11

Conflict of Interest Statement

I have no conflict of interest related to to this presentation…!

Dr. Özen Kaçmaz Başoğlu

22

SUCCESS CRITERIA IN OBSRUCTIVE SLEEP APNEA

SYNDROME TREATMENT

Dr. Özen KAÇMAZ BAŞOĞLUEge University School of Medicine

Department of Chest DiseasesTurkish Thoracic Society 15. Annual Congress

April 14, 2012

Panel: Different Dimensions in the Diagnosis and Treatment of Sleep Disordered Breathing

33

Success Criteria in OSAS Treatment -Outline-

Apnea-hypopnea index, oxygen saturation and

sleep quality

Symptoms (daytime sleepiness) and quality of life

Cardiovascular and metabolic comorbidities

Mortality

Sleep Apnea Circle

Sleep

Bernardo S. Clin Chest Med 2010;31:203-20

Apnea

Ventilation Arousal

Hypoxia Negative pleural pressure Sympathetic activation

Re-oxygenation

Intermittent Hypoxia

Consequences of OSAS

Sympathetic excitation

Atherosclerosis

Cardiovascular diseaseMcNicholas WT. Pro Cardio Dis 2009;51:392-9 & Kent BD. ERM 2010;50:340-59

Oxidative stress

Systemicinflammation

Intermittent hypoxia - reoxygenation

OSAS

Endothelial dysfunc.

Obesity

Metabolic dysfunc.

66

Consequences of OSASHypertension

Coronary heart disease

Left ventricular systolic and diastolic dysfunction

Congestive heart failure

Cardiac arrhytmias

Pulmonary hypertension

Stroke

Metabolic syndrome

Diabetes mellitus

Insülin resistance

Parish JM. Mayo Clin Proc 2004;79:1036-46

MORTALITY

Patients at Risk for OSAS

OSAS

Type II DM

PHT

Nocturnal arrhythmia

Atrial fibrillation

Refractory HT

BMI>35

CHF

Stroke

High-risk driver

OSA Task Force (AASM). J Clin Sleep Med 2009;5:263-76

OSAS is a systemic disease…

88

OSAS Treatment

Consertavive treatment

Specific treatment

- Oral appliance

- Surgery

- CPAP

CPAP Treatment

1010

Effects of CPAP-Effect on Upper Airway Collapsibility-

Montserrat JM. Eur Respir Mon 2010; 50: 244-66

1111

Effect on Upper Airway Collapsibility

Montserrat JM. Eur Respir Mon 2010; 50: 244-66

Spontaneous breathing

CPAPapplication

Effects on Respiratory Events, Saturation and Sleep Stages

Hirshkowitz MP et al. Semin in Respir Crit Care Med 2005; 26: 68-79

1313

Effects on Respiratory Events, Saturation and Sleep Stages

74 snSpO2 %66

Our puppy sleeps very well…

1515

Effect on Subjective Daytime Sleepiness

In pts with AHI≥30/h and ESS≥11 → ESS 4.74

points (p<0.001)

Patel RS. Arch Intern Med 2003;163;565-71

Epworth sleepiness score (ESS) 2.94 points (p<0.001)

1616

Effect on Objective Sleepiness -MSLT or MWT-

Patel RS. Arch Intern Med 2003; 163; 565-71

Sleep latancy 0.93 min (p=0.04)

1717

Effect on Daytime Sleepiness and Quality of Life

Weaver TE. Sleep 2007; 30; 711-19

< 2 h users 41% ESS, 33%, FOSQ, 13% MSLT improvement More than 7 h use → no more benefit

n=1493 months CPAP

1818

Effect on Motor Vehicle Accidents

George CFP. Thorax 2001;56:508-12

210 OSAS with CPAP tx and 210 healthy - 3 yrs follow-up

3-fold decrease in accidents with CPAP

OSAS Healthy

No sleepiness, better QoL…

2020

Effect on Blood Pressure

32 moderate-severe OSAS 9 weeks - CPAP (n=16) and sham CPAP (n=16) [anti-HT (+)]

