Obstructive Sleep Apnea Nite Nite Sleep Right

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Obstructive Sleep ApneaNite Nite Sleep Right

• By
• Justin C. Sebastian MD, FRCPC
• Division of Pulmonary Medicine
• Royal Alexandra Hospital

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Obstructive Sleep Apnea

• Objectives
• Case Presentation
• How to approach patients with OSA
• Basics of sleep physiology
• Definitions and classification of OSA
• Pathophysiology of OSA
• Clinical implications of OSA
• Treatment options

3
Case Summer 2007 RAH

• 56 yo gentleman
• Chest pain
• SOB, orthopnea, PND 3 weeks
• Left heart catheterization for NSTEMI
• Snoring Oxygen desaturation
• Co-morbidities HTN, DM, Depression
• Sleep history
• Snoring, Non-restorative sleep EDS -15years
• Witnessed apneas, Gasping for air, Nocturia,
  Morning headaches, Behavioral changes

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Physical Examination

• Sa02 96 on Room Air HR 76
• Wt 250lbs Ht 56 BMI 40 kg/m2
• Oral Airway Mallampati IV
• Neck Circumference 17(43cm)
• Chest Basal rales
• Heart S3 gallop
• Abdomen Protuberant
• Ext 2 pitting edema

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Who has OSA?

• 4 of men and 2 of women between the ages of
  30-60 years.
• Association with BMI (gt28)
• Men aged 40 years up to 60 (2-3x greater that
  women)
• Ethnicity African American Caucasians
  Chinese/Asian
• Post menopausal women
• Alcohol
• Hypothyroidism
• Nasal congestion

Young T, et al. Amer J Respir Cir Care Med.
20021651271-1239
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Approach to a Patient with Sleep Apnea

• Sleep history
• Daytime sleepiness
• Epworth Sleepiness Scale
• Examination
• BMI, Neck circumference, Airway, DNS
• Co-morbidities
• HTN, DM, Hypothyroidism, COPD, CHF, Affective
  disorders
• Clinical prediction rules for Sleep Apnea

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Approach to a Patient with Sleep Apnea

• Epworth Sleepiness Scale
• Quantifying daytime sleepiness

10 is normal 11-16 mild EDS 16-24 severe EDS
Johns MW. Chest. 199310330-36
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Approach to a Patient with Sleep Apnea

• Epworth Sleepiness Scale
• Quantifying daytime sleepiness
• Daytime functionality
• Concentrating, driving, job performance, quality
  of life.
• Association with ESS and OSA
• Priority and type of testing needed (level I/III)
• Not sen/spec to any pathological illness
• OSA/Depression/Chronic medial illness/Sleep
  deprivation

Johns MW. Chest. 199310330-36
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Approach to a Patient with Sleep Apnea

• Epworth Sleepiness Scale
• Insomnia OSA with RLS, Airway obstruction,
  Depression, Psychotropic medication
• 50 patient (n 231) of OSA patients had symptoms
  of insomnia
• OSA is a reversible causes for insomnia.
• Difficult task for primary care physicians to
  triage patients.
• Sleep study in the work up of insomnia.

Krakow B et al Chest. 20011201923-1929
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Approach to a Patient with Sleep Apnea

• Sleep Apnea Clinical Score (SACS)
• Method to accurately predict the probability of
  sleep apnea
• Independent variables related to OSA
• Neck cir, HTN, Snoring, and Choking/gasping

Flemons WW, et al. Am J Respir Crit Care Med.
19941501279-85.
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Approach to a Patient with Sleep Apnea

• Sleep Apnea Clinical Score (SACS)
• Likelihood ratios post test probability depend
• upon the prevalence of the disorder in the
  population.

Flemons WW, et al. Am J Respir Crit Care Med.
19941501279-85.
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Clinical prediction rules cont

• Adjusted Neck Circumference
• Measure the neck circumference in CM (43cm).
• Add 4 cm for hypertension.
• 3 cm for habitual snoring.
• 2 cm for chocking/gasping most nights.
• Probability of Sleep Apnea
• lt 43 cm Low probability
• 43-48 cm Intermediate probability (odds ratio
  4-8)
• gt48 cm High probability (odds ratio gt 20x)
• Sensitivity 95 and Specificity 63
• Case patient was high probability.

