CHANGING SHAPE OF SLEEP STUDIES

Transcription

1 CHANGING SHAPE OF SLEEP STUDIES JAMES C. O BRIEN MD FCCP, FAASM MEDICAL DIRECTOR, PROHEALTH PHYSICIANS SLEEP CENTERS 10/19/2107

2 GOALS OF MY TALK-- Review the types of sleep studies Provide clinical information and insights into the prevalence of OSA, its pathophysiology and diagnostic challenges. Appreciation of the many different presentations for OSA and the importance of screening and diagnosing OSA within your office practice. To answer any questions you may have along the way.

3 CMS Payments for PSGs 2001: $62 Million 2011: $565 Million

4 SLEEP APNEA PREVALENCE 42 million Americans have a sleep-related breathing disorder. 9% women and 24% men between the ages of 30 and 60 have OSA. As common as diabetes or asthma 80% undiagnosed! The patient is often the last to know they have it!

5 CLINICAL CONTINUUM OF SLEEP DISORDERED BREATHING (SDB) Primary Snoring Increased Upper Airway Resistance Sleep Apnea (obstructive, central, mixed) Nocturnal Hypoventilation Chronic Alveolar Hypoventilation Progression can take months, usually years and even decades! Theoretical impact of preventing snoring is not insignificant.

6 FOUR TYPES OF SLEEP STUDIES Type I Polysomnogram (PSG) performed in Lab with sleep technician in attendance. (Common) Includes EEG, EOG, EMG, EKG, Respiratory Effort/Flow, Oximetry and CPAP/BiPAP Type II PSG performed outside of LAB, without sleep technician (Rarely done) Type III no sleep recorded with minimum 4 channels performed in home without sleep technician. Includes Respiratory effort/flow, pulserate, oximetry and possible positional sensor Type IV no sleep recorded with minimum 3 channels Unattended study includes: airflow, respiratory effort and oximetry.

7 HOME SLEEP APNEA STUDIES Performed to confirm the presence of OSA in a given patient. It is not a valid test to rule out OSA (high false neg rate). Test subject must be able to reliably apply the leads on themselves for this test. It is must be ordered in conjunction with a sleep specialist % of HSAT s are inconclusive studies consider PSG as next step. Consider HSAT in treated OSA patients s/p post weight loss, oral appliance therapy or ENT surgery.

8 HOME SLEEP APNEA TEST (HSAT) DEVICE (TYPE3)

9 HSAT DATA ---3 ½ HRS AND 5 MIN.

10 ADVANTAGES OF HOME SLEEP APNEA STUDY Scheduling Helps patients unable or unwilling to go to the sleep lab for testing Cost convenience for patients with high deductibles Simple setup Easy to use Comfort and accessibility

11 DISADVANTAGES OF HOME SLEEP APNEA TESTS HSAT s are not as accurate and tend to under estimate results (no EEG) Not ideal for patients with other sleep disorders, besides OSA, such as PLMD, Bruxism, RBD and Narcolepsy. Not ideal for patients with significant COPD, CHF, neuromuscular disorders and neurocognitive issues. HST s are not monitored during the test (loosening or loss of a leads can and does occur)

12 POLYSOMNOGRAPHY

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14 POLYSOMNOGRAPHY EEG LEADS

15 INDICATIONS FOR TYPE I SLEEP STUDY (PSG) Insomnias Central Sleep Apnea (narcotic use, CHF, bilateral CNS disease, unilateral carotid stenosis) Periodic Limb Movement Disorder (PLMD) Parasomnias (unusual behaviors during sleep) Hypersomnias MSLT (mean sleep latency test) Narcolepsy MSLT with 2 SOREMs Inconclusive HSAT in a symptomatic patient.

16 30 SECOND EPOCH OF PSG DATA

17 SCORING AND INTERPRETATION OF PSG DATA Raw data must be read and scored in 30 sec epochs which are single pages of data. Average PSG is 8hrs 2 epochs (pages) are recorded per minute 120 epochs recorded per hour 960 pages of data per polysomnogram to be read for report

18 PSG TEST EEG DATA

19 30 SECOND EPOCH OF REM STAGE SLEEP

20 PSG TEST RESPIRATORY DATA (NON EEG)

21 CLINICAL MEASURES OF SLEEP APNEA APNEA is any cessation in airflow lasting more than 10 seconds and associated with a 4% drop in O2 desaturation from baseline. HYPOPNEA is any reduction in airflow greater than 30% of baseline with an associated O2 desaturation of 4% The Apnea-Hypopnea Index (AHI) is the total # of respiratory events/hour of sleep.

