The Snooze News: COPYRIGHT. Sleep Apnea Review and Update

Transcription

1 The Snooze News: Sleep Apnea Review and Update Melanie Pogach, MD Pulmonary, Critical Care, and Sleep Medicine Beth Israel Deaconess Medical Center

2 Sleep Aids to Get You Through the Night Sleep Problems Tied By GREGORY to Diabetes SCHMIDT in Men By Nicholas BakalarSEPT. July 5, 16, Poor Sleep May Spur College Weight Gain Sleep Problems By Jan Tied Hoffman to Type October 2 Diabetes 26, 2015 By Train Nicholas Engineer Bakalarin February Fatal Derailment 4, 2016 Is Said to Have Sleep Apnea April 6, 2014 Extra Sleep Linked With Stroke Risk By Nicholas Bakalar March 2, 2015 Treating Sleep Apnea May Ward off Memory Decline By Nicholas Bakalar April 15, 2015 Sleep Poorly? You May Eat Too Much the Next Day By Nicholas Bakalar November 2, 2016

3 Randy Glasbergen I m the Apnea Fairy. I have orders to give you a wake up call at 10:30, 10:47, 10:53, 11:02, 11:17, 11:26

4 Why be concerned about sleep apnea? Most common sleep d/o Prevalence estimates in US adults million (moderate-severe) 1/5 mild, 1/15 moderate to severe 20-30% 10-15% > 80% remains undiagnosed Increases with Age, BMI Major driver of health care cost Somers et al. Am Coll Cardiol 2008; Young et al. AJRCCM 2002; Tishler et al. JAMA 2003; Kapur et al. Sleep Breath 2002.

5 Why be concerned about sleep apnea? Strong and growing body of evidence links sleep and cardiometabolic co-morbidities Sleep => duration, timing, quality (OSA) Bidirectional and independent associations OSA may impact onset and exacerbate comorbid conditions OSA highly prevalent in individuals with conditions Treating OSA can improve cardiometabolic health

6 Hypoxemia Hypercapnia Intrathoracic pressure Sleep apnea Functional and medical consequences Sleep fragmentation Arousals Sleep deprivation

7 Functional consequences Excessive daytime sleepiness Insomnia Decreased QOL MVAs and workplace accidents Cognitive deficits Drowsy driving Gottlieb et al. AJRCCM 1999; Baldwin et al. Sleep 2001; Teran-Santos et al. NEJM 1999; Simmons and Clark. J Am Dent Assoc 2009.

8 Hypoxemia Hypercapnia Intrathoracic pressure Left atrial enlargement HPA axis alterations Adipokine profiles Fatty acid lypolysis Oxidative stress Sleep apnea Mechanisms Sleep fragmentation Arousals Sleep deprivation Sympathetic activation Inflammation Endothelial dysfunction Hypercoagulability Disease manifestations Malhotra and White. Lancet 2002; Somers et al. JACC 2008; Redline et al. AJRCCM 2010; Yaffe et al. JAMA 2011; Kang et al, Science 2009.

9 Disease manifestations Impaired glucose tolerance T2DM HTN (systemic, pulmonary) Atherosclerosis Cerebral vascular disease MI CHF Arrhythmias Sudden cardiac death Cognitive disorders Malhotra and White. Lancet 2002; Somers et al. JACC 2008; Redline et al. AJRCCM 2010; Yaffe et al. JAMA 2011; Mehra et al., AJRCCM 2006; O Connor et al., AJRCCM 2009; Kang et al, Science 2009; Buchner S et al. Eur Heart J. 2014;Circulation 2016; 134

10 Metabolic syndrome: Constellation of abnormalities that increase T2DM and CVD risk Batsis JA et al. Clin Pharmacol Ther 2007.

