1. Obstructive Sleep Apnea How To Order A Sleep Study? Herbert M. Schub,MD Chief, Pulmonary Diseases Highland Alameda County Hospital Clinical Professor of Medicine, UCSF

2. Obstructive Sleep Apnea Obstructive Apneas, Hypopneas,or Respira- tory Effort Related Arousals Daytime Symptoms Sleepiness, Fatigue, Poor Concentration Snoring, Resuscitative Snorts (Witnessed Apneas)

4. The Essentials to Qualify Symptoms: Snoring Witnessed Apnea Daytime Somnolence &/or Fatigue Recent Weight Gain Use of Steroids Motor Vehicle Accidents Physical Findings: Height Weight BMI Neck size Male:>17” or 43 cm Female:>16” or 41 cm Malimpati Index of Oropharynx I-IV O2 Saturation on RA ABG if O2 Sat<95% RA PFT’s (Spirometry if pCO2 >45 mm

6. Polysomnography EMG Chest & Abdomen Airflow at Nose and Mouth EEG, EOG Oxygen Saturation Cardiac Rhythm Leg Movements

7. Polysomnography Terms Apnea Cessation or less than 30% air flow for at least 10 secs, usually assoc with > 4% decr O2 Sat Hypopnea 30-70 % decr air flow AHI…Apnea Hypopnea Index Apneas +Hypopneas per hour: < 5 hour= normal 5-14= Mild 15-30=Moderate >30=Severe RDI…Respiratory Disturb- ance Index

8. Polysomnograph Terms SPLIT NIGHT STUDY AFTER establishing an accurate measure of REM sleep, RDI, AHI, O2 desat, EKG abnlties THEN, get a proper fitting CPAP/BiPAP mask or other device & identify the minimum CPAP level that abolishes obstructive apneas/hypopneas, O2 desat,respiratory effort- related arousals(RERAs) Pressure needed usually 5-20 cm TITRATION STUDY Dx OSA already established, but need study with CPAP from beginning of night to establish proper pressure and mask AUTO-PAP Automatically changes pressures based on the presence and/or absence of OSA May be used during in the unatt- ended home setting to determine a single pressure for home use

9. Home Based (Portable Monitoring) Testing for OSA 4 Types: type 3: 4 variables: Respiratory movement, Airflow Heart Rate &/or EKG O2 Sat type 4: 1or2 variables: O2 Sat Airflow Overnight Pulse Oximetry alone is inadequate….sensitive but NOT specific for cause Advantages: Low cost/ OK for un- complicated OSA & titration of CPAP Disadvantages: Often underestimate AHI (hours of true sleep???) Type 4 can’t distinguish Central vs OSA or hypo- ventilation) No measure Upper Airway Resistance Awakenings No measure Periodic Limb Movement Awakenings

10. Management OSA in Adults Behaviour Modification Losing weight if Obese Change Sleep Position (if OSA is positional) Abstain from Alcohol, CNS depressants Non-surgical OSA therapy CPAP Bipap Surgical therapy Reserved for Selective patients in whom CPAP/BiPAP was ineffective Exception when OSA due to a clear-cut surgically correctable obstructing lesion Pharmacologic Treatment For patients with sym- ptoms despite adequate therapy

11. Nasal CPAP Therapy Initially described 1981 Most effective treatment Blower unit that produces CONTINUOUS positive pressure airflow Increases the caliber of the airway in the retropalatal and retroglossal regions… acts as a PNEUMATIC SPLINT Medicare Guidelines Severe RDI (20-30) RDI 5-20 if symptoms or co-existent cardiovascular OSA with AHI >15 If AHI 5-15, CPAP only if excessive daytime somnolence, hypertension or cardiovascular disease

13. BiPAP Therapy Permits independent ad- justment of inspiratory and expiratory pressures Generally used in patients who cannot tolerate high CPAP Too expensive to be used as first-line therapy Compliance no better than with CPAP Often used with Obesity- Hypoventlation Synd- rome-m Pickwickian

15. Oral Appliance Therapy Act by Moving (pulling) the tongue forward or by moving the mandible and soft palate anterior- ly More than 40 Oas are available Not as effective as CPAP For mild-to-moderate OSA who cannot tolerate CPAP(and BiPAP) Therapy

19. Nasal Plugs….Provent Patch fits over nostrils Holds 2 small plugs Creates just enough air pressure to keep air- ways open at night Far less intrusive than CPAP Approved by FDA 2008 Requires new patch every night…30 day supply $65-$80 More expensive than CPAP Not covered by Medicare In one study, 1/3 not used: severe nasal allergies,mouth breath

21. Obesity Hypoventilation Syndrome Pickwickian Syndrome pCO2>45mm &NOT due to COPD (severe), kyphoscoliosis, neuro- muscular 95% OSA do NOT have OHS 95% of OHS have OSA O2 Sat as routine screen for OSA. If <95%, get ABG IF ABG pCO2>45, get spirometry IF pCO2>45, & no severe COPD (FEV-1 <50% pred), indicate on “Assessment” the probability of OHS and need to use BiPAP, rather than CPAP during Split Night Study

22. Narcolepsy Clinical Syndrome Daytime Sleepiness Cataplexy Hypnagogic Hallucin- ations Sleep Paralysis Only 1/3 all 4 symp- toms Loss of neuropeptides orexin-A and –B (hypocretin 1 and 2 from hypothalamus Multiple Sleep Latency Test (MSLT) Only valid IF PSG = at least 6 hrs sleep the previous night 4-5 opport to nap q2h the day after the PSG

23. Restless Leg Syndrome Criteria 1.Urge to move legs... usually w/ discomfort 2.Begin or worsen during rest/inactivity/lying etc 3.Relieved by movement 4.Worse in evening/night Supportive criteria: a. Family history RLS b.+ response to dopaminergic c. Periodic Limb Movements during sleep with PSG PSG NOT necessary to make dx Secondary RLS: Iron deficiency End-Stage Renal Disease Diabetes Mellitus Multiple Sclerosis Parkinson disease Pregnancy Rheumatic Disease Venous Insufficiency Miscellaneous

24. Periodic Limb Movements Of Sleep Sudden jerking leg move- ments…repetitive,highly stereotyped…typically involve extension of big toe/partial flex ankle, knee/hip..patient usually unaware…increase w/age VAST majority of RLS Treatment UNNECESSARY if PLMS w/out sleep comp- laints PLMD (Disorder) Partial or Total Arousal from sleep & cause/ contribute insomnia/ daytime drowsy/somn- olence Use same drugs as RLS