Sunil Sharma MD

Diagnosis: HistorySnoring (loud, chronic)Snoring (loud, chronic)Nocturnal gasping and chokingNocturnal gasping and choking

Ask bed partner (witnessed Ask bed partner (witnessed apneas)apneas)

Excessive daytime sleepinessExcessive daytime sleepiness

Sleep Apnea: Is Your Patient at Risk? NIH Publication, No Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.95-3803.

Epworth Sleepiness Score SITUATION CHANCE OF DOZINGSITUATION CHANCE OF DOZING Sitting and reading ---Sitting and reading --- Watching TV ----Watching TV ---- Sitting inactive in a public place (e.g a theater or a meeting) ----Sitting inactive in a public place (e.g a theater or a meeting) ---- As a passenger in a car for an hour without a break ----As a passenger in a car for an hour without a break ---- Lying down to rest in the afternoon when circumstances permit---Lying down to rest in the afternoon when circumstances permit--- Sitting and talking to someone ----Sitting and talking to someone ---- Sitting quietly after a lunch without alcohol Sitting quietly after a lunch without alcohol

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

0 = no chance of dozing0 = no chance of dozing 1 = slight chance of dozing1 = slight chance of dozing 2 = moderate chance of dozing2 = moderate chance of dozing 3 = high chance of dozing3 = high chance of dozing

Unusual Presentation of OSAUncontrolled HTNUncontrolled HTNRecurrent Pulmonary edema / CHFRecurrent Pulmonary edema / CHFUncontrolled AsthmaUncontrolled AsthmaInsomniaInsomniaNocturnal anginaNocturnal anginaNocturiaNocturiaUncontrolled diabetes/ metabolic syndromeUncontrolled diabetes/ metabolic syndromeMemory loss/ Loss of focusMemory loss/ Loss of focusPulmonary HypertensionPulmonary HypertensionHyperactivity / Poor academic performance Hyperactivity / Poor academic performance

(Children)(Children)

Diagnosis: Physical ExaminationUpper body obesity / thick Upper body obesity / thick neckneck

>> 17” males 17” males

>> 16” females 16” females

HypertensionHypertension

Obvious airway abnormalityObvious airway abnormality

Neck circumference

Contd..

Massive Tonsils

BMI

Massive uvula Contd..

Elongated palate High palate and narrow arch

over jet Massive tongue

Contd..

Mallampati score Class I:Class I: soft soft

palate, fauces, palate, fauces, uvula, pillarsuvula, pillarsClass IIClass II: soft : soft palate, fauces, palate, fauces, portion of uvulaportion of uvulaClass IIIClass III: soft : soft palate, base of palate, base of uvulauvulaClass IV:Class IV: hard hard palate onlypalate only

SCREENING TOOLSSCREENING TOOLS

Berlin Questionnaire

High Risk: if there are 2 or more Categories where the score is positive

INVESTIGATIONS

Polysomnography

Patil, S. P. et al. Chest 2007;132:325-337

A summary hypnogram and oximetry tracing in a patient with severe OSA (AHI, 84/h)

Type III devices

Patient /physician educationHTN/ DM/ Afib/ MI/ CHF/ stroke/post-op

complicationsImpotence, reduced memoryIncreased mortalityIncreased deaths after angioplasty and

increased risk of blockage after angioplasty

Why treat OSAImprove neurocognitive symptomsImprove neurocognitive symptomsImprove bed-partners QOLImprove bed-partners QOL

Prevent cardiovascular Prevent cardiovascular complicationscomplications

General treatment measuresAvoid alcohol before bedtimeAvoid alcohol before bedtimeAvoid sedativesAvoid sedativesImprove sleep hygieneImprove sleep hygieneTreat nasal congestionTreat nasal congestionEncourage weight loss/exerciseEncourage weight loss/exerciseEducationEducation

Consequences of EDSConsequences of EDS Impact on CVSImpact on CVS Impact on professional / personal lifeImpact on professional / personal life

Are there any co-existent sleep related issues?

