Sleep Disorders and the Metabolic Syndrome

Transcription

1 Sleep Disorders and the Metabolic Syndrome Tom V. Cloward, M.D. Intermountain Sleep Disorders Center LDS Hospital Objectives Describe how sleep disorders impact your daily medical practice Don Don t do this, do that Why is a sleep doctor speaking at this conference? Screening for sleep apnea 1

2 Depression, Hypertension and OSA Farney, et al. Chest 2004 Depression, Hypertension and OSA Farney, et al. Chest 2004 What Is Sleep Apnea? Snoring is usually present, and is associated with pauses or shallow breathing Repetitive collapse of the upper airway during sleep Every apnea ends with an arousal from sleep Every arousal puts stress on the heart and brain 2

3 How to Recognize Sleep Apnea What Causes Sleep Apnea What Causes Sleep Apnea 3

4 Pathophysiology of Sleep Apnea Mallampati Anesthesia Classification correlates with the presence of sleepsleep-disordered breathing Causes of Sleep Apnea Large uvula, broad soft palate Back of throat is narrow (may be due to enlarged tonsils or fat pads) Causes of Sleep Apnea Enlarged tonsils or congenital facial deformity is usually the cause of sleep apnea in children 4

5 Predicting Sleep Apnea 4 questions can capture the majority of sleep apnea subjects History of snoring Choking, gasping, or pauses in breathing during sleep Presence of high blood pressure Neck circumference > 18.5 inches (men) or >17 inches (women) Determinants Of Sleep Apnea Anatomical Factors Obesity Nasal congestion or obstruction Facial features Enlarged tonsils!!! Decreased Muscle Tone or Respiratory Drive Alcohol Narcotics Muscle relaxants Anesthesia Environmental Factors Sleeping on back Sleep deprivation Living at altitude Case Report 30 year old healthy male developed sore throat Went to emergency room, found to have a viral upper respiratory infection Was given Lortab (an oral narcotic) to relieve throat pain 5

6 Case Report That night, his wife found him in bed not breathing, blue, and without a pulse She called 911, and began CPR Admitted to intensive care unit on ventilator Case Report He survived Had overnight sleep study, and was found to stop breathing 117 times per hour (severe sleep apnea) His apneas lasted for seconds Case Report (Before) Exam shows small mouth, long uvula, and enlarged tonsils Mildly overweight, but not obese 6

7 Case Report He was placed on nasal CPAP (Continuous Positive Airway Pressure) and oxygen Referred to an Ears, Nose and Throat surgeon Individual Health Consequences of Sleep Apnea Depression Stroke Hypertension ADHD GERD CHF Motor Vehicle Accidents Diabetes Coronary Artery Disease Chronic Fatigue Poor Work Performance Cardiovascular Events During an Obstructive Apnea SpO2 7

8 OBSTRUCTIVE SLEEP APNEA Fatigue Unusual craniofacial Hypertensive features Obese Male Impotent Results of Treating Sleep Apnea Effects of nasal CPAP Reduces blood pressure in patients with HTN Reduces left ventricular hypertrophy after 33-6 months of therapy Improves EF by ~7% in patients with CHF Reduces or eliminates nocturnal arrhythmias After diagnosis of CAD, reduces likelihood of 2nd incident of CAD by 2/3 8

9 Effects of CPAP on Blood Pressure 140 b a s e lin e M A P (m m H g ) s u b th e ra p e u tic n C P A P Baseline Arm p m p m 3 15 a m 7 15 a m 140 Therapeutic Arm M A P (m m H g) b a s e line e ffe c tive nc P A P n = 60 patients pm pm 3 15 am 7 15 am Becker et al 2003 Circulation Effect of CPAP on Blood Pressure in Hypertensive Patients Therapeutic Subtherapeutic T = 9 weeks Becker HF, Circ, 2003 Event-free Survival in CAD Patients with OSA: CPAP Therapy and Control Arms N=54 Milleron et al. Eur Heart J 2004;25: Cardiovascular Disease and Sleep-Disordered Breathing ResMed

