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Disease State Crossover Managing the Complex OSA Patient

Disease State Crossover Managing the Complex OSA Patient. Peter Allen, BSRC, RST, RPSGT RRT-NPS-SDS. Conflicts of Interest. Philips Respironics ResMed Corp Fisher & Paykel DeVilbiss MVAP Natus NovaSom Watermark. Content.

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Disease State Crossover Managing the Complex OSA Patient

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  1. Disease State CrossoverManaging the Complex OSA Patient Peter Allen, BSRC, RST, RPSGT RRT-NPS-SDS

  2. Conflicts of Interest • Philips Respironics • ResMed Corp • Fisher & Paykel • DeVilbiss • MVAP • Natus • NovaSom • Watermark

  3. Content • Co-Morbid disease state descriptions and the workflow of those disease states as they pass through the sleep disorders center. • COPD • Diabetes • Morbid Obesity • Cardiovascular • Stroke • Gastroesophageal Reflux/Gerd • Metabolic Syndrome • Intake, Clinical and Marketing Aspects

  4. Learning Objectives • 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.

  5. Attendees • Night Technologists • EEG Background • Respiratory Background • Home Care DME • Home Sleep Testing • Lab Managers • Lab Owners • Hospital Administrators • Nursing • Physician Assistants

  6. Co-Morbid Condition off Your Wing

  7. Introduction • 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.

  8. Introduction Cont’d • 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

  9. Medicare Readmissions Policy • 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.

  10. COPD • 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.

  11. COPD Medications • Oxygen – Physician’s Orders • Theophylline • Ipratropium bromide • Advair’ • Symbicort • Daliresp • Theophylline • Atrovert • Serevent • Salmeterol • Formeterol • Proventol/Ventolin/Abuterol - Nebulizers

  12. COPD Referral Sources • Pulmonologists • Hospitalists • Internal • Family • Internal Medicine • Oncologists

  13. COPD Intake Concerns • Oxygen ? • Liter Flow ? Hypoxic Drive Candidate • Mobility ? • Additional Caretakers? • Medications? • Nebulizers • Short Acting Acute • Long Acting Maintenance Recent Hospitalizations??

  14. COPD Night of Study • Shortness of Breath (SOB) • Ambulation • Oxygen Protocols • Emergency Protocols • Detailed H&P in Chart • Medication Schedules • Thorough Chart Review Early!!!!!

  15. COPD and the Record • High CO2 – 35 Normal>>>50+ • Low Spo2 – 90% to 97%>>>>88% or less • Hypoventilation • Centrals During Titration • Supplemental Oxygen as needed • PVCs, PACs, Uni and Multi-Focal, V-Tach • High Heart Rates • A-Fib

  16. COPD OSA “Overlap Syndrome” • 1. Impaired Lungs plus OSA • 2. COPD and OSA jointly contribute • 3. More nocturnal desaturations • 4. Reduction in respiratory drive-HV • 5. Chest wall hyperinflation causes muscle fatigue in these patients. • 6. COPD has systemic consequences • 7. CO2 High(Retainers), Spo2 Low

  17. Overlap Syndrome Conclusions • 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. • Less readmissions for these patients

  18. Diabetes • 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

  19. Diabetes Medications • Type I Insulin – Oral or Injection • Type II • Metformin • Victoza • Glucophage • Amaryl • Glucotrol • Januvia • Novolin

  20. Diabetes Referral Sources • Family • Internal Medicine • Endocrinologist • Bariatric Medicine

  21. Diabetes Intake Concerns • 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…

  22. Diabetes Night of Study • Tech needs to establish med routine • Patient will always self-administer • Refrigeration for meds • Do not let patients “Take a Night Off” • Call to Physician if need be to clarify/safety concerns/patient coherent?

  23. Diabetes Sleep Loss Effects • 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

  24. Morbid Obesity • Co-Mobidities within a Co-Morbidity • BMI > 32 – Doubles risk of death • High Blood Pressure • Heart Disease – Left and Right side - Lymphedema • High Cholesterol Levels • Diabetes- 10 times- 60% to 80% • Gastroesophageal Reflux • Urinary Stress Incontinence • Degenerative Arthritis-Fall Risk • Skin Infections, Fluid Retention

  25. Morbid Obesity Medications • 1. Metformin – Type II • 2. Diuretics - Lasix • 3. Hypertensive Meds – Lisinopril • 4. Pillows, Pillows, Pillows,- Orthopnea • 5. Insulin – Type 1 • 6. Lymphedema Meds • 7. Oxygen • 8. Lipitor • 9. Vaso…….Cardio Meds

  26. Morbid Obesity Referrals • Family • Internal Medicine • Endocrinologist – Metabolic Syndrome • Bariatric Medicine – Pre and Post Surgical • Nephrologist- Renal Disease • Perioperative Referrals

  27. Morbid Obesity Intake • Weight • Bed Limits • Toilet Limits • Chairs • Ambulation? • Medications? • Drs to be copied? • Special Needs?

