Sponsored by The Foundation For Care Management (FCM)

Transcription

1 This activity was supported by an independent medical education grant from TEVA Pharmaceuticals. Sponsored by The Foundation For Care Management (FCM)

2 evaluation, and score at least 70% on the post-test. A statement of credit will be available for printing upon successful completion. If you have questions about this CME/CE activity, please contact FCM at jdunn@fcmcme.org. PROGRAM OVERVIEW This activity focuses on the symptoms and assessment protocols associated with the diagnosis of Obstructive Sleep Apnea. The goal is to enhance the ability of primary care providers (PCPs) to diagnose and manage patients with Obstructive Sleep Apnea (OSA), thus improving clinical outcomes for each patient. Funded through an education grant from Teva Pharmaceuticals. Release Date: 4/15/2014 Expiration Date: 4/15/2016 TARGET AUDIENCE This course is open to all healthcare providers and is targeted to primary care providers - Physicians, PAs, NPs, RNs, and Pharmacists. PURPOSE To provide the tools to enable the primary care provider to manage the care of patients with sleep apnea and obstructive sleep apnea. LEARNING OBJECTIVE Upon completion of this activity the healthcare provider will be able to: n Describe the risk factors and the screening criteria for the diagnosis of obstructive sleep apnea. METHOD OF PARTICIPATION/CRITERIA FOR SUCCESS: To receive continuing education credit, participants should review all program materials in their entirety, complete and submit the online post-test and ESTEEMED FACULTY Jakdej Nikomborirak, M.D. Board Certified Pulmonary Medicine and Critical Care, Diplomate American Board of Sleep Medicine and Internal Medicine, Bainbridge, WA Dr. Nikomborirak, is the director of the Whidbey Island Sleep Center in Oak Harbor, Wash. Under the leadership of Dr. Jak, as he is known, the center maintains full accreditation by the American Academy of Sleep Medicine, which indicates that it meets the most rigorous standards of excellence in the comprehensive management of sleep disorders. DISCLOSURES: Faculty: Dr. Nikomborirak has no significant financial interest in any of the products or manufacturers mentioned. FCM s Planning Committee: Jeanette M. Dunn, EdD, RN, Nurse Planner; Jakdej Nikomborirak, MD, content expert; Lisa Chamberlain, PharmD, - have no significant financial interest in any of the products or manufacturers mentioned DISCLOSURE DECLARATION It is the policy of Foundation for Care Management (FCM) to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The faculty must disclose to the participants any significant relationships with commercial interests whose products or devices may bementioned in the activity or with the commercial supporter of this continuing education activity. Identified conflict of interest is resolved by FCM prior # 1

3 to accreditation of the activity. FCM planners and reviewers, outside of those listed, have no relevant financial relationships to disclose. DISCLAIMER Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient s conditions and possible contraindications on dangers in use, review of any applicable manufacturer s product information, and comparison with recommendations of other authorities. ACCREDITATION: Physicians: The Foundation for Care Management (FCM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for Physicians. FCM designates this educational activity for a maximum of.25 AMA PRA Category 1 credits. Physicians should only claim credit commensurate with the extent of the participation in the activity. Nurses: The Foundation for Care Management is an approved provider of continuing nursing education by the Washington State Nurses Association Continuing Education Approval & Recognition Program (CEARP), an accredited approver by the American Nurses Credentialing Center s Commission on Accreditation. FEES There is no cost to participate in this program. PRIVACY AND CONFIDENTIALITY POLICY To view our privacy policy click the link provided. HARDWARE AND SOFTWARE REQUIREMENTS To access materials users will need: n n n n A computer with an Internet connection. Internet Explorer 7.x or higher, Firefox 3.x or higher, Safari 3.x or higher, or any other W3C standards compliant browser. Adobe Acrobat Reader or Apple Preveiw. Occasionally other additional software may be required such as Adobe Flash Player and/or an HTML5 capable browser for video or audio playback. Pharmacists: The Foundation for Care Management is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Program # H01-P * This CE activity is knowledge-based. # 2

4 Welcome and thank you for joining me for this online presentation entitled Obstructive Sleep Apnea Case One: Symptoms and Assessment Protocols. I d like to thank the Foundation for Care Management for giving me this opportunity to speak with you about this very important topic. I d also like to acknowledge TEVA Pharmaceuticals for their support. I m Dr. Jakdej Nikomborirak, now lets begin. 3

5 Describe the risk factors and the screening criteria for the diagnosis of obstructive sleep apnea. 4

6 Obstructive sleep apnea is very common in middle-age men. Snoring is almost always the first sign of obstructive sleep apnea. Patients are generally not aware of the frequent nocturnal awakenings but do feel tired in the morning and sleepy during the day. Epworth Sleepiness Scale sore of > 10 suggests excessive daytime sleepiness. Obstructive sleep apnea causes headache that goes away quickly after awakening. The headache is from CO2 retention which resolves quickly after normal breathing. Obstructive sleep apnea is common in hypertensive patients, especially when the blood pressure is difficult to control: requiring 3 or more medications. BMI is a very good predictor of OSA. Nasal insufficiency can contribute to OSA and makes CPAP therapy difficult. Scalloped tongue (teeth marks along the lateral edges) suggests insufficient space in the mandible predisposing hypopharyngeal occlusion during sleep by the tongue base. Retrognathia is receding chin. Mallapati Classification is used to assess how narrow the upper airway is by noting the relative position of the tongue base to the soft palate. Class III is when the uvula is obscured altogether by the tongue base. Edema is important because there is new evidence showing the peripheral edema can migrate north when a person lies down, increasing the neck size and reducing the upper airway caliber. 5

