44th annual new mexico lung disease symposium 50 … · the gold standard is polysomnography (psg)...
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44th ANNUAL NEW MEXICO LUNG DISEASE SYMPOSIUM
50 SHADES OF BLUE (OR GREY)
FEBRUARY 27, 2016
FRANK M. RALLS M.D.
ASSOCIATE PROFFESSOR INTERNAL MEDICINE
PROGRAM DIRECTOR UNM SLEEP MEDICINE FELLOWSHIP
MEDICAL DIRECTOR UNM SLEEP DISORDER’S CLINIC
DIVISION of PULMONARY, CRITICAL CARE, AND SLEEP MEDICINE
UNIVERSITY NEW MEXICO, ALBUQUERQUE, NM
Conflict of Interest & Disclosures for Speakers 1. I do not have any relationships with any entities producing, marketing, re-selling, or
distributing health care goods or services consumed by, or used on patients.
2. I have the following relationships with entities producing, marketing, re-selling, or
distributing health care goods or services consumed by, or used on patients:
Type of Potential Conflict Details of Potential Conflict
Grant/Research Support
Consultant
Speakers’ Bureaus
Financial support
Other Any remaining typos in this presentation are the responsibility of
the editor
NONE
OBJECTIVES
KNOW THE BASICS OF SLEEP APNEA AND SOME OF THE
PATHOLOGICAL PRESENTATIONS
KNOW THE HISTORY OF TREATING SLEEP APNEA
KNOW SOME OF THE RULES BEHIND QUALIFING FOR AN
IN-PATIENT SLEEP STUDY VS A HOME SLEEP TEST: AKA
PORTABLE MONORITING (PM).
KNOW SOME OF THE MANAGEMENT OPTIONS FOR HOME
SLEEP TESTING
Sleep Apnea
Hear Me Snore
Public Concern
October 23, 2009: An airliner with 144 passengers onboard
flew 600 miles as its pilots slept at the controls for more than
an hour.
Untreated Sleep Apnea: 155 seconds
without opening airway
Sleep Apnea: 3 hour recording
PORDI: 43 76 minutes < 88%
Obstructive Sleep Apnea
Reduction in upper airway muscle tone in sleep
Mueller Reflex
Inspiratory efforts against a closed glottis
Sleep Apnea
Patients with sleep apnea have recurrent “cycles” consisting of:
Sleep
Airway obstruction
Arousal
Resumption of ventilation
Resutlant physiologic stressors:
Cyclic hypoxemia
Strenuous respiration
Sympathetic activation
Reduced total sleep time
Obstructive Sleep Apnea
Complete or partial upper airway obstruction occurring during sleep
Often results in reductions in oxygen saturation
Often terminated by brief arousals from sleep
Duration of each obstruction must last at least 10 seconds
Common Sleep Apnea Symptoms
Pauses in Breathing (apnea)
Snoring
Excessive Daytime Sleepiness
Poorly controlled hypertension
Sexual difficulties in men
Hyperactivity in children
Signs/Symptoms are often age dependent
Children:
Pauses in breathing
Secondary enuresis
hyperactivity
Middle Age
Pauses in breathing
Snoring
Excessive daytime sleepiness
BMI > 35, Neck > 16/17
Older > 60 years
Not feeling well rested
Nocturia ≥ 3 xs per night
Sleep Apnea Screening
Scoring: 0-9 = Average daytime
sleepiness
10-15 = Moderate
daytime sleepiness
16-24 = Severe daytime
sleepiness
Obstructive Sleep Apnea
Incidence mild apnea AHI > 5/hr
24% men
9% women
Incidence with excessive daytime sleepiness
4% men
2% women
Flemons N Engl J Med 2002
Ongoing Sympathetic Surges
Untreated Sleep Apnea
Reduction of nocturnal dipping
Sudden cardiac death occurs inverted in OSA
Cardiovascular events typically in the early hours
OSA: peak 12 -6 AM
Sleep apnea associated with a 2X increase risk of stroke or all-cause mortality
Hypertension 4X
If AHI is > 36 Mortality increases 3 fold
Marin, Lancet 2005, Arzt A J Res Crit Care Med 2005, Yaggi, NEJM 2005, Munoz, Stroke 2006
Diagnosing Sleep Apnea: The
The Gold Standard is Polysomnography (PSG)
.
