Management of Complex Patients In Your Sleep Lab Final peter allen.pdf · Management of Complex...
Transcript of Management of Complex Patients In Your Sleep Lab Final peter allen.pdf · Management of Complex...
Peter Allen, BSRC, RST, RPSGT RRT-NPS-SDS
AAST Board Member/Director at Large NEPS Conference 2017
Management of Complex Patients
In Your Sleep Lab
Director at Large for the AAST
Clinical Coordinator Main Line Health Sleep Disorders Centers
US Project Manager
Bermuda Center for Sleep Disorders
Co-Morbid disease state descriptions and the workflow of those disease states as they pass through the sleep disorders center.
COPD
Diabetes Non-Ambulatory
Morbid Obesity Psych Special Needs Patients
Cardiovascular Facility Referrals
Stroke
Gastroesophageal/Reflux/GERD
Metabolic Syndrome
Intake, Safety, Clinical, Patient Experience and Revenue Aspects
1. Attendee will have a better understanding of the underlying physiology of the co-morbid OSA patient and various aspects of overlap syndrome between disease states.
2. Attendee will be better able to plan and cope with the complex patients in their sleep labs.
3. Attendee will learn to grow clinically while realizing the financial opportunity that these patients represent to their sleep centers.
Night Technologists EEG Background Respiratory Background Home Care DME Home Sleep Testing Only Lab Managers Lab Owners Hospital Administrators Nursing/CRNP Physicians/Physician Assistants
Since 1970 when Stanford opened the first sleep center and Dr. Guilleminault later described Obstructive Sleep Apnea(OSA), many studies have been conducted regarding associated disease states.
Many studies have linked OSA to co-morbid disease states and conditions such as:
Cardiovascular and Pulmonary Disease
Congestive Heart Failure – 76%
A-Fib, - 49%
Diabetes – 48%
Obesity - 77%
Stroke
Spinal Cord Injury
Reflux/GERD
End Stage Renal – 10 times Greater than General Population
Headaches, COPD, Cancer, Metabolic Syndrome
Many Co-Morbid disease states that are associated with OSA are being targeted by Medicare as criteria, for financial penalties to Medical Centers where readmissions occurs, within 30 days of discharge.
This puts a spotlight on Diagnosis and Treatment of OSA and its associated co-morbid disease states as an integral part of a medical centers financial integrity plan.
Chronic Obstructive Pulmonary Disease
Two Components
Chronic Bronchitis – Productive cough, three months of the
year, two or more successive years.
Emphysema - Abnormal enlargement of the airspaces in the lungs with destruction to the cell walls.
Primarily caused by cigarette smoking.
Oxygen – Physician’s Orders
Theo
Ipratrop
Adv
Symbi
Dalir
Theo
Atro
Sere
Salmet
Formet
Provent/Ventol/Abuter - Nebulizers
Pulmonologists
Hospitalists
Internal
Family
Oncologists
Nursing
Oxygen ?
Liter Flow ? Hypoxic Drive Candidate
Mobility ?
Additional Caretakers?
Medications? ◦ Nebulizers
◦ Short Acting Acute
◦ Long Acting Maintenance
Recent Hospitalizations??
Shortness of Breath (SOB)
Ambulation
Oxygen Protocols
Emergency Protocols
Detailed H&P in Chart, Always
Medication Schedules
Thorough Chart Review Early!!!!!
High CO2 – 35 Normal>>>50+ End Tidal?
Low SpO2 – 90% to 97%>>>>88% or less
Hypoventilation
Centrals During Titration
Supplemental Oxygen as needed
PVCs, PACs, Uni/Multi-Focal, V-Tach
High Heart Rates
A-Fib, flutter
1. Impaired Lungs plus OSA
2. COPD and OSA jointly contribute
3. More nocturnal desaturations
4. Reduction in respiratory drive-HypoV
5. Chest wall hyperinflation causes muscle fatigue in these patients.
6. COPD has systemic consequences
7. CO2 High(Retainers), SpO2 Low
Overlap syndrome increases risk of death and hospitalization due to COPD.
PAP treatment with or without oxygen is associated with better patient outcomes along with decreased hospitalizations.
More readmissions for these patients
Impairment of the body’s ability to use blood sugar for energy.
Type 1- Insulin producing Beta cells in pancreas destroyed.
