Disclosures. Speaker: Teva, UCB, Purdue Advisory Board: Welltrinsic Sleep Network Consultant: Vapotherm, Inc. National Interpretor: Novasom

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1 So PAP Doesn t Work Rochelle Goldberg, MD, FAASM, FCCP Diplomat, American Board of Sleep Medicine Director Sleep Medicine Services Main Line Health Systems Lankenau Medical Center and Paoli Hospital

2 Disclosures Speaker: Teva, UCB, Purdue Advisory Board: Welltrinsic Sleep Network Consultant: Vapotherm, Inc. National Interpretor: Novasom

3 The Translation What they say... It doesn t work! What they may mean I hate it and don t want to use it. I have problems with it (mask, air, etc) I m still snoring, choking, etc. I still can t fall asleep. I still don t sleep well. I am still sleepy.

4 Translation 101a I hate it and don t want to use it! Is it an education issue? Do they understand sleep apnea? Relate their specific symptoms to the diagnosis. Are they aware of the risks of untreated apnea? Are test results clear? Severity, oxygen and sleep effects; PAP findings Are they aware of other treatment options?

5 Translation 101b I have problems using it. Is it a technical or compliance issue? Do they understand PAP treatment? Are they using equipment properly? Are side effects of PAP interfering with sleep? Are there environmental or family issues?

6 Translation 101c I m still snoring, choking, sleepy, not sleeping well. What were the original symptoms? Is there any symptom resolution? Are these consistent with treatment problems or limited compliance? Are symptoms unrelated to sleep apnea and PAP?

7 PAP Compliance and Sleepiness Weaver TE, Grunstein RR. Proc Am Thorac Soc 2008 Feb 15: 5(2):

8 Excessive Sleepiness Bixler E O et al. JCEM 2005;90:

9 Excessive Sleepiness Bixler E O et al. JCEM 2005;90:

10 Sleep in Translation Are there other sleep problems? It ain t all apnea, and even when it is-it ain t all PAP! R Goldberg-famous sleep philosopher

11 Question 1 Joe Stevens has been using CPAP for 3 months. He is not snoring, but continues to have dry mouth (using a nasal mask). He returns with complaints of continued daytime sleepiness? Which of the following would be most helpful to evaluate his ongoing concerns? A. compliance report B. urine drug screen C. medication review D. Epworth sleepiness scale

12 It s not working ( but it should) Consider timing of the problem: Early: learning curve, settings (pressure, ramp, humidity), training, mask fit, side effects Later: equipment wear, patient changes (weight, allergies, other medical), new side effects

13 Early Equipment Issues Mask vs. machine Fit, leaks, the 180 have patient put mask on; training, refitting; Pressure, ramping, humidity review test, adjust ramp or heater Patient specifics Sleep position review sleep test details, consider pressure Allergies / nasal complaints heater, filter, cleaning, RX Family dynamics, cultural implications Environmental changes Altitude, humidity adjust settings, patient education Swimming with PAP or the dog ate my

14 Later Equipment Issues Mask vs machine Worn supplies, equipment cleaning patient education Patient specifics Weight change consider pressure adjust and / or mask re-fit Other medical, allergies Environmental changes Travel implications and adjustments humidifier, altitude

15 It is working but symptoms persist I still can t fall asleep. I still don t sleep well. I am still sleepy.

16 I still can t fall asleep Insomnia Inadequate sleep hygiene Circadian rhythm disturbance Restless legs syndrome Medications Other medical or psychiatric conditions

17 I still don t sleep well. Insomnia Inadequate sleep hygiene Parasomnias Medications Other medical or psychiatric conditions

18 Question 2 Susan Waakup is a 53 yo woman with OSA. She has been using CPAP regularly for the past 6 months. She reports good PAP compliance and is pleased that she is not snoring. She is still having problems sleeping. These include trouble falling asleep, frequent waking and discomfort. Her medical history includes hypertension, hyperlipidemia, depression. She is perimenopausal. She is married with twins who recently started college in another state. Of the following choices, which is the best next step? A. obtain actigraphy and order a ferritin level. B. download PAP compliance report and start sleep logs. C. repeat PAP titration and review medication list. D. start auto PAP unit and refer back to her psychiatrist.

