44 th ANNUAL NEW MEXICO LUNG DISEASE SYMPOSIUM 50 SHADES OF BLUE (OR GREY) FEBRUARY 27, 2016

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1 44 th ANNUAL NEW MEXICO LUNG DISEASE SYMPOSIUM 50 SHADES OF BLUE (OR GREY) FEBRUARY 27, 2016 FRANK M. RALLS M.D. ASSOCIATE PROFFESSOR INTERNAL MEDICINE PROGRAM DIRECTOR UNM SLEEP MEDICINE FELLOWSHIP MEDICAL DIRECTOR UNM SLEEP DISORDER S CLINIC DIVISION of PULMONARY, CRITICAL CARE, AND SLEEP MEDICINE UNIVERSITY NEW MEXICO, ALBUQUERQUE, NM

2 Conflict of Interest & Disclosures for Speakers 1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients. 2. I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients: Type of Potential Conflict Grant/Research Support Consultant Details of Potential Conflict NONE Speakers Bureaus Financial support Other Any remaining typos in this presentation are the responsibility of the editor

3 OBJECTIVES KNOW THE BASICS OF SLEEP APNEA AND SOME OF THE PATHOLOGICAL PRESENTATIONS KNOW THE HISTORY OF TREATING SLEEP APNEA KNOW SOME OF THE RULES BEHIND QUALIFING FOR AN IN-PATIENT SLEEP STUDY VS A HOME SLEEP TEST: AKA PORTABLE MONORITING (PM). KNOW SOME OF THE MANAGEMENT OPTIONS FOR HOME SLEEP TESTING

4 Sleep Apnea Hear Me Snore

5 Public Concern

6 October 23, 2009: An airliner with 144 passengers onboard flew 600 miles as its pilots slept at the controls for more than an hour.

7 Untreated Sleep Apnea: 155 seconds without opening airway

8 Sleep Apnea: 3 hour recording

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10 PORDI: minutes < 88%

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12 Obstructive Sleep Apnea Reduction in upper airway muscle tone in sleep Mueller Reflex Inspiratory efforts against a closed glottis

13 Sleep Apnea Patients with sleep apnea have recurrent cycles consisting of: Sleep Airway obstruction Arousal Resumption of ventilation Resutlant physiologic stressors: Cyclic hypoxemia Strenuous respiration Sympathetic activation Reduced total sleep time

14 Obstructive Sleep Apnea Complete or partial upper airway obstruction occurring during sleep Often results in reductions in oxygen saturation Often terminated by brief arousals from sleep Duration of each obstruction must last at least 10 seconds

15 Common Sleep Apnea Symptoms Pauses in Breathing (apnea) Snoring Excessive Daytime Sleepiness Poorly controlled hypertension Sexual difficulties in men Hyperactivity in children

16 Signs/Symptoms are often age dependent Children: Pauses in breathing Secondary enuresis hyperactivity Middle Age Pauses in breathing Snoring Excessive daytime sleepiness BMI > 35, Neck > 16/17 Older > 60 years Not feeling well rested Nocturia 3 xs per night

17 Sleep Apnea Screening Scoring: 0-9 = Average daytime sleepiness = Moderate daytime sleepiness = Severe daytime sleepiness

18 Obstructive Sleep Apnea Incidence mild apnea AHI > 5/hr 24% men 9% women Incidence with excessive daytime sleepiness 4% men 2% women Flemons N Engl J Med 2002

19 Ongoing Sympathetic Surges

20 Untreated Sleep Apnea Reduction of nocturnal dipping Sudden cardiac death occurs inverted in OSA Cardiovascular events typically in the early hours OSA: peak 12-6 AM Sleep apnea associated with a 2X increase risk of stroke or all-cause mortality Hypertension 4X If AHI is > 36 Mortality increases 3 fold Marin, Lancet 2005, Arzt A J Res Crit Care Med 2005, Yaggi, NEJM 2005, Munoz, Stroke 2006

21 . Diagnosing Sleep Apnea: The The Gold Standard is Polysomnography (PSG) EEG EOG Nasal EtCO 2 Chin EMG (2) Nasal Oral Airflow Microphone SaO 2 EKG Tech Observer Video Camera Respiratory Effort Leg EMG (2) Records behavior Essentials of Sleep Technology: Pediatrics. Westchester, IL. American Academy of Sleep Medicine, 2006

22 Diagnosing Sleep Apnea: The Gold Standard Polysomnogram

23 Undiagnosed Sleep Apnea 2-4% of general population 75-80% remained undiagnosed and untreated Type II diabetes Hypertension Cardiovascular disease All cause mortality with an AHI of > 35 is 3 fold

24 Guidelines AASM 2007 PM may be used as an alternative to polysomnography (PSG) for the diagnosis of OSA in patients with a high pretest probability of moderate to severe OSA. PM is not appropriate for the diagnosis of OSA in patients with significant comorbid medical conditions that may degrade the accuracy of PM. PM is not appropriate for the diagnostic evaluation of patients suspected of having comorbid sleep disorders. PM is not appropriate for general screening of asymptomatic populations. PM may be indicated for the diagnosis of OSA in patients for whom in-laboratory PSG is not possible by virtue of immobility, safety, or critical illness. PM may also be indicated to monitor the response to non-cpap treatments for sleep apnea. J Clin Sleep Med 2007

25 Canadian Criteria for HST Absence of coexisting cardiac or respiratory disease. Moderate to high pretest probability of OSA. Low risk of hypoventilation. Absence of coexisting sleep conditions such as insomnia or restless legs syndrome. Ability to use level III technology at home with minimal supervision. RESULTS : Wait time for PSG 152 days (2009) to 92 days (2012) Stewart et al., J Resp J 2015

