Can we do it? Yes we can! Managing Obstructive Sleep Apnea in … · Managing Obstructive Sleep...
Transcript of Can we do it? Yes we can! Managing Obstructive Sleep Apnea in … · Managing Obstructive Sleep...
Can we do it? Yes we can!
Managing Obstructive Sleep Apnea
in Primary Care
Dr Andrea Loewen MD, FRCPC, DABIM (Sleep)
Financial disclosures
• No conflict of interest
Objectives
• When and how to order home sleep apnea testing (HSAT) for diagnosis of obstructive sleep apnea?
• What is the evidence for treatment of OSA? • Current standards in Alberta • CPAP machine coverage
WHEN AND HOW TO ORDER HOME SLEEP APNEA TESTING?
Case 1: Albert
• 45M accountant, lives with wife and 2 children • PMHx: Hypertension (controlled with HCTZ) • Chief complaint: Daytime sleepiness, snoring
– Fights sleep at desk, dozes off watching TV in evenings – Not convinced he needs to do anything about this
• Non-smoker; 3 beers on weekend • Physical Exam: BMI 34 kg/m2, BP 128/74
What is the Differential Diagnosis?
Assessing Probability of OSA • Do you Snore Loudly? (loud enough to be heard through
closed doors or your bed partner elbows you for snoring at night)
• Do you often feel Tired, Fatigued or Sleepy during the daytime? (such as falling asleep during driving or talking to someone)
• Has anyone Observed you Stop Breathing or Choking/Gasping during sleep?
• Do you have or are being treated for High Blood Pressure?
• BMI > 35 kg/m2?
• Age > 50 years old? • Neck size ≥ 17 inches/43 cm (M) or 16 inches/41 cm (F)? • Gender = Male?
Risk of OSA Low = 0-2 Intermediate = 3-4 High Risk = 5-8 OR
2 of STOP + Male 2 of STOP + BMI 2 of STOP + Neck
www.stopbang.ca
Assessing Probability of OSA • Do you Snore Loudly? (loud enough to be heard through
closed doors or your bed partner elbows you for snoring at night)
• Do you often feel Tired, Fatigued or Sleepy during the daytime? (such as falling asleep during driving or talking to someone)
• Has anyone Observed you Stop Breathing or Choking/Gasping during sleep?
• Do you have or are being treated for High Blood Pressure?
• BMI > 35 kg/m2?
• Age > 50 years old? • Neck size ≥ 17 inches/43 cm (M) or 16 inches/41 cm (F)? • Gender = Male?
Risk of OSA Low = 0-2 Intermediate = 3-4 High Risk = 5-8 OR
2 of STOP + Male 2 of STOP + BMI 2 of STOP + Neck
www.stopbang.ca
STOP-BANG
Nagappa 2015
Albert (continued)
• Unrefreshed after 7-8 hours of sleep per night – More on weekends, with no relief
• Non-smoker, no significant alcohol or sedative use
• No restless legs, no features of narcolepsy, mood OK
• STOP-BANG – 6
What would you do next?
Diagnostic Sleep Testing
• L1 (Polysomnography) – Gold standard – Resource constrained – May be inconvenient
• L3 (Home Sleep Apnea Test) – Cardiorespiratory channels – Performed in the home – Avoid if:
• Cardiopulmonary • Neuromuscular disease • Other sleep disorder
suspected • Asymptomatic
Home Sleep Apnea Test (HSAT)
Polysomnogram
WHAT IS OSA ANYWAY?
What is OSA? • Intermittent airflow
cessation (apnea) or reduction (hypopnea) during sleep (≥ 5/hr)
• Severity measured by Apnea-Hypopnea Index (AHI) – AHI 5-15/hr = mild – AHI ≥ 15/hr = moderate – AHI ≥ 30/hr = severe
Arnardottir ES et al. Eur Respir J. 2016 Jan;47(1):194-202.
