OBSTRUCTIVE SLEEP APNEA and WORK Treatment Update
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1 OBSTRUCTIVE SLEEP APNEA and WORK Treatment Update David Claman, MD Professor of Medicine Director, UCSF Sleep Disorders Center Disclosres: None Chronic Sleep Deprivation (0 v 4 v 6 v 8 hrs) Lapses in Concentration: big increase if 6 hors (Van Dongen Sleep 2003) 1
2 DEFINITIONS: Apnea: complete cessation of airflow lasting 10 second or more Hypopnea: redced airflow for 10 seconds or more, associated with 4% oxygen desatration 3% is AASM recommendation; 4% is Medicare definition Apnea-hypopnea Index (AHI): average nmber of apneas & hypopneas per hor of sleep AHI < 5 is normal AHI Mild OSA AHI Moderate OSA AHI >= 30 - Severe OSA Wisconsin Sleep Cohort: prevalence of 2% women and 4% in men based on AHI > 5 and symptoms of daytime sleepiness; NEJM 1993; 328(17): CLINICAL PREDICTORS OF OSA Screening qestionnaires Epworth Sleepiness Scale: range 0-24 for 8 qestions Normal score < 10 In OSA poplation, score correlates with AHI SLEEP 1991; 14(6):540-5 Berlin 10 qestions validated in primary care Snoring, apnea, fatige, sleepiness at wheel, Hypertension Ann Intern Med Oct 5;131(7): STOP-BANG sed in Anesthesia Snoring, Tired, Observed apnea, Pressre (HTN), BMI 35, Age 50, Neck circmference 40 cm (15.75 inches), Gender (male) Arch Otolaryngol Head Neck Srg Oct: 136(10): EPWORTH SLEEPINESS SCALE Score < 10 is normal; is sitational sleepiness; 15 > excessive CLINICAL PREDICTORS OF OSA STOPBANG 8 Qestions High risk: yes to 5-8 qestions; Medim risk yes on 3-4;Low risk yes on 0-2 Snoring Tired (fatige) Observed Apnea Pressre (Hypertension) BMI >35 ( 30 is considered obese) Age >50 Neck size > 17 inches for men or >16 inches for women Gender male 2
3 COMPARISON OF QUESTIONNAIRES GE Silva et al. J Clin Sleep Med. 2011; 7(5): PREVALENCE OF SLEEP APNEA 602 working sbjects, age 30-60, stdied by overnight polysomnography Obstrctive sleep apnea defined as both AHI > 5 and hypersomnolence 9% of women had AHI >5; 22% c/o hypersomnolence; yields 2% prevalence 24% of men had AHI >5; 15% c/o hypersomnolence; yields 4% prevalence T Yong; NEJM 1993;328: Cmlative Percentage of New Fatal (A) & non-fatal (B) Cardiovasclar Events JM Marin et al. Lancet Mar 16;365(9464): KEY POINTS: 1. Increased mortality seen if AHI>30 2. CPAP redced this risk CPAP as Secondary Prevention of Cardiovasclar Events in OSA Randomized trial CPAP v sal care; n=2717 Age 61; 80% men; AHI 29; BMI 28 Pre-existing CAD or cerebrovasclar disease Mean f/ 3.7 years; CPAP se 3.3 hrs No change in primary cardiovasclar otcomes CPAP did improve qality of life measres McEvoy RD et al. NEJM 2016;375:
4 OSA TREATMENT CPAP to Prevent Cardiovasclar Events Weight loss (10% weight loss redces AHI 25%) Avoid alcohol for 3+ hor before bed Postral training (side sleeping since apnea worse on back) Nasal patency (treat allergies) CPAP (inclding atocpap; Bi-level less common) Oral (dental) appliances ENT srgery: McEvoy RD et al. NEJM 2016;375: WHY TREAT SLEEP APNEA? Improve patient s daytime alertness (big motivator!) Redce cardiovasclar risk Tonsillectomy in kids UPPP in adlts <50% sccess Hypoglossal nerve stimlator now FDA approved Nasal expiratory resistor (Provent) Nasal adhesive micro-valve resistor delivers approx 5 cm pressre MANDIBULAR ADVANCEMENT DEVICES Advancement of mandible Enlarge airway behind tonge, bt may also enlarge airway behind palate Still debated Improve partner s sleep 4
5 ORAL APPLIANCE THERAPY: ANTERIOR MANDIBULAR REPOSITIONING WHEN TO USE ORAL APPLIANCES? Mild to moderate OSA (AHI <30) Intolerant of CPAP After failed UPPP Significant overbite Mst have teeth! Relative contraindications: Severe OSA with severe oxygen desatration TMJ symptoms Fergson;Chest 1996;109: CPAP Site Non-specific CPAP: Nasal Mask or Pillows 5
6 LONGTERM USE OF CPAP Best compliance if AHI >30 & ESS >10 SURGICAL THERAPY (primarily if non-compliant with CPAP) Nasal Srgery Tonsillectomy: if 3-4++, can be 80-90% sccess (common approach in kids) Uvlopalatopharyngoplasty (UPPP) redces AHI by 50% in 40-50% of patients For snoring: laser or radiofreqency Mandiblar advancement Genioglosss advancement with hyoid Mandiblar-maxillary osteotomy & advancement Hypoglossal Nerve Stimlator Tracheotomy remains gold standard McArdle N et al. AJRCCM 1999;159: Qestion 1 Based on sleep deprivation data, when do shorter sleep hors case more symptoms? A. 8 hors B. 7 hors C. 6 hors D. 4 hors Qestion 2 Which of the following is NOT part of STOPBANG? A. BMI B. Alcohol C. Hypertension D. Observed apnea 6
OBSTRUCTIVE SLEEP APNEA and WORK Treatment Update
OBSTRUCTIVE SLEEP APNEA and WORK Treatment Update David Claman, MD Professor of Medicine Director, UCSF Sleep Disorders Center 415-885-7886 Disclosures: None Chronic Sleep Deprivation (0 v 4 v 6 v 8 hrs)
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