Sleep Apnea
And Conditions seen in the ICU
Sleep Basics
Some Definitions
Obstructive Sleep Apnea OSA
Central Sleep Apnea CSA
Excess Daytime Somnolence EDS
Polysomnography PSG (Sleep Study)
Continuous Positive Airway Pressure CPAP
Epworth Sleepiness Scale a screening
questionnaire ESS
 Berlin Screen a set of questions to
determine the risk of OSA
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Sleep Basics
 MOST
OF US SPEND ONE
THIRD OF OUR LIVES
ASLEEP
 PS
WHAT IS 1/3 OF 24
HOURS (HINT IT IS NOT 4
OR EVEN 6)
SLEEP IS ESSENTIAL TO HEALTH
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Infant
One Year
Two Years
Ten Years
Adolescents
Adults
16 Hours
13 Hours
12 Hours
9-10 Hours
9-10 Hours
7-8 Hours
Normal Sleep times
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THE MOST COMMON
CAUSE OF TIREDNESS
IS INSUFFICIENT OR
POOR QUALITY SLEEP
YOUR SLEEP AMOUNT
IS ADEQUATE WHEN
YOU CAN GET
THROUGH YOU DAY
WITHOUT TIREDNESS
DAYTIME
SOMULENCE
THERE ARE SCALES SUCH AS
THE EPWORTH SLEEPINESS
SCALE TO QUANTIFY THIS
SYMPTOM.
THE EPWORTH SCALE ASKS
YOU TO QUANTIFY HOW
LIKELY YOU ARE TO DOZE OFF
IN SITUATIONS SUCH AS
READING, WATCHING TV,
RIDING IN A CAR, SITTING
QUIETLY AFTER LUNCH.
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Stable bed time and awakening time
Morning Bright Light (Sun works)
Daily activity (exercise in AM or before
dinner)
Dark and comfortable bed room, avoid TV,
computers, phones, games
Only relaxing activities before bed
Sleep Hygiene
Naps
Alcohol, caffeine, nicotine
Evening bright light
Exercise within 3 hours of bed
Big meals within 3 hours of bed
Noise or excessive heat/cold in bedroom
Use bed for anything other than sleep or
sex
 Clock watching or trying to force sleep
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Sleep Hygiene What Not to Do
COPD
And Sleep Apnea
COPD
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Prevalence 7-19%
worldwide (1/5 > 30
who have smoked
over 10 years)
Men: Women 2:1
Lifetime Risk ¼
Age > 50 years
Groups at Risk
OSA
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Prevalence 4% men,
2%women
75% undiagnosed
Weight 10% weight
gain gives 6 fold rise in
OSA
Middle age up to 65 is
peak
Obese teens can need
CPAP
COPD
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Airflow Obstruction
Low FEV 1
Nocturnal
Desaturation
Daytime Hypoxemia
Pulmonary
Hypertension
Definitions
Obstructive Sleep
Apnea
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Repetitive airflow
cessation or
reduction
Airway collapse
Nocturnal
desaturations
Pulmonary
Hypertension
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Of patients with OSA 10-15% will have the overlap
syndrome
Spirometry shows Obstruction
Rates of hypoxemia, hypercarbia and Pulmonary
hypertension are all increased over uncomplicated
OSA patients
Hypercarbia occurs at a lower BMI and AHI than
Obesity Hypoventilation
Hypercarbia occurs at a higher FEV 1 than in pure
COPD
Intermittent hypoxemia promotes atherosclerosis
Lee,R. McNicholas, W.T Cur Opin Pulm Med 2011,
17(2) 79-83.
Overlap Syndrome
Stroke
And Sleep Apnea
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Sleep Heart Health Study
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5422 Participants over 40 followed for 8.7 yrs.
Stroke risk almost 3 times higher for men with
AHI above 19. In men the risk increased as the
AHI increased.
Women had an increased risk if the AHI was
above 25
These numbers held up when controlled for other
stroke risk factors (Am J Resp Crit Care Med.
4/25/10)
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Stroke and Sleep Apnea
Sleep Apnea is found in 9% of acute
stroke patients in some studies
 In a MRI study of Clinically Silent Infarcts
58% had severe OSA. In fact the higher
the AHI the more likely they were to have
CSI
 With Chronic Microvascular Changes on
MRI 38% had Severe OSA
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(High Rate of Sleep Apnea in Patients with Silent Strokes.
