Sleep Apnea: What the internist needs to know Updates in Internal - - PowerPoint PPT Presentation

Sleep Apnea: What the internist needs to know

Updates in Internal Medicine: March 8th, 2019

Douglas Beach, MD, MPH Pulmonary, Critical Care, and Sleep Medicine Beth Israel Deaconess Medical Center

Objectives

• Understand why sleep apnea is important

particularly in terms of co-morbid conditions.

• Understand what diagnostic tests do we use

and why

• Learn treatment options and the impact of

treating sleep apnea on co-morbid conditions

CASE 1: Ms. M

56 y/o woman with rhinitis, hyperlipidemia and HTN seen for routine follow up. No complaints. Gained 5 pounds since last

• year. Less active due to knee injury. Nonsmoker. Works FT.

Meds: statin, HCTZ, atenolol, lisinopril, fluticasone nasal spray VS: BP 165/91, HR 80, RR 12, SpO2 97% BMI 31 kg/m2

Should you be thinking about sleep apnea?

Why should you care about sleep apnea?

• Most common sleep d/o
• Prevalence estimates in US adults 18-

23 million (moderate-severe) 1/5 mild, 1/15 moderate to severe 20-30% ♂ 10-15% ♀ > 80% remains undiagnosed

• Increases with Age, BMI
• Major driver of health care cost

Somers et al. Am Coll Cardiol 2008; Young et al. AJRCCM 2002; Tishler et al. JAMA 2003; Kapur et al. Sleep Breath 2002; Peppard et a. Am J Epidemiol 2013

Sleep apnea

Sleep fragmentation Arousals Sleep deprivation Hypoxemia Hypercapnia Intrathoracic pressure

Functional consequences

Functional consequences

Excessive daytime sleepiness Insomnia Decreased QOL MVAs and workplace accidents Cognitive deficits

Malhotra and White. Lancet 2002; Somers et al. JACC 2008; Redline et al. AJRCCM 2010; Yaffe et al. JAMA 2011; Kang et al, Science 2009. Bratton et al.,JAMA 2015.

Mechanisms

Sympathetic activation Inflammation Endothelial dysfunction Hypercoagulability Left atrial enlargement Fatty acid lypolysis Oxidative stress

Disease manifestations Sleep apnea

Sleep fragmentation Arousals Sleep deprivation Hypoxemia Hypercapnia Intrathoracic pressure

Disease manifestations

• Impaired glucose tolerance
• Type 2 DM
• HTN (systemic, pulmonary)
• Atherosclerosis
• Cerebral vascular disease
• MI
• CHF
• Arrhythmias
• Sudden cardiac death
• Cognitive disorders

Malhotra and White. Lancet 2002; Somers et al. JACC 2008; Redline et al. AJRCCM 2010; Yaffe et al. JAMA 2011; Mehra et al., AJRCCM 2006; O’Connor et al., AJRCCM 2009; Kang et al, Science 2009; Buchner S et al. Eur Heart J. 2014;Circulation 2016.

Shared features

OSA Metabolic Syndrome

Hypertension

*** **

Central obesity

** ***

Insulin resistance

** ***

Sympathetic activation

*** *

Inflammation

** **

Endothelial dysfunction

** **

Batsis JA et al. Clin Pharmacol Ther 2007

OSA prevalence in CVS patients

60% 60%

Stroke Bazzano et al. Hypertension 2007; Haentjens et al. Arch Intern Med 2007; Pedrosa et

• al. Hypertension 2011; Redline et al. AJRCCM 2010; Mehra et al. AJRCCM 2006;

Bratton et al.,JAMA 2015.

CASE 1: Ms. M

56 y/o woman with rhinitis, hyperlipidemia and HTN seen for routine follow up. No complaints. Gained 5 pounds since last

• year. Less active due to knee injury. Nonsmoker. Works FT.

Meds: statin, HCTZ, atenolol, lisinopril, Flonase VS: BP 165/91, HR 80, RR 12, SpO2 97% BMI 31 kg/m2

Should you be thinking about sleep apnea? (If not, why not?)

OSA: No perfect screening tool

History and physical exam Epworth sleepiness scale STOP-BANG Overnight oximetry

Physical exam can suggest increased risk

• VS
• Nasal and upper airway exam
• Neck circumference
• Signs of heart failure or other comorbid conditions

History can provide clues

even when overt sleep symptoms are not present

Oropharyngeal, nasal, craniofacial features

Retrognathia/Micrognathia Tooth wear Dental malocclusion Mallampati Classification

Likelihood of dozing or falling asleep

1)

Sitting and reading

2)

Watching TV

3)

Sitting, inactive in a public place

4)

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

5)

Lying down to rest in the afternoon when circumstances permit

6)

Sitting and talking to someone

7)

Sitting quietly after a lunch without alcohol

8)

In a car, while stopped for a few minutes in the traffic Total: 0–10 Normal range 10–12 Borderline 12–24 Abnormal

Epworth sleepiness scale

0 = would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing

1) Do you snore loudly? 2) Are you tired or sleepy during the

daytime?

