sleep apnea and conditions seen in the icu sleep basics some definitions
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Sleep ApneaAnd Conditions seen in the ICU
Sleep BasicsSome Definitions
Sleep Basics
Obstructive Sleep Apnea OSACentral Sleep Apnea CSAExcess Daytime Somnolence EDSPolysomnography PSG (Sleep Study)Continuous Positive Airway Pressure CPAPEpworth Sleepiness Scale a screening
questionnaire ESSBerlin Screen a set of questions to
determine the risk of OSA
SLEEP IS ESSENTIAL TO HEALTH
MOST OF US SPEND ONE THIRD OF OUR LIVES ASLEEP
PS WHAT IS 1/3 OF 24 HOURS (HINT IT IS NOT 4 OR EVEN 6)
Normal Sleep times
Infant 16 HoursOne Year 13 HoursTwo Years 12 HoursTen Years 9-10 HoursAdolescents 9-10 HoursAdults 7-8 Hours
DAYTIME SOMULENCETHERE ARE SCALES SUCH AS THE EPWORTH SLEEPINESS SCALE TO QUANTIFY THIS SYMPTOM.
THE EPWORTH SCALE ASKS YOU TO QUANTIFY HOW LIKELY YOU ARE TO DOZE OFF IN SITUATIONS SUCH AS READING, WATCHING TV, RIDING IN A CAR, SITTING QUIETLY AFTER LUNCH.
THE MOST COMMON CAUSE OF TIREDNESS IS INSUFFICIENT OR POOR QUALITY SLEEP
YOUR SLEEP AMOUNT IS ADEQUATE WHEN YOU CAN GET THROUGH YOU DAY WITHOUT TIREDNESS
Sleep Hygiene
Stable bed time and awakening timeMorning Bright Light (Sun works)Daily activity (exercise in AM or before
dinner)Dark and comfortable bed room, avoid TV,
computers, phones, gamesOnly relaxing activities before bed
Sleep Hygiene What Not to Do
NapsAlcohol, caffeine, nicotineEvening bright lightExercise within 3 hours of bedBig meals within 3 hours of bedNoise or excessive heat/cold in bedroomUse bed for anything other than sleep or
sexClock watching or trying to force sleep
COPDAnd Sleep Apnea
Groups at Risk
COPD OSA
Prevalence 7-19% worldwide (1/5 > 30 who have smoked over 10 years)
Men: Women 2:1Lifetime Risk ¼Age > 50 years
Prevalence 4% men, 2%women
75% undiagnosedWeight 10% weight gain
gives 6 fold rise in OSAMiddle age up to 65 is
peakObese teens can need CPAP
Definitions
COPD Obstructive Sleep Apnea
Airflow ObstructionLow FEV 1Nocturnal
DesaturationDaytime HypoxemiaPulmonary
Hypertension
Repetitive airflow cessation or reduction
Airway collapseNocturnal
desaturationsPulmonary
Hypertension
Overlap Syndrome
Of patients with OSA 10-15% will have the overlap syndrome
Spirometry shows Obstruction Rates of hypoxemia, hypercarbia and Pulmonary
hypertension are all increased over uncomplicated OSA patients
Hypercarbia occurs at a lower BMI and AHI than Obesity Hypoventilation
Hypercarbia occurs at a higher FEV 1 than in pure COPD Intermittent hypoxemia promotes atherosclerosis
Lee,R. McNicholas, W.T Cur Opin Pulm Med 2011, 17(2) 79-83.
StrokeAnd Sleep Apnea
Stroke and Sleep Apnea
Sleep Heart Health Study
5422 Participants over 40 followed for 8.7 yrs.Stroke risk almost 3 times higher for men with AHI
above 19. In men the risk increased as the AHI increased.
Women had an increased risk if the AHI was above 25
These numbers held up when controlled for other stroke risk factors (Am J Resp Crit Care Med. 4/25/10)
Stroke and Sleep Apnea
Sleep Apnea is found in 9% of acute stroke patients in some studies
In a MRI study of Clinically Silent Infarcts 58% had severe OSA. In fact the higher the AHI the more likely they were to have CSI
With Chronic Microvascular Changes on MRI 38% had Severe OSA
(High Rate of Sleep Apnea in Patients with Silent Strokes. Medscape. Feb 02, 2012)
Congestive Heart FailureAnd Sleep Apnea
CHF and OSA
Sleep Heart Health StudyIn men 40-70 with AHI above 30: 68%
more likely to develop CHD (MI, Revascularization or death)
This same group was 58% more likely to get CHF than those without OSA
(The Sleep Heart Health Study, Circulation 2010)
CHF and OSA
Sleep Disordered Breathing is identified in 70% of Decompensated CHF patients
Central Sleep Apnea predicted elevated readmission rates at 3 and 6 months and a 2/3 increase in 3 year mortality
Sleep Apnea worsens Acute HF outcomes: testing for it at Admission proposed. Medscape. Oct4, 2013. Abstract from Heart Failure Society of America Meeting 9/23/2013;Orlando FL.
