Obstructive Sleep Apnea Julia Buchfuhrer, PGY-II Updated March 2018

Objectives Define OSA Recognize Risk Factors for OSA Know when to refer for PSG Know the available treatments for OSA

Case 52y/o obese gentleman comes into clinic complaining of being tired everyday. He often falls asleep at work or while driving home. He gets about 8 hours of sleep most nights and falls asleep right away. Vitals signs normal except BP 145/90 Physical exam BMI 40, enlarged neck All other labs normal including EKG

Case We’ll get back to him later…

What is OSA? Collapse of the oropharynx during sleep causing decreased airflow Includes spectrum from apneas to hypopneas to breathing related arousals Hypopnea defined as <88% oxygen saturation

More Pathophys Increased work of breathing against closed airway leads to arousals during sleep Patients often don’t remember these arousals Sleep arousals  poor quality sleep  daytime sleepiness

Chief Complaint Most often the patient’s complaint is excessive daytime sleepiness In the setting of 7+ hours of sleep at night If the patient is getting less than 7 hours of sleep at night, daytime sleepiness is likely due to this

When does OSA occur? REM SUPINE SLEEP most commonly, why? Pharyngeal airway muscles relaxed during REM sleep Neck habitus while supine physically collapses pharynx

Epidemiology 20-30% of male Americans 10-15% of female Americans THAT’S A LOT OF PEOPLE!

Risk Factors Age Gender: M>F Obesity, especially BMI >40 Small airway Large neck size

When to screen? Patient with concerning RFs and complaint of excessive daytime sleepiness How to screen? STOP-BANG Questionnaire RFs – risk factors Questionnaire on next slide

STOP-BANG Scoring <3 is low risk, 3-5 medium, 5+ high risk

Back to our patient 52y/o obese gentleman comes into clinic complaining of being tired everyday. He often falls asleep at work or while driving home. He gets about 8 hours of sleep most nights and falls asleep right away. Vitals signs normal except BP 145/90 Physical exam BMI 40, enlarged neck

What’s his STOP-BANG? Tired, BP, BMI, Age, Neck, Gender = 6 This is the key slide here, go through this thoroughly Tired, BP, BMI, Age, Neck, Gender = 6

So now what? Send for “sleep testing”, what is that? PSG = Polysomnographic study No need to go over this picture, just here for reference

Treatment - CPAP CPAP - the mainstay of OSA treatment Uses PEEP to open posterior oropharynx

Treatment WEIGHT LOSS! Decreases BMI, neck size, BP – 3 of the STOP-BANG A 2009 Randomized control trial showed 10kg weight loss lead to decrease in AHI by approx 10 (A LOT). P<.001

Summary Sleep apnea is collapse of the oropharynx during sleep causing reduced airflow Rougly ¼ of Americans have sleep apnea STOP BANG Questionairre > 3 = PSG Treatment = CPAP + weight loss

THE END! UpToDate.com. Accessed 3/5/2018. https://www.uptodate.com/contents/overview-of-obstructive-sleep-apnea-in-adults/abstract/30-36 Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial. Dixon et. Al. JAMA. 2012 Sep;308(11):1142-9.  A randomized study on the effect of weight loss on obstructive sleep apnea among obese patients with type 2 diabetes: the Sleep AHEAD study. Foster et. Al. Arch Intern Med. 2009 Sep;169(17):1619-26.  Effectiveness of lifestyle interventions on obstructive sleep apnea (OSA): systematic review and meta-analysis. Araghi et al. Sleep. 2013;36(10):1553. Epub 2013 Oct 1.  Continuous positive airways pressure for obstructive sleep apnoea in adults. Giles et al. Cochrane Database Syst Rev. 2006.