3) Are you observed to stop breathing? 4) Do you have high blood pressure? 5) BMI ≥ 35 kg/m2 6) Age > 50 yo? 7) Neck circumference > 40 cm? 8) Gender male?

STOP-BANG questionnaire

Risk of OSA High if yes to ≥ 3 items Low if yes to < 3 items

Chung et al. Anesthesiology 2008.

CASE 1: MS. M

56 y/o woman with rhinitis, hyperlipidemia and HTN seen for routine follow up. No complaints. Gained 5 pounds since last

• year. Less active due to knee injury. Nonsmoker. Works FT.

Meds: statin, HCTZ, atenolol, lisinopril, Flonase VS: BP 165/91, HR 80, RR 12, SpO2 97% BMI 31 kg/m2 On your questioning, reports loud snoring - bed partner sleeps in separate room. Never fully refreshed. Wakes 4 time/night to urinate. ESS 12 Exam: 16 inch/40 cm neck, MM 3, slight retrognathia.

Diagnosis

1.) What test would you recommend?

• A. Overnight oximetry
• B. Overnight attended PSG

C.Overnight portable limited channel sleep study (HST) D.Arterial blood gas

• E. Echocardiogram

1.) What test would you recommend?

• A. Overnight oximetry
• B. Overnight attended PSG

C.Overnight portable limited channel sleep study (HST) D.Arterial blood gas

• E. Echocardiogram

Patient selection for home study

• Appropriate patients
• No contraindications (pulmonary, CHF, neuro)
• High pretest probability
• No other sleep disorder suspected
• Assess non-CPAP treatment (for example: oral

appliance/positional therapy)

Portable Monitoring Task Force, Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adult Patients. JCSM 2007.

Should NOT get HST

• Evaluate –
• parasomnias, narcolepsy, REM behavior disorder
• Dementia/physical issues limiting proper use without tech supervision
• Not preferred but can be used if patient otherwise refuses or is

unable to come to sleep lab

• CHF/Advanced pulmonary disease
• Suspected hypoventilation (HCO3 ≥ 28, persistent hypoxia)
• Suspected OSA with severe insomnia

What if the HST returns as “no sleep apnea”?

False negatives are possible

Disease burden is underestimated vs. in-lab PSG

• AHI calculated based on recording, not time of sleep
• Only apneas and events with 4% or 3% desaturations

are scored

• No EEG so events causing arousals are missed
• Artifacts/missing data

Screening for Obstructive Sleep Apnea in Adults. US Preventive Services Task Force Recommendation Statement. JAMA 2017.

Portable monitors: Home sleep tests

Lower cost, convenient Limited: no EEG or EMG information

Snore Nasal flow Thorax effort SpO2 HR

• Apnea hypopnea index, AHI 4%
• Apneas + hypopneas / hour sleep
• Marker of disease severity/hypoxia
• Apnea hypopnea index, AHI 3% (i.e. 3%

desaturation or associated with EEG arousal)

• Sometimes referred to as “alternative criteria”
• Respiratory disturbance index, RDI
• All resp events / hour, regardless of desaturation
• Marker of sleep fragmentation/UARS

Sleep apnea definitions

OSA severity based on AHI

Mild: 5-15 Moderate: 15-30 Severe: ≥ 30

2.) What if Ms. M had excessive sleepiness (ESS 20/24), and the HST showed no sleep apnea?

• A. Order an MSLT, since she

probably has narcolepsy

• B. Ask her to sleep more

C.Start a stimulant D.Refer to sleep clinic

• E. Repeat the HST or in-lab PSG

2.) What if Ms. M had EDS (ESS 20/24), and the HST showed no sleep apnea?

• A. Order an MSLT, since she

probably has narcolepsy

• B. Ask her to sleep more

C.Start a stimulant D.Refer to sleep clinic

• E. Repeat the HST or in-lab PSG

Polysomnogram (PSG)

PSG multistage hypnogram

Oximetry banding vs. V-shaped

Desat Obstructive apnea Rapid eye movements

EEG arousal

Tachycardia

• A. Auto continuous positive

airway pressure (APAP)

• B. Oral appliance
• C. Weight loss
• D. Stimulant medication
• E. Nocturnal oxygen

3.) Ms. M’s HST shows OSA (AHI 32/hr, O2 nadir 79%). What treatment(s) would you recommend?

