Disclosures Obstructive Sleep Apnea in the Underserved I have - PowerPoint PPT Presentation

2/23/2017 Disclosures Obstructive Sleep Apnea in the Underserved I have nothing to disclose February 23, 2017 George Su, MD Medical Director, Sleep Program Zuckerberg San Francisco General Hospital Associate Professor of Medicine, UCSF Objectives Obstructive sleep apnea (OSA) 1. Pathogenesis and definitions • Estimated general prevalence 15% in U.S. (50-70 million cases) 2. Prevalence/risk factors • 50-78% rates reported in patients with obesity and diabetes 3. Diagnosis • Absenteeism, loss of productivity, 2x workplace accidents and MVAs 4. Management challenges • 30% increased likelihood of death or heart attack, increased risk of HTN, stroke, depression • $3.4 billion in medical costs • ~2x increase in healthcare utilization Young, et al., 2009; Fredheim et al., 2011; Leong et al., 2013; Olson et al., 2006; Seicean et al., 2008; Ohayon, et al., 2009; Kapur, et al., 1999 1

2/23/2017 Loss of tone of pharyngeal dilators GG EMG (% of max) Genioglossus (phasic) Pressure Genioglossal nerve (cm H2O) activity Tensor palatine (tonic) Schwab, 1996 Remmers, et al., 1984; Fogel et al., 2000 Cortical arousal OSA definition • Aiflow can increase without a • Decreased airflow due to repetitive complete or partial obstruction of cortical arousal the upper airway • Arousal threshold lower with • Compensatory increase in respiratory effort OSA • Typically associated with cortical microarousals and decreased SaO2 • Sleep fragmentation and increased sympathetic neural activity Younes et al., 2004 2

2/23/2017 Clinical presentation Scoring: “obstructive apnea” Nasal • Excessive daytime sleepiness (EDS) Pressure ≥90% cessation • Snoring, nocturnal choking or gasping of airflow for Thermal • Witnessed apneas Sensor ≥ 10 seconds • Insomnia (maintenance insomnia, sleep initiation less affected) (with continued Inductance respiratory • Nocturia, enuresis, frequent arousals, diaphoresis, impotence Pleth Sum effort) • Fatigue, memory impairment, personality changes, morning nausea, a.m. headaches, automatic behaviors, and depression SaO2 AASM Scoring Manual Version 2.1, 2014 Scoring: respiratory event related arousal Scoring: “hypopnea” (RERA) ≥ 30% decrease Nasal in (baseline) • Effort increase (flattening of the nasal pressure inspiratory curve) Pressure airflow for ≥ 10 followed by a cortical arousal seconds: Thermal Sensor Nasal ↓ ≥ 4% SaO2 Pressure Inductance or , with↓ ≥ 3% Pleth Sum SaO2 or cortical arousal event SaO2 (requires EEG) AASM Scoring Manual Version 2.1, 2014 3

2/23/2017 Apnea Hypopnea Index/Respiratory “Standard” for diagnosis and therapy Disturbance Index • AHI = (apneas + hypopneas)/sleep hour Normal: < 5 Pre-test Pre-test PSG PAP Rx Adherence Mild: 5 – 15 Moderate: 15 – 30 - Prevalence Severe: > 30 - Incidence • RDI = (apneas + hypopneas + RERAs)/sleep hour - Presentation ‒Can be large difference in AHI vs. RDI - Awareness ‒e.g. with a young, thin patient who is less likely to desaturate by - Undiagnosed 4% with events AASM Scoring Manual Version 2.1, 2014 Diagnosis disparities Risk disparities in OSA Heritable Environmental • 26% high-risk adults and ~80% with mod/severe OSA remain undiagnosed Cultural: • Lower socioeconomic status associated with barriers to diagnosis Attitude, support Symptom reporting • Presentation disparities Upper airway anatomy Perception Race/ Regional fat distribution Socioeconomic status Ethnicity/ Craniofacial anatomy Diet/physical activity Gender Other genetic factors Education/awareness Access Co-morbidity Simon-Tuval et al., 2009; Young, et al., 2002; Young, et al., 2002 4

