sleep apnea – 2017 update on evaluation and management
TRANSCRIPT
SLEEP APNEA 2017
UPDATE ON EVALUATION AND MANAGEMENT
February 22, 2017
Disclosures
Marc L Benton, MD, FAASM, FCCP• Medical Director, The Sleep Disorders Center at
Summit Medical Group, Madison, NJ.
Kerry Kelley, RN, RRT, RPSGT• Manager – Sleep Services• The Sleep Disorders Center at Summit Medical
Group, Madison, NJ.
Sleep Apnea - 2017 Update
• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes
• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes
Sleep Apnea - 2017 Update
Sleep affects, and in turn is affected by, almost every physiological and psychological process, i.e.,
Physical performance – work, school, life The ability to socially and emotionally relate to others Improving learning and memory Reduction in health problems and optimization of health Functioning in a safe, efficient and effective way
The Three R’s Rejuvenate, Restore, Re-energize
Sleep Apnea - Introduction
All mammals and birds “sleep” as we know sleep to be.Sleep has also been observed in reptiles, fish and insects,
although it is differently defined – more as a behavioral phenomenon, and is less well-understood physiologically
Sometimes sleep needs to be ‘adaptive’, so that other basic needs can be simultaneously accommodated…
Sleep Apnea - Introduction
Dolphins sleep by resting one half of their brain at a time. This is called “unihemispheric” sleep. The brain waves of dolphins that have been studied while asleep demonstrate that one side of the brain is awake while the other side is in deep sleep. Also, the eye on the side of the awake-half of the brain is open, while the
other eye is closed.
This assures that dolphins can meet their respiratory needs while also remaining vigilant enough to protect
themselves from predators even when “asleep”.
Sleep Apnea - Introduction
Sleep Needs by Age
Newborns/Infants 0 - 2 months2 - 12 months
10.5 – 18 hours14 - 15 hours
Toddlers/Children 12 – 18 months18 mo. – 3 years3 – 5 years5 – 12 years
13 – 15 hours12 – 14 hours11 – 13 hours10 – 11 hours
Adolescents Average 9.25 hoursAdults Average 7 – 9 hoursOlder Adults Average Widely variable
Older adults need just as much sleep…they just don’t get itLess deep sleep = more arousals and awakenings
Medical conditions/pain = more arousals and awakenings“Sleep Debt” - just like money…
Sleep Apnea - Introduction
The average person needs 7 to 9 hours sleep per 24-hour period.The “normal” sleep-onset latency is about 10 minutes.The “normal” sleep stage distribution for young-middle aged adults is:
• 5% stage I• 50% stage II• 15-25% stage III, slow wave or deep sleep• 20-25% stage REM
Sleep Apnea - Introduction
Sleep Apnea - Introduction
84 SLEEP DISORDERSIMPACTING
OVER 100 MILLION AMERICANS
Sleep Apnea - Introduction
Classifications of sleep disorders:• Sleep-related breathing disorders• Insomnia • Central sleep apnea• Circadian rhythm sleep disorders• Parasomnias• Sleep-related movement disorders• Narcolepsy
Sleep Apnea - Introduction
• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes
Sleep Apnea - 2017 Update
• Prevalence: True frequency depends upon
definitions/cutoffs Increasing incidence from 18-45 y/o Plateau incidence over 55 y/o Males > Females AA > Caucasians - obesity, cardiovascular
disease and hypertension Asian = Caucasian despite lower BMI – narrow
anterior airway, recessed lower jaw
Demographics
• Common factors that impact the frequency and severity of sleep apnea:
Body mass index (BMI) Physical characteristics – airway structure,
craniofacial abnormalities Family history – inherited structural
abnormalities, genetically prone to airway collapse
Age – loss of muscle tone Medical conditions – respiratory issues, muscular
and diaphragm issues
Demographics
• OSA prevalence is estimated to be about 25% in adult males, 9-13% females
• 80-90% OSA currently undiagnosed • The worsening epidemic of obesity in the
United States guarantees a large at-risk population
• The prevalence of obesity is still increasing, although the rate of that increase is slowing
Demographics
Demographics
• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes
Sleep Apnea - 2017 Update
Definition of Sleep:• A normal, reversible, recurring
behavioral state of disengagement and unresponsiveness to the environment that is characterized by typical changes in the electroencephalogram.
