What is SDB? Obstructive sleep apnea-hypopnea syndrome (OSAHS)

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1 Have a Good Sleep? Estimated 70 million Americans have clinically significant sleep problems Chronic insomnias report decreased quality of life, memory and attention problems, decreased physical health 70% are primary sleep disorders Total direct costs of insomnia in U.S. $13.9 billion (1995) At least 2300 sleep studies/ people/year needed to adequately address the demand for diagnosis and treatment.

2 What is SDB? SDB (Sleep disordered breathing) include breathing disorders list bellow Obstructive sleep apnea-hypopnea syndrome (OSAHS) Central sleep apnea-hypopnea syndrome (CSAHS) Cheyne Stokes breathing syndrome (CSBS) Sleep hypoventilation syndrome (SHVS) Complex sleep disorder breathing (CSDB)

3 What Is OSA? Most common form of SDB OSA (Obstructive Sleep Apnea) occurs when the upper airway repeatedly collapses during sleep, causing cessation of breathing (apnea) or inadequate breathing (hypopnea) and sleep fragmentation Serious disorder linked to leading causes of death in the US (heart disease, stroke)

4 Risk Factor? Male gender Obesity (BMI >30) Diagnosis of hypertension Excessive use of alcohol or sedatives Upper airway or facial abnormalities Smoking Family history of OSA Large neck circumference (>17 men; >16 women) Endocrine and metabolic disorders

5 Obstructive Sleep Apnea Cycle Awake: Small airway + neuromuscular compensation Loss of neuromuscular compensation + Decreased pharyngeal muscle activity Sleep Onset Airway opens Airway collapses Apnea Pharyngeal muscle activity restored Hypoxia & Hypercapnia Arousal from sleep Increased ventilatory effort

6 Pathophysiology of Sleep Apnea Sleep-Apnea Hypoxia & Hypercapnia Hyperventilate Intermediate mechanisms Arousal Sleep fragmentation Physiologic perturbations Decreased pleural pressure Increased cardiac afterload Vagal bradycardia Ectopic cardiac beat Pulmonary vasoconstriction Systemic vasoconstriction Acute CO 2 retention Increased Inflammation Increased Oxidative Stress Metabolic Dysfunction/ Insulin Resistance Hyper-coaguability Endothelial Dysfunction Autonomic Dysfunction Cerebral dysfunction Loss of deep sleep Sleep fragmentation Excessive motor activity Clinical outcomes Systemic Hypertension Atherosclerosis Diastolic Dysfunction Congestive Heart Failure Stroke Impaired glucose tolerance Increased Mortality and Sudden Death Cardiac Arrhythmias Chronic hypoventilation Excessive daytime sleepiness Intellectual deterioration Personality changes Behavioral disorders Restless sleep

7 Impact of OSA OSA impact on automotive accidents Treating all US drivers suffering from sleep apnea would save $11.1 billion in collision costs and save 980 lives annually Sleep-related accidents comprise 15~20% of all motor vehicle crashed People with moderate to severe sleep apnea have an up to 15-fold increase of being involved in a traffic accident HEALTH CARE COSTS (Economic consequences of untreated SDB) Undiagnosed patients used $200,000 more in the two-year period prior to diagnosis than matched controls Prior to sleep apnea diagnosis, patients utilized 23 50% more medical resources Total economic cost of sleepiness = approximately $43 56 billion Undiagnosed moderate to severe sleep apnea in middle-aged adults may cause $3.4 billion in additional medical costs in the US

8 Obesity Trends Among U.S. Adult (*BMI 30, or about 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS, Behavioral Risk Factor Surveillance System http: //

9 Obesity Trends Worldwide It is predicted that over the course of the next 20 years obesity will be the #1 health problem throughout the world

10 How to Diagnose OSA? Screening in Clinic Risk Factors Obesity( BMI) Collar size (> 17 for men) Family history Hypertension Alcohol / sedative use Symptoms Excessive Daytime Sleepiness Questionnaires Epworth sleepiness scale Multiple sleep latency test (MSLT) Maintenance of Wakefulness Test (MWT) Overnight sleep study (PSG) Full night PSG Split night PSG Portable devices 20 85% have not been diagnosed 10 Undiagnosed Diagnosed Millions of Americans (Adults) Diabetes OSA Young 2002, 1997