  28. Morbid Obesity Night of Study • 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

  29. Morbid Obesity Record • 1. Loud Snoring • 2. Deep Desaturations • 3. Irregular EKG 4. Usually Severe OSA • 5. CPAP to BI-Level Protocols? • 6. Frequent breaks in recording • 7. Artifact, movement, sweat • 8. Speaking

  30. Morbid Obesity OSA Overlap • 1. OSA Influence on other conditions, high • 2. Cardio • 3. Pulmonary • 4. High Blood Pressure • 5. Fluid Retention • 6. 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

  31. Cardiovascular • 1. 70% of patients admitted to the hospital for coronary artery disease were found to have sleep Apnea • 2. Patients with OSA have a 50% risk of hypertension • 3. OSA starves heart of oxygen while making it work harder leading to higher blood pressures through the night. • 4. Untreated OSA is well documented as a factor in causing heart disease • 5. A patient’s chance of having OSA if they have heart failure 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

  32. Congestive Heart Failure • 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

  33. CHF and Sleep • Shortness of Breath • RLS Symptoms • Diuretics = Increased Bathroom Breaks • OSA and CSA • Insomnia – Daytime Sleepiness • Short Sleep Duration

  34. Cardiovascular Medications • 1. Lisinopril • 2. Atenolol • 3. Diovan • 4. Norvasc • 5. Clonidine • 6. Azor • 7. Verapamil • 8. Furosemide • 9. Lasix • 10.Coreg • 11. Zestril • 12. Vasotec • 13. Lopressor • 14. Levatol • 15. ……anybody

  35. Cardiovascular Referral • Family • Internal Medicine • Cardiology • Surgeons - Perioperative • Hospitalist

  36. Cardiovascular Intake • Oxygen? • Get both Family and Specialists • Last Hospitalization? • Medications and average BP

  37. Cardiovascular Night of Study • 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

  38. Cardiovascular Record • Irregular EKG • PVCs, PACs, V-Tach, A-Fib, Pauses • Full or Partial Heart Block • Breaks in record-Diuretics/Lazix Insomnia from Anxiety Cheyne Stokes Breathing Pattern – 73% in CHF patients • Left ventricular dysfunction-Hyper and Hypo ventilation • Waxing and Waning breathing pattern • Pacing Spikes • OSA and CSA • CSA sometimes evoked by O2 and PAP, Auto Servo Ventilation

  39. Cardiovascular OSA Overlap • 1. Elevated Blood Pressure during Sleep • 2. Elevated Sympathetic Tone leads to HBP • 3. About 30% of patients with hypertension have OSA • 4. Congestive Heart Failure well documented connection • 5. Left ventricle enlargement/increased workload/events • 6. Effects are both acute and chronic • 7. Cessation of airflow and subsequent desat starves heart of oxygen. • 8. PAP Treatment is shown to have positive effect on all • 9. Heart Failure associated with Cheyne Stokes Pattern • 10. OSA occurs in 50% of atrial fibrillation patients

  40. Stroke • 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

  41. Stroke Onset Symptoms • Sudden Slurring of Speech • Muscle control deficit in face/body affecting one side or bilaterally

  42. Stroke Medications • Anti-platelet • Aspirin • Plavis/Clopidogrel • Ticlid/Ticiopidine • Anti-clot • Warfarin/Coumadin • Heparin-Hospital via IV • Acute Phase • Thrombolytic Agents-”Clot Busters”

  43. Stroke Patient Referral Sources • Family • Internal Medicine • Neurology • Hospitalist • Case Managers • CRNPs

  44. Stroke Intake • 1. Hemorrhagic • 2. Ischemia (TIA) or Embolic • 3. Left or Right Side Deficit • 4. Speech? • 5. Ambulatory ? 6. Aide or Family Member 7. Time of Day or Night –Triggers

  45. Stroke Night of Study • Left side Right side? • Full 10-20? • Fall Risk? • Medication Schedule? • BP in the evening and morning • Medical Director Parameters for BP • Time of Day/Night-Triggers

  46. Stroke Patient Record Aspects • 1. Left Side or Right Side EEG differences • 2. Non-Homologous electrodes can cause voltage asymmetries. • 3. Measure, Measure, Measure • 4. Do not eye-ball EEG set-up • 5. Full 10/20 frequently ordered

  47. Stroke Patient OSA Overlap • 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.

  48. Gastroesophageal Reflux(Gerd) • 1. Human PH – 1 TO 14 • 2. Arterial PH – Normal 7.35 – 7.45 • 3. Stomach PH – 4 or less • 4. Adults and Infants • 5. Apnea causes Reflux or is Reflux causing Apnea? • 6. Heartburn most common symptom • 7. Chronic Illness 5-7% Worldwide • 8. Middle Age-Esophageal Valve Weakens • 9. Opening pressure of that valve?? PAP concerns?

  49. Reflux/Gerd Medications • 1. Zantac • 2. Reglin • 3. Nexium-Purple Pill • 4. Pepto-Bismol • 5. Ranitidine • 6. Lansoprazole • 7. Famotidine • 8. Simethicone • 9. Gavison • 10. Maalox • 11. Mylanta • 12. Prevacid • 13. Pepcid • 14. Tums

  50. Reflux/Gerd Referral Sources • Family • Internal Medicine • Cardiology • Gastroenterologists • Neonatologists • Pediatricians

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