Sleep Medicine. Paul Fredrickson, MD Director. Mayo Sleep Center Jacksonville, Florida.

Transcription

1 Sleep Medicine Paul Fredrickson, MD Director Mayo Sleep Center Jacksonville, Florida

2 DISCLOSURES No relevant conflicts to report.

3 Obstructive Sleep Apnea The most common sleep disorder seen at Mayo Clinic

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6 Obstructive Sleep Apnea (OSA) Moderate to severe sleep apnea prevalence estimated at 10% of men ages 30-49, 17% ages 50-70; percentages for women are 3% and 9%, respectively Prevalence of OSA has increased 14-55% past two decades, depending on the subgroup* OSA increases risk of hypertension, heart disease, Type 2 diabetes, stroke and depression OSA is associated with several adverse outcomes, including impaired cognitive function, vehicle crashes, occupational injuries and death *Am J Epidemiol. 2013; 177:

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10 How are patients evaluated? Comprehensive examination (history and physical) Questionnaires and diaries Home testing Sleep center overnight sleep study Polysomnography

11 How are patients evaluated? Comprehensive examination (history and physical) Questionnaires and diaries Home testing oximetry Sleep center overnight sleep study Polysomnography

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14 Profox analysis of overnight oximetry Normal Tracing 97% Sleep Onset

15 Profox Analysis of Overnight Oximetry Severe OSA Awakening

16 How are patients evaluated? Comprehensive examination (history and physical) Questionnaires and diaries Home testing oximetry, actigraphy Sleep center overnight sleep study Polysomnography

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18 Polysomnography

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25 Measuring arterial tone changes in peripheral arterial beds recording finger arterial pulsatile volume changes

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27 OSA Treatment Options Newer CPAP technology Oral Appliances Weight Loss

28 OSA Treatment Options Newer CPAP technology Oral Appliances Weight Loss

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31 OSA Treatment Options Newer CPAP technology Oral Appliances Weight Loss

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34 Oral Appliances for OSA Most oral appliances are mandibular advancement devices (MAD) Current guidelines from AASM state MAD devices are acceptable for treatment of mild to moderate sleep apnea Often considered to be better tolerated than CPAP; however, this comparison is based on self reported use (for MAD) vs. objective data (CPAP)

35 Oral Appliance vs. CPAP No significant differences were found in sleepiness and quality of life measures between oral appliance therapy (OAT) and CPAP in treating mild to severe OSA in a 2 year follow-up CPAP was more effective in lowering the AHI and showed higher oxyhemoglobin saturation levels compared to OAT Sleep 2013; 36:

36 Oral Appliance vs. CPAP, cont. Mandibular advancement device not inferior to CPAP on measures of BP, sleepiness and quality of life at 2 month follow-up in moderate to severe OSA, although AHI reduction greater in CPAP group. Oral appliances are probably the second best treatment option for severe OSA if CPAP is not tolerated. Am J Respir Crit Care Med 2012; 187:

37 OSA Treatment Options Newer CPAP technology Oral Appliances Weight Loss

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39 The Problem of Obesity 30% of adults are obese (BMI>30 kg/m2) Overweight and obese patients comprise 70% of subjects with OSA Obesity a major risk factor for OSA Prevalence is twice that of normal weight adults

40 PRE-WEIGHT LOSS POST-WEIGHT LOSS

41 Sleeve Gastrectomy The Canadian Experience Condition Resolved Improved Type 2 DM n=19 Hypertension n=17 OSA n=21 Dyslipidemia n=11 Knee Pain n=21 74% 26% 53% 47% 76% 19% 45% 45% 38% 52% Canadian Journal of Surgery 2011;54:

42 OSA Treatment Options On the horizon:

43 OSA Treatment Options On the horizon: Nasal Valves Wink Inspire

44 OSA Treatment Options On the horizon: Nasal Valves Wink Inspire

45 Provent Approved by FDA 2008 Requires a prescription One months supply = $65 (not covered) Not effective for mouth breathers

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47 Nasal Expiratory Positive Airway Pressure (EPAP) Device for Treatment of OSA Effective for mild to moderate OSA, although considerable variability in response has been noted. Not a suitable alternative to CPAP for most patients with moderate to severe OSA due to limited efficacy. Sleep 2010; 34: Thorax2013; 68:

48 OSA Treatment Options On the horizon: Nasal Valves Winx Inspire

49 Winx Approved by FDA March 2012 Uses neg pressure to pull tongue and soft palate forward Works best when collapse is at the level of the soft palate $1,000 price tag Not covered by most insurances (yet)

50 Less effective than CPAP (average improvement in moderate to severe OSA was 50% reduction in AHI) Adherence to therapy high in initial testing, with motivated subjects Requires good nasal airflow (similar to CPAP or Provent)

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52 OSA Treatment Options On the horizon: Nasal Valves Wink Inspire

53 Strollo et al NEJM 2014;370:

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55 Upper Airway Stimulation

56 Inspire Approved by FDA Stimulates hypoglossal nerve (unilateral) May not work with soft-palate collapse (clinical trial subjects carefully screened with endoscopy during drug-induced sleep) Results to date reflect use in non-obese and relatively healthy subjects Risk of infection, tongue soreness and abrasion Long term effects unknown

57 Take Home Messages CPAP is still the gold standard treatment of OSA You will be seeing more home testing, especially in high risk populations without cardiorespiratory comorbidities Oral appliance therapy is a viable option for CPAP intolerant patients who can afford it Weight loss improves OSA and also addresses other medical issues Consider bariatric referrals in all obese patients

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59 Mayo Clinic Sleep Center 4643 Worrall Way West Campus