Natalia Usatii, MD Sleep Medicine SCMG

Transcription

1 Natalia Usatii, MD Sleep Medicine SCMG

2 Disclosures Reported relevant financial relationships with commercial interests: N/A Conflict of Interest STOP-Bang questionnaire: Property of University Health Network

3 Outline Obstructive sleep apnea introduction Diagnostic modalities Treatment modalities Sleep deprivation outcomes in adults and adolescents Multidisciplinary communication strategy to improve patient care in the area Questions

4 Obstructive Sleep Apnea (OSA) OSA is a disease characterized by recurrent collapse of the upper airway during sleep which results in sleep fragmentation, excessive daytime sleepiness and nocturnal hypoxemia.

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6 Won t breathe : central apnea Can t breathe : obstructive or mixed apnea

7 Clinical Features Symptoms During Sleep Loud disruptive snoring Awakenings with gasping &/or choking Morning dry mouth &/or headaches Witnessed apnea Awakens unrefreshed Frequent urination at night Body movements and leg jerks at night Symptoms While Awake Excessive sleepiness (including involuntary dozing & asleep at wheel ) Poor performance at work Fatigue Irritability, Depression, Anxiety

8 STOP-Bang Epworth Score

9 Symptoms that predict high pre-test probability for OSA Anesthesiology 2008; 108:812 21

10 Predictive Parameters for STOP -BANG Score of 3or greater Cutoff Sensitivity Specificity PPV NPP AHI> AHI> AHI> SnNout (high Sensitivity, Negative test = rule out) STOP-Bang 0-2 * Value expressed as percentage with 95% confidence interval

11 Examination for OSA Mallampati Score

12 Estimated Prevalence of OSA (China, Japan, India) (UK, France, Germany, Spain)

13 1) Increased risk of accident 2) Decreased productivity 3) Decreased ability to learn 4) Decreased adaptability 5) Risk to public 6) Increased lost work day 1) Diminished Performance 2) Impaired Procedural memory 3) Impaired working memory 4) Fatigue 5) Impaired mood (depression and anxiety) 6) Impaired quality of life Low O2 during Sleep Obstructive Sleep Apnea (OSA) Sleep Deprivation 1) Cardiac Diseases including Heart Failure, Myocardial Ischemia 2) Brain Disease including Stroke 3) Metabolic Disease including Diabetes 4) Increased risk of cancer 1) Increased direct health care cost 2) Increased lost work day 3) Fatigue 4) Reduced Performance 5) Impaired mood (depression and anxiety) 6) Impaired quality of Life

14 OSA Remains Largely Undiagnosed 15 20% Diagnosed 80 85% Undiagnosed 1. Young T, Evans L, Finn L, et al. Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 1997; 20: Young T, Palta M, et al. The Occurrence of Sleep-Disordered Breathing Among Middle-Aged Adults. N Eng J Med. 1993;328:

15 Nocturnal polysomnography

16 Difficulties with in lab PSG: lots of wires long waiting list inconvenience frustration

17 Cost & Access to Care Issues at SCMG Sleep Labs (Bend and Redmond) We get 480 consults per month 33% are new 58 baseline sleep studies + 88 titration studies= 146 studies/month To keep up, we would need a 12 bed lab running 360 days a year We currently have a 6 bed Bend and 6 bed Redmond running 5 days a week OUR SOLUTION: 2 MORE BEDS OPENED IN REDMOND LAST YEAR

18 Solution FROM OTHER PROVIDERS/PCPs??? Home Sleep Testing (HST)

19 ORDER HST

20 Study results showed that HST is valid Sleep Jun 1;35(6): doi: /sleep A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study. Rosen CL 1, Auckley D, Benca R, Foldvary-Schaefer N, Iber C, Kapur V, Rueschman M, Zee P, Redline S.

21 Polysomnography Performed in the Unattended Home Versus the Attended Laboratory Setting Sleep Heart Health Study Methodology Conrad Iber, MD1; Susan Redline, MD2; Adele M. Kaplan Gilpin, PhD3; Stuart F. Quan, MD4; Lin Zhang, MD3; Daniel J. Gottlieb, MD5; David Rapoport, MD6; Helaine E. Resnick, PhD7; Mark Sanders, MD8; Philip Smith, MD9

22 Types of Sleep Testing

23 Apnea Link Ares Night One Alice PDX WatchPAT

24 PSG vs. HST: Conceptual Difference PSG is a tool of discovery HST is a tool of verification HST is not sensitive but specific If HST is negative CANNOT rule out OSA!!! Refer to in-lab polysomnography

25 NO HST IN CHILDREN!!

26 How to treat OSA?

27 Positive Airway Pressure Therapy GOLD STANDARD

28 Access to care Titration studies in the laboratory still have the same issues of being labor intensive and time consuming. Shortage of PSG beds and techs contribute to a back-log in titration studies as well

29 Auto-PAP Positive airway in which the pressure is set at a range rather than a fixed pressure

30 Sleep Program Schematic Sleep Clinic HST AutoPAP AutoPAP: Rule-out if patient has 1)COPD, daytime hypoxemia or hypercapnia 2)CHF or other heart disease 3)Morbid obesity (BMI 40) 4)Upper airway surgery 5)Opioid analgesics use 6)Neuromuscular, neurological or neurodegenerative disease; history of stroke; or seizure disorder Attended PSG Attended PSG Input Sources: If patient 1)Needs titrations or re-study 2)Has low clinical suspicion for SRBD or high suspicion for narcolepsy or seizure 3)Had negative HST or needs lab titration 4)Had AutoPAP failure

31 Positive airway pressure therapy CPAP BiPAP AutoPAP

32 BiPAP: Bilevel positive airway pressure BiPAP sets two pressures above the ambient, a higher inspiratory positive airway pressure (IPAP) and a lower expiratory positive airway pressure (EPAP).