Cardiovascular Mortality and OSA
In a recently published Korean Study the Hazard Ratio for Cardiovascular Mortality was elevated 4.66 times by an AHI >30.
All cause Mortality in the same group was elevated 2.47 times.
Lee, J.E. et al. J. Clin Sleep Med 2013, 9(10) 997-1002
Atrial FibrillationAnd Obstructive Sleep Apnea
Atrial Fibrillation and OSA
Do they Coexist or is there a Causative Effect
Severe OSA patients are more likely to have AF than would be predicted by chance. Range Gami 17% > controls, Bitter 42.7% OSA prevalence in AF patients, Braga 81.6%
OSA patients are more likely to have recurrent AF and it recurrence post cardioversion.
Atrial Fibrillation and OSA
CPAP treatment decreases recurrence post cardioversion rates
The worse the OSA the higher the recurrence rate
CPAP reduces the recurrence rate by halfEven with catheter ablation OSA patients have a
40% recurrence rate
(Lettieri, Christopher. The Relationship Between OSA and AF:Guidance for Clinicians. Medscape. Dec 19, 2012.
Sleep Apnea and Obesity
We all know that Obesity can lead to OSABut Just as likely OSA may worsen OBESITY
OSA worsens how the liver handles glucose and is linked to glucose intolerance. It is also linked to disorders of fat metabolism.
Intermittent hypoxemia can promote insulin resistance and hyperlipidemia
Sleep Apnea and Obesity
New DataLeptin (from fat cells and signals the brain
you are full)Ghrelin (from your stomach tells your
brain you are hungry)When you are sleep deprived your Leptin
is reduced and your Ghrelin is elevated)So you eat and you crave high fat and
high calorie foods
Traffic AccidentsAnd Sleep Apnea
Traffic Accidents and OSA
Remember 92% of OSA patients are undiagnosedIt may Occur in 24% of Adult MalesTiredness affects reaction time, lane position and
steeringOSA patients are 2-15 time as likely to have an
accident as the general populationWith an AHI of 10 or more the risk of an accident
goes up 6.3 timesThe FAA says the performance degradation of mild
to moderate OSA can equal BAL 0.08%Teng and Won. Clin in Chest Med 33(2012) 731-44.
Traffic Accidents and OSA
In a recent Australian Study there was an increased rate of near-misses in men and women with untreated obstructive sleep apnea. The risk of motor vehicle crashes was higher in men. The higher the sleepiness score the higher the risk of crashes.
Ward, KL et al. J. Clin Sleep Med 2013 9(10) 1013-1021.
References
Gottleib, DJ et al. Prospective Study of OSA and Incident Coronary Artery Disease and Heart Failure. Circulation 2010:(122)352-360Nainggolan, L. Sleep apnea Linked to Heart Failure in Men, But Not Women. Medscape. Jul 14, 2010.Stiles, S. Sleep Apnea Worsens Acute HF Outcomes; Testing for it at Admission Proposed. Medscape Oct 4, 2013.Lettieri, C. The relationship Between Obstructive Sleep Apnea and Atrial Fibrillation: Guidance for Clinicians. Medscape. Dec 19, 2012.
References
Lee, J. et al. Mortality of Patients with Sleep Apnea in Korea. J. Clin Sleep Med 2013:9(10) 997-1002.
Lee, R., McNicholas, WT, Obstructive Sleep Apnea in COPD patients. Cur Opin Pulm Med. 2011:17(2):79-83.
Teng, AY and Won, C., Implications of OSA on Work and Work Disability Including Drivers. Clin Chest Med: 33(2012) 731-44.
References
Anderson, P.: High Rate of Sleep Apnea in patients with Silent Strokes. Medscape. Feb 2, 2012.
Kelly, J.C.: Mild to Moderate Sleep Apnea Increases Stroke Risk. Medscape. April 15, 2010.
Ward, KL et al. Excessive Daytime Somnolence Increases the Risk of Motor Vehicle Crash in Obstructive Sleep Apnea. J Clin Sleep Med2013,9(10) 1013-1021.
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