Can we do it? Yes we can! Managing Obstructive Sleep Apnea in Primary Care. Dr Andrea Loewen MD, FRCPC, DABIM (Sleep)

Transcription

1 Can we do it? Yes we can! Managing Obstructive Sleep Apnea in Primary Care Dr Andrea Loewen MD, FRCPC, DABIM (Sleep)

2 Financial disclosures No conflict of interest

3 Objectives When and how to order home sleep apnea testing (HSAT) for diagnosis of obstructive sleep apnea? What is the evidence for treatment of OSA? Current standards in Alberta CPAP machine coverage

4 WHEN AND HOW TO ORDER HOME SLEEP APNEA TESTING?

5 Case 1: Albert 45M accountant, lives with wife and 2 children PMHx: Hypertension (controlled with HCTZ) Chief complaint: Daytime sleepiness, snoring Fights sleep at desk, dozes off watching TV in evenings Not convinced he needs to do anything about this Non-smoker; 3 beers on weekend Physical Exam: BMI 34 kg/m 2, BP 128/74 What is the Differential Diagnosis?

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7 Assessing Probability of OSA Do you Snore Loudly? (loud enough to be heard through closed doors or your bed partner elbows you for snoring at night) Do you often feel Tired, Fatigued or Sleepy during the daytime? (such as falling asleep during driving or talking to someone) Has anyone Observed you Stop Breathing or Choking/Gasping during sleep? Do you have or are being treated for High Blood Pressure? BMI > 35 kg/m 2? Age > 50 years old? Neck size 17 inches/43 cm (M) or 16 inches/41 cm (F)? Gender = Male? Risk of OSA Low = 0-2 Intermediate = 3-4 High Risk = 5-8 OR 2 of STOP + Male 2 of STOP + BMI 2 of STOP + Neck

8 Assessing Probability of OSA Do you Snore Loudly? (loud enough to be heard through closed doors or your bed partner elbows you for snoring at night) Do you often feel Tired, Fatigued or Sleepy during the daytime? (such as falling asleep during driving or talking to someone) Has anyone Observed you Stop Breathing or Choking/Gasping during sleep? Do you have or are being treated for High Blood Pressure? BMI > 35 kg/m 2? Age > 50 years old? Neck size 17 inches/43 cm (M) or 16 inches/41 cm (F)? Gender = Male? Risk of OSA Low = 0-2 Intermediate = 3-4 High Risk = 5-8 OR 2 of STOP + Male 2 of STOP + BMI 2 of STOP + Neck

9 STOP-BANG Nagappa 2015

10 Albert (continued) Unrefreshed after 7-8 hours of sleep per night More on weekends, with no relief Non-smoker, no significant alcohol or sedative use No restless legs, no features of narcolepsy, mood OK STOP-BANG 6 What would you do next?

11 Diagnostic Sleep Testing L1 (Polysomnography) Gold standard Resource constrained May be inconvenient L3 (Home Sleep Apnea Test) Cardiorespiratory channels Performed in the home Avoid if: Cardiopulmonary Neuromuscular disease Other sleep disorder suspected Asymptomatic

12 Home Sleep Apnea Test (HSAT)

13 Polysomnogram

14 WHAT IS OSA ANYWAY?

15 Intermittent airflow cessation (apnea) or reduction (hypopnea) during sleep ( 5/hr) Severity measured by Apnea-Hypopnea Index (AHI) AHI 5-15/hr = mild AHI 15/hr = moderate AHI 30/hr = severe What is OSA? Arnardottir ES et al. Eur Respir J Jan;47(1):

16 Pathophysiology of OSA Upper Airway Collapsibility Anatomic Upper Airway Dilators Neural Ventilatory Sensitivity Drive Arousal Threshold Cortical Obstructive Sleep Apnea Sleep Disruption Intermittent Hypoxemia Eckert 2015; Edwards 2017

17 OSA and Cardiovascular Disease - Mechanisms Arousal Sleep Fragmentation Dewan 2015; Ayas 2016

18 and has Important Consequences All severities of OSA Quality of life Depression Motor vehicle collisions Workplace productivity Post-op complications Healthcare utilization Severe OSA Hypertension Diabetes Cardiovascular events Stroke Atrial fibrillation (new and recurrent)

19 EVIDENCE FOR OSA TREATMENT

20 MOSAIC Trial Craig 2012

21 Multicentre, open-label RCT of CPAP vs. no CPAP for moderate to severe OSA 2717 patients Australia, USA, China, India, Brazil, Spain Pre-existing cardiovascular disease Moderate-severe OSA on ambulatory testing Excluded: severe sleepiness or hypoxemia, safety-critical occ. McEvoy 2016

22 SAVE Trial Summary No difference in any cardiovascular outcomes Sleepiness, HRQOL, HADS all improved with CPAP Fewer work days missed Issues Adherence: 3.3 hrs/night Variable OSA care Secondary prevention McEvoy 2016

23 OSA Treatment Does it reduce CV risk? Great question! Strong biological basis for risk reduction CPAP and oral appliance both improve BP Other risk reduction may depend on other factors Disease severity and control Primary vs. secondary prevention Treatment adherence CPAP in isolation vs. chronic disease management

24 Back to Albert He has severe OSA (RDI 45/hr, mean SpO2 87%), you recommend CPAP and Albert agrees You refer him for a CPAP setup and early feedback suggests he is feeling much better 2 months later, he returns with complaints of sleepiness My CPAP just isn t working anymore! Now what?

