Understanding and Recognizing Obstructive Sleep Apnea

1. Understanding and Recognizing Obstructive Sleep Apnea Barbara Phillips, MD, MSPH, FCCP August 9, 2008

2. Disclosures • Consulting, speaking • Boehringer Ingelheim • Department of Transportation, FMCSA • GSK • Jefferson County Metro Government • TempurPedic • Ventus • Leadership position • American College of Chest Physicians • National Sleep Foundation

3. Pre-Test Questions

5. Meet Mr S Nora • A 55 year old man complains that his wife will no longer sleep with him because he is too noisy and it is disrupting her sleep. • This has been going on for several years, but has worsened in the past 18 months as he has gained weight. • Last year, he ran off the road while driving back from a sales meeting in the evening.

6. Mr S Nora • Past Medical History • Hypertension • Glucose intolerance • Medications • Metoprolol • HCTZ • Examination: bp 146/94, BMI 33 Kg/m2 • Neck circumference=18.5 inches

8. The Epworth Sleepiness Scale   How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to chose the most appropriate number for each situation: 0=would never doze 1=slight chance of dozing 2= moderate chance of dozing 3=high chance of dozing Situation Chance of Dozing Sitting and reading _____ Watching TV _____ Sitting, inactive, in a public place _____ As a passenger in a car for an hour _____ Lying down in the afternoon _____ Sitting and talking to someone _____ Sitting quietly after a lunch without alcohol _____ In a car, while stopped for a few minutes in traffic _____

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11. Risk Factors for Obstructive Sleep Apnea • Obesity (Kripke DF 1997; Tsai WH 2003) • Male Gender (until about age 50) • Postmenopausal state (Young T, 2003) • Upper airway anatomic obstruction • African-American, Asian, or Hispanic ethnicity (Kripke DF 1997; Young T 2003; Stepanski E 1999; Li KK 1999) • Being a football player (George CF 2003) or truck driver (Howard, 2005)

12. Clinical Practice Recommendation • Practice Recommendation: The risk for obstructive sleep apnea correlates on a continuum with obesity, large neck circumference, and hypertension. Combinations of these factors increase the risk for OSAHS in a non-linear manner. • Evidence-Based Source: Institute for Clinical Systems Improvement • Web Site of Supporting Evidence: http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html • Strength of Evidence: • Class A: Randomized, controlled trial; Class B: Cohort study; Class C: Non-randomized trial with concurrent or historical controls, Case-control study, Study of sensitivity and specificity of a diagnostic test, Population-based descriptive study; Class D: Cross-sectional study, Case series, Case report; Class R: Consensus statement, Consensus report, Narrative review

13. Clinical Practice Recommendation • Practice Recommendation: Polysomnography is the accepted standard test for the diagnosis of obstructive sleep apnea syndrome. The benefit of using attended polysomnography for diagnosis is the ability to establish a diagnosis and ascertain an effective CPAP treatment pressure. • Evidence-Based Source: Institute for Clinical Systems Improvement • Web Site of Supporting Evidence: http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html • Strength of Evidence: • Class C: Non-randomized trial with concurrent or historical controls, Case-control study, Study of sensitivity and specificity of a diagnostic test, Population-based descriptive study; Class D: Cross-sectional study, Case series, Case report; Class M: Meta-analysis, Systematic review, Decision analysis, Cost-effectiveness analysis; Class R: Consensus statement, Consensus report, Narrative review

14. Weight Loss for OSA • Modest (10%) weight loss results in significant improvement in AHI (Yee BJ, Int J Obes 2006) • Bariatric Surgery results in 75-88% cure rate at 1 year, independent of approach. (Guardiano SA Chest 2003, Crooks, PF, Annu Rev Med 2006)

15. Change in Weight and BMI over 4 Yrs(Peppard PE, JAMA 2000, WSCS, n=690) Mean Change in AHI, Events/h -20% to < -10% (n = 22) -10% to < - 5% (n = 39) - 5% to < + 5% (n = 371) + 5% to < + 10% (n = 179) + 10% to + 20% (n = 79) Change in Body Weight