• A. Auto continuous positive

airway pressure (APAP)

• B. Oral appliance
• C. Weight loss
• D. Stimulant medication
• E. Nocturnal oxygen

3.) Ms. M’s HST shows OSA (AHI 32/hr, O2 nadir 79%). What treatment(s) would you recommend?

• Patient education
• Treat predisposing or modifiable factors
• Weight loss
• Treatment of nasal congestion
• Avoidance of supine sleep
• Avoidance of alcohol/sedatives
• Treatment selection (symptomatic,

moderate to severe OSA)

• PAP

Treatment approach

APAP vs. in-lab titration

• If only OSA is found, EVEN if severe, APAP is

appropriate, but might change the settings

• 5-15 cm H20 usual empiric setting
• Higher if obese (8-20) cm H20
• In-lab titration recommended if HST shows
• Baseline hypoxia
• Concern for hypoventilation
• Central / complex sleep apneas or periodic

breathing

Randy Glasbergen www.glasbergen.com

Positive airway pressure

Continuous-CPAP, Bilevel-BPAP, Auto-titrating-APAP Gold standard / first-line therapy

Johnson and Johnson. Medical Devices: Evidence and Research. 2015. Busetto et al. Chest. 2005; Philips et al. AJRCCM 2013.

Treatment (PAP) benefits for OSA

• Sleepiness, QOL, cognition, depression

Effect > more severe OSA better adherence

• Hypertension
• LVEF in CHF
• Cardiac remodeling
• Glucose parameters (data is variable)
• Pulmonary hypertension

Bazzano et al. Hypert 2007; Haentjens et al. Arch Int Med. 2007; Patel et al. Arch Int Med. 2003; Colish J et al.,Chest 2012; Babu et al. Arch Int Med. 2005; Bratton et al.,JAMA 2015; Lee et al. Circulation 2016.

CVS events increased in untreated OSA

Marin et al. Lancet 2005

CPAP improves 24-hour BP

After treatment

Time from wake and sleep onset (hours) Mean blood pressure (mmHg)

85 90 95 100 105 110 115 120

sub-therapeutic therapeutic

wake 4 8 12 16 sleep 4 8

Before treatment

Mean blood pressure (mmHg)

85 90 95 100 105 110 115 120

Time from wake and sleep onset (hours)

wake 4 8 12 16 sleep 4 8

sub-therapeutic therapeutic

Pepperell et al. Lancet 2002.

Diagnosing/treating SDB reduces readmission rates in cardiac patients

Kauta SR et a., JCSM 2014;10:1051-59.

N

CASE 2: EJ

49 y/o man with obese BMI (32 kg/m2), HTN, who has moderate OSA (AHI 4% 16). He presented with loud snoring, EDS, frequent awakenings, and naps. He was started on APAP 8-14 cm with a full face mask. He returns to clinic and states that he is doing well with APAP. He reports nightly use. He still feels tired and notes no improvement in his sleep continuity. He does not have problems with his mask and does not report leaking as a problem.

A.Send him to see a sleep specialist B.Schedule a lab titration

• C. Start a stimulant medication
• D. Look at his machine data
• E. Ask about his sleep schedule
• F. All of the above

1.) What should you do?

Online data tracking

AirView (ResMed)

Encore (Respironics): APAP data

• Interface

Leak, mouth breathing, nasal patency, skin breakdown

• Pressure

Positional disease, weight change, need for repeat titration

• Aerophagia

Flex, expiratory pressure relief, Bilevel

• Another disorder / overlap conditions
• Central or complex sleep apnea

Trouble shooting poor adherence

Alternative / adjunctive treatments

• Oral appliances
• Surgical treatment
• Surgical weight loss
• Adaptive-servo ventilation

(non-systolic CHF with central/complex disease)

• Nasal EPAP (Provent)
• Upper airway stimulation

Expiratory positive airway pressure (EPAP)

• FDA approved
• ~$70/month
• Improvement in ESS and AHI

maintained at 3 months compared to sham

Berry et al., Sleep. 2011.

Upper airway (hypoglossal nerve) stimulation for OSA

Strollo et al. NEJM 2014

When / who to refer to sleep specialist?

Inconclusive testing Severe OSA Hypoxia out of proportion to degree of OSA Shift workers/overlap conditions Treatment intolerant / nonadherent Suboptimal treatment response

Take Home Points

• OSA is common / does not discriminate

but prevalence is highest in co-comorbid

• conditions. Screen high risk patients!
• Treatment impacts co-morbid conditions
• Trouble shoot – if patient is intolerant or not

improving, there is usually a reason.

• Look at device data – efficacy, not just use

duration matters

• Involve sleep specialist

Thanks!

• Special thanks to:
• Melanie Pogach, MD
• BIDMC Sleep Disorders Center