11 Shared features Hypertension Central obesity Insulin resistance Sympathetic OSA Metabolic Syndrome *** ** ** *** ** *** activation *** * Inflammation ** ** Endothelial dysfunction ** **

12 OSA prevalence in CVS patients Stroke 60% Bazzano et al. Hypertension 2007; Haentjens et al. Arch Intern Med 2007; Pedrosa et al. Hypertension 2011; Redline et al. AJRCCM 2010; Mehra et al. AJRCCM 2006

13 CVS and metabolic disease common in OSA Hypertension - 43% mild OSA, 70% severe OSA IGT/IR 30% of patients presenting to sleep clinic OSA severity associated with degree of IR Stroke and death increase with OSA severity Young et al. Sleep 2008; Meslier et al. Eur Resp J 2003; Ip et al. AJRCCM 2002; Punjabi et al. Am J Epidemiol 2004; Stamatakis and Punjabi Chest 2009; Spiegel et al. J Appl Physiol 2005; Spiegel et al. Lancet 1999;

14 OSA prevalence from excess weight Young et al. J Appl Physiol. 2005;99:

15 Increased Severity of OSA and Stroke or Death from Any Cause Yaggi et al. NEJM 2005.

16 OSA and Incident Hypertension 4-Year Follow Up Odd Ratio (OR) for Hypertension at Followup AHI = 0 AHI<5 AHI 5-15 AHI >15 Baseline AHI OR adjusted for baseline hypertension status OR for above + age, gender, BMI, etc. Peppard et al. NEJM

17 High risk patients Obesity (BMI > 35) Congestive heart failure Atrial fibrillation Treatment-refractory hypertension T2DM Nocturnal dysrhythmias Stroke Pulmonary hypertension High-risk driving population Pre-operative for bariatric surgery Adult OSA Task Force. JCSM 2009.

18 Bi-directional relationships Joint National Committee on Hypertension JNC VI (1997) - consider OSA as a cause of resistant HTN, especially in obese patients JNC VII (2003) - OSA 1 st on list of identifiable causes of HTN AACE Task Force (2011) - OSA is common and should be screened for in T2DM, especially > 50 yrs old OSA Task Force AASM (2009) - screen for OSA in high risk patients IDF Consensus Statement people with OSA should be routinely screened for possible metabolic disorders and cardiovascular risk

19 Bi-directional relationships Healthy People 2020 (Department of Health and Human Services) - sleep health goals American Heart Association Scientific Statement (2016, Circulation) Both short and long-duration sleep and sleep disorders such as SDB and insomnia are associated with adverse cardiometabolic risk profiles and outcomes. Treating those with sleep disorders may provide clinical benefits, particularly for blood pressure.

20 OSA: No perfect screening tool History and physical exam Epworth sleepiness scale BERLIN questionnaire STOP-BANG Overnight oximetry

21 Common symptoms Snoring, gasping arousals, witnessed apneas Excessive daytime sleepiness Dry mouth / throat in the morning Sleep-disrupting / morning headaches Nocturia Decreased libido Cognitive complaints Moodiness Insomnia

22 History can provide clues even when overt sleep symptoms are not present Physical exam can suggest increased risk Vital signs Obesity Nasal and upper airway exam Neck circumference Signs of heart failure or comorbid conditions

23 Oropharyngeal, nasal, craniofacial features Mallampati Classification Tooth ware Dental malocclusion Retrognathia/Micrognathia

24 Epworth sleepiness scale Likelihood of dozing or falling asleep 1) Sitting and reading 2) Watching TV 3) Sitting, inactive in a public place 4) As a passenger in a car for an hour without a break 5) Lying down to rest in the afternoon when circumstances permit 6) Sitting and talking to someone 7) Sitting quietly after a lunch without alcohol 8) In a car, while stopped for a few minutes in the traffic 0 = would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Total: 0 10 Normal range Borderline Abnormal

25 STOP-BANG questionnaire 1) Do you snore loudly? 2) Are you tired or sleepy during the daytime? 3) Are you observed to stop breathing? 4) Do you have high blood pressure? 5) BMI 35 kg/m 2 6) Age > 50 yo? 7) Neck circumference > 40 cm? 8) Gender male? Risk of OSA High if yes to 3 items Low if yes to < 3 items Chung et al. Anesthesiology 2008.

26 Diagnosis and treatment Rapid eye movements Obstructive apnea EEG arousal tachycardia Desat

27 Polysomnogram (PSG)

28 Portable monitors: Home sleep tests Limited: no sleep or EMG information Lower cost, convenient Disease severity is underestimated compared to attended studies / False negatives

29 Patient selection for home study Comprehensive sleep evaluation Appropriate patients No co-morbid disease (pulmonary, CHF, neuro) High pretest probability Not for asymptomatic populations No other sleep disorder suspected Assess non-cpap treatment Trained individual applies the device Portable Monitoring Task Force, Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients. JCSM 2007.

