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