OBJECTIVES
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Recognize risk factors for OSA
Recognize potential complications of OSA
Know how diagnose OSA
Discuss treatment options
Snoring can be more than just noise!!
New Insights to Obtructive Sleep Apnea
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Sheila Y. Garris, M.D., F.A.C.P., F.A.S.H.
Associate Professor Clinical Internal Medicine, EVMS
Certified Clinical Hypertension Specialist
President, Contemporary Medicine Specialists
Past President Leadership Board ADA Hampton Rds
Epidemiology
• Current Environment
33% of adults are
at risk for OSA
– OSA prevalence and importance
– 4-7% adults affected
– Men:women =10:1
– 80-90% undiagnosed
– Most affected age 40-70 with an
Increase in prevalence by 7-20% ages 3560
--Perimenopausal/menopausal women
more affected and is offset by ERT
therefore gender difference is offset by
age.
--Can affect children
OSA is a Largely Undiagnosed Epidemic
• 18 million suffer (prevalence similar to Diabetes)
• 85% have not been diagnosed
Diabetes and OSA Prevalence is Similar
20
Undiagnosed
10
Diagnosed
Millions of
Americans
(Adults)
Diabetes
Young 2002, 1997
OSA
Risks
Elevated Risk Factors
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Male, overweight BMI>30
Over 40 years of age
Neck size 17 or greater
Family history of OSA
Smoking
Excessive alcohol use
Ethnic origin: African American, Hispanic
Small oralpharynx
Definition
• A condition of frequent episodes breathing pauses.
• Pauses due to sleep induced complete or partial
airway collapse.
• Often results in O2 desaturation.
OSA Deprives Organs of Oxygen
• “Apnea” – Greek for “without breath”
• Blockage of airway during sleep – relaxed throat
muscles allow soft tissue to collapse
• Temporary suspension of breathing for 10+ seconds
• Airflow interruption occurs as often as 100 times/night
• Organs deprived of oxygen – heart overworks to
compensate
Common Signs of Sleep Apnea
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Loud or disruptive snoring
Gasping or choking during sleep
Restless sleep
Loss of energy
Excessive daytime sleepiness
Morning headaches
Dry or sore throat
Depression, irritability or difficulty concentrating
High blood pressure
Weight gain
ADHD in children/behavioral problems /poor grades
OSA Increases Co-Morbid Health Risks
• OSA is an independent risk factor for HTN & Type II DM
% Disease Co-morbidity with OSA
Obesity
40%
Wolk et al 2003
Depression
50%
Smith et al 2002,
Schroder et al 2005
CHF
Diabetes
50%
50%
Einhorn ADA 2005
Stroke
Javaheri et al 1999,
Somers et al 2007
Hypertension
35%
50%
Sandberg et al 2008
= With OSA
Sjostrom et al 2004
• Left undiagnosed, OSA increases risk of stroke by 2X, risk of fatal
cardiovascular events by 5X, and risk of serious vehicular accidents
Sources: Yaggi et al, NEJM 2005; Young et al, Sleep 2008; Teran-Santos, NEJM 1999
Pathophysiology
• Apneic episodes result in sleep disturbance=sleep
loss
• This causes an increase in sympathetic tone and
inflammation and endothelial dysfunction resulting
in increased oxidative stress leading to increases in
blood pressure
• Sleep loss also causes increase in insulin resistance
possibly leading to an increase in blood glucose
Pathophysiology
osa
Sleep
disturbance
BMI
OSA Impacts QOL and Cost of Care
• Aggravates / causes
- Gastroesophageal reflux GERD
- Obesity (cortisol release from apnea events)
- Headaches
- Frequent urination
- Erectile dysfunction
- Cardiac arrhythmias
- Cognitive impairment
• In aggregate, these generate significant medical
expense
Excessive Fatigue Can Lead to Poor Performance
WORK
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Absenteeism: Employees suffering from OSA are absent
almost 3 times as long as peers Servera and Signes-Costa 1995
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Productivity: Productivity levels of employees suffering
from OSA are 20% lower than their colleagues Ulfberg 1996
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Retention: Employees treated for OSA are 2.3 times less
likely to change jobs Berger 2005
MOTOR VEHICLE •
OPERATION
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People with OSA have a 15 fold increase of being involved
in a traffic accident Horstmann 2000
Treating all drivers suffering from OSA would save $11.1
billion in collision costs and 980 lives annually Sassani 2004
Primary Care Physicians: “Front Line” for OSA Management
SSI focuses on training PCPs to diagnose & treat OSA, because
most co-morbid at-risk patients are already in their care.
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37.5% of patients in PCP practices have signs of sleep disorder and should
be screened for OSA risk assessment Netzer 1999
At diagnosis, avg. OSA patient has been symptomatic for ~7 years
– Has seen FP ~17 times & sub-specialist ~9 times Rahaghi 1999
“Knowing what we know about OSA and how it affects health & quality of
life, it is imperative that as PCPs on the front line, the diagnosis of OSA is
not missed and is appropriately treated.”*
Amit Khanna, MD, DABSM, DABFM
Medical Director of Charles Cole Mem.
Hospital Sleep Disorder Center
“We have to think of this as a lifelong illness…we will be managing it in a
new way…it requires primary care involvement – it cannot be managed by
Kingman P. Strohl, MD (IM /Pulmonologist)
specialists alone.” *
Professor of Medicine, Director of Center for
Sleep Education & Research, Case Western
Reserve School of Medicine
* From Understanding the Diagnosis & Treatment of OSA,
2009, Temple University School of Medicine, CME Course
Diagnosis
• Who should be screened?
• How are patients screened ?
