sleep medicine something old / something new

Sleep MedicineSomething Old / Something New

Glenn W. Burris, MD, MS, FAASMMedical Director

The SOMC Sleep Diagnostic CenterPortsmouth, Ohio

Learning Objectives

1. The learner will understand the basic components of a diagnostic polysomnogram and the speaker will explain the definitions of respiratory events used to calculate the Apnea-Hypopnea Index.

2. The speaker will present clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea

3. The learner will understand some of the health benefits of treating obstructive sleep apnea with nasal CPAP.

The Study of Sleep

1834 – Robert McNish

“ Sleep is the intermediate state between wakefulness and death, wakefulness being regarded as the

active state of all the animal and intellectual functions, and death as that of their total suspension.”

The Study of Sleep

1937 – Davis, Loomis, Harvey, Hobart - different stages of sleep were reflected in changes of the EEG

1953 – Asereinsky & Kleitman -Identification of Rapid Eye Movements during Sleep

1957 – Dement & Kleitman - Relationship between eye movements, body motility, and dreaming

1968 – Rechtschaffen and Kales (R&K) - standard sleep scoring technique

2007 – American Academy of Sleep Medicine - Manual for the Scoring of Sleep and Associated Events

PolysomnogramContinuous monitoring of physiology during sleep

Electroencephalogram (EEG) Eye Movements Nasal and Oral Air flow Submental Muscle activity (EMG) Respiratory Effort – Chest and Abdomen Cardiac Rhythm Leg Muscle Activity – tibialis anterior Pulse oximetry Snore Microphone Video Monitoring

Polysomnogram

Information is included in 30 second epochs

PolysomnogramFollowing completion of the study the information is scored:

Lights out Sleep Latency – from lights out to onset of sleep Sleep Stages

Non-REM – N1, N2, N3 REM

Sleep Efficiency – percentage of time asleep Respiratory Events Leg Movements Arousals Heart Rhythms Snoring intensity Lights on Quality of patient’s sleep compared to baseline

Scoring Respiratory Events

Apnea – when all of the following criteria are met1) There is a drop in the peak thermal sensor excursion by >90% of

baseline2) The duration of the event lasts at least 10 seconds3) At least 90% of the event’s duration meets the amplitude criteria for

apnea4) Classified as: obstructive, central, or mixed based on respiratory effort

Hypopnea – when all of the following are met1) The nasal pressure signal excursion drops by 30% of baseline2) The duration of this drop occurs for a period of at least 10 seconds3) There is a 4% desaturation from pre-event baseline4) At least 90% of the event’s duration meets the amplitude criteria

The AASM Manual for the Scoring of Sleep and Associated Events, 2007

Obstructive Sleep Apnea

Respiratory Disturbance Index (RDI) – no longer used apneas, hypopneas, respiratory related arousals

Apnea-Hypopnea Index (AHI) total number of respiratory events / hours of sleep

Severity of OSA defined by the AHI:less than 5 – not sleep apnea5 – less than 15 – MILD15 – less than 30 – MODERATE

> 30 – SEVERE

Portable Monitoring for OSA in Adults

In home diagnostic test for OSA

Advantages Convenience Less costly Attending technologist not required

Disadvantage Fewer physiologic variables that lead to misdiagnosis Technical limitations (apparatus malfunction) = repeat studies Validation of the device


Types of Monitoring Devices

Type 1 – in sleep center, attended, overnight polysomnogram

Type 2 – record same variables as type 1, unattended

Type 3 – evaluate four physiologic parameters – not sleeprespiratory movement and airflowheart ratearterial oxygen saturations(snoring), (position)

Type 4 – evaluate one or two parameters (saturation and airflow)


Limitations of Type 3 devices

Apnea Hypopnea Index – abnormal breathing events by recording time as sleep can not be recorded

Unless the patient was sleeping the entire recording time, the AHI calculated by a portable monitor will likely be lower than an attended polysomnogram

Can not distinguish sleep stages

Portable Monitors and OSA

2005 Center for Medicare and Medicaid Services (CMS) evidence was not adequate to conclude, tests remained uncovered

2008 Reconsidered and will allow for coverage of CPAP therapy based on a

positive diagnosis of OSA by home sleep testing

Must fulfill all requirements in the National Coverage Determination, CR6048

Clinical evaluation as a positive diagnosis from PSG or unattended, type 2, 3, 4(measuring at least 3 channels)

Diagnostic tests that are not ordered by the beneficiary’s treating physician and not considered reasonable and necessary


Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in

AdultsPortable Monitoring Task Force of the American Academy

of Sleep Medicine1

Clinical Guidelines for the Evaluation, Management, and Long-term Care of Obstructive Sleep Apnea in Adults2

