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 8 th , 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

Hypoxemia Sleep Sleep Hypercapnia fragmentation apnea Intrathoracic Arousals pressure Sleep deprivation Functional consequences

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

Hypoxemia Sleep Sleep Hypercapnia fragmentation apnea Intrathoracic Arousals pressure Sleep deprivation Left atrial enlargement Sympathetic activation Fatty acid lypolysis Inflammation Mechanisms Oxidative stress Endothelial dysfunction Hypercoagulability Disease manifestations 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 .

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; R edline 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

History can provide clues even when overt sleep symptoms are not present Physical exam c an suggest increased risk  VS  Nasal and upper airway exam  Neck circumference  Signs of heart failure or other comorbid conditions

Oropharyngeal, nasal, craniofacial features Tooth wear Mallampati Classification Dental malocclusion Retrognathia/Micrognathia

Epworth sleepiness scale Likelihood of dozing or falling asleep Sitting and reading 1) Watching TV 2) Sitting, inactive in a public place 3) As a passenger in a car for an hour without a break 4) Lying down to rest in the afternoon when circumstances 5) permit Sitting and talking to someone 6) Sitting quietly after a lunch without alcohol 7) In a car, while stopped for a few minutes in the traffic 8) 0 = would never doze Total: 0 – 10 Normal range 10 – 12 Borderline 1 = Slight chance of dozing 12 – 24 Abnormal 2 = Moderate chance of dozing 3 = High chance of dozing

STOP-BANG questionnaire 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/m 2 6) Age > 50 yo? 7) Neck circumference > 40 cm? 8) Gender male? 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

Sleep apnea definitions  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 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

EEG arousal Rapid eye movements Tachycardia Obstructive apnea Desat

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? A. Auto continuous positive airway pressure (APAP) B. Oral appliance C. Weight loss D. Stimulant medication E. Nocturnal oxygen

Treatment approach  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

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