Advanced Sleep Apnea Treatments and Benefits: A Comprehensive Guide by Dr. C. Tyler

1. Sleep Apnea: • C Tyler

2. Sleep Apnea Kaiser SF Sleep Lab a.k.a. ‘apnea clinic’ Part 4 C Tyler, Sep 2016 Medical Director Kaiser, San Francisco

3. Alternative Therapies: • CPAP • Gold Standard • Most effective • Titratable (auto) • Verifiable (compliance) • Safe Positional Therapy Weight Loss Smoking Cessation Treat Allergy Treat Acromegaly Treat Hypothyroid Oral Appliance (M.A.D.) Provent Surgery

4. Weight Loss

5. Positional Therapy

6. Allergy Rx / Stop Smoking

7. Provent

8. Surgery: UPPP • Irreversible • Pain, Death • Oro-nasal reflux • Voice change • 50% “effective” • Surgical Literature: • ‘Efficacy’ = 50% reduction in AHI

9. Genioglossus advancement

10. Maxillo-mandibular advancement

11. Oral Appliances • Mechanical Mandibular Advancement - ‘Jaw Thrust • Efficacy - 50% • Compliance - ? Better ? • Complications - TMJ, discomfort….

12. Oral Appliance • AASM recommendations: • mild-to-moderate OSA (AHI < 25), • severe OSA who are intolerant or refuse CPAP • Good dentition: no periodontal disease • $1600 vs $800 for CPAP • 50% effective 50% of the time

13. Hypoglossal Nerve Stimulator • Recently FDA approved • Propofol Endoscopy • $40,000 • No long term data

14. Benefits of Treatment: • Sleep Quality • Quality of wakefulness (and of life) • Cardiovascular risk reduction

15. OSA as a CardiovascularRisk Factor • Hypoxia • Adrenergic discharge • Sleep Fragmentation

16. HTN • ? 70% with essential HTN have OSA • ? 80% with refractory HTN have OSA • ? 50% with HFrEF or HFpEF have OSA

17. Hypertension and OSA

18. Cardiovascular Eventsin untreated OSA • 7 year follow up study of healthy middle aged men • Event = new CAD, HTN, MI, Stroke, CV Death

19. OSA+CHF: Probability of hospitalization or death in 5 years

20. CSA + SHF:CPAP responders vs non-responders

21. Cardiovascular Endpoints: • CONCLUSIONS • Therapy with CPAP plus usual care, as compared with usual care alone, did not prevent cardiovascular events in patients with moderate-to-severe obstructive sleep apnea and established cardiovascular disease. • Average CPAP use < 4 hr per night • Inadequate treatment = no benefit

22. Summary: • OSA causes sleep deprivation • OSA causes oxidative vascular injury • Treatment of OSA • reduces risk of cardiovascular events • reduces motor vehicle accidents • CPAP is the Gold Standard • Alternative treatments exist • for those intolerant of CPAP

23. Thank you - Chris Tyler

24. Quiz: • How long do Ducks sleep? • Stanley Kubrick’s work on crime and punishment. • Over geologic and evolutionary time, days are getting (longer:shorter)? • The supra-chiasmatic nucleus responds to (light, melatonin, a $100,000 drug) • Caffeine antagonizes adenosine (yes/no)

25. The End

26. CPAP and Heart Failure • CANPAP trial: no benefit to CPAP in CHF+CSR • f/u paper showed improved outcome IF marked reduction in AHI

27. Cheyne-Stokes respirations • Crescendo-decrescendo • Arousal at peak hyperpnea • PLM coexists in 85% • 20-40% of HFrEF • Hypocapneic (high loop gain) • Resolves in REM sleep (reduced loop gain) • CPAP reduces catechol levels and increases LVEF

28. Hypoventillation Syndromes • Ondine’s Curse: Central Congenital Hypoventillation • Primary Alveolar Hypoventillation

29. Central Apnea: • Periodic breathing at altitude • Sleep transition apneas • Any fragmentation of sleep • (insomnia, PLMS, pain, ) • Treatment emergent central apneas • CO2 falls below apnea threshold • Frequently resolves with time • narcotic-induced central apnea

30. Future Opportunities: • Linkage to Obesity Efforts • nutritionist, metabolic clinic, etc. • Regional Registry • Population Management Tools • Comprehensive follow-up program • Questionnaire • Oximetry, Repeat diagnostics • Re-titrations • Compliance checks • New technologies - ie telephonic monitoring

31. MRI x-section

32. Cheyne-Stokes Resp • Periodic Breathing • Arterial BP • Sympathetic activity • (note: C-S resp is not a hypercarbic condition)

33. Prevalence of OSA/CSA in SHF • Prevalence is higher in men

34. CHF: Cheyne-Stokes Resp • Modest hypoxemia • Not associated with hypercarbia

35. Prevelence of CSA in LV dysfunction

36. CSA and probability of death

37. Rx of SRBD in Systolic HF • Optimize HF Rx • O2 • Resp stimulants • (CO2??) • CPAP/BiPAP • adaptive pressure support servoventilation

38. NC O2 reduces AHI in SHF

39. CPAP troubles: air leak

41. When REM goes Bad Figure: Neuropharmacologic and neurochemical control of cataplexy and excessive daytime sleepiness. Cataplexy, like REM sleep, regulated by balance of adrenergic and cholinergic tone.

42. preoptic area (POA) lesions • loss of circadian sleep • Sustained wake state

43. Encephalitis Lethargica

44. Pharmacologic • Amphetamine – blocks DA/NE reuptake • Caffeine – antagonized Adenosine • Modafinil - – blocks DA/NE reuptake

45. Follow-up and Compliance • Annual checks (ideal) • If significant weight gain or loss (+/- 10%) • Return of symptoms • Machine / mask problems • Compliance Check: • AHI, hrs of use, average use • Questionnaire: sx, sleep quality, problems

46. Sleep Latency (MSLT) and sleep deprivation

47. OSA epi-phenomena • REM rebound • Sleep transition phenomena