1. J Clinical Sleep Medicine, Vol 3, 20072. J Clinical Sleep Medicine, Vol 5, 2009


American Academy of Sleep Medicine Guidelines Should be performed only in conjunction with a comprehensive

sleep evaluation, preferably by a sleep medicine specialist

May be used as an alternative to PSG for the diagnosis of OSA in patients with a high pretest probability of moderate to severe OSA

Should not be used in patients who have comorbid medical conditions that predispose to sleep related breathing disorders

Must record air flow, respiratory effort and blood oxygen information


Guidelines – cont Experienced persons should educate the patient or directly apply

the the monitoring equipment

Should be a method to monitor the quality of the recordings

Monitors must be capable of displaying the raw date for clinical review

All patients should have a follow-up visit with a provider able to discuss the results of the test


Charles Dickens ( 1812 – 1870)

The Posthumous Papers of the Pickwick Club

Described Joe, a fat boy, who was always excessively sleepy. A loud snorer.

First reported in 1965 during the study of severely obese patients 1

1. Brain Res 1965; 2: 167-186


Wisconsin Sleep Cohort Study

Random, n=602, ages 30 – 60

• Sleep disordered breathing as high as: 24% of men 9% of women

• 4% of men, 2% of women had symptomatic OSA AHI - >5 Daytime hypersomnolence

NEJM 1993;328(17):1230-35.

Risk of OSA in the US Population

Results from the National Sleep Foundation Sleep In America 2005 Poll

n= = 1506 adults (775 were women) Mean age 49 Berlin Questionnaire 26% of respondents (31% of men and 21% women) found to be at

high risk of OSA

As many as one in four American adults could benefit from an evaluation for OSA!

CHEST 2006; 130: 780-786

Identifying Patients with OSA

Clinical Presentation

Threshold to symptoms highly variable

Insidious

Unaware or underestimate their degree of impairment

Elderly patients aware of frequent awakenings

Complaints of insomnia and unrefreshing sleep

Excessive body movement, kicking in sleep

Decrements in short-term memory

Moodiness, irritability

Identifying Patients with OSA

Clinical Presentation – cont

Lack of concentration

Anxiety / depression

Morning headaches – up to 50%

Sensation of choking / dyspnea

Decreased libido and impotence

GERD, worse at night

Nocturia, 28% of patients report 4 to 7 episodes of nightly


“My wife made me come!”


Cardiovascular diseaseHypertensionCoronary Artery DiseaseStrokeArrhythmiaPulmonary HypertensionCongestive Heart Failure

HematologicalPlatelet ActivationHypercoaguable state

NeurologicalTIAStrokeDaytime FatigueMemory / Intellectual impairmentMorning Headaches

GastrointestinalGERDFatty Liver

MetabolicAltered Leptin LevelsPoor Gylcemic ControlRapid Weight Gain

PsychologicalDepressionIrritability / Mood ChangesNocturnal Panic AttacksBed partner Relationships

GenitourinaryImpotenceNocturia

RenalProteinuriaFocal Segmental Glomerulosclerosis

ImmuneElevated TNF-a Decreased IgMElevated IL-6Decreased NK cellsIncreased C3

InflammationC-reactive protein

Berlin Questionnaire

Berlin Questionnaire

A means of identifying patients with sleep apnea

n = 744 adults completed the questionnaire 279 were in a high-risk group 100 patients (equal representation of high and low risk group)

underwent a portable sleep study

Being in the high-risk group predicted an RDI of greater than 5 with a sensitivity of 0.86 and a specificity of 0.77

Ann Intern Med, 1999, 131: 485-491


Physical exam of the Upper Airway

Lack of consensus in describing the physical findings

Nose Nasal Obstruction

Oropharynx Mallampati Class

Retrognathia Risk of narrow airway at the base of the tongue

Mallampati Class

Scoring is as follows:

Class 1: Full visibility of tonsils, uvula and soft palateClass 2: Visibility of hard and soft palate, upper portion of tonsils and uvulaClass 3: Soft and hard palate and base of the uvula are visibleClass 4: Only Hard Palate visible

Can Anaesth Soc J, 1985 Jul; 32(4) 250-1

Mallampati ClassMallampati Score as an Independent Predictor of


n=137

80 (58%) had OSA as defined as AHI 5 or greaterLikelihood Ratio

Class I - 4 of 12 patients 0.4Class II - 24 of 50 patients 0.7Class III - 45 of 65 patients 1.6Class IV - 7 of 10 patients 1.7

For every increase in Mallampati Score by one, increased odds of having OSA by about 2 fold the AHI increased by more than 9 events / hour

Sleep 2006; 29 (7) 903-908

Obstructive Sleep Apnea - HypertensionSleep Heart Health Study

Multicenter Study, n= 6132Age > 40 years, 53% female

AHI Hypertension<1.5 43%1.5 – 4 53%5 -14 59%15 – 29 62%>30 67% JAMA 2000;283:1829-1836

JNC 7 – OSA identifiable cause of hypertension JAMA 2003; 289: 2560-2572

Obstructive Sleep Apnea - Hypertension Treatment of OSA with CPAP can Improve Hypertension