2/23/2017 Familial and genetic predisposition Obesity • First degree relatives at increased risk • Increased prevalence with increase in any measure of obesity (BMI, waist-hip ratio, neck girth) • Risk increases with number of affected family members • 10% increase in weight increases odds of developing or worsening of • Susceptibility foci identified for OSA with locations for the linkage OSA by 6-fold patterns differing between Caucasians and African Americans • 1986-2000 prevalence of severe obesity (BMI ≥ 40 kg/m 2 ) increased 4-fold, and BMI ≥ 50 kg/m 2 increased 5-fold • Populations with high rates of obesity and diabetes, such as urban non-white populations, may suffer disproportionate risk • Impact of BMI on OSA is less significant after age 60 Bixler et al., 2005; Bixler et al., 1998; Ip et al., 2001; Peppard, et al., 2000; Strohl et al., 1978; Redline, 2000; Palmer, et al., 2004; Buxbaum, et al., 2002 Tishler, et al, 2003; Ip et al., 2004; Young, et al., 2002 Pre-weight loss Post-weight loss Prevalence of OSA by age 0.30 0.25 Prevalence 0.20 0.15 0.10 0.05 0.00 35 45 55 65 75 85 Para-pharyngeal Pharyngeal Pharyngeal Para-pharyngeal Age (years) fat pad wall wall fat pad Young, et al., 2002 Schwab, 1996 5

2/23/2017 Craniofacial anatomy Disparities with women • OSA a/w with higher • Clinic-based studies OR: 4.13 for male risk factor; but recent large thryomental angle population-based studies show prevalence 1.5-3 times higher in men (TMA) and Mallampati scores • Gap narrows after menopause and with hormone replacement • Asians with higher • LESS likely to report: “classic” snoring and witnessed apneas TMA, Mallampati, and • MORE likely to report : daytime fatigue, morning headache, mood smaller thyromental disturbance, depression distance (TMD) (after • Fewer apneic events and shorter duration with less O2 desaturation controlling for BMI and neck circumference) • Symptomatic at lower RDI • “retrognathia” Ancoli-Israel et al., 1995; Redline et al., 1994; Collop, 2004; Duran et al., 2001; TMD TMA Bixler et al., 1998; Breugelmans et al., 2004; Ware et al., 2000; Bixler et al., 2001; Lam et al., 2005 Shahar et al., 2003; O’Connor et al, 2000; Young et al., 1996 Disparities with ethnicity Barriers to diagnosis • African American (AA): ‒more common in young (< 25 y.o.) vs. Caucasian (OR 1.88) Pre-test PSG Rx Adherence ‒> 65 y.o. severe OSA (AHI ≥ 30 events/hr) more common (OR 2.55) ‒Bed partners more likely to accept snoring - Prevalence - Specialized lab • Asian: weaker association elevated BMI and OSA (prevalence similar) - Incidence - Access (wait times) ‒Craniofacial anatomy differences - Presentation - Costs • Hispanic: increased rates of obesity, diabetes, CV disease - Awareness - Overnight test ‒Prevalence of OSA may be higher (questionnaire and indirect - Undiagnosed - Inconvenience measurements) - Safety, comfort Redline et al., 1997; Young et al, 2002; Ancoli-Israel et al., 1995; Simon-Tuval et al., 2009; Billings et al., 2011; Friedman et al., 2006; Ip et al., 2001; Ip et al., 2004 Kim et al., 2009; Bakker et al., 2011; Young, et al., 2002 6

2/23/2017 Polysomnography: “in-lab sleep testing” Polysomnography • EEG, EOG, EMG → Wakefulness and stage of sleep • ECG → Cardiac rate/rhythm • Airflow monitors → Apnea/hypopnea • Chest/abdominal bands → Respiratory effort • Pulse oximeter → SaO2 • Left/right leg EMG → Leg movements Polysomnography • Gold standard • Small margins, no-shows are significant financial burden for labs • Repeal of ACA • “Split-night” studies (combine a diagnostic PSG and therapeutic positive pressure titration) may decrease need for multiple studies ‒However, decreased time for diagnosis/titration often leads to need for repeat testing 7

2/23/2017 Portable sleep testing: “home sleep testing” Portable sleep test--home sleep test (HST) • Airflow • SaO2/HR • Chest/abdominal excursion • No EEG • Uses wear time, as opposed to sleep time • No technician Portable sleep testing as strategy for high-risk Home sleep test (HST) vulnerable population? Events • Validated with increasing sensitivity and specificity (76.7% and 92.5%) • Recent studies on clinical outcomes support the use of HST in patients Flow with high pretest probability • Using “type 3” data (as with HSTs) non-inferior to PSG Effort • Implementation of a billing code (in 2008) • PSG is the recommended follow-up for a negative HST (high pretest probability) • No standard for lower pretest probability and limited access to PSG SaO2 • Access benefit and cost-effectiveness still unclear (payer vs. provider) Sunwoo et al., 2010; Oktay et al., 2011; Collop et al., 2007; Pulse Chai-Coetzer et al., 2017; Kim et al., 2015 8