11 PSG vs. HST IN LAB SLEEP STUDY Must record at least 12 channels of information if a AASM-accredited center $$$ Airflow Breathing Efforts Blood Oxygen Heart Activity Snoring Brain Waves Eye Movements Chin Movements Leg Movements Unusual Behavior Body Position Sleep Architecture IN HOME OSA STUDY HST captures only what is necessary for OSA diagnosis $ The area highlighted in the lower right hand corner demonstrates decreased oxygen saturations resulting from increased airflow obstruction. Note the increased wave patterns in the nasal, thoracic and abdominal areas right above the oxygen saturation monitor.

12 OSA Treatment Options(1) Conservative measures Weight Loss! Positional therapy Avoid alcohol < 4 hours before sleep Smoking cessation Treat nasal congestion Sleep hygiene Surgery T&A for young children Uvulopalatal Pharyngoplasty (UPPP) Laser Maxillary-Mandibular Advancement Tracheostomy Definitive therapy Only specific therapy until early CPAP ( 80s) Pillar Procedure Nasal Surgery Septoplasty-Rhinoplasty

13 OSA Treatment Options(2) Positive airway pressure (CPAP/APAP/BiPAP) Most widely used and most effective therapy Improves symptoms, reduces mortality, physician & hospital costs Patient tolerance and adherence variable 30~80% non-adherence (<4 hours use/night) Conservative measures Dental appliance Reasonable alternative to CPAP for selected patients Best patient characteristics Mild-moderate OSA Supine predominant Healthy dentition Dental, jaw side-effects

14 CPAP Treatment From 1985 To 2011 CPAP is indicated for the treatment of moderate to severe OSA (Standard) CPAP is indicated for improving self reported sleepiness in patients with OSA (Standard) CPAP is recommended for the treatment of mild OSA (Option) CPAP is recommended for improving quality of life in patients with OSA (Option) CPAP is recommended as an adjunctive therapy to lower blood pressure in hypertensive patients with OSA (Option) Sleep :

15 Fixed Pressure CPAP Devices Auto Pressure CPAP Devices CPAP machines provide a single, fixed pressure through out the night. The intent of CPAP is to splint open the upper airway to prevent obstruction. Auto pressure devices automatically adjust the pressure in response to changes in the patients airway. Results in lower overall mean pressure.?increased comfort for patient. Bi-level Devices (NIV) Bi-level systems deliver two different pressures a higher pressure on inspiration (IPAP) a lower pressure on expiration (EPAP) Acts as a non-invasive VENTILATOR (NIV)

16 Factors Affecting Adherence Clinicianrelated Equipmentrelated CPAP ADHERENCE Lesser severity of symptoms Little or no perceived benefit from therapy Failure to understand importance of or directions for CPAP use Use of prescription/non-prescription drugs or alcohol Lack of social support Other medical illnesses or fatigue Physical limitations (i.e. vision, hearing, hand coordination) Patientrelated Complexity of therapy/device use Increased rate of adverse reactions that go unaddressed Lack of efficacy Expense of device Poor relationship with patient Lack of clinician follow-up Expression of doubt concerning therapeutic potential OR creating falsely elevated expectations Unwillingness to educate patients Lack of knowledge of other medications patients may be taking (i.e. alcohol, sedatives)

17 CPAP: Adverse Effects Mask marks on face Nasal bridge discomfort or breakdown Nasal congestion/nose bleeds Dry nose/dry or red eyes Machine noise Prolific rhinitis Facial acne under mask Difficulty exhaling Ear pain Air-swallowing Tube condensation Claustrophobia/anxiety Day-to-day inconvenience Difficulty traveling/poor portability Relationship discord CPAP is so un-sexy

18 Histograms of Normal Sleep

19 Have a Nice Sleep!!

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