Type 2- Most common 90% to 95%, Weight, Food
Insulin resistance by body, so pancreas overproduces
Gestational - during pregnancy- Usually Temp
Over 6 million in the US alone
Type I Insulin – Oral or Injection
Type II Met
Vict
Gluco
Amar
Gluco
Janu
Novo
Family
Internal Medicine
Endocrinologist
Bariatric Medicine
Diabetes Educators
Nutritionists
Dietician
Type 1:
When do they take their meds?
Reinforce that patient needs to bring meds.
Type II:
When do they take their meds?
Labs are Out-Patient Facilities, So…
Tech needs to establish med routine
Patient caregiver or self-administer
Refrigeration for meds
Cola and crackers that staff will not eat….
Do not let patients “Take a Night Off”
Call to Physician if need be to clarify/safety concerns/patient coherent?
Frequent urination common during PSG
Sleep loss leads to: ◦ Altered glucose and metabolism
◦ Reduced Leptin/Increased Ghrelin
◦ Up regulation of appetite/weight gain
◦ Lower energy = Weight Gain(OSA Factor)
◦ Insulin resistance = Type 2
◦ Increased Risk for Diabetes Adapted from Parker, K.P. (2011) Sleep disorders and sleep promotion in nursing practice; p. 180
Co-Morbidities within a Co-Morbidity BMI > 32 – Doubles risk of death
High Blood Pressure
Heart Disease – Left and Right side - Lymphedema
High Cholesterol Levels
Diabetes - 60% to 80% have OSA
Gastroesophageal Reflux
Urinary Stress Incontinence
Degenerative Arthritis-Fall Risk Protocols?
Skin Infections, Fluid Retention
1. Met – Type II
2. Diuretics
3. Hypertensive Meds
4. Pillows, Pillows, Pillows,- Orthopnea
5. Insulin – Type 1
6. Lymphedema Meds
7. Oxygen
8. Lip
9. Vaso…….Cardio Meds
Family
Internal Medicine
Endocrinologist – Metabolic Syndrome
Bariatric Medicine – Pre and Post Surgical
Nephrologist- Renal Disease
Perioperative Referrals
Surgeons and Anesthesiologists
Weight Bed Limits Toilet Limits Chairs Ambulation? Medications? Drs to be copied? Special Needs?
PSG Set-Up – Belts, leads, sensors… Titration Night Mask Fitting Concerns Headgear Big Enough?- Call Reps Does your lab have a weight limit? Bariatric Approved Beds? Fall Risk? Culture of Safety Concerns all Around Meds Frequent bathroom breaks Possible Incontinence
Loud Snoring
Deep Desaturations
Irregular EKG
Usually Severe OSA
CPAP to Bi-Level Protocols?
Frequent breaks in recording
Artifact, movement, sweat
Speaking while asleep
OSA Influence on other conditions, high
Cardio
Pulmonary
High Blood Pressure
Fluid Retention
Bariatric Surgery or Intensive Lifestyle Changes
Metabolic Syndrome, Insulin Resistance – Type 2
Haines et al. Surgery 2007; 141: 354-8
Look Ahead Research Group, Diabetes Care 2007
70% of patients admitted to the hospital for coronary artery disease were found to have sleep Apnea
Patients with OSA have a 50% risk of hypertension
OSA starves heart of oxygen while making it work harder leading to higher blood pressures through the night.
Untreated OSA is well documented as a factor in causing heart disease
A patient’s chance of having OSA if they have heart disease is very high.
AM J Respir Crit Care Med Vol. 188, P1-P2, 2013
ATS Patient Education Series 2013 Chowdhuri, S., MD, Weingarten, J., MD
Systolic Failure Failure to eject/pump blood out of the heart effectively
Diastolic Failure Heart muscles have become stiff and do not fill easily
Fluid builds up in the lungs, liver, gastrointestinal tract, arms and legs/ankles.
Zee, P & Naylor, E http://www.medscape.org/viewarticle/491026
Shortness of Breath
RLS Symptoms
Diuretics = Increased Bathroom Breaks
OSA and CSA
Insomnia – Daytime Sleepiness
Short Sleep Duration
Lisin
Aten
Dio
Norv
Clonid
Azo
Verapa
Furose
Las
Cor
Zest
Vaso…
Lopres
Leva
……anybody
Family
Internal Medicine
Cardiology
Surgeons - Perioperative
Hospitalist
CRNP & PA
Oxygen?
Get both Family and Specialists
Last Hospitalization?
Medications and average BP
BP Pre and Post Study – Both Arms
Ask when they last took their medications
DeFib Unit Operational – Signed off on?