Becker HF. Circulation 2003;107:68-73 9.9±11.4 mmHg

CPAP

Sham CPAP

CPAP

Sham CPAP

2121

Effect on Blood Pressure

Duran-Cantolla J. BMJ 2010;341:c5991

HT + OSA → 3 months - CPAP (n=169) ve sham CPAP (n=171) (anti-HT Ø) Significant decrease in diurnal and nocturnal blood pressures with CPAP

2222

Effect on Blood Pressure

Bazzano LA. Hypertension 2007;50:417-23

-1.83 mmHg change in diastolic pressure

16 RCT, n=818

-2.46 mmHg change in systolic pressure

2323

Effect on Coronary Artery Disease

Peker Y. ERJ 2006;28:596-602

OSA

Non-OSA

Development of CHD in 7 yrs follow-up → In 105

OSA 16.2% and in 203 snorer 5.4% In OSA with treatment 4%, in OSA with no treatment

25% → CHD (+)

24

Effects on Early Signs of Atherosclerosis

24 severe OSA pts without comorbidity - 4 months follow-up CPAP (+) (n=12) and CPAP (-) (n=12) Decrease in carotid intima-media thickness and pulse-wave

velocity with CPAPDrager LF. AJRCCM 2007;176:706-12

2525

Effect on Heart Failure

Wang H. J Am Coll Cardiol 2007;49:1625–31

CHF and moderate-severe OSA (+) (n=37), CHF and snorer

+mild OSA (n=113) - 3 yrs follow-up No mortality in 14 pts using CPAP

AHI<15/h(n=113)

AHI≥15/h(n=37)

26

Effect on Arrhytmia

Kanagala R. Circulation 2003;107:2589-94

Control CPAP CPAP (+) (-)

Postcardioversion pts with AF/flutter - 1 yr follow-up Control (n=79), CPAP (+) (n=12) ve CPAP (-) (n=25) Recurrence of AF 53%, 42% and 82%, respectively

2727

Effect on Pulmonary Artery Pressure

12 weeks CPAP, 12 weeks sham CPAP (cross-over)

Arias MA. Eur Heart J 2006;27:1106-13 Sham CPAP CPAP

OSAS Control(n=23) (n=10)

29.8 mmHg 23.4 mmHg

28.9 mmHg → 24.0 mmHg

23 OSAS (10 with PH), 10 control (no PH)

2828

Effect on Stroke

Martinez-Garcia MA. ERJ 2012;39:906-12

p<0.01

166 pts with stroke+OSA - 7 yrs follow-up 89 deaths during follow-up (52% in pts with no CPAP tx

2929

Effect on Insulin Sensitivity

Lam JCM. ERJ 2010;35:138-45

61 moderate-severe OSA

without comorbidity → 1

week - sham CPAP (n=31),

CPAP (n=30) In CPAP group, insulin

sensitivity ↑ in 1 week In CPAP group with

BMI≥25, insulin sensitivity ↑

in 12 weeks

3030

Effect on Mortality

Marin JM. Lancet 2005;365:1046-53

Healthy (n=264), primary snoring (n=377), mild-moderate OSA (n=403), severe OSA (n=235), severe OSA with CPAP use (n=372) - 10 yrs follow-up 3-fold ↑ in fatal&non-fatal CVS events in pts without tx

Non

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Fat

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31

Other Effects Reduction in inflammatory changes

and sympathetic activation

Improvement in cognitive function

Decrease in nocturia

Enhancement in erectil dysfunction

Decrease in epilepsy seizures

Reduction in adverse effects of

bariatric surgery

Montserrat JM. Eur Respir Mon 2010; 50: 244-66

Comorbidities are better…

3333

Recommended Procedures in CPAP Follow-up CPAP adherence

Mask leaks

Information about AHI

Weight and habits

Evaluation of daytime sleepiness with ESS

Improvement in sleep and symptoms

Adverse effects

Blood pressure if patient had HT

Secondary effects of treatmentMontserrat JM. Eur Respir Mon 2010; 50: 244-66

3434

What are the Success Criteria in OSAS Treatment?

Apnea-hypopnea index and oxygen saturation

Symptoms (daytime sleepiness), quality of sleep

and life

Blood pressure

Other cardiovascular and metabolic comorbidities

Mortality

ALL

Thanks…