19 I am still sleepy. Insufficient sleep (sleep deprivation) Circadian rhythm disorders Narcolepsy and other hypersomnias Medications Other medical or psychiatric conditions

20 Medications and Poor Sleep Cold and allergy remedies Antihypertensives (beta antagonists) Cardiac treatments (digoxin) Lipid-lowering drugs Thyroid supplements Birth control medications Asthma therapy Pain medications Antidepressants (especially SSRIs)

21 Medications and Sleepiness Codeine (pain medications and cough suppressants) Morphine (and other pain medications) Antihypertensives (alpha 2 agonists) Antiarrhythmic agents (fatigue) Dopamine agonists (pramipexole, ropinirole) Antiepileptics Sleep aids (including benzos, non-benzos, OTC remedies) Anxiolytics Antihistamines (prescription and OTC) Antidepressants (older TX-TCAs, MAOIs)

22 Medical Conditions and Sleep Medical conditions commonly associated with sleep problems: Pregnancy Menopause Headaches Cardiac disease Pulmonary diseases GERD Rheumatologic conditions Chronic pain conditions (including fibromyalgia) Degenerative neurologic disease Stroke Substance abuse (alcohol, drugs active and withdrawal)

23 Psychiatric Conditions and Sleep Depression Insomnia or sleepiness Insomnia as a risk factor for depression Bipolar disorder Sleep complaints vary with cycling Generalized anxiety Sleep initiation problems, or extended wake time Panic disorder May be isolated nocturnal Schizophrenia In schizophrenia, sleep is habitually disturbed. -Bleuler 1950

24 Insomnia(s) Characterized by difficulty initiating sleep, disturbed sleep during the night (or non-restorative sleep complaint). Considered a hyperarousal phenomenon. May be primary; secondary to other sleep, medical or psychiatric conditions. Prevalence 5-48% in general population. Varies broadly by definition applied. Increased risk: female, older, lower socioeconomic status Growth industry! Role of pharmacology?? Treatment generally includes behavioral measures. Cognitive therapy, stimulus control.

25 Inadequate Sleep Hygiene Behavioral condition (lifestyle). Routines that interfere with proper sleep timing and stability. Frequent component to insomnia and sleepiness complaints.

26 Good sleep hygiene 1. Keep a regular schedule for bedtime and wake time. 2. Avoid mentally or physically stimulating activities, and emotional stress close to bed. Relax prior to getting into bed. 3. The bedroom should be cool, dark and quiet. 4. No TV in the bedroom. Turn clock away-do NOT CLOCK WATCH. 5. The bedroom is reserved for sleep (and sex). 6. Avoid naps. 7. Maintain regular daily activites. Avoid exercise close to bedtime. 8. If hungry, have a light snack at bedtime. 9. Avoid alcohol late in the evening. 10. Limit caffeine later in the day. 11. Avoid sleeping medications (prescription and OTC).

27 Circadian rhythm disorders Common theme is misalignment of body clock and environment. Supported by temperature disregulation and melatonin. Delayed sleep phase, advanced sleep phase, shift work disorder, jet lag.

28 Question 3 Jay Night is a 22 year old man who complains of significant daytime sleepiness. This has been a problem for 4 years. He may nap on weekends but does not find naps refreshing. The Epworth score is 15. Statistically, the most likely explanation for his sleepiness is: A. Sleep apnea B. Narcolepsy C. Insufficient sleep D. Restless legs syndrome

29 Insufficient Sleep Behavioral condition. Limited time in bed, does not meet sleep needs. Sleep itself is not impaired. Daytime sleepiness results. Extended sleep hours improve symptoms. An epidemic!

30 Good Sleep Care Recipe Take a thorough sleep history Order sleep testing (if needed) Apply education Provide support Combine gently Repeat as needed

31 It ain t all apnea! Conclusion Even when it is apnea, patients may have other sleep problems! It is our job as sleep clinicians and educators to spread this word to patients, other clinicians (and those who determine treatment authorizations)

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