26 Humana Humana Inc. is an American Louisville, Kentucky-based for-profit health insurance company. As of 2014 Humana has had over 13 million customers in the U.S., reported a 2013 revenue of US$41.3 billion, and has had over 52,000 employees. In 2013, the company ranked 73 on the Fortune 500 list, which made it the highest ranked company based in Kentucky. It has been the third largest

27 Humana Health Help In-home diagnostic HSTs are not recommended for individuals suspected of having OSA if any of the following comorbidities are present: Moderate-to-severe pulmonary disease, such as chronic obstructive pulmonary disease (COPD) Moderate-to-severe neuromuscular/neurodegenerative disorder causing restrictive lung diseases (e.g., kyphoscoliosis, myasthenia gravis, amyotropic lateral sclerosis [ALS], polio, polymyositis, Guillain Barre syndrome) Congestive heart failure, class III or IV Obesity hypoventilation syndrome, previously Documented Pulmonary hypertension Additional sleep disorders other than OSA (e.g.,central sleep apnea, parasomnias, narcolepsy, REM behavior sleep disorder)

28 Alsher, 2016, Current Hyperten Review Technologies for Diagnosing Sleep Apnea Portal Polygraphy Mattress like devices Remote sensing Acoustic technologies

29 Alternatives for children Questionnaires Single channel recordings Home PSGs Biomarkers Gozal et al., Pul Med 2015

30 Home Sleep Studies False Negatives High pre-test probability with an ESS of > 10 and clinical symptoms No: Heart disease Significant sleep disorder Competency to put on the equipment approximately 20% will have a false negative PM. (*Clinical symptoms include snoring, witnessed apneas, obesity, pulmonary hypertension, refractory hypertension, morning headaches, increased neck circumference-->17 inches in men, >16 inches in women--daytime sleepiness.) Walia et al., J Okla Med Assoc 2014

31 Watch Pat vs PSG in Children 50 children Ages 6-11 no difference Ages 3-5 Heart Rate Variability reflect the autonomic nervous system during sleep apnea. Heart Rate Variability using a support vector machine which is a pattern recognition method. Sensitivity 100%, Specificity 86% (AHI > 20). Zu, et al., Zhonghua 2015 Nakayama et al.

32 R-R Interval is converted into Heart Rate Variability Nakayama, et al., 2015, IEEE.org. UNM

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34 Pulse Oximetry Recorded from the Phone Oximeter for OSA Utilizes Pulse Rate Variability (PRV) along with oximetry (Sp02). 74% accuracy for an AHI > 5 74% specificity 75% sensitivity Garde et al., Conf Proc IEEE Eng Med Bio Soc 2015

35 Breath-By-Breath Detection of Apneic Events for OSA Severity Estimation Using Non-Contact Audio Recordings 93 patients who had sleep apnea: snore sounds obtained during a PSG test were digitalized 93 recorded in own apartment with a Watch Pat Device and Audio Inspiration (snore) Expiration Non-respiration noise Diagnostic Agreement 76% Rosenwein et al., Conf Proc IEEE Eng Med Biol Soc Aug;2015:

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38 Novel Head Actigraphy Technique ApneaDX: First we take Ontario, then we take the world Detects sleep with 93% accuracy Wake 43% accuracy 95% accuracy vs PSG Hummell, et al., Conf Proc IEEE Eng Med Biol Soc Aug;2015:54

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40 Special Populations Parkinson s Disease PM underestimated the AHI on average of 12 events per hour compared to PSG Technical failure rate 27%. The worse the motor symptoms the worse the failure rate. Sensitivity/Specificity 84%/ 66% AHI 5 36%/83% AHI 15 50%/100% AHI 30 Gross et al., PD, 2015

41 Other factors affecting results Temperature 17, 22, 29 Actiwatch II SenseWear Arm band Reliable degree but not at 29 degrees Polysomnography 29 degrees Scin et al., Sleep Sci 2015

42 Therapies Mild Apnea: Nasal steroid preparations Leukotriene receptor antagonists Moderate-severe Tonsillectomy and Adenoidectomy 85% effective

43 Primary Treatment: Continuous Positive Airway Pressure REVERSAL OF OBSTRUCTIVE SLEEP APNOEA BY CONTINUOUS POSITIVE AIRWAY PRESSURE APPLIED THROUGH THE NARES Original Text The original machine contained a reversed vacuum cleaner motor that blew air into the affected person s nasal passage using tubing to keep the airway open. ColinE. Sullivan, Michael Berthon-Jones, FaiqG. Issa, Lorraine Eves Abstract Five patients with severe obstructive sleep apnoea were treated with continuous positive airway pressure (CPAP) applied via a comfortable nose mask through the nares. Low levels of pressure (range cm H2O) completely prevented upper airway occlusion during sleep in each patient and allowed an entire night of uninterrupted sleep. Continuous positive airway pressure applied in this manner provides a pneumatic splint for the nasopharyngeal airway and is a safe, simple treatment for the obstructive sleep apnoea syndrome. Lancet April 1981

44 Primary Treatment: Continuous Positive Airway Pressure (CPAP)

45 Pre and Post CPAP Treatment OSA without CPAP With CPAP

46 Treating OSA Better than Wednesdays.

47 Continuous Positive Airway Pressure (CPAP)

48 CPAP Well Tolerated

49 What questions do you have?

50 The Great Health Care Provider One Great Man Said: The initials following the name gives you power Use it wisely. One great patient said: You ve got a blank script baby and I got some pain