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Sleep Medicine Something Old / Something New. Glenn W. Burris, MD, MS, FAASM Medical Director The SOMC Sleep Diagnostic Center Portsmouth, Ohio. Learning Objectives.

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Sleep medicine something old something new

Sleep MedicineSomething Old / Something New

Glenn W. Burris, MD, MS, FAASM

Medical Director

The SOMC Sleep Diagnostic Center

Portsmouth, Ohio


Learning objectives
Learning Objectives

  • The learner will understand the basic components of a diagnostic polysomnogram and the speaker will explain the definitions of respiratory events used to calculate the Apnea-Hypopnea Index.

  • The speaker will present clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea

  • The learner will understand some of the health benefits of treating obstructive sleep apnea with nasal CPAP.


The study of sleep
The Study of Sleep

1834 – Robert McNish

“ Sleep is the intermediate state between wakefulness and death, wakefulness being regarded as the active state of all the animal and intellectual functions, and death as that of their total suspension.”


The study of sleep1
The Study of Sleep

1937 – Davis, Loomis, Harvey, Hobart - different stages of sleep were reflected in changes of the EEG

1953 – Asereinsky & Kleitman -Identification of Rapid Eye Movements during Sleep

1957 – Dement & Kleitman - Relationship between eye movements, body motility, and dreaming

1968 – Rechtschaffen and Kales (R&K) - standard sleep scoring technique

2007 – American Academy of Sleep Medicine - Manual for the Scoring

of Sleep and Associated Events


Polysomnogram
Polysomnogram

Continuous monitoring of physiology during sleep

  • Electroencephalogram (EEG)

  • Eye Movements

  • Nasal and Oral Air flow

  • Submental Muscle activity (EMG)

  • Respiratory Effort – Chest and Abdomen

  • Cardiac Rhythm

  • Leg Muscle Activity – tibialis anterior

  • Pulse oximetry

  • Snore Microphone

  • Video Monitoring


Polysomnogram1
Polysomnogram

Information is included in 30 second epochs


Polysomnogram2
Polysomnogram

Following completion of the study the information is scored:

  • Lights out

  • Sleep Latency – from lights out to onset of sleep

  • Sleep Stages

    • Non-REM – N1, N2, N3

    • REM

  • Sleep Efficiency – percentage of time asleep

  • Respiratory Events

  • Leg Movements

  • Arousals

  • Heart Rhythms

  • Snoring intensity

  • Lights on

  • Quality of patient’s sleep compared to baseline


Scoring respiratory events
Scoring Respiratory Events

Apnea – when all of the following criteria are met

  • There is a drop in the peak thermal sensor excursion by >90% of baseline

  • The duration of the event lasts at least 10 seconds

  • At least 90% of the event’s duration meets the amplitude criteria for apnea

  • Classified as: obstructive, central, or mixed based on respiratory effort

    Hypopnea – when all of the following are met

    1) The nasal pressure signal excursion drops by 30% of baseline

  • The duration of this drop occurs for a period of at least 10 seconds

  • There is a 4% desaturation from pre-event baseline

  • At least 90% of the event’s duration meets the amplitude criteria

    The AASM Manual for the Scoring of Sleep and Associated Events, 2007


Obstructive sleep apnea
Obstructive Sleep Apnea

Respiratory Disturbance Index (RDI) – no longer used

  • apneas, hypopneas, respiratory related arousals

    Apnea-Hypopnea Index (AHI)

  • total number of respiratory events / hours of sleep

    Severity of OSA defined by theAHI:

    less than 5 – not sleep apnea

    5 – less than 15 – MILD

    15 – less than 30 – MODERATE

    > 30 – SEVERE


Portable monitoring for osa in adults
Portable Monitoring for OSA in Adults

In home diagnostic test for OSA

Advantages

  • Convenience

  • Less costly

  • Attending technologist not required

    Disadvantage

  • Fewer physiologic variables that lead to misdiagnosis

  • Technical limitations (apparatus malfunction) = repeat studies

  • Validation of the device


Portable monitoring for osa in adults1
Portable Monitoring for OSA in Adults

Types of Monitoring Devices

Type 1 – in sleep center, attended, overnight polysomnogram

Type 2 – record same variables as type 1, unattended

Type 3 – evaluate four physiologic parameters – not sleep

respiratory movement and airflow

heart rate

arterial oxygen saturations

(snoring), (position)