Medscape. Feb 02, 2012)
Stroke and Sleep Apnea
Congestive Heart
Failure
And Sleep Apnea
Sleep Heart Health Study
 In men 40-70 with AHI above 30: 68%
more likely to develop CHD (MI,
Revascularization or death)
 This same group was 58% more likely to
get CHF than those without OSA
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(The Sleep Heart Health Study, Circulation
2010)
CHF and OSA
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Sleep Disordered Breathing is identified in
70% of Decompensated CHF patients
Central Sleep Apnea predicted elevated
readmission rates at 3 and 6 months and a
2/3 increase in 3 year mortality
Sleep Apnea worsens Acute HF outcomes:
testing for it at Admission proposed.
Medscape. Oct4, 2013. Abstract from Heart
Failure Society of America Meeting
9/23/2013;Orlando FL.
CHF and OSA
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In a recently published Korean Study the
Hazard Ratio for Cardiovascular Mortality
was elevated 4.66 times by an AHI >30.
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All cause Mortality in the same group was
elevated 2.47 times.
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Lee, J.E. et al. J. Clin Sleep Med 2013,
9(10) 997-1002
Cardiovascular Mortality and OSA
Atrial Fibrillation
And Obstructive Sleep Apnea
Do they Coexist or is there a Causative
Effect
 Severe OSA patients are more likely to
have AF than would be predicted by
chance. Range Gami 17% > controls,
Bitter 42.7% OSA prevalence in AF
patients, Braga 81.6%
 OSA patients are more likely to have
recurrent AF and it recurrence post
cardioversion.
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Atrial Fibrillation and OSA
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CPAP treatment decreases recurrence post
cardioversion rates
The worse the OSA the higher the recurrence
rate
CPAP reduces the recurrence rate by half
Even with catheter ablation OSA patients
have a 40% recurrence rate
(Lettieri, Christopher. The Relationship
Between OSA and AF:Guidance for Clinicians.
Medscape. Dec 19, 2012.
Atrial Fibrillation and OSA
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We all know that Obesity can lead to OSA
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Just as likely OSA may worsen
OBESITY
 OSA worsens how the liver handles
glucose and is linked to glucose
intolerance. It is also linked to
disorders of fat metabolism.
 Intermittent hypoxemia can
promote insulin resistance and
hyperlipidemia
Sleep Apnea and Obesity
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New Data
Leptin (from fat cells and signals the brain
you are full)
Ghrelin (from your stomach tells your
brain you are hungry)
When you are sleep deprived your Leptin
is reduced and your Ghrelin is elevated)
So you eat and you crave high fat and
high calorie foods
Sleep Apnea and Obesity
Traffic Accidents
And Sleep Apnea
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Remember 92% of OSA patients are undiagnosed
It may Occur in 24% of Adult Males
Tiredness affects reaction time, lane position and
steering
OSA patients are 2-15 time as likely to have an
accident as the general population
With an AHI of 10 or more the risk of an accident
goes up 6.3 times
The FAA says the performance degradation of
mild to moderate OSA can equal BAL 0.08%
Teng and Won. Clin in Chest Med 33(2012) 73144.
Traffic Accidents and OSA
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In a recent Australian Study there was an
increased rate of near-misses in men and
women with untreated obstructive sleep
apnea. The risk of motor vehicle crashes
was higher in men. The higher the
sleepiness score the higher the risk of
crashes.
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Ward, KL et al. J. Clin Sleep Med 2013
9(10) 1013-1021.
Traffic Accidents and OSA
Gottleib, DJ et al. Prospective Study of OSA and
Incident Coronary Artery Disease and Heart
Failure. Circulation 2010:(122)352-360
Nainggolan, L. Sleep apnea Linked to Heart Failure
in Men, But Not Women. Medscape. Jul 14, 2010.
Stiles, S. Sleep Apnea Worsens Acute HF
Outcomes; Testing for it at Admission Proposed.
Medscape Oct 4, 2013.
Lettieri, C. The relationship Between Obstructive
Sleep Apnea and Atrial Fibrillation: Guidance for
Clinicians. Medscape. Dec 19, 2012.
References
Lee, J. et al. Mortality of Patients with
Sleep Apnea in Korea. J. Clin Sleep Med
2013:9(10) 997-1002.
 Lee, R., McNicholas, WT, Obstructive Sleep
Apnea in COPD patients. Cur Opin Pulm
Med. 2011:17(2):79-83.
 Teng, AY and Won, C., Implications of OSA
on Work and Work Disability Including
Drivers. Clin Chest Med: 33(2012) 73144.
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References
Anderson, P.: High Rate of Sleep Apnea in
patients with Silent Strokes. Medscape.
Feb 2, 2012.
 Kelly, J.C.: Mild to Moderate Sleep Apnea
Increases Stroke Risk. Medscape. April
15, 2010.
 Ward, KL et al. Excessive Daytime
Somnolence Increases the Risk of Motor
Vehicle Crash in Obstructive Sleep Apnea.
J Clin Sleep Med2013,9(10) 1013-1021.
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References