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 rateCPAP 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.