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Obstructive Sleep Apnea How To Order A Sleep Study?

Obstructive Sleep Apnea How To Order A Sleep Study?. Herbert M. Schub,MD Chief, Pulmonary Diseases Highland Alameda County Hospital Clinical Professor of Medicine, UCSF. Obstructive Sleep Apnea. Obstructive Apneas, Hypopneas,or Respira - tory Effort Related Arousals

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Obstructive Sleep Apnea How To Order A Sleep Study?

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  1. Obstructive Sleep ApneaHow To Order A Sleep Study? Herbert M. Schub,MD Chief, Pulmonary Diseases Highland Alameda County Hospital Clinical Professor of Medicine, UCSF

  2. Obstructive Sleep Apnea • Obstructive Apneas, • Hypopneas,orRespira- • tory Effort Related • Arousals • Daytime Symptoms • Sleepiness, Fatigue, • Poor Concentration • Snoring, Resuscitative • Snorts (Witnessed • Apneas)

  3. The Essentials to Qualify • Symptoms: • Snoring • Witnessed Apnea • Daytime Somnolence &/or • Fatigue • Recent Weight Gain • Use of Steroids • Motor Vehicle Accidents • Physical Findings: • Height • Weight • BMI • Neck size • Male:>17” or 43 cm • Female:>16” or 41 cm • Malimpati Index of • Oropharynx I-IV • O2 Saturation on RA • ABG if O2 Sat<95% RA • PFT’s (Spirometry if pCO2 • >45 mm

  4. Polysomnography • EMG Chest & Abdomen • Airflow at Nose and Mouth • EEG, EOG • Oxygen Saturation • Cardiac Rhythm • Leg Movements

  5. PolysomnographyTerms • Apnea • Cessation or less than • 30% air flow for at • least 10 secs, usually • assoc with > 4% decr • O2 Sat • Hypopnea • 30-70 % decr air flow • AHI…Apnea Hypopnea • Index • Apneas +Hypopneas • per hour: • < 5 hour= normal • 5-14= Mild • 15-30=Moderate • >30=Severe • RDI…Respiratory Disturb- • ance Index

  6. Polysomnograph Terms SPLIT NIGHT STUDY AFTER establishing an accurate measure of REM sleep, RDI, AHI, O2 desat, EKG abnlties THEN, get a proper fitting CPAP/BiPAP mask or other device & identify the minimum CPAP level that abolishes obstructive apneas/hypopneas, O2 desat,respiratory effort- related arousals(RERAs) Pressure needed usually 5-20 cm TITRATION STUDY Dx OSA already established, but need study with CPAP from beginning of night to establish proper pressure and mask AUTO-PAP Automatically changes pressures based on the presence and/or absence of OSA May be used during in the unatt- ended home setting to determine a single pressure for home use

  7. Home Based (Portable Monitoring)Testing for OSA • 4 Types: • type 3: 4 variables: • Respiratory movement , • Airflow • Heart Rate &/or EKG • O2 Sat • type 4: 1or2 variables: • O2 Sat • Airflow • Overnight Pulse Oximetry alone • is inadequate….sensitive but • NOT specific for cause • Advantages: • Low cost/ OK for un- • complicated OSA & • titration of CPAP • Disadvantages: • Often underestimate AHI • (hours of true sleep???) • Type 4 can’t distinguish • Central vs OSA or hypo- • ventilation) • No measure Upper Airway • Resistance Awakenings • No measure Periodic Limb • Movement Awakenings

  8. Management OSA in Adults Behaviour Modification Losing weight if Obese Change Sleep Position (if OSA is positional) Abstain from Alcohol, CNS depressants Non-surgical OSA therapy CPAP Bipap • Surgical therapy • Reserved for Selective • patients in whom • CPAP/BiPAP was • ineffective • Exception when OSA • due to a clear-cut • surgically correctable • obstructing lesion • Pharmacologic Treatment • For patients with sym- • ptoms despite adequate • therapy

  9. Nasal CPAP Therapy Initially described 1981 Most effective treatment Blower unit that produces CONTINUOUS positive pressure airflow Increases the caliber of the airway in the retropalatal and retroglossal regions… acts as a PNEUMATIC SPLINT Medicare Guidelines Severe RDI (20-30) RDI 5-20 if symptoms or co-existent cardiovascular OSA with AHI >15 If AHI 5-15, CPAP only if excessive daytime somnolence, hypertension or cardiovascular disease

  10. BiPAP Therapy Permits independent ad- justment of inspiratory and expiratory pressures Generally used in patients who cannot tolerate high CPAP Too expensive to be used as first-line therapy Compliance no better than with CPAP Often used with Obesity- HypoventlationSynd- rome-m Pickwickian

  11. Oral Appliance Therapy Act by Moving (pulling) the tongue forward or by moving the mandible and soft palate anterior- ly More than 40 Oas are available Not as effective as CPAP For mild-to-moderate OSA who cannot tolerate CPAP(and BiPAP) Therapy

  12. Nasal Plugs….Provent • Patch fits over nostrils • Holds 2 small plugs • Creates just enough air • pressure to keep air- • ways open at night • Far less intrusive than • CPAP • Approved by FDA 2008 • Requires new patch • every night…30 day • supply $65-$80 • More expensive than • CPAP • Not covered by • Medicare • In one study, 1/3 not • used: severe nasal • allergies,mouth breath

  13. Obesity Hypoventilation SyndromePickwickian Syndrome • pCO2>45mm &NOT due • to COPD (severe), • kyphoscoliosis, neuro- • muscular • 95% OSA do NOT have • OHS • 95% of OHS have OSA • O2 Sat as routine screen • for OSA. If <95%, get • ABG • IF ABG pCO2>45, get • spirometry • IF pCO2>45, & no severe • COPD (FEV-1 <50% pred), • indicate on “Assessment” • the probability of OHS • and need to use BiPAP, • rather than CPAP during • Split Night Study

  14. Narcolepsy • Clinical Syndrome • Daytime Sleepiness • Cataplexy • HypnagogicHallucin- • ations • Sleep Paralysis • Only 1/3 all 4 symp- • toms • Loss of neuropeptides • orexin-A and –B • (hypocretin 1 and 2 • from hypothalamus • Multiple Sleep Latency • Test (MSLT) • Only valid IF PSG = • at least 6 hrs sleep • the previous night • 4-5 opport to nap q2h • the day after the PSG

  15. Restless Leg SyndromeCriteria 1.Urge to move legs... usually w/ discomfort 2.Begin or worsen during rest/inactivity/lying etc 3.Relieved by movement 4.Worse in evening/night Supportive criteria: a. Family history RLS b.+ response to dopaminergic c. Periodic Limb Movements during sleep with PSG • PSG NOT necessary to make dx • Secondary RLS: • Iron deficiency • End-Stage Renal Disease • Diabetes Mellitus • Multiple Sclerosis • Parkinson disease • Pregnancy • Rheumatic Disease • Venous Insufficiency • Miscellaneous

  16. Periodic Limb Movements Of Sleep Sudden jerking leg move- ments…repetitive,highly stereotyped…typically involve extension of big toe/partial flex ankle, knee/hip..patient usually unaware…increase w/age VAST majority of RLS Treatment UNNECESSARY if PLMS w/out sleep comp- laints • PLMD (Disorder) • Partial or Total Arousal • from sleep & cause/ • contribute insomnia/ • daytime drowsy/somn- • olence • Use same drugs as RLS

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