Room Temp Important if Sweating
Note any swelling in arms or legs
Note Pacemaker and Type – Constant/As Need
BLS, ACLS, PALS
911 , 711 depending on hospital/freestanding
Irregular EKG
PVCs, PACs, V-Tach, A-Fib, Flutter, Systole/Pauses
Full or Partial Heart Block
Breaks in record-Diuretics Insomnia from Anxiety
Cheyne Stokes Breathing Pattern – 73% in CHF patients
Left ventricular dysfunction-Hyper and Hypo ventilation
Waxing and Waning breathing pattern
ASV Considerations?
Pacing Spikes
OSA and CSA
CSA sometimes evoked by O2 and PAP = Auto Servo Ventilation
Elevated Blood Pressure during Sleep Elevated Sympathetic Tone leads to HBP. About 30% of patients with hypertension have OSA. Congestive Heart Failure well documented connection Left ventricle enlargement/increased workload/events. Effects are both acute and chronic. Cessation of airflow and subsequent desaturation starves
heart of oxygen. PAP Treatment is shown to have positive effect on all. Heart Failure associated with Cheyne Stokes Pattern OSA occurs in 50% of atrial fibrillation patients.
Hemorrhagic-Vessel breakdown
Ischemic-transient ischemic attack (TIA) Narrowing
Embolic-Clot local or from other area blocks flow
OSA and SDB contributes to increased risk of stroke.
Stroke can contribute to OSA or CSA
Reduced muscle tone and control of upper airway
Sudden Slurring of Speech
Muscle control deficit in face/body affecting one side or bilaterally
Time = Brain
Anti-platelet Aspirin
Plav/Clop
Tic/Ticio
Anti-clot War/Coum
Hepar-Hospital via IV
Acute Phase Thrombolytic Agents-”Clot Busters”
Family
Internal Medicine
Neurology
Hospitalist
Case Managers
CRNPs
Hemorrhagic
Ischemia (TIA) or Embolic
Left or Right Side Deficit
Speech?
Ambulatory ?
Aide or Family Member
Time of Day or Night –Triggers
Left side Right side?
Full 10/20??
Fall Risk?
Medication Schedule?
BP in the evening and morning
Medical Director Parameters for BP
What time of the day/night did stroke occur?
Left Side or Right Side EEG differences
Non-Homologous electrodes cause voltage asymmetries.
Measure, Measure, Measure
Do not eye-ball EEG set-up
Full 10/20 frequently ordered
OSA increase risk of stroke, independent of other risk factors.
Males with mild sleep apnea have doubled stroke risk
Stroke patients-63% have SDB Stroke patients w SDB have higher mortality, 1yr
Even higher frequency of SDB in stroke patients with high BMI
and Type 2 Diabetes.
Human PH – 1 TO 14 Arterial PH – Normal 7.35 – 7.45 Stomach PH – 4 or less Adults and Infants Apnea causes Reflux or is Reflux causing Apnea? Heartburn most common symptom Chronic Illness 5-7% Worldwide Middle Age-Esophageal Valve Weakens Opening pressure of that valve?? PAP concerns?
Zan Reg Nex Pepto Ranit Lanso Famo Simeth Gav Maa Myl Prev Pep Tu
Family
Internal Medicine
Cardiology
Gastroenterologists
Neonatologists
Pediatricians
CRNPs
Medication Schedule
Physicians orders regarding meds
Hospitalizations?
Barrett’s esophagus or other Upper GI?
Dr’s Orders Followed? Last Meal time documented Last Med Does patient have a logbook? Flat or Raised? Document Patients Snacking/Eating Spicy, acidic, fried foods, tomato based
Infant Study - Arousals, Body Posture Adults- Arousals, Frequent breaks Document Patient Observations GERD with OSA events? Choking Aspiration Risk? Upright Posture Left side/Right side/Recovery Position Dr’s orders regarding food/meds/body position
Not a clear causal relationship
Chicken/Egg or Egg/Chicken
Hard breathing during events?
Different mechanisms can cause both
Multifactorial Origin – Shared risk factors
Aspiration risk at end of apnea is of concern to the technologists.