17 hypertensive patients, 7 normotensive patientsModerate to severe OSA (AHI 60 +/- 19)Four to six months CPAP

NEJM 2000: 343:967

Obstructive Sleep Apnea – Congestive Heart Failure

OSA in Dilated Cardiomyopathy: The effects of CPAP

N = 8Dilated cardiomyopathy and severe OSA (AHI 54)

Baseline CPAPLeft ventricle ejection fraction 37% 49%

Stopped CPAP for one week 53% 45%

Lancet 1991; 338:1480-4

Obstructive Sleep Apnea – Cardiac Remodeling

Effects of Continuous Positive Airway Pressure on Cardiac Remodeling as Assessed by Cardiac Biomarkers, Echocardiography, and Cardiac

MRI

•Prospective Study, n = 52, years 2007-2010

•AHI > 15, Epworth Sleepiness Score >10

•Evaluation before CPAP, 3 mos, 6 mos and 12 mos

•At each visit: TnT, CRP, and NT-proBNP levels, and a standard TTE

•CMR at baseline and 6 and12 months after the initiation of CPAP treatment.

CHEST 2012; 141(3):674–681

Obstructive Sleep Apnea - Cardiac Remodeling

• Following 12 months of CPAP therapy, levels of CRP, NT-proBNP, and TnT did not change

• As early as 3 months after initiation of CPAP, TTE revealed an improvement in right ventricular end-diastolic diameter, left atrial volume index, right atrial volume index, and degree of pulmonary hypertension, which continued to improve over 1 year of follow-up.

• Left ventricular mass, as determined by CMR, decreased from

159 g/m 2 to 141 8 g/m 2 as early as 6 months into CPAP therapy and continued to improve until completion of the study at 1 year.

CHEST 2012; 141(3):674–681

Obstructive Sleep Apnea - Diabetes

CPAP Therapy of Obstructive Sleep Apnea in Type 2 Diabetics Improves Glycemic Control During Sleep

n=20, type 2 diabetes and newly diagnosed OSA measured glucose levels every five minutes during sleep baseline and after treatment with CPAP (average 41 nights)

Mean glucose decreased in 10 of 11 subjects with glucose > 100mg/dL

No decrease in subjects with glucose < 100mg/dL

J of Clin. Sleep Med. Dec 15, 2008


Impact of Untreated Obstructive Sleep Apnea on Glucose Control in Type 2 Diabetes

n = 60, 14 without OSA, 46 with OSA

Controlled for: sex, race, BMI, waist circumference, Hgb A1C, year of diagnosis, medications (insulin and oral), exercise, hypertension and snoring.

Increasing severity of OSA was associated with poorer glucose control.

Am J Respir Crit Care Med Vol 181. pp 507–513, 2010


Compared to controls the mean HbA1c:

Mild OSA - increased by 1.49% (P= 0.0028) Moderate OSA - increased by 1.93% (P= 0.0033) Severe OSA – increased by 3.69% (P< 0.0001)

Linear Trend (P< 0.0001)

inverse relationship between OSA severity and glucose control in patients with type 2 diabetes

Am J Respir Crit Care Med Vol 181. pp 507–513, 2010

Obstructive Sleep Apnea – Mortality

One of the first reports of adverse consequences was published 1988

8 year study, n=385

severe OSA compared to less severe OSA (AHI >20, <20)

significant increase in all cause mortality (death)

change in mortality corrected by tracheostomy and CPAP

CHEST 1988; 94:9-14

Obstructive Sleep Apnea - Mortality

Sleep Apnea as an Independent Risk Factor for All-Cause Mortality: The Busselton Health Study

Sleep Apnea diagnosedScreened 380: 18 had moderate to severe OSA 77 had mild OSA

followed up to 14 years6 of the 18 died 33% (moderate to severe OSA)5 of the 77 died 6% (mild OSA)

SLEEP 2008 Vol 31, No 8

Obstructive Sleep Apnea – MortalitySleep Disordered Breathing and Mortality: Eighteen-Year

Follow-up of the Wisconsin Sleep Cohort

n= 1546, mean observation period of 13.8 years

AHI n Deaths0 < 5 1157 46 (4%)

5 - <15 220 16 (7.3%) 15 - <30 82 6 (7.0%)

>30 63 12 (19.75%)

Cardiovascular death – 42% of persons with severe OSA 26% of persons without OSA

SLEEP 2008 Vol 31, No 8

Clinical Pearls Obstructive Sleep Apnea is a common medical condition that

contributes significantly to a multitude of comorbid diseases

Presenting symptoms are heterogeneous and clinical evaluation should be frequently considered

Untreated OSA in intimately related to worsening of many medical conditions

Identification and treatment of OSA has a positive impact on individual health and health care resources

The Nightmare – Henry Fuseli, 1781

sleep medicine something old / something new

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