25 Why CPAP Doesn t Work Nonadherence/intolerance Minimum use 4 hours/night on 70% of nights Mask leak Facial hair, weight gain Sub-therapeutic pressure Weight gain, alcohol/sedative use Equipment failure Mask replacement annually Another sleep disorder 25-30% of OSA patients

26 CPAP Intolerance

27 Sample Download

28 Sample Download (2)

29 Motor Vehicle Safety & Reporting Requirement to report varies by jurisdiction Alberta: Patient responsible for self-reporting Commercial drivers: periodic medical required But, general principles are similar Symptoms/risk not a function of severity Efficacy includes adequate compliance, improvement in objective measure of OSA and symptoms Compliance: 4 hours/night on 70% of nights over 30 days Treatment effectiveness: AHI < 20/hr Reduced daytime sleepiness Ayas 2014

30 Case: Gerald 57M, admitted to hospital with anasarca BMI 56 kg/m 2 Sleepy and snores loudly ABG: PaCO 2 49 mmhg, PaO 2 54 mmhg

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32 Hypoventilation Elevation in arterial CO 2 Abnormal increase during sleep or awake hypercapnia Pathophysiology Inability to clear CO 2 COPD, neuromuscular disease Derangement in central control of breathing narcotics, obesity hypoventilation syndrome CPAP or oxygen started in an unmonitored setting may lead to acute respiratory failure Refer for polysomnographic PAP titration May require bilevel PAP +/- supplemental oxygen

33 Case: Cecile 68F, recent admission for CHF Noted by nursing staff to have intermittent breathing pauses and hypoxemia at night BMI 22 kg/m 2 Not sleepy

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35 Central Sleep Apnea Intermittent in airflow without UA obstruction No ventilatory effort Pathophysiology Chemoreceptor hyperresponsiveness ( loop gain) Circulatory delay (Cheyne-Stokes Respiration) - CHF Disruption in respiratory pacemaker narcotics, stroke Goal of treatment is to address underlying problem Consider PAP if symptomatic usually not CPAP Oxygen can stabilize breathing Specialist consultation may be warranted

36 SLEEP CARE IN ALBERTA

37 Current Landscape A Mix! Mix of providers Primary care, specialists (sleep/non-sleep), RRTs, NPs, RNs. RCPSC AFC Sleep Disorders Medicine July 2018 Mix of funding for sleep diagnostic testing Limited public funding for sleep laboratories (PSG) Privately funded PSG laboratories (independent centres) No funding for HSAT (hospitals, homecare companies) Mix of regulations CPSA standards (PSG update, new for HSAT) Jan 2018

38 Cost of Treatment (Alberta) Out-of-pocket or private insurance for most therapies CPAP ~ $ Online purchase ~$600 but no service provided OA ~ $ Less expensive options compromise efficacy Surgery maxillomandibular advancement covered Other procedures offered privately (limited evidence) Special groups receive government funding AISH, AB Works, low-income seniors (Special Needs Assistance for Seniors Program SNAP), NIHB AADL: severe sleep-disordered breathing bilevel PAP, O 2

39 Patient Pathways Referral options (testing and treatment) Respiratory homecare company for OSA HSAT (+/- cost), CPAP if prescribed May or may not see physician (sleep, resp, general) Independent sleep centres Usually sleep trained physicians (or supervision) Affiliated with polysomnography lab (cost) +/- HSAT Public sleep centres Edmonton, Lethbridge Public sleep centres - Foothills Medical Centre Sleep physician (mostly respirologists) +/- sleep-trained RRT HSAT and/or polysomongraphy

40 Considerations for referral Pre-test probability of OSA Is HSAT appropriate? Requirement for clinical review Is a Sleep Physician assessment needed? Choice of treatment CPAP provided by respiratory homecare companies Dental referral for oral appliance Upper airway surgery suggest sleep physician consult, and ENT or oromaxillofacial surgeon consult

41 New Initiatives FMC Sleep Centre Delegation of follow-up for uncomplicated OSA requiring therapy to primary care physician and homecare company Have met with many companies to lay out expectations Return of non-urgent mild/moderate OSA referrals (after review of patient questionnaire and HSAT by clinician) to referring physician, usually primary care MD Accompanying information package

42 Can we do it? Yes we can! OSA is prevalent Like hypertension, Family MDs have the tools available in Alberta to Diagnose OSA Discuss and advise treatment options for mild/moderate obstructive sleep apnea with their patients Consider behaviour modification, driving safety in all Refer for all patients with suspected sleep disorders to sleep physician Have severe OSA/OHS, complex and non-respiratory sleepdisorders managed by a sleep specialist

43 NEW INITIATIVES

44 New Initiatives Sleep Disorders Working Group Part of the Respiratory Health Strategic Clinical Network Clinicians, researchers, policy-makers interested in improving sleep care for Albertans Projects Regulations for HSAT (CPSA to implement late 2018) Defining practice competencies for sleep providers Improve integration of primary/specialty sleep care

45 Progress to Date Needs Assessment Primary care survey summer 2016 Patient focus groups & interviews - spring 2017 Provider workshops May 29 (Calgary), June 1 (Edmonton) Partnerships AHS Primary Healthcare Integration Office Toward Optimized Practice (guideline scheduled for 2018) AMA Physician Learning Program, Respiratory Medicine Alberta College of Family Physicians Respiratory Home Care Association of Alberta Initial conversations with Calgary Zone Secretariat Health Systems Support Task Force

46 Questions?