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Sleep Apnea:

Sleep Apnea:. C Tyler. Sleep Apnea. Kaiser SF Sleep Lab a.k.a. ‘ apnea clinic ’ Part 4 C Tyler, Sep 2016 Medical Director Kaiser, San Francisco. Alternative Therapies:. CPAP Gold Standard M ost effective Titratable (auto) Verifiable (compliance) Safe. Positional Therapy

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Sleep Apnea:

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  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

  40. 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.

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

  42. Encephalitis Lethargica

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

  44. 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

  45. Sleep Latency (MSLT) and sleep deprivation

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

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