Flemons WW, et al. NEJM. 2002347500.
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Clinical Practice
14
Case Summer 2007 RAH

• 56 yo gentleman
• Chest pain
• SOB, orthopnea, PND 3 weeks
• Left heart catheterization for NSTEMI
• Snoring Oxygen desaturation
• Co-morbidities HTN, DM, Depression
• Sleep history
• Snoring, Nonrestorative sleep EDS -15years
• Witnessed apneas, Gasping for air, Nocturia,
  Morning headaches, Behavioral changes

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Physical Examination

• Sa02 97 on O2 at 2l/min HR 76
• Wt 250lbs Ht 56 BMI 40 kg/m2
• Oral Airway Mallampati IV
• Neck Circumference 17(43cm)
• Chest Basal rales
• Heart S3 gallop
• Abdomen Protuberant
• Ext 2 pitting edema
• Adjusted Neck Circ. 52

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Suggestion

• Severe Obstructive Sleep Apnea
• Level III sleep study to confirm the diagnosis
  and determine severity.
• Auto CPAP titration while in a monitored setting.

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Findings
CPAP of 12 cm H20
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Follow up 6 weeks
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Sleep Physiology

• Definition A reversible behavioral state of
  perceptual disengagement from and
  unresponsiveness to the environment.
• Divided into 3 stages
• Wakefulness
• Non-Rapid Eye Movement (NREM)
• Rapid Eye Movement (REM)

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Sleep Physiology

• NREM is divided into 4 stages
• Stages 1 to 4
• Stages roughly parallel the depth of sleep
• Arousal thresholds generally lowest in Stage 1
  and highest in Stage 4 sleep
• Stages 1,2 are called light sleep
• Stages 3,4 are called deep sleep or SWS
• A relatively inactive brain in a movable body

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Sleep Physiology

• REM
• Generally not divided into stages
• Defined by
• EEG activation
• Episodic burst of rapid eye movement
• Muscle atonia
• Mental activity involves dreaming
• A highly activated brain in a paralyzed body

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Need for Sleep

• Average adult requires about 8 hours of sleep.
  The is extremely variable.

Kripke, D. F. et al. Arch Gen Psychiatry
200259131-136.
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Need for Sleep

• Survey of 1.1 million US citizens b/w 1982-1988.

For 636 095 women, the average reported frequency
of insomnia, the average number of sleeping pills
used per month, and the mean body mass index
(BMI) according to reported hours of sleep
For 480 841 men, data comparable to those shown
in Figure 1
Kripke, D. F. et al. Arch Gen Psychiatry
200259131-136.
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Sleep Disorder Breathing (SBD)

• Health problems associated with SDB gained
  recognition in the past three decades.

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Definitions of SBD

• Polysomnography as the gold standard
• Apnea Cessation of breathing gt 10sec
• Hypopnea 50 decrease in air flow oxygen
  desaturation gt 4
• AHI
• Severity
• 5 events/hour is normal
• 5-15 events/hour - mild
• 15-30 events/hour - moderate
• gt30 events/hour - severe

Apneas Hypopnea Total Sleep Time
Can Respir J. 13(7) October 2006
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Sleep Disorder Breathing

• Two distinct syndromes
• Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS)
  
• AHI gt5 plus symptoms
• Obesity Hypoventilation Syndrome (OHS)
• Daytime PaCO2 gt 45 or gt10 with sleep and Pulm
  HTN, RHF or erythrocytosis
• Overlap Syndrome
• OSA with COPD (FEV1lt 1L lt 40)
• Upper-Airway Resistance Syndrome (URAS)
• AHI lt5 plus symptoms
• Central Sleep Apnea (CSA)
• Cheyne-Stokes Respiration

