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:

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Use it wisely.

One great patient said:

“You’ve got a blank script baby and I got some pain”