensive treatment program for obese adults diagnosed with obstructive sleep apnea: a pilot study. Topics in Clinical Nutrition, 25(2), doi: /TIN.0b013e3181dbb7ff Richards. (2007). Increased adherence to CPAP with a group cognitive behavioral treatment intervention: A randomized trial. Sleep (New York, N.Y.), 30(5). Research Support, Non-U.S. Gov't]. J Adv Nurs, 55(3), doi: /j x Weaver. (2007). Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep (New York, N.Y.), 30(6). Weaver, T. E., & Grunstein, R. R. (2008). Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc, 5(2), doi: /pats MG 22