Can Respir J. 13(7) October 2006
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Mechanisms of Airway Obstruction
1
5
2
3
4
Multiple causes of airway collapse during sleep
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Mechanisms of Airway Obstruction
Principles and Practice of Sleep Medicine
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Mechanisms of Airway Obstruction
Principles and Practice of Sleep Medicine
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Pathophysiology of Sleep Apnea
Sleep Onset
Hyperventilate correct hypoxia hypercapnia
Decreased pharyngeal muscle activity
Airway opens
Pharyngeal muscle activity restored
Airway collapses
Arousal from sleep
Apnea
Increased ventilatory effort
Hypoxia Hypercapnia
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Pathophysiology of Sleep Apnea
Sleep Fragmentation Hypoxia/ Hypercapnia
Excessive Daytime Sleepiness
Cardiovascular Complications
Morbidity Mortality
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ConsequencesExcessive Daytime Sleepiness

• Poor job performance
• Depression
• Family discord
• Decreased quality of life
• Increased motor vehicle crashes
• Increased work-related accidents

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Consequences of Sleep Apnea

• Impaired cognition
• Behavioral changes
• Hypertension
• Arrhythmias
• Myocardial Ischemia
• Cerebrovascular diseases
• Hypercoagulability/Platelet Dysfunction
• Mortality

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Sleep Apnea and HypertensionWisconsin Sleep
Cohort Study
Prospective Study of Association Between OSA and
Hypertension
3
2.5
2.89
Adjusted Age, sex, BMI, neck circ., cigs., ETOH,
baseline HTN
2
Odds Ratio
1.5
2.03
1
1.42
0.5
0
0
0.1 - 4.9
5 - 14.9
gt 15
Apnea / Hypopnea Index (AHI)
Peppard PE et al. N Engl J Med 2000342.
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Sleep Apnea and Hypertension

• Hypertension is more difficult to control with
  conventional antihypertensives, in men with OSA,
  than in non-apneic men.
• Hirshkowitz M et al Sleep. 198912223.
• Conversely, OSA is common in patients with
  difficult to control hypertension.
• Grote L et al J Hypertens. 200018679.
• Hypertensives refractory to maximal medical
  therapy, had a high prevalence of undetected OSA
  (83).
• Logan AG et al High prevalence of unrecognized
  sleep apnoea in drug-resistant hypertension. J
  Hypertens. 2001192271.

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Sleep Apnea and Cardiovascular DiseaseSleep
Heart Health Study
Cross Sectional Study of Association Between OSA
and CVD
2.5
2
AHI
0 - 1.3
1.5
Odds Ratio
1.4 - 4.4
1
4.5 - 11.0
gt 11.0
0.5
0
CAD
HF
CVA
Adjusted for age, sex, race, BMI, HTN, smoking,
chol.
Shahar E et al. Am J Respir Crit Care Med
2001163.
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Sleep Apnea and StrokeObstructive Sleep Apnea as
a Risk Factor for Stroke and Death
Cohort Study to Determine the Independent Effect
of OSA on CVA and Death From Any Cause.
Conclusion OSA is an independent risk factor for
stroke and death of any cause.
Yaggi H et al. N Engl J Med 2005 3532034-41.
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Sleep Apnea and Atrial FibrillationStroke

• Circulation. 20031072589
• Patients with OSA have a higher recurrence of AF
  after cardioversion than patients without PSG
  diagnosis of sleep apnea. Appropriate therapy
  with CPAP in OSA patients is associated with
  decreased recurrence.

Recurrence of AF at 12 months comparing patients
who did not have sleep studies (controls) with
treated OSA patients and with untreated
(including noncompliant) OSA patients (meanSD).
Kanagala R et al. Circulation. 2003 1072589-94.
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Sleep Apnea and Atrial FibrillationStroke

• Circulation. 2004110364
• There is a strong association between OSA and AF
  (adjusted odds ratio gt2). OSA is strikingly more
  prevalent in patients with AF than in patients
  with multiple other cardiovascular co-morbidities.

