In-Patient Sleep Testing/Management Boaz Markewitz, MD Objectives: Discuss inpatient sleep programs and if they provide a benefit to patients and sleep centers Identify things needed to be considered when setting up and running an inpatient sleep program Discuss why to consider an inpatient sleep program
Utah Sleep Society November 6, 2015
No financial conflicts to report with this presentation It is not only the money that can lead to bias Fame, promotion, publication, speaking invitations, etc JAMA 2015; 314:1791
Spectrum of conditions including: Snoring, UARS, OSA, CSA, obesity hypoventilation Epidemiology Estimated prevalence of is OSA 25% and OSA S 5% Estimated prevalence of CSA < 1% Increases with age Increased prevalence in patients with HF, stroke, opiate use Recurrent occurrences of apnea/hypopnea during sleep Defined by the number of occurrences per hour of sleep or the apnea hypopnea index (AHI) Mild (5), moderate (15), severe (30) Am J Respir Crit Care Med 2002; 165:1217; Am J Respir Crit Care Med 1998; 157:144; Sleep Breath 2009; 13:181
Study Location AHI >5/hr AHI >15/hr Age Men Women Men Women Range n Years % % % % Wisconsin 626 30 60 24 9 9 4 Pennsylvania 1741 20 99 17 Not given 7 2 Spain 400 30 70 26 28 14 7 Am J Respir Crit Care Med 2002; 165:1217
The Sleep Heart Health Study Arch Intern Med. 2002;162(8):893
SDB by age, yrs Prevalence 1988 94 (%) Prevalence 2007 10 (%) AHI > 5 30 49 20 26 50 70 38.5 43.2 AHI >15 30 49 6.2 9.5 50 70 13.9 17.4 AHI > 5 + ESS > 10 30 49 8.5 11.7 50 70 15.3 17.6 AHI >15 + ESS > 10 30 49 3.1 4.8 50 70 5.4 7.0 Am J Epidemiol 2013; 177:1006
SDB by age, yrs Prevalence 1988 94 (%) Prevalence 2007 10 (%) AHI > 5 30 49 6.6 8.7 50 70 24.4 27.8 AHI >15 30 49 1.9 2.7 50 70 7.4 9.1 AHI > 5 + ESS > 10 30 49 2.1 2.9 50 70 6.6 7.5 AHI >15 + ESS > 10 30 49 0.55 0.79 50 70 2.6 3.2 Am J Epidemiol 2013; 177:1006
Wisconsin Sleep Cohort Study (n=282) Axes are log scaled Am J Respir Crit Care 2002; 165:1217
SDB is indeed common Estimated prevalence of SDB is increasing over time Individuals can experience a progression of disease over time Potential adverse health effects of SDB include Hypertension Coronary artery disease Congestive heart failure Ischemic cerebrovascular disease Motor vehicle accidents Cognitive function? Am J Respir Crit Care Med 2002; 165:1217
Retrospective study using National Hospital Discharge Survey data Representative sample of discharges from non federal acute care hospitals ICD 9 discharge codes used Extrapolated that there were nearly 300,000 estimated cases of sleep apnea Most common diagnoses in these patients were: Morbid obesity, CHF, CAD, AECOPD, pneumonia CPAP therapy was provided to only 5.8% of hospitalized patients with sleep apnea Sleep Breath 2008; 12:229
Retrospective study to assess prevalence of SDB in patients referred for inpatient PSG in tertiary care centers Evaluated Primary diagnosis, BMI, TST, sleep stage distribution, sleep efficiency, SDB, primary (>50%) apnea type, D/C with CPAP Portable PSG performed and used R&K scoring guidelines SDB defined as an AHI of at least 10/hr 42% studies on supplemental oxygen J Clin Sleep Med 2008; 4:105
PSG ordered in only 100 of over 117,ooo admissions 94 studies acceptable for review Patient demographics Age, mean: 54.o years Gender: female 54% BMI, mean: 40.2 kg/m 2 (86.2% were obese) Sleep architecture TST, mean: 225.1 min Sleep efficiency: 76% REM as % of TST: 10.9 J Clin Sleep Med 2008; 4:105
SDB present in 77% OSA in nearly all (95%) Increased odds of having SDB with increasing BMI Significant association between SDB and CHF Women higher AHI than men