Insufficient sleep/circadian rhythm disInsufficient sleep/circadian rhythm disDepressionDepressionNarcolepsyNarcolepsyIdiopathic hypersomnolenceIdiopathic hypersomnolencePoor insight in his medical conditionPoor insight in his medical conditionMedicationsMedications

PAP therapy. Who should be treated?Most effective therapy-splits airway openMost effective therapy-splits airway open

IndicationsIndicationsAll patients with AHI>15All patients with AHI>15AHI of 5 -15 with symptoms or underlying AHI of 5 -15 with symptoms or underlying

CVDCVD

Modes of PAPBiPAP W/WO back-upAuto- PAPASV

When to use bipapObesity hypoventilation syndromeIntolerance to cpap ( high pressure)COPD+OSAChronic Respiratory failureNeuro-muscular disorders

services2 weeks chief technologistAdjusted hospital/ home trial2 monthly Compliance data reviewOver-read and consultation50% off for physiciansRental basis

Compliance improvement model Involve the partner!Involve the partner! EDUCATION!! –cardiovascular and cognitive implicationsEDUCATION!! –cardiovascular and cognitive implications Watch for red flagsWatch for red flags

Poor sleep efficiency on CPAP trialPoor sleep efficiency on CPAP trial Low EPSLow EPS Symptoms of claustrophobiaSymptoms of claustrophobia

Consider compliance clinics or frequent follow-ups in the Consider compliance clinics or frequent follow-ups in the first 4 weeks!first 4 weeks!

Mask acclimitization before instituting therapyMask acclimitization before instituting therapy OSA related literature to patientsOSA related literature to patients Encourage grp sessions or support grps Encourage grp sessions or support grps Troubleshoot interphase related problems/nasal symptoms Troubleshoot interphase related problems/nasal symptoms Pay attention to cultural beliefs and ethnic differences.Pay attention to cultural beliefs and ethnic differences. Consider management under one roof.Consider management under one roof.

Dental devicesTwo main typesTwo main types

Mandibular repositioning appliances ( MRA)Mandibular repositioning appliances ( MRA) Protrude the mandible forwardProtrude the mandible forward

Tongue repositioning devicesTongue repositioning devices Protrude the tongueProtrude the tongue

Indications for Dental devicesMild – moderate OSAMild – moderate OSAUARSUARSSnoringSnoringAs adjunct to CPAP for Severe OSAAs adjunct to CPAP for Severe OSA* useful in pts. With micrognathia, overbite, * useful in pts. With micrognathia, overbite,

retrognathiaretrognathia

Contra-indicationsSevere SDBSevere SDBNocturnal desaturationsNocturnal desaturationsPoor dentition *Poor dentition *Severe nasal obstructionSevere nasal obstruction? Bruxism? BruxismDementia/ strokeDementia/ stroke

* Use tongue repositioning device* Use tongue repositioning device

MY TOP TEN reasons to get Sleep evaluation in patients with CVD/ DM EDS with snoring or witnessed apneasEDS with snoring or witnessed apneas Newly diagnosed HTNNewly diagnosed HTN

Too young or too old!Too young or too old! Family h/o SDB or no family h/o HTNFamily h/o SDB or no family h/o HTN Associated obesity , snoring or signs of OSAAssociated obesity , snoring or signs of OSA

Uncontrolled HTNUncontrolled HTN CHFCHF

Nocturnal dyspnea, excessive daytime fatigue despite optimal Nocturnal dyspnea, excessive daytime fatigue despite optimal management of CHFmanagement of CHF

CAD- nocturnal angina, SOB, EDSCAD- nocturnal angina, SOB, EDS Uncontrolled diabetes/ insulin resistance/metabolic Uncontrolled diabetes/ insulin resistance/metabolic

syndromesyndrome Strokes- excessive daytime fatigue/ snoringStrokes- excessive daytime fatigue/ snoring Arrhythmias- ventricular irritability/ atrial fibrillationArrhythmias- ventricular irritability/ atrial fibrillation Pulmonary HTNPulmonary HTN ESRD with EDS/snoring ESRD with EDS/snoring