Proportion and 95 CI of patients with OSA.
Prevalence of OSA is significantly higher in
patients with AF than in patients without past or
current AF in general cardiology practice (49
95 CI 41 to 57 vs 32 95 CI 27 to 37,
P0.0004).
Gami A et al. Circulation. 2004 110364-367.
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Types of Diagnostic Sleep Studies
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Indications for Level 1 Study

• Severe Heart Disease
• Stroke
• Psychotropic Medications
• Severe Excessive Daytime Sleepiness (ESSgt15)
• Insomnia
• Safety Critical Occupation

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Treatment
Modified From Can Respir J. 13(7) October 2006
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Conservative Therapy

• Behavioral Interventions
• Weight Loss

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Mechanisms of Airway Obstruction
Principles and Practice of Sleep Medicine
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Conservative Therapy

• Behavioral Interventions
• Weight Loss
• Avoid alcohol and sedatives
• Avoid sleep deprivation
• Avoid supine sleep position
• Stop smoking

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Conservative Therapy

• Behavioral Interventions

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Medical Therapy

• Positive airway pressure
• Continuous positive airway pressure (CPAP)
• Bi-level positive airway pressure
• Oral appliances
• Surgical Therapies
• Other (limited role)
• Medications
• Oxygen

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Positive Airway Pressure
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Positive Airway Pressure
Principles and Practice of Sleep Medicine
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Medical Therapy
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Sleep Apnea and MortalityOutcomes With and
Without CPAP Therapy.

• Lancet. 2005 3651046.
• Revealed that among 264 healthy men, 377 simple
  snorers, 403 mild OSA, 235 with untreated severe
  disease and 372 patients with severe OSA treated
  with CPAP

Odd Ratio 3.17
Odd Ratio 2.87
Cumulative percentage of individuals with new
fatal (A) and non-fatal (B) cardiovascular
events.
Conclusion Severe OSA increases the risk of
fatal an non fatal cardiovascular events. CPAP
treatment reduce this risk.
Marin JM et al. Lancet 2005 3651046
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Sleep Apnea and Driving

• Predicting motor vehicle accidents in patients
  with OSA is inexact due to multiple cofactors
  (prior sleep, shift work, medications etc.) all
  which may influence risk.
• Drivers responsibility and statutory duty to
  drive safely and avoid foreseeable harm.
  Physicians must advise patients with OSA to avoid
  driving when sleepy.
• Mandatory reporting?
• Resume driving after initiation of appropriate
  therapy.

Can Respir J. 13(7) October 2006
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Take Home Message

• OSA is common, dangerous, easily recognizable and
  treatable.
• Epworth Sleepiness Scale and Clinical Prediction
  Rules (SACS or Adjusted Neck Circum.).
• Significant social and medical implications with
  untreated OSA.
• Sleep history in all newly diagnosed Hypertensive
  patients.
• Limitations to testing facilities.
• Most effective therapy is a combination of Life
  Style Continuous Positive Airway Pressure.

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Good sleep leads to good health
Thank you
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History of Sleep Apnea.
1590Shakespeare

• Henry IV act II, scene IVon Falstaff Thou art
  so fat-witted, with drinking of old sack, and
  unbuttoning thee after supper, and sleeping upon
  benches after noon Fast asleep behind arras, and
  snorting like a horse. Hark, how hard he
  fetches breath
• Sleep Apnea

Falstaff and Mistress by Joseph Meadows 1869
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History of Sleep Apnea.
1837Charles Dickens

• Fat Boy Joe
• on the box sat a fat and red-faced boy, in a
  state of somnolency.

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History of Sleep Apnea.
1918Sir William Osler

• PickwickianObese and hypersomnolent patient

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History of Sleep Apnea.
1956S. Burwell

• Obese and hypersomnolent patient with
  respiratory and cardiac failure.

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History of Sleep Apnea.
1976S. Burwell

• Condition characterized by recurrent airway
  obstruction during sleep.

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History of Sleep Apnea.
1981Colin Sullivan
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