Type 4 – evaluate one or two parameters (saturation and airflow)


Portable monitoring for osa in adults2
Portable Monitoring for OSA in Adults

Limitations of Type 3 devices

  • Apnea Hypopnea Index – abnormal breathing events by recording time as sleep can not be recorded

  • Unless the patient was sleeping the entire recording time, the AHI calculated by a portable monitor will likely be lower than an attended polysomnogram

  • Can not distinguish sleep stages


Portable monitors and osa
Portable Monitors and OSA

2005 Center for Medicare and Medicaid Services (CMS)

  • evidence was not adequate to conclude, tests remained uncovered

    2008

  • Reconsidered and will allow for coverage of CPAP therapy based on a positive diagnosis of OSA by home sleep testing

  • Must fulfill all requirements in the National Coverage Determination,

    CR6048

  • Clinical evaluation as a positive diagnosis from PSG or unattended, type 2, 3, 4(measuring at least 3 channels)

  • Diagnostic tests that are not ordered by the beneficiary’s treating physician and not considered reasonable and necessary


Portable monitors and osa1
Portable Monitors and OSA

Clinical Guidelines for the Use of Unattended Portable Monitors in the Diagnosis of Obstructive Sleep Apnea in Adults

Portable Monitoring Task Force of the American Academy of Sleep Medicine1

Clinical Guidelines for the Evaluation, Management, and Long-term Care of Obstructive Sleep Apnea in Adults2

1. J Clinical Sleep Medicine, Vol 3, 2007

2. J Clinical Sleep Medicine, Vol 5, 2009


Portable monitors and osa2
Portable Monitors and OSA

American Academy of Sleep Medicine Guidelines

  • Should be performed only in conjunction with a comprehensive sleep evaluation, preferably by a sleep medicine specialist

  • May be used as an alternative to PSG for the diagnosis of OSA in patients with a high pretest probability of moderate to severe OSA

  • Should not be used in patients who have comorbid medical conditions that predispose to sleep related breathing disorders

  • Must record air flow, respiratory effort and blood oxygen information


Portable monitors and osa3
Portable Monitors and OSA

Guidelines – cont

  • Experienced persons should educate the patient or directly apply the the monitoring equipment

  • Should be a method to monitor the quality of the recordings

  • Monitors must be capable of displaying the raw date for clinical review

  • All patients should have a follow-up visit with a provider able to discuss the results of the test



Obstructive sleep apnea1
Obstructive Sleep Apnea

Charles Dickens ( 1812 – 1870)

The Posthumous Papers of the Pickwick Club

  • Described Joe, a fat boy, who was always excessively sleepy.

    A loud snorer.

  • First reported in 1965 during the study of severely obese patients 1

    1. Brain Res 1965; 2: 167-186


Obstructive sleep apnea2
Obstructive Sleep Apnea

Wisconsin Sleep Cohort Study

Random, n=602, ages 30 – 60

Sleep disordered breathing as high as:

24% of men

9% of women

4% of men, 2% of women had symptomatic OSA

AHI - >5

Daytime hypersomnolence

NEJM 1993;328(17):1230-35.


Risk of osa in the us population
Risk of OSA in the US Population

Results from the National Sleep Foundation Sleep In America 2005 Poll

  • n= = 1506 adults (775 were women)

  • Mean age 49

  • Berlin Questionnaire

  • 26% of respondents (31% of men and 21% women) found to be at high risk of OSA

    As many as one in four American adults could benefit from an evaluation for OSA!

    CHEST 2006; 130: 780-786


Identifying patients with osa
Identifying Patients with OSA

Clinical Presentation

  • Threshold to symptoms highly variable

  • Insidious

  • Unaware or underestimate their degree of impairment

  • Elderly patients aware of frequent awakenings

  • Complaints of insomnia and unrefreshing sleep

  • Excessive body movement, kicking in sleep

  • Decrements in short-term memory

  • Moodiness, irritability


Identifying patients with osa1
Identifying Patients with OSA

Clinical Presentation – cont

  • Lack of concentration

  • Anxiety / depression

  • Morning headaches – up to 50%

  • Sensation of choking / dyspnea

  • Decreased libido and impotence

  • GERD, worse at night

  • Nocturia, 28% of patients report 4 to 7 episodes of nightly


Obstructive sleep apnea3
Obstructive Sleep Apnea

“My wife made me come!”