Disappointing low level of referrals Sleep testing not available? There is significantly more undiagnosed SDB in hospitalized patients than is being evaluated Disappointing level of CPAP use in hospitalized patients with a diagnosis of SDB Sleep Breath 2008; 12:229; J Clin Sleep Med 2008; 4:105
Level I: Standard Polysomnography Minimal Requirements EEG, EOG, EMG, ECG, airflow, respiratory effort and SpO2, body position Attended by trained personnel Optional Leg movement recording Level II: Comprehensive Portable Polysomnography Minimal Requirements Same as Level I except heart rate instead of ECG is acceptable Optional Attended by trained personnel Sleep 1994; 17(4):372; J Clin Sleep Med 2007; 3(7):737
Level III: Modified Portable Sleep apnea Testing Minimal requirements Ventilation (at least 2 channels of respiratory movements or respiratory movements and airflow), ECG or heart rate, and SpO2 Typically not attended by trained personnel Level IV: Continuous (single or dual) Bioparameter Recording Minimal requirements 1 or 2 physiological variables recorded Trained personnel not required Sleep 1994; 17(4):372; J Clin Sleep Med 2007; 3(7):737
PSG historically has been overwhelmingly an outpatient diagnostic procedure In patient sleep studies would allow: Testing in a safe environment Timely diagnosis and treatment initiation Impact disease outcome? Concerns about in patient testing: Electrical interference Increased sweat artifact Data transmission (wireless) Insufficient sleep time Sleep tech interactions with nurses and RTs
Patients studied in own hospital room 16 channel PSG Data acquired at bedside Data stored on bedside computer and wirelessly transmitted to allow for remote viewing Remote computer control CPAP adjustments Figure 1 Schematic of Wireless Polysomnography J Clin Sleep Med 2006; 2:28
Gender No. (%) Mean Age, y Mean BMI kg/m 2 Female 20 (39%) 57.5 35.1 Male 31 (61%) 60.2 33.4
Technical Issues Adequate data in all pts Includes 3 ICU pts More cognitively impaired pts (eg stroke) required more attention and time Time from sleep lab to pt room was < 5 min PSG N TST SE 1 2 3 R AHI 51 3.3 55 11 70 3 10 35 48% discharged on oxygen 31% discharged on CPAP
Diagnosis of SDB in hospitalized patients may be beneficial PSG may not be an option Portable monitors for the diagnosis of SDB in hospitalized patients is supported by the AASM when in lab PSG is not possible J Clin Sleep Med 2007; 3:737; Can Respir J 2014; 21:96
Study aims: Determine technical success rate Evaluate diagnostic information obtained Evaluate the impact on inpatient management Can Respir J 2014; 21:96
Retrospective analysis of inpatient PM from January 2010 to December 2011 at 3 tertiary hospitals Inclusion > 18, pulmonary consult, inpatient PM study, hospital record available for review Studies were both diagnostic and assessing adequacy of therapy At one site the device was assessed by a RT at least once during the night SDB diagnosis was based upon an AHI of > 15/hr Type of SDB was determined by majority of events
Complete absence of recorded data Collected data unreliable Collected data insufficient Analysis time < 4 hours SpO 2 signal present for < 30% recording time or < 3 hr Airflow and/or effort band channels present for < 50% of recording time or < 3 hr
116 studies reviewed, 2 excluded as medical record not found Studies typically performed after patient stabilization 101 diagnostic r/o OSA 73% 37% on oxygen 13 assess Rx adequacy COPD/CHF Baseline Characteristics Male 53% Age (mean, yr) 65 LOS (median) 14 Day of study (median) 7