Pathophysiology
• Apnea: cessation of airflow for at least 10 seconds and an arousal from sleep
• Hypopnea: diminished effort in breathing lasting at least 10 seconds and associated with a 3 or 4% oxygen desaturation and an arousal from sleep
• Respiratory Event-Related Arousal (RERA): diminished effort in breathing resulting in an arousal from sleep
Pathophysiology
Respiratory Disturbances - Definitions
• Apnea: cessation of airflow for at least 10 seconds and an arousal from sleep
• Hypopnea: diminished effort in breathing lasting at least 10 seconds and associated with a 3 or 4% oxygen desaturation and an arousal from sleep
• Respiratory Event-Related Arousal (RERA): diminished effort in breathing resulting in an arousal from sleep
Pathophysiology
Respiratory Disturbances - Definitions
• Apnea: cessation of airflow for at least 10 seconds and an arousal from sleep
• Hypopnea: diminished effort in breathing lasting at least 10 seconds and associated with a 3 or 4% oxygen desaturation and an arousal from sleep
• Respiratory Event-Related Arousal (RERA): diminished effort in breathing resulting in an arousal from sleep
Pathophysiology
Respiratory Disturbances - Definitions
• Apnea: cessation of airflow for at least 10 seconds and an arousal from sleep
• Hypopnea: diminished effort in breathing lasting at least 10 seconds and associated with a 3 or 4% oxygen desaturation and an arousal from sleep
• Respiratory Event-Related Arousal (RERA): diminished effort in breathing resulting in an arousal from sleep
Pathophysiology
Respiratory Disturbances - Definitions
Apnea-Hypopnea Index (AHI): • the number of apneas and hypopneas per
hour of sleep
Respiratory Disturbance Index (RDI): • the number of apneas + hypopneas + RERA’s
per hour of sleep
Pathophysiology
Respiratory Disturbances - Definitions
Pathophysiology
Anatomy of Obstructive Apnea
Pathophysiology
10 Minute Compressions – Severe Sleep Apnea
Pathophysiology
Severe Sleep Apnea
• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes
Sleep Apnea - 2017 Update
Common complaints:• Loud snoring, irregular breathing• Problems initiating sleep• Problems maintaining sleep• Non-restorative sleep• Early morning awakenings• Excessive daytime sleepiness• Nighttime urination• Restless legs
Risk Assessment
Body-type profiling:• Elevated BMI• Compromised airway
• Large tongue• Hypertrophied tonsils• Recessed jaw
• Broad/short neck• Family history
Risk Assessment
Medical co-morbidities:• Cardiac disorders• Endocrine/metabolic disorders• Neurologic disorders• Psychiatric disorders• Pre-operative evaluation• Chronic pain• Pregnancy
Risk Assessment
Every day problems:• Motor vehicle accidents – trains, planes,
autos• Industrial accidents/errors • High-risk occupations• Compromised work or school
performance• Sexual dysfunction• Athletic performance
Risk Assessment
OSA and children:• Poorly tolerated• School performance• Attention deficit disorders• Learning disorders• Behavioral disorders• Attendance problems• Bedwetting
Risk Assessment
Exxon Valdez – Oil Spill
Chernobyl Nuclear Disaster
Three Mile Island Nuclear Meltdown
AA Flight 1420 Crash
Multiple Recent Train Accidents
Untreated Sleep Apnea?
Routine medical/dental provider evaluation
Validated questionnaires Family/friend concerns Occupational/licensing screening
Risk Assessment
Screening Tools
• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes
Sleep Apnea - 2017 Update
What testing is appropriate?• Home/portable vs. in-labWho/what decides what testing is done?• Medical provider• Insurance company• Medical conditions• Prior sleep history
Evaluation ProcessSleep Apnea Testing
Evaluation ProcessHome Sleep Apnea Testing
Evaluation ProcessHome Sleep Apnea Testing
Evaluation ProcessHome Sleep Apnea Testing
Evaluation ProcessHome Sleep Apnea Testing
Evaluation ProcessAttended Sleep Testing
Types of attended sleep studies• Diagnostic• Therapeutic • Split-night • NPSG + MSLT• MWT• MATRx
Evaluation ProcessAttended Sleep Testing
• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes
Sleep Apnea - 2017 Update
• Positive Airway Pressure therapy• Dental appliances• Surgery• Weight loss• Nasal valves• Positional therapy• Implantable neurostimulator• Exercises/Didgeridoo• Combination therapy
Treatment Options
Treatment OptionsPAP Therapy
Treatment OptionsPAP Therapy
Treatment OptionsAttended testing
Treatment OptionsAttended testing – pre-treatment
Treatment OptionsAttended testing – initial treatment titration
Treatment OptionsAttended testing – successful treatment titration
Sleep Apnea – Pathophysiology10 Minute Compression – Severe Sleep Apnea
Sleep Apnea – Pathophysiology10 Minute Compression – No Sleep Apnea
Treatment OptionsPAP Therapy - Then and Now
Treatment OptionsNew PAP Devices
Treatment OptionsPAP Therapy
• Auto-PAP• CPAP• CPAP with C-Flex• BiPAP• BiPAP with BiFlex• AVAPS• BiPAP-SV
Treatment OptionsInterfaces
Treatment OptionsPAP Therapy
Upsides:• Best outcomes, especially in more severe OSA• Detailed feedback on efficacy and compliance• Widely varied and customizable treatment options
Downsides:• Requires maintenance (cleaning and parts replacement)• Side effects (sinus issues, air-swallowing, dry mouth)• Problems with equipment suppliers• Less portable
Treatment OptionsOral Appliance Therapy
Treatment OptionsOral Appliance Therapy
Treatment OptionsOral Appliance Therapy
Treatment OptionsOral Appliance Therapy
Upsides:• Easier to manage• More portable• Less likely to exacerbate sinus problems
Downsides:• Less likely to be effective, especially in more severe cases• No feedback regarding efficacy• Provider variability in proficiency• Cost• Side effects
Sleep 2013 Oct 1;36(10):1517-25, 1525A
Treatment OptionsOral Appliance Therapy - MATRx
• Procedures• Nasal surgery• Tonsillectomy• UP3• LAUP• Somnoplasty• Pillar procedure• Tongue ablation• Tongue or hyoid advancement• Mandibular advancement• Tracheostomy
Treatment OptionsUpper Airway Surgery
Weight loss strategies Bariatric medical evaluation Bariatric surgery
• Gastric sleeve• Lap band surgery• Roux-en-y gastric bypass surgery
Treatment OptionsWeight Loss
Treatment OptionsPositional Therapy
Treatment OptionsInspire Implantation
"In a study published in the British Medical Journal, 25 patients with sleep apnea whopracticed playing it for about 30 minutes a day, six days a week for four months, significantly reduced the number of apneas they had during sleep; daytime sleepiness also decreased. Scientists believe the breathing technique required to play the didgeridoo strengthens the upper airway and makes it less likely to collapse."