16. From JNC7…

18. Refractory HTN in OSA(Logan J Hypertension 2001) • N = 41 • BP > 140/90 on  3 antiHTN meds • Excluded causes of secondary HTN, poor compliance • Prevalence of 95% in men and 65% of women

19. Effect of CPAP on Blood Pressure in Hypertensive Patients (Becker HF, Circ, 2003)

20. Polysomnography Results • AHI 42 events/hour • Sa02 lowest 76%; 26 minutes with Sa02 below 85% • Sleep Efficiency 64%, TST 4.8 hours • No Stage 3 sleep, 5% REM sleep

21. CMS’s Definition of Obstructive Sleep Apnea (OSA) CPAP will be covered for adults with sleep-disordered breathing if: • AHI or RDI > 15 OR • AHI or RDI > 5 with (“mild, symptomatic”) • Hypertension • Stroke • Sleepiness • Ischemic heart disease • Insomnia • Mood disorders

22. Apnea + Hypopnea Index (AHI), AKARespiratory Disturbance Index (RDI)And Oxygen Desaturation Index (ODI) • AHI = Apneas + Hypopneas Total Sleep Time, in Hours • RDI = AHI, more or less (may include RERA’s) • ODI = Number of 4% desats/hr • SDB = Sleep-Disordered Breathing (What you say when you are not sure what you are including. May include snoring, RERA’s, oxygen desaturation)

23. Sleep Heart Health Study: Apneas and Hypopneas • Decrease in airflow or chest wall movement to an amplitude smaller than approximately 25% (apnea) or 70% (hypopnea) of baseline • At least 10 seconds • Associated with oxyhemoglobin desaturation of 4% or greater as compared with baseline

24. Arousal from sleep L EOG R EOG O1 A2 C3 A2 Chin EMG ECG Apnea Leg EMG NC AF Th AF Chest Abd SaO2

25. L EOG R EOG O1 A2 C3 A2 Chin EMG ECG Leg EMG NC AF Th AF Chest Abd SaO2

26. Severity Criteria Based on PSG From the American Academy of Sleep Medicine (Sleep, 1999) • “Mild” sleep apnea is 5-15 events/hr • “Moderate” sleep apnea is 15-30 events/hr • “Severe” sleep apnea is over 30 events/hr • (“Events” includes apneas, hypopneas, and RERA’s)

27. Which Patient Has “Mild” OSA? Patient 1 Patient 2 AHI (events/hr) 40 10 Apnea duration (secs) 10-22 10-90 Lowest Sa02 (%) 90 71 % REM on study 18 0 Arousals/hr 8 80 Cardiac arrhythmias none v tach

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30. Increased Risk of Crash with OSA (FMCSA, 2007)

31. Howard ME, AJRCCM 2004 N=3268

32. Crashes and CPAP (n=210, with OSA, 210 controls) George, C F P Thorax 2001;56:508-512

33. BMI and OSA Predict Atrial Fibrillation(Gami AS, JACC 2007)

34. Association of nocturnal arrhythmias with sleep-disordered breathing. The Sleep Heart Health Study(Mehra et al, AJRCCM 2006) (N= 228 with RDI > 30 c/w n=338 with RDI < 5)

35. Recurrence of Atrial Fibrillation Following Cardioversion Is Higher in Patients with Untreated Obstructive Sleep Apnea(Kanagala et al, Circ, 2003) *,** *p<0.009 compared to controls **p<0.013 compared to treated OSA