30 Preauthorizations for studies Treatment algorithms Criteria for treatment coverage Adherence to maintain treatment coverage

31 Sleep apnea definitions Apnea hypopnea index, AHI (4% desaturation) Apneas + hypopneas / hour sleep Marker of disease severity/hypoxia Respiratory disturbance index, RDI All resp events / hour, regardless of desaturation Marker of sleep fragmentation OSA severity by on AHI Mild: 5-15 Moderate: Severe: 30

32 Treatment approach Patient education Treat predisposing or modifiable factors Treatment selection

33 Positive airway pressure Continuous-CPAP, Bilevel-BPAP, Auto-titrating-APAP Gold standard / first-line therapy Johnson and Johnson. Medical Devices: Evidence and Research Busetto et al. Chest. 2005; Philips et al. AJRCCM 2013.

34 Treatment (PAP) benefits Sleepiness, QOL, cognition, depression Effect > more severe OSA better adherence Hypertension LVEF in CHF (predominantly OSA) Cardiac remodeling Glucose parameters (data is variable) Pulmonary hypertension Bazzano et al. Hypert 2007; Haentjens et al. Arch Int Med. 2007; Patel et al. Arch Int Med. 2003; Colish J et al.,chest 2012; Babu et al. Arch Int Med. 2005;

35 CVS events increased in untreated OSA Marin et al. Lancet 2005

36 HbA1c improves with CPAP use HbA1c improved in patients (n=12) using CPAP 4 h/d No change in patients (n=12) using < 4h/d Babu et al. Arch Intern Med

37 CPAP improves 24-hour BP 120 Before treatment 120 After treatment Mean blood pressure (mmhg) sub-therapeutic therapeutic Mean blood pressure (mmhg) sub-therapeutic therapeutic wake sleep 4 8 Time from wake and sleep onset (hours) wake sleep 4 8 Time from wake and sleep onset (hours) Pepperell et al. Lancet 2002.

38 Diagnosing/treating SDB reduces readmission rates in cardiac patients N Kauta SR et a., JCSM 2014;10:

39 CPAP for Prevention of Cardio-vascular Events in Obstructive Sleep Apnea R. Doug McEvoy, M.D., Nick A. Antic, M.D., Ph.D., et al., for the SAVE Investigators and Coordinators NEJM 2016 Conclusions: CPAP plus usual care, as compared with usual care alone, did not prevent cardiovascular events in patients with moderate-to-severe obstructive sleep apnea and established cardiovascular disease. Read the fine print- Definition for adherence, Residual disease on treatment. Inadequate power

40 Trouble shooting poor adherence Interface Leak, mouth breathing, nasal patency, skin breakdown Pressure Positional disease, weight change, need for repeat titration Aerophagia Flex, expiratory pressure relief, Bilevel Another disorder / overlap conditions Central or complex (treatment emergent) sleep apnea

41 Alternative / adjunctive treatments Oral appliances Surgical treatment Hybrid therapy Surgical weight loss Adaptive-servo ventilation (non-hfref) central/complex disease) Nasal EPAP Winx Upper airway stimulation Medications

42 Expiratory positive airway pressure (EPAP) FDA approved Not covered by insurance (~$70/month) Improvement in Epworth score and AHI maintained at 3 months compared to sham Berry et al., Sleep

43 WINX Oral pressure therapy (OPT) FDA approved Not covered by most insurers Console Tubing Mouthpiece

44 Upper airway stimulation for OSA Strollo et al. NEJM 2014

45 RCT-Rx withdrawal vs. continuation

46 Newer concepts on pathogenesis, rx Compression stockings and controlling na Trunk/head position Phenotyping patients Digital / Apps Redolfi et al. AJRCCM. 2011; Van Kesteren et al. Sleep 2011; Eckert et al. AJRCCM 2013; Nakano et al. JCSM 2014;