Obstructive sleep apnea4

Cardiovascular disease

Hypertension

Coronary Artery Disease

Stroke

Arrhythmia

Pulmonary Hypertension

Congestive Heart Failure

Hematological

Platelet Activation

Hypercoaguable state

Neurological

TIA

Stroke

Daytime Fatigue

Memory / Intellectual impairment

Morning Headaches

Gastrointestinal

GERD

Fatty Liver

Metabolic

Altered Leptin Levels

Poor Gylcemic Control

Rapid Weight Gain

Psychological

Depression

Irritability / Mood Changes

Nocturnal Panic Attacks

Bed partner Relationships

Genitourinary

Impotence

Nocturia

Renal

Proteinuria

Focal Segmental Glomerulosclerosis

Immune

Elevated TNF-a Decreased IgM

Elevated IL-6 Decreased NK cells

Increased C3

Inflammation

C-reactive protein

Obstructive Sleep Apnea



Berlin questionnaire1
Berlin Questionnaire

A means of identifying patients with sleep apnea

  • n = 744 adults completed the questionnaire

  • 279 were in a high-risk group

  • 100 patients (equal representation of high and low risk group) underwent a portable sleep study

  • Being in the high-risk group predicted an RDI of greater than 5 with a sensitivity of 0.86 and a specificity of 0.77

    Ann Intern Med, 1999, 131: 485-491


Obstructive sleep apnea5
Obstructive Sleep Apnea

Physical exam of the Upper Airway

Lack of consensus in describing the physical findings

Nose

  • Nasal Obstruction

    Oropharynx

  • Mallampati Class

    Retrognathia

  • Risk of narrow airway at the base of the tongue


Mallampati class
Mallampati Class

Scoring is as follows:

Class 1: Full visibility of tonsils, uvula and soft palateClass 2: Visibility of hard and soft palate, upper portion of tonsils and uvulaClass 3: Soft and hard palate and base of the uvula are visibleClass 4: Only Hard Palate visible

Can Anaesth Soc J, 1985 Jul; 32(4) 250-1


Mallampati class1
Mallampati Class

Mallampati Score as an Independent Predictor of Obstructive Sleep Apnea

n=137

80 (58%) had OSA as defined as AHI 5 or greater

Likelihood Ratio

Class I - 4 of 12 patients 0.4

Class II - 24 of 50 patients 0.7

Class III - 45 of 65 patients 1.6

Class IV - 7 of 10 patients 1.7

For every increase in Mallampati Score by one,

  • increased odds of having OSA by about 2 fold

  • the AHI increased by more than 9 events / hour

    Sleep 2006; 29 (7) 903-908


Obstructive sleep apnea hypertension
Obstructive Sleep Apnea - Hypertension

Sleep Heart Health Study

Multicenter Study, n= 6132

Age > 40 years, 53% female

AHIHypertension

<1.5 43%

1.5 – 4 53%

5 -14 59%

15 – 29 62%

>30 67%JAMA 2000;283:1829-1836

JNC 7 – OSA identifiable cause of hypertension

JAMA 2003; 289: 2560-2572


Obstructive sleep apnea hypertension1
Obstructive Sleep Apnea - Hypertension

Treatment of OSA with CPAP can Improve Hypertension

17 hypertensive patients, 7 normotensive patients

Moderate to severe OSA (AHI 60 +/- 19)

Four to six months CPAP

NEJM 2000: 343:967


Obstructive sleep apnea congestive heart failure
Obstructive Sleep Apnea – Congestive Heart Failure

OSA in Dilated Cardiomyopathy: The effects of CPAP

N = 8

Dilated cardiomyopathy and severe OSA (AHI 54)

BaselineCPAP

Left ventricle ejection fraction 37% 49%

Stopped CPAP for one week 53% 45%

Lancet 1991; 338:1480-4


Obstructive sleep apnea cardiac remodeling
Obstructive Sleep Apnea – Cardiac Remodeling

Effects of Continuous Positive Airway Pressure on Cardiac Remodeling as Assessed by Cardiac Biomarkers, Echocardiography, and Cardiac MRI

  • Prospective Study, n = 52, years 2007-2010

  • AHI > 15, Epworth Sleepiness Score >10

  • Evaluation before CPAP, 3 mos, 6 mos and 12 mos

  • At each visit: TnT, CRP, and NT-proBNP levels, and a standard TTE

  • CMR at baseline and 6 and12 months after the initiation of CPAP treatment.