Essentials of Sleep Technology: Pediatrics. Westchester, IL.
American Academy of Sleep Medicine, 2006
Tech Observer Video Camera
SaO2
Leg EMG (2)
Microphone
EKG
Chin EMG (2)
EEG EOG
Nasal EtCO2
Records behavior
Respiratory Effort
Nasal Oral Airflow
Diagnosing Sleep Apnea: The Gold Standard
Polysomnogram
Undiagnosed Sleep Apnea 2-4% of general
population
75-80% remained
undiagnosed and untreated
Type II diabetes
Hypertension
Cardiovascular disease
All cause mortality with an
AHI of > 35 is 3 fold
Guidelines AASM 2007
PM may be used as an alternative to polysomnography (PSG)
for the diagnosis of OSA in patients with a high pretest
probability of moderate to severe OSA. PM is not appropriate
for the diagnosis of OSA in patients with significant comorbid
medical conditions that may degrade the accuracy of PM. PM
is not appropriate for the diagnostic evaluation of patients
suspected of having comorbid sleep disorders. PM is not
appropriate for general screening of asymptomatic
populations. PM may be indicated for the diagnosis of OSA in
patients for whom in-laboratory PSG is not possible by virtue
of immobility, safety, or critical illness. PM may also be
indicated to monitor the response to non-CPAP treatments for
sleep apnea.
J Clin Sleep Med 2007
Canadian Criteria for HST
Absence of coexisting cardiac or respiratory disease.
Moderate to high pretest probability of OSA.
Low risk of hypoventilation.
Absence of coexisting sleep conditions such as insomnia or restless legs syndrome.
Ability to use level III technology at home with minimal supervision.
RESULTS : Wait time for PSG 152 days (2009) to 92 days (2012)
Stewart et al., J Resp J 2015
Humana
Humana Inc. is an American Louisville, Kentucky-based
for-profit health insurance company. As of 2014 Humana
has had over 13 million customers in the U.S., reported
a 2013 revenue of US$41.3 billion, and has had over
52,000 employees. In 2013, the company ranked 73 on
the Fortune 500 list, which made it the highest ranked
company based in Kentucky. It has been the third largest
Humana Health Help
In-home diagnostic HSTs are not recommended for individuals suspected of having OSA if any of the following comorbidities are present:
Moderate-to-severe pulmonary disease, such as chronic obstructive pulmonary disease (COPD)
Moderate-to-severe neuromuscular/neurodegenerative disorder causing restrictive lung diseases (e.g., kyphoscoliosis, myasthenia gravis, amyotropic lateral sclerosis [ALS], polio, polymyositis, Guillain Barre syndrome)
Congestive heart failure, class III or IV Obesity hypoventilation syndrome, previously
Documented Pulmonary hypertension Additional sleep disorders other than OSA (e.g.,Central sleep apnea, parasomnias, narcolepsy, REM behavior sleep disorder)
Technologies for Diagnosing Sleep
Apnea
Portal Polygraphy
Mattress like devices
Remote sensing
Acoustic technologies
Alsher, 2016, Current Hyperten
Review
Alternatives for children
Questionnaires
Single channel recordings
Home PSGs
Biomarkers
Gozal et al., Pul
Med 2015
Home Sleep Studies False
Negatives
High pre-test probability with an ESS of > 10 and clinical
symptoms
No:
Heart disease
Significant sleep disorder
Competency to put on the equipment
approximately 20% will have a false negative PM. (*Clinical
symptoms include snoring, witnessed apneas, obesity,
pulmonary hypertension, refractory hypertension, morning
headaches, increased neck circumference-->17 inches in
men, >16 inches in women--daytime sleepiness.)