7 OSA is most common of the sleep-related breathing disorders. In obstructive sleep apnea, the patient tries to breathe but unable due to collapse of the upper airway. Central sleep apnea, on the other hand, occurs because lack of respiratory effort. This condition is most commonly seen in patients with congestive heart failure and in combination with Cheyne-Stokes breathing which is a waxing-waning breathing pattern. Nocturnal hypoventilation occurs naturally because of body position and diminished muscle tone during sleep. However, this becomes a problem when ventilation is marginal to begin with, such as in patients with COPD, chronic lung diseases, neuromuscular diseases, and morbid obesity. In such patients, carbon dioxide rises and hypoxia ensues, especially during REM sleep where only the diaphragm is working. 6

8 Obstructive sleep apnea occurs because of collapse of the upper airway behind the soft palate and tongue base (velopharynx and hypopharynx). The collapse is due to the narrow airway caliber and loss of muscle tone during sleep. Sleeping on the back is usually worse than sleeping in lateral recumbent or prone position. Snore occurs when the upper airway starts to narrow. Hypopneas occur when the lumen is so narrow that the airflow decreases and the patient has to put in extra effort to breathe. Apneas occur when lumen completely occluded. 7

9 Obstructive sleep apnea is very common especially in the US where two-third of the population is either overweight or obese. CMS anticipates a quarter of all medicaid/medicare recipients to have obstructive sleep apnea. 8

10 The risk of obstructive sleep apnea increases with comorbid conditions. It is part of the metabolic syndrome. 9

11 Male have about 2:1 risk over female. This is because male s weight distribution is around the chest and neck. The male:female risk ratio becomes the same after menopause. The larger the neck, the smaller the upper airway caliber. Family history is important, especially when affected members are not obese. 10

12 Again, snore is the precursor of obstructive sleep apnea. The louder the snore is, the more likely the individual has obstructive sleep apnea. In OSA, snore is usually irregular and unsteady. There are snorts and pauses. Not too many patients can recall choking at night. Many patients complain of having to urinate 4 5 times a night and attribute it to urinary problems. Surprisingly, these patients do not have to urinate as often during the day an important piece of evidence that this is not a urinary problem. Unrefreshed sleep, fatigue, and excessive daytime sleepiness are common symptoms. It should be noted that a lot of patients do not differentiate between fatigue and excessive daytime sleepiness. Fatigue has many possible causes, where as excessive daytime sleepiness generally is caused by lack of sleep (excluding those patients that take sedating drugs during the day). Morning headache that is due to obstructive sleep apnea will resolve spontaneously within a hour of awakening. Patients typically say that the headache is gone with the shower of morning cup of coffee. If the headache lasts half a day or all day, it is not from obstructive sleep apnea. Many obstructive sleep apnea symptoms overlap with those of depression. Gastroesophageal reflux at night occurs in patients with obstructive sleep apnea because the increased negative intrathoracic pressure that is generated after the upper airway has collapsed. 11

13 BMI and neck circumference are standard measurements in OSA evaluation. Throat exam should address the uvula, soft palate, tongue/tongue base volume, tonsils, and dentition. Overlapping of incisors suggests that the mandible width is inadequate. Poor dentition may prevent the use of oral appliance as a treatment for OSA. On the other hand, oral appliance works better when there is retrognathia. Abnormal cardiopulmonary findings make home sleep test inappropriate. 12

14 We do not want to miss diagnosing patients because there are risks to untreated obstructive sleep apnea. Symptoms of obstructive sleep apnea deteriorate quality of life and increase accident. Risk of being involved in a traffic accident has been reported somewhere between 2 and 15 times that of normal individuals. The FMCSA suspects that 28% of all commercial drivers have obstructive sleep apnea and a few years ago wanted all commercial drivers with BMI > 35 to have a sleep study. However, Congress stopped it from becoming a regulation. The FAA two months ago proposed a regulation requiring all airmen and air traffic controllers with BMI > 40 to be evaluated for OSA. Again, the proposal is about to be blocked by the Congress. It is well accepted now that OSA causes hypertension and CPAP therapy improves blood pressure. The Joint National Committee on hypertension recommends ruling out OSA as it is the most common treatable cause of hypertension. A study by Yaggi published in New England Journal of Medicine showed that when OSA in stroke patients was untreated, the risk of having a second stroke doubled. The increased sympathetic tone during apneic episodes raises heart rate, blood pressure, and induces cardiac arrhythmias which include SVT, atrial fibrillation, and sometimes VT when hypoxia is severe. There are several studies showing an independent association of moderate to severe OSA with increased mortality risk (Marshal et Ann Lower, ARNP. Sleep 2008). 13

15 CLAIMING CREDIT To receive CE/CME credits you must successfully complete the online program post-exam and evaluation. To complete the online exam and evaluation proceed to and follow these easy steps to earn credit. 1. Sign-In or Register at 2. Once signed in, select the course from the Online Courses listing. 3. Complete the online course selection process in its entirety. The course title will be added to your User Record page. 4. Select the Take Exam link and answer all the questions. When ready submit the online Exam. An immediate grade report will be displayed. Upon successful completion of the post-exam with a score of 70% or higher click continue and complete the program evaluation. 5. A Print/View Certificate link will be provided from within the User Record page (across from the course title). Click to view or print your statement of credit. Important Credit Note: Credit may not be claimed if completed after the course expiration date. 14