Obstructive Sleep Apnea (OSA) Ryan Pavlovich, M.D., Ph.D. Medical Director, NSA Sleep Medicine

Important CME Information DISCLOSURE INFORMATION: The planners of this activity and the speaker, Ryan Pavlovich, MD, PhD, do not have affiliations with any corporate organizations that may constitute a conflict of interest with this presentation. CME CREDIT: Attendees must sign in to receive the online evaluation survey for this presentation. CME Credit will only be issued to attendees who complete the evaluation survey within the next 30 days.

OSA Process for Diagnosing OSA Limitations of Ambulatory Sleep Testing Follow up for Sleep Apnea New guidelines for commercial drivers Contact Information

WatchPat Class Set Up:

A typical class held twice daily

Respiratory therapist after getting berated by a patient inappropriately booked in the class:

PROCESS FOR DIAGNOSING OSA

Econsult Page: To Facility: Vacaville To Specialty: Sleep Lab Problem/Reason: Sleep Apnea Referral Guidelines: Adult Referrals Only This appointment is for patients with signs/symptoms of (OSA) obstructive sleep apnea with NO prior diagnosis. READ THE OPTIONS CAREFULLY. THE OPTION YOU CHOOSE WILL DETERMINE IF THE PATIENT RECEIVES THE CORRECT TESTING DEVICE Please inform the patient that the testing device must be returned the next day (or Monday for an appointment on Friday)

QUESTION 4. 4. In order to determine an appropriate testing method, please select the following items that apply: Pacemaker/implantable defibrillator (AICD) CHF <18 yrs old Inappropriate for group setting Spanish speaker, Patient unable to hold short acting nitrates and/or alpha blockers for five days prior to appointment.

5. READ THIS QUESTION CAREFULLY 5. READ THIS QUESTION CAREFULLY. THE OPTION YOU CHOOSE WILL DETERMINE IF THE PATIENT RECEIVES THE CORRECT TESTING DEVICE Takes short acting nitrates &/or alpha blockers that CANNOT be held five days prior to this study. Takes short acting nitrates &/or alpha blockers that CAN be held five days prior to this study. Patient not currently taking short acting natrates &/or alpha blockers.

Alpha Blockers include: Flomax/Tamsulosin Hytrin/Terazosin Cardura/Doxazosin Minipress/Prazosin Uroxatral/Alfuzosin Rapaflo/Silodosin Catapres/Clonidine Aldomet/Methyldopa Alpha Blockers interrupt the detection of the Stage of sleep with a standard watchpat. These will render the WatchPat test inaccurate

Limitations of a Three Channel Home Ambulatory Slee Test (WatchPat)

Limitations of WatchPat WatchPat Sleep Tests are of questionable validity in the following patients: Alpha Blockers: The Watchpat extrapolates stage of sleep by an algorithm that evaluates peripheral vasodilation. Alpha blockers increase vasodilation and make the study invalid. CHF: A watchpat does not differentiate between obstructive and central sleep apnea. These patients require evaluation for both central and obstructive sleep apnea which requires testing capable of monitoring air flow and effort. Group Setting: Patients who are directly booked through this page are placed in a classroom and a WatchPat device is programmed for them. The respiratory therapist instructs the patient on placing the device and how to return it to us.

NOOOOOooooooooooooo!

To Facility: Vacaville To Specialty: Sleep Lab Problem/Reason: Other “If patient has a known diagnosis of sleep apnea and requires treatment advice, please go to problem reason OTHER” Diagnosed with MILD OSA, Wants to Try CPAP Previous Dx of OSA at KP AND documented in HC who previously refused/intolerant/never treated, now wants to try CPAP New to KP with documented (not pt states) OSA who needs new CPAP/BiPAP CPAP not working Wants to try ORAL APPLIANCE

Follow up for sleep apnea

Follow up on Positive Pressure Therapy “Too much pressure” “CPAP not working” “I have an Air Leak” “I’m still tired during the day” *These patients rarely need a repeat sleep study.

Resmed Airview

New guidelines for commercial drivers

Question 3. Indication For Study: Work related or DMV regulation “Chain of Command”

OSA and commercial drivers Federal Motor Carrier Safety Administration (FMCSA) 37 pages recommendations manual “May require physicians to provide proof for CPAP compliance”

OSA and commercial drivers Initial acceptable compliance is defined as at least 4 hours/ day on at least 70% of days in a two-week period For yearly recertification, these patients are now required to show proof of CPAP usage for at least 70% of the year (minimum 4 hours per night) FOR THE ENTIRE YEAR.

Contact Information Ryan Pavlovich M.D., Ph.D. Medical Director Sleep Medicine Kaiser Permanente Napa Solano Ryan.Paul.Pavlovich@kp.org 707 651 5619 Office 707 724 0564 Cell

REMINDER ABOUT CME CREDIT Attendees must sign in to receive the online evaluation survey for this presentation. CME Credit will only be issued to attendees who complete the evaluation survey within the next 30 days.

Diagnostic studies

Available Sleep Studies WatchPat Embletta Nox-3 Polysomnogram

Watch-PAT

Peripheral Arterial Tone (PAT) technology Measures peripheral vascular responsiveness, finger blood flow and oxygen saturation Detects transient elevation in peripheral resistance and heart rate which correlates with arousal and OSA Studies have shown a high correlation with attended polysomnogram in AHI, lowest O2 saturation and sleep time

Contraindication for using Watch-PAT Permanent pacemaker Taking an alpha blocker or short-acting nitrates Concern for central sleep apnea (CHF, opioid use) Evaluation for anything other than obstructive sleep apnea. !!!!Only the WatchPat tests are available for direct booking.

Embletta

Nox-3

Polysomnogram