114 studies with available records to review Technical success rate of 94 (82%) No data recorded due to battery or programming error Recording length inadequate Failure of one or more recording channels Site in which RT assessed device during the night had the lowest technical problems
Diagnostic n=101 Therapeutic n=13 OSA 48 (48%) 1 (8%) CSA 5 (5%) 2 (15%) Nocturnal hypoventilation 2 (2%) 3 (23%) Indeterminate hypoxemia 4 (4%) 0 (0%) No diagnostic abnormality 22 (22%) 7 (54%) Technical limitation 20 (20%) 0 (0%)
Action Adequate Dx Test n=81 Technically Inadequate Dx Test n=20 Therapeutic Test n=13 Repeat Study 0 2 0 Data not used 11 5 1 Applied during outpatient followup Applied during same admission 13 7 1 59 6 11
Of 114 PM subjects, 11 underwent subsequent outpatient PSG 8/11 (73%) findings were concordant for diagnosis and severity 3/11 (27%) findings were discordant 2 had negative PM but positive PSG 1 had had resolution of CSR with treatment of HF
PSG and PM are technically feasible Including ICU patients Significant portion of studies yield diagnostic information Newly obtained information often leads to initiation or modification of SDB treatment during the hospitalization Studies remain limited Prospective studies are needed J Clin Sleep Med 2006; 2:28; Heart Lung 2014; 43:445: Can Respir J 2014; 21:96
Cardiac conditions Stroke Perioperative AECOPD
SDB is a risk factor for development of hypertension and is associated with cardiovascular disease including heart failure OSA, through hypoxia, increased sympathetic activity, and large intrathoracic pressure swings, has a negative impact on cardiac function Up to 80% of patients with HF have SDB Treating SDB with CPAP in cardiac patients can have a positive effect on cardiovascular disease Decrease rate of recurrent atrial fibrillation Increase ejection fraction J Card Fail 2009; 15:739; J Clin Sleep Med 2014; 10:1051
Patients hospitalized at HUP from January 2012 to March 2013 with a cardiac condition (HF, arrhythmia, MI) Patients deemed at risk for SDB underwent an unattended multichannel sleep study (level 3) Patients diagnosed with sleep apnea (AHI > 5/hr) were offered positive airway pressure with auto titrating CPAP or auto bilevel PAP compliance was collected via modem or data card Full user, non user, or partial user Primary outcome was 30 day readmission or ED visit J Clin Sleep Med 2014; 10:1051
106 patients identified 104 had conclusive studies BMI 34.1; EF 36.3; HF 87%; Afib 47%; Htn 82% 81 (78%) had SDB OSA 80%; CSA 20% 50 (62%) of patients with SDB prescribed PAP at D/C 45 OSA; 5 CSA 42 of PAP patients had usage data 19 full users; 20 partial users; 3 non users
Variable Non User Partial User Full User Age, y 63.1 56.2 63 BMI, kg/m2 33.5 36.1 37.2 EF, % 37.6 35.5 46.1 HF, % 88.2 90 84.2 A Fib, % 58.8 40 47.4 Htn, % 100 85 84.2 AHI, events/hr 27.7 31.4 28.9 NYHA=4, % 28.6 47.4 47.1 30 day readmit/ed, % * 29.4 30 0
Association between readmission and several variables studied in bivariate analysis LVEF and CPAP adherence only variables significantly associated with readmission No difference between patients with OSA and CSA Intriguing study that needs to be repeated with larger numbers
SDB is common in hospitalized patients Often with history of symptoms but no previous dx In hospital testing for SDB appears effective Initiation of treatment in the hospital may impact outcome of co morbid conditions
Sleep medicine consultant Sleep technologist(s) Limited cardiopulmonary testing devices with associated software PSG? CPAP* units Pulse oximetry? IT support?
Diagnosis not otherwise made Unload outpatient clinic Captive audience window of opportunity Favorable impact on co morbidities Reduce readmissions?
Noise Light Untreated SDB Patient Care Interactions Medications