Obstructive Sleep Apnea: when dreams turn deadly

Troy Glembot, MD MBA CPE FACS FASMBS

Medical DirectorWinchester Medical Center Bariatric Program

Objectives

Define OSA and identify its prevalence Identify patients who are at risk of having

OSA Implications of untreated OSA Treatment options for patients who have

OSA OSA and potential safety issues in the

workplace

Define OSA

Sleep disordered breathing (SDB)Obstructive sleep apnea (OSA)Sleep apnea/hypopnea (SAH)Sleep apnea/hypopnea syndrome (SAHS)Obstructive sleep apnea syndrome (OSAS)

Obstructive Sleep Apnea

OSA is characterized by intermittent airway obstruction Results in nocturnal desaturations

hypercapnea Increased inspiratory efforts lead to

awakenings resulting in disturbed sleep

How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent time. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation.

0 = would never doze

1 = slight chance of dozing

2 = moderate chance of dozing

3 = high chance of dozing

SITUATIONCHANCE OF

DOZINGSitting and reading _____

Watching TV _____

Sitting and inactive in a public place (theater or meeting)

_____

As a passenger in a car for an hour without a break

_____

Lying down to rest in the afternoon when circumstances permit

_____

Sitting and talking to someone _____

Sitting quietly after lunch (without alcohol) _____

In a car, while stopped for a few minutes in the traffic

_____

TOTAL _____

From Johns MW: A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 1991;14:540–545.

Epworth Sleepiness Scale

Obstructive Sleep ApneaBox 92-3. Diagnostic Criteria for the Obstructive Sleep Apnea-Hypopnea

SyndromeThe individual must fulfill criterion A or B, plus criterion C A. Excessive daytime sleepiness that is not better explained by other factors B. Two or more of the following (not better explained by other factors)

Choking or gasping during sleep Recurrent awakenings from sleep Unrefreshing sleep Daytime fatigue Impaired concentration

C. Overnight monitoring demonstrating five or more obstructed breathing events per hour during sleep; events may include any combination of obstructive apneas/hypopneas or respiratory effort-related arousals

Adapted from American Academy of Sleep Medicine Task Force: Sleep-related breathing disorders in adults: Recommendations for syndrome definition and measurement techniques in clinical research. Sleep 1999;22:667–689.

Obstructive Sleep Apnea

Obstructive Sleep Apnea

Principles of Sleep Medicine 2005

Prevalence of OSA

4% of men and 2% of women have OSA Prevalence peaks in men between 50-59

yrs. Prevalence increases with older age in

women

Young et al, N Engl J Med 328: 1230-1235 1993

Prevalence of OSA

Ethnicity plays a role as well Asian and Japanese patients have

craniofacial geometries and smaller airway passages that may predispose OSA

African Americans typically have more severe OSA than whites even when adjusting for BMI, gender and age.

Prevalence of OSA

What role does obesity play?

Prevalence of OSA

BMI = Weight(kg)/Height(m)2

= (lbs./in.2)x 705

BODY MASS INDEX

Prevalence of OSA

BMI Indicators

Acceptable Range 18.5 – 24.9Overweight 25.0 – 29.9Obese 30.0 – 34.9Severe Obesity 35.0 – 39.9Morbid Obesity 40.0 – 49.9Super-Morbid Obesity > 50

BMI CHART(Sample Portion)

200

205

210 215

220

225

230

235 240

245

250

255

260

265

4’10

42 43 44 45 46 47 48 49 50 51 52 53 54 56

5’0”

39 40 41 42 43 44 45 46 47 48 49 50 51 52

5’2”

37 38 38 39 40 41 42 43 44 45 46 47 48 49

5’4”

34 35 36 37 38 39 40 40 41 42 43 44 45 46

5’6”

32 33 34 35 36 36 37 38 39 40 40 41 42 43

5’8”

30 31 32 33 34 34 35 36 37 37 38 39 40 40

5’10”

29 30 30 31 32 32 33 34 35 35 36 37 37 38

6’0”

27 28 29 29 30 31 31 32 33 34 35 35 36 37

6’2”

26 26 27 28 28 29 30 30 31 32 32 33 33 34

Hei

gh

t

Overweight Class I Obesity Class II Serious Obesity Class III Morbid Obesity

Weight

Role of obesity in OSA BRFSS, 1985

No Data <10% 10%–14%

(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

Role of obesity in OSA BRFSS, 2010

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

• One in five people in the United States is obese

• Three in five Americans are either overweight or obese

• In the past 20 years, obesity among adults has doubled

Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity.