    CHEST 2012; 141(3):674–681


Obstructive sleep apnea cardiac remodeling1
Obstructive Sleep Apnea - Cardiac Remodeling

  • Following 12 months of CPAP therapy, levels of CRP, NT-proBNP, and TnT did not change

  • As early as 3 months after initiation of CPAP, TTE revealed an improvement in right ventricular end-diastolic diameter, left atrial volume index, right atrial volume index, and degree of pulmonary hypertension, which continued to improve over 1 year of follow-up.

  • Left ventricular mass, as determined by CMR, decreased from

    159 g/m 2 to 141 8 g/m 2 as early as 6 months into CPAP therapy and

    continued to improve until completion of the study at 1 year.

    CHEST 2012; 141(3):674–681


Obstructive sleep apnea diabetes
Obstructive Sleep Apnea - Diabetes

CPAP Therapy of Obstructive Sleep Apnea in Type 2 Diabetics Improves Glycemic Control During Sleep

  • n=20, type 2 diabetes and newly diagnosed OSA

  • measured glucose levels every five minutes during sleep

  • baseline and after treatment with CPAP (average 41 nights)

    • Mean glucose decreased in 10 of 11 subjects with glucose > 100mg/dL

    • No decrease in subjects with glucose < 100mg/dL

      J of Clin. Sleep Med. Dec 15, 2008


Obstructive sleep apnea diabetes1
Obstructive Sleep Apnea - Diabetes

Impact of Untreated Obstructive Sleep Apnea on Glucose Control in Type 2 Diabetes

  • n = 60, 14 without OSA, 46 with OSA

  • Controlled for: sex, race, BMI, waist circumference, Hgb A1C, year of diagnosis, medications (insulin and oral), exercise, hypertension and snoring.

  • Increasing severity of OSA was associated with poorer glucose control.

    Am J RespirCrit Care Med Vol 181. pp 507–513, 2010


Obstructive sleep apnea diabetes2
Obstructive Sleep Apnea - Diabetes

Compared to controls the mean HbA1c:

  • Mild OSA - increased by 1.49% (P= 0.0028)

  • Moderate OSA - increased by 1.93% (P= 0.0033)

  • Severe OSA – increased by 3.69% (P< 0.0001)

  • Linear Trend (P< 0.0001)

  • inverse relationship between OSA severity and glucose control

    in patients with type 2 diabetes

    Am J RespirCrit Care Med Vol 181. pp 507–513, 2010


Obstructive sleep apnea mortality
Obstructive Sleep Apnea – Mortality

One of the first reports of adverse consequences was published 1988

8 year study, n=385

severe OSA compared to less severe OSA (AHI >20, <20)

significant increase in all cause mortality (death)

change in mortality corrected by tracheostomy and CPAP

CHEST 1988; 94:9-14


Obstructive sleep apnea mortality1
Obstructive Sleep Apnea - Mortality

Sleep Apnea as an Independent Risk Factor for All-Cause Mortality:

The Busselton Health Study

Sleep Apnea diagnosed

Screened 380: 18 had moderate to severe OSA

77 had mild OSA

followed up to 14 years

6 of the 18 died 33% (moderate to severe OSA)

5 of the 77 died 6% (mild OSA)

SLEEP 2008 Vol 31, No 8


Obstructive sleep apnea mortality2
Obstructive Sleep Apnea – Mortality

Sleep Disordered Breathing and Mortality: Eighteen-Year

Follow-up of the Wisconsin Sleep Cohort

n= 1546, mean observation period of 13.8 years

AHI n Deaths

0 < 5 1157 46 (4%)

5 - <15 220 16 (7.3%)

15 - <30 82 6 (7.0%)

>30 63 12 (19.75%)

Cardiovascular death – 42% of persons with severe OSA

26% of persons without OSA

SLEEP 2008 Vol 31, No 8


Clinical pearls
Clinical Pearls

  • Obstructive Sleep Apnea is a common medical condition that contributes significantly to a multitude of comorbid diseases

  • Presenting symptoms are heterogeneous and clinical evaluation should be frequently considered

  • Untreated OSA in intimately related to worsening of many medical conditions

  • Identification and treatment of OSA has a positive impact on individual health and health care resources



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