Martin Duke, MD, MROFebruary 20, 2014

Agenda

What is OSA?Obstructive Sleep Apnea CycleSteps in OSA Evaluation

OSA is defined as a condition, where during sleep, a narrowing or closure of the upper airway causes repeated sleep disturbances.These sleep disturbances lead to poor sleep quality and excessive daytime sleepiness.

The muscles that keep airways open in the day relax at night

The throat is blocked by collapse of posterior pharynx during sleep

Obstruction of air flow

Oxygen levels in the blood fall

The brain starts to arouse the person from sleep

Breathing is restored

Sleep resumes

Obstruction recurs

ScreeningTreatment Methods and OutcomesCertifications for Work

Factors with high riskNeck size > 17” (male); > 16” (female)BMI > 35 (Weight x 703 / Height x Height)Hypertension – new, uncontrolled, or hard to controlType 2 DiabetesLoud SnoringDaytime sleepiness in monotonous situations

Self Assessment QuestionnairesEpworth Sleepiness Scale (ESS) > 10 Indicates level of daytime sleepiness

Measures general level of daytime sleepinessWas a great screening item but the CDL drivers got ‘wise’ and began to reduce their dozing answers Can still be used but with caution

Scoring Results

1 - 6 Good

7 - 9 Okay

10 or more Likely Sleep Apnea

Epworth Sleepiness Scale Form

Factors with high riskNeck size > 17” (male); > 16” (female)BMI > 35Hypertension – new, uncontrolled, or hard to controlType 2 DiabetesLoud SnoringDaytime sleepiness in monotonous situations

Self Assessment QuestionnairesEpworth Sleepiness Scale (ESS) > 10Berlin Questionnaire

I – SnoringII – SleepinessIII – Physical (BMI & BP)

Level of risk is based on responses in symptom categories. In categories 1 and 2, high risk is characterized by continuing symptoms (more than three or four times a week) in two or more questions on snoring and on sleepiness during wake time or driving, respectively. For category 3, high blood pressure or body mass index

>30 are considered high risk. Patients with high-risk features in any two of the three categories warrant referral to sleep clinic.

Factors with high riskNeck size > 17” (male); > 16” (female)BMI > 35Hypertension – new, uncontrolled, or hard to controlType 2 DiabetesLoud SnoringDaytime sleepiness in monotonous situations

Self Assessment QuestionnairesEpworth Sleepiness Scale (ESS) > 10Berlin Questionnaire

Sleep StudyAHI > 30 from current study or reported in prior study (not currently being treated)

Categorizes severity of sleep apnea.Counts number of times the patient has apnea/hypopnea per night

This number is divided by total hours slept, giving an average of episodes/hour for interpretation

Report Scale

< 5 Normal

5 - 15 Mild

15 - 30 Moderate

> 30 Severe

AHI is determined by:Laboratory Sleep Study

Cost $1500 - $3000; reimbursement depends on insurance plan

In-home StudyMay underestimate AHIDoes not consider total sleep timeME must use clinical judgment in interpretationCost $250 - $1000; reimbursement depends on insurance plan

Factors with high riskNeck size > 17” (male); > 16” (female)BMI > 35Hypertension – new, uncontrolled, or hard to controlType 2 DiabetesLoud SnoringDaytime sleepiness in monotonous situations

Self Assessment QuestionnairesEpworth Sleepiness Scale (ESS) > 10Berlin Questionnaire

Sleep StudyAHI > 30 currently or in prior study

Physical findingsMallampati Score = 3 or 4

Airway size can be classified using the Mallampati Scale

Scoring Results

Class 1 Good

Class 2 Okay

Class 3 or 4 High Risk for Sleep Apnea

CPAP (Continuous Positive Airway Pressure)Machine must auto-titrate pressure and record interval used.If treated for one week, can be certified for 90 days if:

Demonstrate minimal use of machine 4 hours per night, 70% of nights No report of excessive sleepiness in major wake periodAnnual recertification with or without sleep study

Bariatric SurgeryCertifiable 6 months after surgery – awaiting weight loss

CPAP compliance for 6 monthsClearance by treating physicianNo report of excessive sleepiness in major wake periodRequires repeat sleep study Annual recertification with or without sleep study

Other SurgeryOropharyngeal SurgeryFacial Bone SurgeryTracheostomyImplanted Neurostimulator

Certifiable 1 month after surgeryClearance by treating physicianNo report of excessive sleepiness in major wake periodRequires repeat sleep studyAnnual recertification with or without sleep study

Other TreatmentsDental Appliances

Not approved by FMCSACan be used but must have a sleep study to prove efficacy

Immediate disqualification – any of the following:Excessive sleepiness during major wake periodsAutomotive crash attributed to falling asleepNon compliant in treatment of previous diagnosed sleep disorder

Driver has AHI > 20 until CPAP CompliantBMI > 35 pending sleep studyTwo or more risk factorsProcess for certification

60 days pending sleep study and CPAP treatmentAdditional 90 days if complaint with treatment

After 90 days certification for one year if continued compliance

Recertification annually with or without sleep study

Questions?