Treatment OptionsExercises, Didgeridoo
Treatment OptionsAlternative Facts
• Introduction• Demographics• Pathophysiology• Risk Assessment• Evaluation Process• Treatment Options• Optimizing Outcomes
Sleep Apnea - 2017 Update
• Good data, good decisions• Education, education, education• Close follow-up through initial phases of
therapy• Compliance tracking• Manage the home care (DME) issues• Train and utilize Compliance Specialists• Long term follow-up
Optimizing Outcomes
• Get good data, make good decisions The correct treatment of the wrong problem is
the incorrect treatment Perform high-quality diagnostic and
therapeutic sleep studies, and make sure the results are consistent with clinical expectations
Getting prior test results and treatment information can be very useful
Know when an attended sleep study is necessary, and fight to get it done
Optimizing Outcomes
• Education, education, education For the patient, for the providers, and the staff The better-informed the patient is, the better
patient they will be (usually) Education can help the patient assume some
ownership of the problem, which should facilitate better outcomes
Providing regular and constructive feedback to the patient can be invaluable
Optimizing Outcomes
• Close follow-up through initial phases of therapy
Performance in the first week and first month most commonly predict long-term outcomes
You cannot find solutions until you are aware that there is a problem
Fixing problems earlier rather than later improves patient satisfaction, outcomes, and retention
Early feedback and additional education help prevent the development of behavior patterns that undermine successful treatment
Optimizing Outcomes
• Compliance tracking The ability to obtain accurate
usage/compliance and treatment efficacy data has revolutionized the treatment of OSA
Patient’s subjective assessments of their status is often useful but frequently incorrect
Acquiring compliance and efficacy data, and acting on it as needed is the current standard-of-care in sleep medicine
Acquiring and integrating real-time compliance data into the patient record is becoming easier and more beneficial to patients and providers
Optimizing Outcomes
• Manage the equipment issues This is often the weak link in managing OSA
treatment This is by far the most common thing that
patients complain about It contributes to poor outcomes, abandoned
therapy, and patient migration to other doctors Investing the time and effort in knowing which
companies to use, which to avoid, and how to get the patients the services that they need is key
Optimizing Outcomes
• Train and utilize Compliance Specialists In order to optimize outcomes and patient
satisfaction, it is necessary to have personnel who are able to turn failures into successes, and problems into solutions
This requires expertise, experience, insight, observational and communication skills, along with the time and tools to perform the work that is required
Developing and customizing algorithms, cultivating relationships with patients and being accessible and helpful will always result in a better product
Optimizing Outcomes
Treatment OptionsNasal Masks
Treatment OptionsNasal Pillows
Treatment OptionsFull Face Masks
Optimizing Outcomes
Optimizing Outcomes
Optimizing Outcomes
Optimizing Outcomes
% Nights CPAP Used: 90%, % Nights Used > 4 hrs: 10%, Ave. Daily Usage: 2h:17m
Optimizing Outcomes
% Nights CPAP Used: 90%, % Nights Used > 4 hrs: 10%, Ave. Daily Usage: 2h:17m
Optimizing Outcomes
% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 60%, Ave. Daily Usage: 4h:35m
% Nights CPAP Used: 90%, % Nights Used > 4 hrs: 10%, Ave. Daily Usage: 2h:17m
Optimizing Outcomes
% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 60%, Ave. Daily Usage: 4h:35m
% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 87%, Ave. Daily Usage: 5h:24m
% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 90%, Ave. Daily Usage: 5h:44m
• Long term follow-up People change – medications, new medical
problems, lifestyles, priorities – and treatments often need to be modified
Successfully treated patients can slowly drift away from those successes if they are not periodically monitored
The condition that is being treating will evolve over time, and it may require different therapy
New treatments, better ideas, and different approaches need to be integrated into management plans over time
Optimizing Outcomes