22 CLINICAL SEVERITY OF SLEEP APNEA MILD>5-15 events/hour. MODERATE >15-30 events/hour. SEVERE >30 events/hour.

23 MORTALITY OF UNTREATED OSA

24 CLINICAL SEVERITY OF SLEEP APNEA MUCH MORE than just a mild, moderate or severe AHI. Multifactorial and variable expression. Involves the degree of hypersomnolence. Degree of neurocognitive impairment. Presence and severity of comorbid medical conditions.

25 SLEEP APNEA PREVALENCE IN CDV DISEASE PATIENTS Drug-Resistant Hypertension Congestive Heart Failure Atrial Fibrillation 50% 50% 80% Javaheri et al. Circulation 1999 Logan et al.j. Hypertension 2001 All Hypertension Coronary Artery Disease 35% 30% Sjostrom et al. Thorax 2002 Somers et al. Circulation 2004 Angina 30% Schafer et al. Cardiology 1999 Sanner et al. Clin Cardiology 2001

26 SIGNS AND SYMPTOMS FOR OSA

27 OSA AND THE CONSEQUENCES OF SLEEP DEPRIVATION, IN GENERAL. NEUROCOGNITIVE IMPAIRMENTS Judgment impaired. Short term memory reduced. Pain tolerance is lowered or MORE sensitive to pain. More moody or irritable than previously. More difficulty focusing attention. More difficulty concentrating on a task

28 POTENTIAL NOCTURNAL SYMPTOMS OF OBSTRUCTIVE SLEEP APNEA Dyspnea inspiratory vs expiratory Urgent Nocturia and scant donation Reflux/GERD Palpitations Nightmares (jumping, chasing, underwater) Diaphoresis Bruxism

29 UNDERSTANDING THE VARIABLE PRESENTATIONS OF OSA PATIENTS Comorbidities of OSA: The presence of one or more disorders that are caused or contributed to by the presence of obstructive sleep apnea. Knowing them and understanding their significance is key!

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32 CLINICAL PEARL.. Everybody who snores doesn t have sleep apnea, but everybody who snores will likely get sleep apnea, IF they live long enough!

33 MALLAMPATI SCORE- AIRWAY ANATOMY FOOT IN A SHOE ANALOGY

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35 CARDIOVASCULAR DISEASES AND OSA CDV---leading cause of death in world CDV---leading cause of disability and healthcare expenditure in the US OSA magnifies the physiologic consequences of any underlying Cardiovascular Diseases(CDV)! CDV + OSA = trouble!

36 OSA COMORBIDITIES AND CVD DEATH 42% of deaths in people with severe sleep apnea were attributed to CVD or stroke, compared with 26 percent of deaths in people with no sleep apnea. Young et al. Sleep 2008

37 SLEEP IS A DANGEROUS PLACE BECAUSE SO MANY PEOPLE DIE THERE. MARK TWAIN

38 INTOXICATED FROM SLEEP LOSS Consequences of: 2 hrs sleep loss = drinking oz beers Equivalent to blood alcohol level of.05 4 hrs sleep loss = drinking oz beers Equivalent to blood alcohol level of.10 Legal limit for intoxication in MA =.08

39 NEURO COGNITIVE IMPAIRMENTS Short term memory loss Increased moodiness Reduced concentration and focus Driven by sleep deprivation, particularly REM stage sleep. Gradual process potentially over many years, even decades! OFTEN THE PATIENT IS THE LAST TO KNOW!

40 CLINICAL IMPACT OF OSA OSA can act as an accelerant for the evolution of certain medical disorders that a given patient is genetically predisposed to. OSA can influence both the rate of progression and current degree of severity of any medical comorbidity that is currently active within their lives.

41 THANK YOU! There is no such thing as a bad question, only bad answers!

42 CONTACT INFORMATION James O Brien MD, FCCP, FAASM Offices located in West Hartford, Wallingford, Bristol and Glastonbury. Sleep Centers located in Wallingford and West Hartford. phone: jobrien@prohealthmd.com