Presentation is loading. Please wait.

Presentation is loading. Please wait.

A PRACTICAL APPROACH TO YOUR PATIENT WITH SLEEP APNEA

Similar presentations


Presentation on theme: "A PRACTICAL APPROACH TO YOUR PATIENT WITH SLEEP APNEA"— Presentation transcript:

1 A PRACTICAL APPROACH TO YOUR PATIENT WITH SLEEP APNEA
TEHMINA BADAR, M.D., F.C.C.P.

2 FORMAT Signs and Symptoms Medical Sequelae Treatment
Who needs a sleep study? What kind of sleep study to order? Reports Follow up Difficult patients

3 DEFINITIONS Obstructive Apnea-a cessation of airflow-at least 10 s w/ continued effort to breathe Central Apnea-apnea w/ no effort to breathe Mixed Apnea-apnea begins as central but towards end there is effort to breathe without airflow Clinical definitions and research definitions

4 DEFINITIONS Hypopnea-variable
CMS approved-at least a 30% reduction in thoracoabdominal movement or airflow as compared to baseline lasting at least 10 seconds and with > 4% drop in SpO2 Or w/ arousal? Frequency of apneas and hypopneas per hour of sleep=“apnea-hypopnea index”-AHI Several clinical definitions exist and clear consensus

5 Signs and Symptoms Cardinal symptom-daytime sleepiness
Sleep fragmentation due to repetitive arousals Chronic fatigue or tiredness-? females Ann Intern Med 1995;122. Snoring Common Frequently disrupts bedpartner Witnessed apneic episodes (breathing pauses) Not all pts EDS esp women

6 Signs and Symptoms Awakening w/ headache Arch Int Med 1997;159.
Impotence Awakening w/ dry throat Awakening gasping for air or w/ smothering sensation Restless sleep Memory impairment-often ?aging Lower scores on neurocognitive testing Am J Resp Crit Care Med 1997;156.

7 SEQUELAE Cardiovascular Metabolic Systemic HTN Pulmonary HTN
Cardiac arrhythmias Transient ischemic attack/stroke Metabolic Glucose intolerance/diabetes

8 SEQUELAE Other Motor Vehicle Accidents Traffic citations
Neurocognitive impairment Mood Disorders

9 SEQUELAE Arrhythmias and conduction disturbances usually resolve w/ tx of OSA Thorax 199;53. Am J Respir Crit Care Med 1991;151. Increased prevalence in CHF w/ prevalence 5-37% Resp Physiol Neurobiol 2003;136 Diastolic dysfunction seem to be more commonly associated w/ OSA Chest 1997;111.

10 SEQUELAE In pts who present to hospital w/ TIA/CVA prevalence of OSA very high Neurology 1996;47. Stroke 1996;27. Sleep Heart Health Study-strongest association b/w CVA and OSA than any other CV disease Am J Respir Crit Care Med 2001;163. Pts w/ concomitant CVA and OSA have a worse functional outcome and higher mortality Stroke 1996;27.

11 SEQUELAE Higher no. of at fault accidents and traffic tickets Am J Respir Crit Care Med 1998;158. N Engl J Med 1999;340. The worse the OSA, the more accidents. Sleep 1999;22. Tx w/ CPAP effective in lowering accident rates Thorax 2001;56.

12 SEQUELAE When evaluating a pt w/ ?OSA, always ask about falling asleep while driving If had MVAs or near MVAs related to falling asleep, should be urged to curtail driving until testing completed Document Am J Resp Crit Care Med 1994;150.

13 DIAGNOSIS Polysomnogram-gold standard EEG, EOG, muscle activity
Various cardiorespiratory parameters Airflow Respiratory effort Oximetry ECG

14 TREATMENTS Behavioral Devices Weight loss Avoidance of supine position
Avoidance of exacerbating substances (e.g. ETOH) Devices Positive pressure devices Oral appliances

15 TREATMENTS Surgery Bariatric surgery for morbidly obese Tracheotomy
UPPP Maxillomandibular advancement

16 Who Needs a Sleep Study? Practice Parameters for the Indications for Polysomnography and Related Procedures: An Update for 2005 –Sleep ;4 A first night psg for all with suspicion of Sleep Related Breathing Disorder (SRBD) In those w/ strong suspicion of OSA, if other causes for symptoms have been excluded, a 2nd night of diagnostic PSG m/b necessary

17 Who Needs a Sleep Study? Polysomnogram indicated for positive airway pressure titration in pts w/ SRBD RDI of >15 regardless of symptoms RDI of >5 with excessive daytime sleepiness

18 Who Needs a Sleep Study? Should you order a split night???
Diagnostic, therapeutic An AHI of at least 40 documented during a minimum of 2 hours of diagnostic PSG An AHI between based on clinical judgment Repetitive long obstructions and/or major desaturations Repetitive dysrhythmias At RDI < 40, CPAP pressure requirements may be less accurate vs full night