36. Stroke or Death (Yaggi HK NEJM 2005)

37. Hazard Ratios for Death by RDI Adjusted for BMI(Lavie P, Eur Respir J 2005)

38. Relative Mortality RDI > 50/hr (Lavie Eur Respir J 2005)

39. CPAP, OSA, and Death (Doherty LS, Chest 2005)

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41. Clinical Practice Recommendation • Practice Recommendation: Lifestyle modifications, particularly weight loss and reduced alcohol consumption can play a significant role in the reduction of severity of sleep apnea • Evidence-Based Source: Institute for Clinical Systems Improvement • Web Site of Supporting Evidence: http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html • Strength of Evidence: • Class A: Randomized, controlled trial; Class B: Cohort study; Class C: Non-randomized trial with concurrent or historical controls, Case-control study, Study of sensitivity and specificity of a diagnostic test, Population-based descriptive study; Class D: Cross-sectional study, Case series, Case report; Class R: Consensus statement, Consensus report, Narrative review

42. Alcohol and OSA • “Most but not all studies … have demonstrated harmful effects on nocturnal respiration, including increased number and duration of hypopnea and apnea events.” (Young T, AJRCCM 2002) • Alcohol may not change CPAP pressure needed (Wessendorf TW, Sleep Med Rev 2002)

44. Cigarette Smoking and OSA • Most data indicates relationship • OR 2.05 (Khoo SM, Respir Med 2004, n=2298) • OR 2.5 (Kashyap R, Sleep Breath 2001, n=108) • OR 4.4 (Wetter D, Arch Intern Med 1994, n=811) • Some does not • No diff (Casasola, Sleep Breath 2002, n=38) • Ex-smokers do NOT appear to have increased risk of OSA • Parental smoking appears to be a risk for SDB in children (Kadatis AG, Pediatr Pulmonol 2004, n=3680)

45. Cigarette Smoking and Other Problems • Reduced CPAP compliance (Russo-Magno P, J Am Geriatr Soc 2001, n=33) • Greater oxygen desaturation (Casasola, Sleep Breath 2002, n=38)

46. Exercise for OSA?(Quan SF, Sleep Breath 2007) • 4275 SHHS participants • Logistic regression analysis • > 3 hrs/week of self-reported vigorous exercise reduced risk of AHI > 15 (Adjusted OR, 0.68; 95%CI, 0.51-0.91 ) • Similar but weaker associations for less vigorous exercise or different definitions of OSA

47. Oral Appliance Reviews • Cochrane Database Review (Lim, 2004) • OA improved sleepiness and SDB compared to controls, but CPAP is the more effective of the two treatment modalities • Ferguson KA, Sleep 2006 • 52% chance of control of sleep apnea with OA • Successful treatment more likely in mild-to-moderate sleep apnea • Greater degrees of mandibular protrusion more successful. • High BMI predicts failure • Hoekema, Crit Rev Oral Biol Med, 2004 • OA are more effective than controls for treating OSA, and possibly more effective than UPPP • OA are less effective than CPAP, but patients generally preferred OA therapy to CPAP • OA are a viable treatment for mild-moderate OSA

48. Do Oral Appliances Work?(Cochrane Database Syst Rev. 2006 Jan 25;(1):CD001106) “CPAP is effective in reducing symptoms of sleepiness and improving quality of life measures in people with moderate and severe obstructive sleep apnea (OSA). It is more effective than oral appliances in reducing respiratory disturbances in these people but subjective outcomes are more equivocal. Certain people tend to prefer oral appliances to CPAP where both are effective. This could be because they offer a more convenient way of controlling OSA.”

49. Indications for Oral Appliances (Kushida C, Sleep 2006) • Primary snoring • Mild to moderate OSA patients who: • Prefer OAs to CPAP • Do not respond to CPAP • Are not appropriate candidates for CPAP • Fail treatment attempts with CPAP or behavioral changes • Patients with severe OSA should have an initial trial of nasal CPAP [before considering OAs] • Upper airway surgery may also supersede use of OAs in patients for whom these operations are predicted to be highly effective in treating sleep apnea

50. Types of Oral Appliances (OA) • There > 50 different OAs commercially available; only about 30 have been approved by the FDA for OSA • Two basic types: • Mandibular repositioners (MRD); reposition and maintain the mandible and tongue in a forward position • Tongue retainers (TRD); engage and hold only the tongue in a forward position without affecting the mandible or teeth (not FDA approved for OSA)