A Rapidly Expanding Problem

The Obesity Crisis

Role of obesity in OSA

http://www.google.com/imgres?q=bmi+and+obstructive+sleep+apnea&um=1&hl=en&biw=1280&bih=649&tbm=isch&tbnid=ev_aW35GBInbaM:&imgrefurl=http://journal.publications.chestnet.org/article.aspx%3Farticleid%3D1085729&imgurl=http://journal.publications.chestnet.org/data/Journals/CHEST/22068/zcb0100712270004.jpeg&w=1800&h=982&ei=CMlIUPzgE83GqAGz5oHYAw&zoom=1&iact=hc&vpx=933&vpy=368&dur=20240&hovh=166&hovw=304&tx=219&ty=148&sig=108640793115164267964&page=2&tbnh=95&tbnw=174&start=18&ndsp=24&ved=1t:429,r:17,s:18,i:184 accessed on 6 Sept 2012

Role of obesity in OSA

Potentially life-threatening sleep apnea is unrecognized without aggressive evaluation Hallowell et al, The American Journal of Surgery 193: 364-367. 2007

Expert Panel Recommendations Obstructive Sleep Apnea and Commercial Motor Vehicle Safety http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep-MEP-Panel-Recommendations-508.pdf accessed on 6 Sept 2012

Role of obesity in OSA

Expert Panel Recommendations http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep-MEP-Panel-Recommendations-508.pdf accessed on 6 Sept 2012

Initially considered anyone with BMI > 30 kg/m2 to be screened for OSA

over 41% of the drivers would need screenedBMI cutoff raised to 33 kg/m2 , only 24% of drivers

need screened

Implications of OSA

So they snore

Implications of OSA

00.10.20.30.40.50.60.70.80.9

1

0 1 2 3 4 5 6 7 8 9

AI <20AI>20

Cum

ulat

ive

surv

ival

Interval (years)

* **

* *

Chest 88:9-14, 1988

Effect of apnea index on mortality

Implications of OSA CAD

ACS Angina

HTN Systemic HTN Pulmonary HTN

Ventricular hypertrophy and dysfunction

Cardiac dysrhythmias Bradycardia Tachycardia

Atrial fibrillation CVA

Implications of OSA OSA is strongly linked to CVD

CAD appears associated with OSA

• Up to 46% of patients presenting with an acute cardiac event had OSA

• Moderately severe OSA (AHI > 20) is an independent risk factor for MI

Skinner et al Chest 127(1): 2005Schafer et al Cardiol 92(2): 79-84 1999

Implications of OSA

OSA is strongly linked to CVD Hypertension appears exacerbated by OSA

• Increased activation of sympathetic nervous system

• Vascular endothelial dysfunction

Somers et al J Clin Invest 96(4): 1897-1904 1995

Implications of OSA OSA is strongly linked to CVD

OSA exacerbates CHF

Treatment of OSA results in improvement in LVEF and improved QOF on SF36 and chronic heart failure questionnaires.

Kaneka et al, N Engl J Med 348(13): 1233-1244 2003

Implications of OSAOSA is strongly linked to CVD

Almost 60% of patients with OSA have dysrhythmias

Both tachy and brady dysrhythmias• Up to 10% of patients develop transient

heart block

Hoffstein et al Chest 106: 466-471 1994Harbison et al Chest 118: 591-595 2000

Implications of OSA

OSA is strongly linked to CVA Up to 60% of stroke patients have OSA

The Sleep Heart Health Study demonstrated that OSA was associated with an increased prevalence of stroke

Kaneko et al Sleep 26: 293-297 2003Shahar et al Am J Respir Crit Care Med 163: 19-25 2001

Implications of OSA

Sleep disordered breathing linked to apnea-induced hyperglycemia in diabetes

Nocturnal glucose values significantly higher in patients with OSA compared to those without OSA

European Association for the Study of Diabetes meeting May 2007

Obstructive Sleep Apnea

OSA isn’t just snoring Think systemic…..

Hypertension, ischemic heart disease, stroke, pulmonary hypertension, cor

pulmonale, right heart failure

Obstructive Sleep Apnea

Implications of OSA Over time, OSA gets

worse

Am J Respir Crit Care Med 2002;165:1217-1239

Implications of OSA

The economic cost of sleep disorders SLEEP 2006;29(3):299-305

Evaluation of the direct and indirect costs attributable to sleep disorders

• Work related accidents, MVC, productivity losses

Implications of OSA

SLEEP 2006;29(3):299-305

Implications of OSA

SLEEP 2006;29(3):299-305

Implications of OSA

Untreated OSA adversely affects worker productivity Excessive sleepiness, cognitive dysfunction,

increased irritability and reduced vitality results in 30% reduction in productivity

Effect spans job salary levels

American Academy of Sleep Medicine reported by New York Times June 14, 2011

Treatment

Lifestyle Avoid alcohol, sedatives, sleep on your side,

decongestants, quit smoking Mouthpieces Breathing devices (CPAP) Surgery (UP3)

Treatment

Treatment

Am J Respir Crit Care Med 2002;165:1217-1239

OSA and workplace safety

Why would employers be concerned about OSA?

OSA and workplace safety

Happier employees Untreated OSA is associated with depression

and chronic fatigue

OSA and workplace safety

Happier employees Untreated OSA is associated with depression

and chronic fatigue Healthier employees

Less time off work

OSA and workplace safety

Happier employees Untreated OSA is associated with depression

and chronic fatigue Healthier employees

Less time off work Less expensive

By keeping overall employee health optimized, heath care costs may be reduced

OSA and workplace safety

Untreated, OSA causes reduced psychomotor function, cognition which is directly related to accidents MVC’s are particularly a concern

J Clin Sleep Med 2009;5(6):573-581

Conclusions

OSA is a life threatening medical condition Untreated OSA causes many other

medical conditions Untreated OSA is associated with

increased health care costs and reduces worker productivity

Untreated OSA threatens worker safety OSA can be effectively treated