19 Who Needs a Sleep Study? CPAP titration (split)
At least 3 hrs (because respiratory events worsen as night progresses) Must include REM sleep with pt in supine position If does not achieve REM, supine m/ need to order full CPAP titration study for most accurate pressure

20 Who Needs a Sleep Study? Those undergoing upper a/w surgery for snoring or OSA If using oral appliance to ensure therapeutic benefit After surgical treatment of pts w/ mod-severe OSA to ensure satisfactory response

21 Who Needs a Sleep Study? After substantial weight loss (10%) to ascertain necessity of CPAP at previously titrated pressure After weight gain (10%) who are again symptomatic despite continued use of CPAP at previous setting When clinical response in insufficient or when sxs reoccur despite good initial response; ? Concurrent sleep disorder

22 Who Needs a Sleep Study? A f/u psg not routinely indicated in pts treated w/ CPAP who continue to do well Pts w/ systolic or diastolic heart failure if they have nocturnal symptoms suggestive of SRBD Disturbed sleep Nocturnal dyspnea Snoring Or if remain symptomatic despite optimal medical management of CHF

23 Who Needs a Sleep Study? Pts w/ CAD w/ symptoms of sleep apnea
Pts w/ hx of CVA or TIA w/ symptoms of sleep apnea Pts w/ significant tachyarrythmias or bradyarrhythmias w/ symptoms

24 Preparing the patient What I do when ordering a sleep study
Discuss with patients the importance of sleep apnea and its relevance to many diseases Explain to them what a sleep study entails Leads Spending the night Sleep tech bathroom Sleep literature Sinus congestion/allergic rhinitis Nasal steroid

25 SLEEP REPORTS What to look for?
Sleep onset-normal between minutes REM onset >60 minutes Sleep stages??? (first night effect) Respiratory events Obstructive Central Minimum oxygen saturation Limb movements ECG Abnormal movements

26 Polysomnogram (PSG) Diagnostic or first night study Full report
Hypnogram Interpretation

27 CPAP TITRATION Sleep onset CPAP table Any abnormal movements
ECG abnormalities Trouble tolerating the device Mask best fitting, size and type

28 What to do with the report
CPAP/Bilevel pressure Prescription filled out according to report If in agreement sign prescription and fax back to lab Prescription sent to DME Machine will be brought to patient’s house, ideally within 48 hours Follow up phone call by DME Follow up in office 1 month after positive pressure tx

29 ONE MONTH FOLLOW UP Compliance Smart card Snoring Daytime symptoms
Naps Energy level Concentration Memory

30 COMPLIANCE Education Masks Pressure Head gear
FINE TUNE THE PRESCRIPTON TO FIT YOUR PATIENT

31 COMMON PATIENT ISSUES Mouth breathing Chin strap Nasal decongestants
Allergy evaluation ENT evaluation

32 COMMON PATIENT ISSUES Compliance Cannot tolerate the device
Change mask Change pressure Add heated humidification Try Bi-level therapy High pressure >16 cm Difficult to exhale against high pressure

33 COMMON PATIENT ISSUES Not able to tolerate device regardless of adjustments How severe Mild-moderate ENT evaluation Oral device? Insurance coverage questionable TMJ issues Best for mild OSA

34 COMMON PATIENT ISSUES Moderate-Severe ENT evaluation
Higher likelihood of success if enlarged tonsils, uvula May need sequential surgeries UPPP Genioglossus Maxillo-mandibular advancement Surgery (UP3) will at least decrease pressure requirements More easily tolerate pressure

35 COMMON PATIENT ISSUES Severe/obese
Unable to tolerate positive pressure UP3/tracheostomy Tracheostomy patent Gives time for UP3 to heal Decreased upper airway edema (repeated injury form closing/opening of airway) Repeat study with tracheostomy plugged Sleep apnea will unlikely be cured Lower positive pressure

36 COMMON PATIENT ISSUES IF unable to tolerate lower pressure/positive pressure therapy-tracheostomy to remain patent Plugged during day Unplugged at night

37 CONCLUSIONS Sleep apnea-significant public health burden
Associated with significant common medical problems DM HTN CAD CHF CVA/TIA

38 CONCLUSIONS Prepare patient for sleep study report specifics
2nd night study Prescription Compliance Fine tuning Close follow up Final resorts

39 PSG Report (Page 1)

40 PSG Report (Page 2)

41 PSG Report (Page 3)

42 Split Study Report (Page 1)

43 Split Study Report (Page 2)

44 Split Study Report (Page 3)

45 CPAP Table

46 Hypnogram


Download ppt "A PRACTICAL APPROACH TO YOUR PATIENT WITH SLEEP APNEA"

Similar presentations


Ads by Google