Walia et al., J Okla Med Assoc
2014
Watch Pat vs PSG in Children
50 children
Ages 6-11 no difference
Ages 3-5
Heart Rate Variability reflect the autonomic nervous system during sleep apnea.
Heart Rate Variability using a support vector machine which is a pattern recognition method. Sensitivity 100%, Specificity 86% (AHI > 20).
Zu, et al., Zhonghua 2015
Nakayama et al.
R-R Interval is converted
into Heart Rate Variability
Nakayama, et al.,
2015, IEEE.org. UNM
Pulse Oximetry Recorded from the Phone Oximeter
for OSA
Utilizes Pulse Rate
Variability (PRV) along with
oximetry (Sp02).
74% accuracy for an AHI > 5
74% specificity
75% sensitivity
Garde et al., Conf Proc IEEE Eng Med
Bio Soc 2015
Breath-By-Breath Detection of Apneic Events for OSA
Severity Estimation Using Non-Contact Audio
Recordings
93 patients who had sleep
apnea: snore sounds
obtained during a PSG test
were digitalized
93 recorded in own
apartment with a Watch
Pat Device and Audio
Inspiration (snore)
Expiration
Non-respiration noise
Diagnostic Agreement 76%
Rosenwein et al., Conf Proc IEEE Eng Med Biol
Soc. 2015 Aug;2015:7688-91.
Novel Head Actigraphy Technique ApneaDX: “First we take Ontario, then we take the world”
Detects sleep with 93%
accuracy
Wake 43% accuracy
95% accuracy vs PSG
Hummell, et al., Conf Proc IEEE Eng
Med Biol Soc. 2015 Aug;2015:54
Special Populations
Parkinson’s Disease
PM underestimated the AHI on average of 12 events per hour compared to PSG
Technical failure rate 27%. The worse the motor symptoms the worse the failure rate.
Sensitivity/Specificity
84%/ 66% AHI 5
36%/83% AHI 15
50%/100% AHI 30
Gross et al., PD, 2015
Other factors affecting results
Temperature 17, 22, 29
Actiwatch II
SenseWear Arm band
Reliable 17-22 degree but not at 29 degrees
Polysomnography 29 degrees
Scin et al., Sleep Sci 2015
Therapies
Mild Apnea:
Nasal steroid preparations
Leukotriene receptor antagonists
Moderate-severe
Tonsillectomy and Adenoidectomy
85% effective
Primary Treatment: Continuous Positive
Airway Pressure
REVERSAL OF OBSTRUCTIVE SLEEP APNOEA BY CONTINUOUS POSITIVE AIRWAY PRESSURE APPLIED THROUGH THE NARES
Original Text
ColinE. Sullivan , Michael Berthon-Jones , FaiqG. Issa , Lorraine Eves
Abstract
Five patients with severe obstructive sleep apnoea were treated with continuous positive airway pressure (CPAP) applied via a comfortable nose mask through the nares. Low levels of pressure (range 4·5-10 cm H2O) completely prevented upper airway occlusion during sleep in each patient and allowed an entire night of uninterrupted sleep. Continuous positive airway pressure applied in this manner provides a pneumatic splint for the nasopharyngeal airway and is a safe, simple treatment for the obstructive sleep apnoea syndrome.
The original machine contained a reversed vacuum cleaner motor that blew air into the affected person’s nasal passage using tubing to keep the airway open.
Lancet April 1981
Primary Treatment: Continuous Positive
Airway Pressure (CPAP)
Pre and Post CPAP Treatment
OSA without CPAP
With CPAP
Treating OSA Better than Wednesdays.
Continuous Positive Airway Pressure
(CPAP)
CPAP Well Tolerated
What questions do you have?
The Great Health Care Provider
One Great Man Said:
“The initials following the name gives you power”
Use it wisely.
One great patient said:
“You’ve got a blank script baby and I got some pain”