33 Indications OSA, not tolerating or ineffective CPAP COPD/CHF exacerbation OHS with worsening hypercapnia Neuromuscular disease, providing assistance with nocturnal ventilation.

34 Other Treatment modalities for OSA

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36 Hypoglossal Nerve Stimulation for Treatment of Obstructive sleep apnea

37 STAR Trial Stimulation Therapy for Apnea Reduction (STAR) 22 leading medicalcenters across the US and Europe 126 patients Results published in the N ew England Jou rnal of Med icine, January 9, 2014 Up pe r-airway Stimulation for O bstructive Sleep Apnea Strollo PJ Jr, Soose RJ, Maure r J T et a l. N Eng J Med. 2014;370(2): Inspire "'1ed cal Syster1s, I 1c All Rights Reserved

38 STAR Trial Inclusion Criteria AHI of 20 to 50 BMI < 32 Central apneas < 25% of total events on PSG Absence of concentric collapse of airway on sleep endoscopy Absence of significant tonsillar hypertrophy Absence of severe restrictive pulmonary disease or COPD Absence of severe hypertension, pulmonary hypertension, heart failure, or severe valvular heart disease Absence of neuromuscular disease Absence of severe psychiatric disease

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40 Tonsillectomy indications for OSA Tonsillectomy in children only with abnormal polysomnography: pulse oximetry levels less than 90-92% -AHI >1 -AHI >5 may warrant tonsillectomy Otolaryngology Head and Neck Surgery144(1S) S1 S

41 Treatment Of OSA Improved Sleep Quality No more Hypoxia (low Oxygen) Improved Quality of Life Improved Sleep Quantity No more rapid heart rate Improved Performance Improved Learning/Adaptability Decreased Accidents Decreased Disability Improved Mood Improved Comorbid Conditions Decreased Absenteeism/unproductive hours while at work Decreased Health Care Cost Potentially decreased Death Rate

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45 Benjamin Bugsy Siegel

46 Venkatraman et al (Duke University): (fmri)found that the nucleus accumbens, an area in the brain involved with the anticipation of reward, IS ACTIVE when high risk-high payoff choices made sleep deprivation. "Sleep Deprivation Elevates Expectation of Gains and Attenuates Response to Losses Following Risky Decisions", Sleep, May 1, 2007.

47 SLEEP DEPRIVATION IN TEEN

48 Impacts of chronic sleep loss: A brief literature review

49 Sleep and Suicide Over 60 studies have found correlations between chronic insufficient sleep and suicide. Unlike other suicide risk factors, sleep complaints may be particularly amenable to treatment. (pg 1) - Bernert and Joiner, Sleep disturbances and suicide risk: A review of the literature

50 Sleep and Dietary Choices 13,284 teens surveyed. Teens who slept less than 7 hours per night (compared to teens who slept more) were: More likely to consume fast food two or more times per week Less likely to consume fruits and vegetables Despite race, gender, SES, physical activity and family structure we need to start thinking about how to more actively incorporate sleep hygiene education into obesity prevention and health promotion interventions. -Lead researcher Dr. Lauren Hale, Stony Brook Medicine Press Release, June 20, 2013

51 Sleep and Insulin Resistance Matthews et al, 2012: 245 healthy white and black adolescents: Elevated insulin resistance [HOMA-IR] associated with shorter sleep duration Findings were independent of age, race, gender and adiposity [amount of body fat] interventions designed to extend sleep in short sleepers may be beneficial for metabolic health in adolescence and beyond. (pg 1357)

52 Sleep and appetite Ghrelin INCREASED Leptin DECREASED

53 Risk-Taking Obesity Stress Grades Sports Injuries Car Crashes Cancer Suicide Depression Drug Use Disparities High Blood Pressure Diabetes Pedestrian Accidents Emotional Intelligence Violence Anxiety Food Choices Immune Functioning Stroke

54 QUESTIONS Which score from STOP-Bang questionnaire predicts high pre-test probability for OSA? Answer: 3 or higher

55 Which type of home sleep testing is FDA-approved for OSA diagnosis? Answer: All types

56 In absence of cardiac, pulmonary, vascular, neurologic conditions, which test should be ordered to diagnose OSA? HST

57 What is the main indication for BiPAP? Answer: CPAP failure

58 What is the sensitivity and specificity of the home sleep testing? Answer: Low sensitivity and high specificity Negative HST CANNOT rule out OSA

59 When tonsillectomy is the first choice in treatment of obstructive sleep apnea? In pediatrics

60 Thank you