Pathophysiology of OSA
Eckert 2015; Edwards 2017
Upper Airway Collapsibility “Anatomic”
Upper Airway Dilators “Neural”
Obstructive Sleep Apnea
Ventilatory Sensitivity
“Drive”
Arousal Threshold “Cortical”
Intermittent Hypoxemia
Sleep Disruption
OSA and Cardiovascular Disease - Mechanisms
Dewan 2015; Ayas 2016
Arousal
Sleep Fragmentation
…and has Important Consequences
• All severities of OSA – Quality of life – Depression – Motor vehicle collisions – Workplace productivity – Post-op complications – Healthcare utilization
• Severe OSA – Hypertension – Diabetes – Cardiovascular events – Stroke – Atrial fibrillation (new
and recurrent)
EVIDENCE FOR OSA TREATMENT
MOSAIC Trial
Craig 2012
• Multicentre, open-label RCT of CPAP vs. no CPAP for moderate to severe OSA – 2717 patients – Australia, USA, China, India, Brazil, Spain – Pre-existing cardiovascular disease – Moderate-severe OSA on ambulatory testing – Excluded: severe sleepiness or hypoxemia, safety-critical
occ.
McEvoy 2016
SAVE Trial
• Summary – No difference in any
cardiovascular outcomes – Sleepiness, HRQOL, HADS
all improved with CPAP – Fewer work days missed
• Issues – Adherence: 3.3 hrs/night – Variable OSA care – Secondary prevention
McEvoy 2016
OSA Treatment – Does it reduce CV risk?
• Great question! • Strong biological basis for risk reduction • CPAP and oral appliance both improve BP • Other risk reduction may depend on other
factors – Disease severity and control – Primary vs. secondary prevention – Treatment adherence – CPAP in isolation vs. chronic disease management
Back to Albert
• He has severe OSA (RDI 45/hr, mean SpO2 87%), you recommend CPAP and Albert agrees
• You refer him for a CPAP setup and early feedback suggests he is feeling much better
• 2 months later, he returns with complaints of sleepiness – “My CPAP just isn’t working anymore!”
Now what?
Why CPAP “Doesn’t Work” • Nonadherence/intolerance
– Minimum use 4 hours/night on 70% of nights
• Mask leak – Facial hair, weight gain
• Sub-therapeutic pressure – Weight gain,
alcohol/sedative use • Equipment failure
– Mask replacement annually • Another sleep disorder
– 25-30% of OSA patients
CPAP Intolerance
Sample Download
Sample Download (2)
Motor Vehicle Safety & Reporting • Requirement to report varies by jurisdiction
– Alberta: Patient responsible for self-reporting • Commercial drivers: periodic medical required • http://www.transportation.alberta.ca/1929.htm
• But, general principles are similar – Symptoms/risk not a function of severity – Efficacy includes adequate compliance, improvement
in objective measure of OSA and symptoms • Compliance: ≥ 4 hours/night on 70% of nights over 30 days • Treatment effectiveness: AHI < 20/hr • Reduced daytime sleepiness
Ayas 2014
Case: Gerald
• 57M, admitted to hospital with anasarca – BMI 56 kg/m2 – Sleepy and snores loudly – ABG: PaCO2 49 mmHg, PaO2 54 mmHg
Hypoventilation
• Elevation in arterial CO2 – Abnormal increase during sleep or awake hypercapnia
• Pathophysiology – Inability to clear CO2 – COPD, neuromuscular disease – Derangement in central control of breathing –
narcotics, obesity hypoventilation syndrome • CPAP or oxygen started in an unmonitored setting
may lead to acute respiratory failure – Refer for polysomnographic PAP titration – May require bilevel PAP +/- supplemental oxygen
Case: Cecile
• 68F, recent admission for CHF – Noted by nursing staff to have intermittent
breathing pauses and hypoxemia at night – BMI 22 kg/m2 – Not sleepy
Central Sleep Apnea • Intermittent ↓ in airflow without UA obstruction
– No ventilatory effort • Pathophysiology
– Chemoreceptor hyperresponsiveness (↑ loop gain) – Circulatory delay (Cheyne-Stokes Respiration) - CHF – Disruption in respiratory pacemaker – narcotics, stroke
• Goal of treatment is to address underlying problem – Consider PAP if symptomatic – usually not CPAP – Oxygen can stabilize breathing – Specialist consultation may be warranted
SLEEP CARE IN ALBERTA
Current Landscape – A Mix!