Intake is paramount here
Most cases have a caregiver
Out-Patient Hotel Setting Stressed
Must bring everything needed
Safety, Safety, Safety
Again Intake
Handling the Surprise Drinker
Systemic rather than local disorder
OSA & Metabolic = Syndrome Z
Causal Relationship Probable
Repetitive Hypoxia
Adipokines and Inflammatory Cytokines
Estimated 24% of US Population
Three of the following five variables:
Hypertension
Insulin resistance – Type 2
Low high-density lipoprotein cholesterol
Elevated serum triglyceride
Abdominal Obesity-Visceral Fat
Multiple studies have shown that association between OSA plus Metabolic Syndrome increases as severity of the patient’s OSA increases.
PAP has been shown to improve high blood pressure but not insulin resistance or lipid profiles.
Coughlin et al.
Studies are showing that OSA and Metabolic Syndrome are not separate co-morbidities but actually linked to each other very closely.
Linkage between OSA and Diabetes is very well documented and appears to play a role in Metabolic Syndrome.
Prevalence of OSA in obese Type 2 Diabetic patients with moderate to obstructive severe sleep apnea has been reported as high as 70%.
Hypothalmic-pituitary-Adrenal(HPA) Axis
Cortisol – Hormone/Steroid is released – Adrenal Gland
Cortisol secretion was increased by sleep apnea
Study shows that obese men with OSA have abnormally higher sympathetic nervous system activity and HPA.
Autonomic(ANS), Sympathetic(SNS), Parasympathetic(PNS)
OSA has inflamatory cascade component, although linkage to OSA is still unclear.
Repetitive hypoxia and reoxygenation lead to oxidative stress
Oxidative stress appears to be a consequence of metabolic syndrome and visceral obesity.
Oxidative stress activates an inflammatory response.
Inflammatory responses activate Cytokines.
Inflammation, metabolic syndrome ties in with atherosclerosis.
Biomarkers are used by researchers to track the bodies inflammatory responses and associate them with OSA.
Obesity is the common factor that connects OSA TO Metabolic syndrome.
Monocytes and Macrophages abound and increase through what is known as the “Cascade”. Monocytes>>Macrophages eat/destroy
Adipokines-Fat derived Cytokines-One is Leptin. Leptin plays a role in appetite and energy.
Ghrelin-Hormone that also regulates appetite. High levels after weight loss. CPAP reduces
Metabolic syndrome consists of a systemic and complicated chain of events and components, one of which can be the presence of Obstructive Sleep Apnea.
Research is showing that Sleep Disorder Medicine will be playing a major role in the diagnosis and treatment of patients with Metabolic Syndrome or Syndrome Z.
Sleep Technologists/Sleep Medicine Field
You will be seeing more complex patients Get as much additional training as you can
Is your sales department, physician liaison, lab
owner, hospital focusing on these patients?
They Should Be For Economic Survival of Your Sleep Lab
AM j Resp Crit Care Med 2010 Aug 1;182(3):325-31
Int J Chron Obstruct Pulmon Dis. Dece. 2008: 3(4): 671-682
Adaptation from Parker, K.P. (2011) Sleep disorders sleep, nursing P180
ATS J Vol; 181, Issue 5(March1, 2010) Impact of Untreated OSA on Glucose Control in Type 2 Diabetes
Grimaldi, D. et al. Diabetes Care February 2014 vol. 37 no. 2 355-363 Glycemic Control in Type 2 Diabetes
University of Chicago, et al., Sleep Diagnosis and Therapy “Sleep Apnea Can Worsen Blood Sugar Control in People with Type 2 Diabetes”
WebMD, Mann, Denise, Smith , Michael, MD Reviewed Jan10th 2010 “The Sleep-Diabetes Connection
Coughlin, et al. Eur Heart J. 2004 International Diabetes Foundation Brussels
Einhorn et al. Edocr Pract. 2007
Resmed.com
Woidtke, Robyn, APSS Boston 2012
Resnick HE, Redline S, Share E, Gilpin A, ET al.
NM: Heart Health Study. Diabetes and Sleep Disturbances
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Foster, Gary, PhD, Temple University School of Medicine Diabetes Care. Net “Obstructive Sleep Apnea and Diabetes” 6/21/2010
Look AHEAD Research Group Diabetes Care 2007
Hanes et al., Surgery 2007; 141:354-8“Change in OSA Following Bariatric Surgery”
WebMD Drugs & Medications Search March 2004
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Ferreira, S et al. BMC Pulm Med 2010
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Calvin, Andrew, D., et al. “Obstructive Sleep Apnea, Inflammation, and the Metabolic Syndrome” Mtab Syndr Relat Discord. Aug 2009; 7(4): 271-277
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Peter Allen, BSRC, RRT-NPS-SDS, RST, RPSGT