10 OSA and Metabolic Dysfunction OSA is associated with glucose intolerance and insulin resistance, independent of potential confounders OSA is an independent risk factor for the metabolic syndrome (Coughlin et al. Eur Heart J. 2004) Hypoxemia may be the predisposing factor to the metabolic alterations associated with OSA. CPAP improves insulin sensitivity in some patients with OSA (Harsch I, et al Am J Respir Crit Care Med 2004) Change in Glucose with CPAP (Babu Arch Intern Med 2005) N = 25 Continuous glucose monitoring system q 5 minute measurements over 72 hours Change in HbA1c with CPAP 10

11 Type 2 Diabetes, Glycemic Control and CPAP in OSA Postmeal glucose values significantly reduced with CPAP 225 CPAP use <4 hrs. (n=12) CPAP use >4 hrs. (n=12) Pretherapy Dinner Lunch Breakf Dinner 100 Lunch 125 Breakf Glucose Mean mg/dl 250 Posttherapy Ambika R. Babu, MD, James Herdegen, MD Department of Medicine, Rush University Medical Ctr. Archives of Internal Medicine VOL 165, FEB 28, 2005 CPAP Improves Insulin Sensitivity after 2 Days and 3 Months Harsch, et al. AJRCCM 2004 Utah Obesity Study N= 153 Walker, Cloward, et al; ERS National Congress

12 Improvement Following Bariatric Surgery T=26 months Walker, Cloward, et al; ERS National Congress 2007 Screening For Sleep Apnea Several questionnaires exist (Flemons (Flemons Sleep Apnea Clinical Score, Berlin Questionnaire, and STOPSTOP-BANG) All of which focus on: Snoring Observed Apneas Presence of Hypertension Neck circumference STOP-BANG Questionnaire A Tool to Screen Patients for OSA S T O P Snoring Tired Observed apnea Pressure (HTN) B BMI (greater than 35) A Age (50 and older) N Neck Size (>40 cm) G Gender (male) High risk of OSA: answering yes to 3 or more items Chung F Anesthesiology 2008; 108: Low risk of OSA: answering yes to less than 3 items N=177 (2974 pre-operative pts screened) 12

13 STOP-BANG Questionnaire A Tool to Screen Patients for OSA >5 > 15 > 30 Sensitivity Chung F Anesthesiology 2008; 108: STOP-BANG Questionnaire A Tool to Screen Patients for OSA >5 > 15 > 30 Sensitivity PPV Chung F Anesthesiology 2008; 108: STOP-BANG Questionnaire A Tool to Screen Patients for OSA >5 > 15 > 30 Sensitivity PPV Specificity Chung F Anesthesiology 2008; 108:

14 STOP-BANG Questionnaire A Tool to Screen Patients for OSA >5 > 15 > 30 Sensitivity PPV Specificity NPV Chung F Anesthesiology 2008; 108: Positive Predictive Value using STOPSTOP-BANG Criteria Chung F Anesthesiology 2008; 108: Summary Common medical problems are often manifestations of sleep disorders If your patient complains of poor sleep quality, think AIR AIR Apnea, Insomnia, Restless Legs Avoid muscle relaxants, respiratory depressants, and opioids if sleep apnea diagnosed or suspected 14

15 Summary Fatigue, Sleepiness, and Insomnia are symptoms, not diseases Determine underlying cause of symptom first (if possible) before prescribing the antianti-symptom symptom medication Summary Obstructive Sleep Apnea is a risk factor for glucose intolerance, insulin resistance, and metabolic syndrome CPAP improves insulin sensitivity (both acutely and chronically), acute glycemic control, and HgA1C STOPSTOP-BANG screening questionnaire is easy to administer with high sensitivity, PPV, and NPV Summary Screen for Sleep Apnea? 15