• Mix of providers – Primary care, specialists (sleep/non-sleep), RRTs, NPs,
RNs. – RCPSC AFC Sleep Disorders Medicine July 2018
• Mix of funding for sleep diagnostic testing – Limited public funding for sleep laboratories (PSG) – Privately funded PSG laboratories (independent
centres) – No funding for HSAT (hospitals, homecare companies)
• Mix of regulations – CPSA standards (PSG update, new for HSAT) Jan 2018
Cost of Treatment (Alberta)
• Out-of-pocket or private insurance for most therapies – CPAP ~ $1500-2800
• Online purchase ~$600 but no service provided – OA ~ $300-3000
• Less expensive options compromise efficacy
• Surgery – maxillomandibular advancement covered – Other procedures offered privately (limited evidence)
• Special groups receive government funding – AISH, AB Works, low-income seniors (Special Needs
Assistance for Seniors Program – SNAP), NIHB – AADL: severe sleep-disordered breathing – bilevel PAP, O2
Patient Pathways
• Referral options (testing and treatment) – Respiratory homecare company – for OSA
• HSAT (+/- cost), CPAP if prescribed • May or may not see physician (sleep, resp, general)
– Independent sleep centres • Usually sleep trained physicians (or supervision) • Affiliated with polysomnography lab (cost) +/- HSAT
– Public sleep centres – Edmonton, Lethbridge – Public sleep centres - Foothills Medical Centre
• Sleep physician (mostly respirologists) +/- sleep-trained RRT • HSAT and/or polysomongraphy
Considerations for referral
• Pre-test probability of OSA – Is HSAT appropriate?
• Requirement for clinical review – Is a Sleep Physician assessment needed?
• Choice of treatment – CPAP provided by respiratory homecare companies – Dental referral for oral appliance – Upper airway surgery – suggest sleep physician
consult, and ENT or oromaxillofacial surgeon consult
New Initiatives
• FMC Sleep Centre – Delegation of follow-up for uncomplicated OSA
requiring therapy to primary care physician and homecare company
• Have met with many companies to lay out expectations – Return of non-urgent mild/moderate OSA referrals
(after review of patient questionnaire and HSAT by clinician) to referring physician, usually primary care MD
• Accompanying information package
http://www.albertahealthservices.ca/info/Page5037.aspx
Can we do it? Yes we can!
• OSA is prevalent • Like hypertension, Family MDs have the tools available
in Alberta to – Diagnose OSA – Discuss and advise treatment options for mild/moderate
obstructive sleep apnea with their patients – Consider behaviour modification, driving safety in all – Refer for all patients with suspected sleep disorders to
sleep physician – Have severe OSA/OHS, complex and non-respiratory sleep-
disorders managed by a sleep specialist
NEW INITIATIVES
New Initiatives
• Sleep Disorders Working Group – Part of the Respiratory Health Strategic Clinical
Network – Clinicians, researchers, policy-makers interested in
improving sleep care for Albertans • Projects
– Regulations for HSAT (CPSA to implement late 2018) – Defining practice competencies for sleep providers – Improve integration of primary/specialty sleep care
http://www.albertahealthservices.ca/scns/Page9823.aspx
Progress to Date • Needs Assessment
– Primary care survey – summer 2016 – Patient focus groups & interviews - spring 2017 – Provider workshops – May 29 (Calgary), June 1 (Edmonton)
• Partnerships – AHS Primary Healthcare Integration Office – Toward Optimized Practice (guideline scheduled for 2018) – AMA – Physician Learning Program, Respiratory Medicine – Alberta College of Family Physicians – Respiratory Home Care Association of Alberta
• Initial conversations with Calgary Zone Secretariat – Health Systems Support Task Force
Questions? [email protected]