• Physical exam
• Those with snoring with:
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1) daytime drowsiness &/or
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2) short term memory loss
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3) AM headache
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4) depression /mood alterations
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5) nocturia
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6) GERD, DM, CHF, IHD. RESISTANT HTN!!!
Diagnosis
• Two tests are available
• 1) Epworth sleepiness scale (see handout) score
>10 suggestive of sleep apnea-Used to evaluate
subjective sleepiness but not as effective as:
• 2)Berlin scale- has sensitivity of 88% with a
specificity of 77%
• Three categories:
• 1)snoring/stop breathing (pos if any one is pos)
• 2)fatigue after sleep /falling asleep while
driving/fatigue after sleep /falling asleep during
wakeful hours unintentionally (pos if any one is pos)
Diagnosis
• 3)resistant HTN/BMI>30
• If any 2 categories are pos then patient is at high
risk for having OSA
• PE
• Measure BMI with vitals
• Evaluation of upper airway (elongated
uvula/enlarged tonsils/low soft palate etc.
• Measure neck size
• Cardiopulmonary evaluation
Diagnosis
• Two types of lab evaluations
• 1) PSG-polysomography single night testing
• 2) HST-home sleep testing multi-night testing
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Both measure;
1) O2 desaturation
2) chest wall movement
3) apnea/ hypopneas
4) heart activity
5) air flow
6 ) snoring
PSG vs. HST
The home sleep test measures the same 5 essential channels
for diagnosing OSA as the lab PSG. Other PSG measurements
apply to non-OSA clinical evaluations.
IN LAB SLEEP STUDY
Must record at least
12 channels of
information if a AASMaccredited center
$$$
Other Metrics
OSA
STANDARD IN LAB SLEEP STUDY
Airflow
Airflow
Breathing Efforts
Breathing Efforts
Blood Oxygen
Blood Oxygen
Heart Activity
Heart Activity
Snoring
Snoring
Brain Waves
Eye Movements
Chin Movements
Leg Movements
Unusual Behavior
Body Position
Sleep Architecture
IN HOME OSA STUDY
HST captures only
what is necessary for
OSA diagnosis
> 90% of All Sleep Disorders Diagnosed Are OSA
$
Diagnosis
The diagnosis of sleep apnea is made if the AHI is >15
OR >5 with PMH of HTN/ stroke/ daytime sleepiness/
Insomnia/ IHD mood disorders
AHI=apneas+hypopneas/1hr must be at least 10 sec
long and associated with 4% desaturation
What Do Study Results Look Like?
Mild
AHI: 8.9
Moderate
AHI: 25.1
Severe
AHI: 95.9
Sample Sleep Study Reports
Limitations of PSG Lab Tests
Sleep labs were designed to perform comprehensive
measurement tasks, but not to be efficient at OSA diagnosis:
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Cost - $2,000-3,000 test – 3 to 4 times the cost of portable test
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Decreased accessibility
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Patient refusal to go to sleep lab for testing
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Completion rates – walk-outs, “1st night” effect (false negatives)
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Inability to sleep in lab
Limitations of HST
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Inadequate number of clinical trials
Best data in mild OSA patients with PSG
Does not avoid need for sleep lab
Can’t do split testing ie. Dx 1st four hours/CPAP
titration last four hours
Treatment
• Who should we treat?
• How should we treat?
• Treat all patients with an AHI>30 with CPAP,
BIPAP, APAP, or UPPP (if above not tolerated
/effective)
• All patients with AHI>5<30 with symptoms/with
symptoms/ co-morbid conditions.
• Dental devices in those with mild OSA ie., those with
symptoms with AHI>5 who are intolerant of CPAP
etc.
OSA Can Be Easily Treated
• Patients feel better and most health costs decrease
with CPAP treatment
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Heart Health: One month of CPAP improves daytime
blood pressure, heart rate and left ventricular function
Kaneko 2003
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Stroke and CHF: With CPAP treatment, stroke risk is
reduced 35% and CHF is reduced 20% Becker 2003
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Diabetes: After-meal blood glucose levels can be
reduced with compliant CPAP therapy Babu 2005
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Hypertension: Effective OSA therapy has been
associated with a 10mm Hg fall in blood pressure
Harsch
2004
… so why is OSA under diagnosed today?
The Tipping Point: CMS Approval of HST
Recent evaluations by Medicare, AHRQ, AASM & AAO have
validated the vital role of HST in OSA diagnosis:
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AHRQ comprehensive clinical literature review
New AASM Guidelines issued December 2007
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CMS coverage determination – CPAP with HST
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AAO-HNS statement applauding CMS decision
August 2007
March 2008
March 2008
Patients Now Have a Choice in Sleep Diagnosis and Treatment
“This is a great victory for patients who may suffer from OSA and the numerous medical issues caused
by sleep apnea,” said Academy spokesman Eric Mair, MD, who testified before CMS in support of
changing the national coverage determination. “Because home testing will now be an option, scores of
patients who may have otherwise gone undiagnosed will be able to seek the best treatment for
OSA, and hopefully see an improvement in their quality of life. With this change, CMS has taken a bold
step forward to overcome the limitations of the current system and ensure patients nationwide
have access to the best care available.”
Questions?
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References
Somers V, et al circulation 2003 107:2589=94
Flemons WW. N England J Med.2002
:347(7):498-504
Young T. et al. Arch Int Med. 2002;162:893—36
Punjabi N et al AM J Epidemiology
2004;160(6):521-30
Logan AG J HTN,2001;19:2271-7
Levie P, et al Eur Respir J. 2005;25:514-20
Institutes of Medicine Sleep disorders and sleep
deprivation: an unmet public health problem
American Academy of Sleep Medicine. Sleep
Apnea Fact Sheet 2008