47 When / who to refer to sleep specialist? Not clearly established Pre or post PSG Severe OSA Shift workers/overlap conditions (Narcolepsy) Treatment intolerant /nonadherent Suboptimal treatment response

48 OSA and cardiometabolic health OSA is common / does not discriminate but prevalence is highest in co-comorbid conditions Screen high risk patients Think about cardiometabolic syndrome in patients with OSA OSA has multi-system effects Sleep duration and timing also important Treatment impacts co-morbid conditions HTN, T2DM (glucose, A1c), risk reduction from CVD mortality

49 Case of JP 54W seen for routine fup. Endorses financial/personal stress, work hours recently cut, problems with her son in college. Insomnia, rumination. Feels anxious. Gained ~ 10 pounds. Not exercising. PMH: Obese BMI, HTN, Dyslipidemia, Anxiety (takes Fluoxetine), GERD. Low back pain. MEDS: Zantac, Stimvastatin, Lisinopril, Metoprolol, HCTZ, Fluoxetine SH: Manager at a dental office. Works 10-3 M-F. Former 10 PY smoker, 2-3 glasses wine/night

50 Case of JP FH: Dad deceased at 68, MI (obese, smoked) Mom age 80, HTN, obesity, T2DM, anxiety Brother -T2DM, overweight, Sister-OSA EXAM: BP 159/92 HR 89 SpO2 96% Wt 240 lb (108 kg) / BMI 35.4 kg/m 2 Nasal turbinates enlarged, crowded posterior airway (MM 3), Neck 16 in circumference. No JVD. No carotid bruits. Lungs-CTA bl; CVS-RRR S1S2, Central obesity. No edema

51 What to focus on? Stress/anxiety, insomnia, obesity, lack of exercise, refractory HTN, EtOH, screening Are you concerned about sleep apnea in this patient? Why or why not? What else do you want to know? What do you suggest next?

52 1.) What test would you recommend? A. Overnight oximetry B. Overnight attended PSG C.Overnight portable limited channel sleep study (HST) D.Arterial blood gas E. Echocardiogram

53 1.) What test would you recommend? A. Overnight oximetry B. Overnight attended PSG C.Overnight portable limited channel sleep study (HST) D.Arterial blood gas E. Echocardiogram

54 2.) The HST shows OSA (AHI 32/hr, O2 nadir 79%). What treatment(s) would you recommend? A. Auto continuous positive airway pressure (APAP) B. Oral appliance C. Weight loss D. Stimulant medication E. Nocturnal oxygen

55 2.) The HST shows OSA (AHI 32/hr, O2 nadir 79%). What treatment(s) would you recommend? A. Auto continuous positive airway pressure (APAP) B. Oral appliance C. Weight loss D. Stimulant medication E. Nocturnal oxygen

56 3.) What if his HST showed mild OSA (AHI 8, O2 88%), then what would you recommend? A. Auto continuous positive airway pressure (APAP) B. Oral appliance C. Weight loss D. Stimulant medication E. Nocturnal oxygen

57 3.) What if his HST showed mild OSA (AHI 8, O2 88%), then what would you recommend? A. Auto continuous positive airway pressure (APAP) B. Oral appliance C. Weight loss D. Stimulant medication E. Nocturnal oxygen

58 4.) What if JP s also had severe COPD and chronic CHF (EF 35%)? Then what test would you request? A. Overnight oximetry B. Overnight attended PSG C.Overnight portable limited channel sleep study D.Arterial blood gas E. Echocardiogram

59 4.) What if JP s also had severe COPD and chronic CHF (EF 35%)? Then what test would you request? A. Overnight oximetry B. Overnight attended PSG C.Overnight portable limited channel sleep study D.Arterial blood gas E. Echocardiogram

60 4.) What if JP had EDS (ESS 20/24), and the HST showed no sleep apnea? A. Order an MSLT, since she probably has narcolepsy B. Ask her to sleep more C.Start a stimulant D.Refer to sleep clinic E. Repeat the HST

61 4.) What if JP had EDS (ESS 20/24), and the HST showed no sleep apnea? A. Order an MSLT, since she probably has narcolepsy B. Ask her to sleep more C.Start a stimulant D.Refer to sleep clinic E. Repeat the HST