1. Obstructive Sleep Apnea: when dreams turn deadly Troy Glembot, MD MBA CPE FACS FASMBS Medical Director Winchester Medical Center Bariatric Program

2. Objectives  Define OSA and identify its prevalence  Identify patients who are at risk of having OSA  Implications of untreated OSA  Treatment options for patients who have OSA  OSA and potential safety issues in the workplace

3. Define OSA Sleep disordered breathing (SDB) Obstructive sleep apnea (OSA) Sleep apnea/hypopnea (SAH) Sleep apnea/hypopnea syndrome (SAHS) Obstructive sleep apnea syndrome (OSAS)

4. Obstructive Sleep Apnea  OSA is characterized by intermittent airway obstruction Results in nocturnal desaturations hypercapnea Results in nocturnal desaturations hypercapnea Increased inspiratory efforts lead to awakenings resulting in disturbed sleep Increased inspiratory efforts lead to awakenings resulting in disturbed sleep

5. How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent time. Even if you have not done some of these things recently, try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation. 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing SITUATION CHANCE OF DOZING Sitting and reading_____ Watching TV_____ Sitting and inactive in a public place (theater or meeting) _____ As a passenger in a car for an hour without a break _____ Lying down to rest in the afternoon when circumstances permit _____ Sitting and talking to someone_____ Sitting quietly after lunch (without alcohol)_____ In a car, while stopped for a few minutes in the traffic _____ TOTAL_____ From Johns MW: A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep 1991;14:540–545. Epworth Sleepiness Scale

6. Obstructive Sleep Apnea Box 92-3. Diagnostic Criteria for the Obstructive Sleep Apnea-Hypopnea Syndrome The individual must fulfill criterion A or B, plus criterion C A.Excessive daytime sleepiness that is not better explained by other factors B.Two or more of the following (not better explained by other factors) Choking or gasping during sleep Choking or gasping during sleep Recurrent awakenings from sleep Recurrent awakenings from sleep Unrefreshing sleep Unrefreshing sleep Daytime fatigue Daytime fatigue Impaired concentration Impaired concentration C.Overnight monitoring demonstrating five or more obstructed breathing events per hour during sleep; events may include any combination of obstructive apneas/hypopneas or respiratory effort-related arousals Adapted from American Academy of Sleep Medicine Task Force: Sleep- related breathing disorders in adults: Recommendations for syndrome definition and measurement techniques in clinical research. Sleep 1999;22:667–689.

7. Obstructive Sleep Apnea

8. Principles of Sleep Medicine 2005

9. Prevalence of OSA  4% of men and 2% of women have OSA  Prevalence peaks in men between 50-59 yrs.  Prevalence increases with older age in women Young et al, N Engl J Med 328: 1230-1235 1993

10. Prevalence of OSA  Ethnicity plays a role as well Asian and Japanese patients have craniofacial geometries and smaller airway passages that may predispose OSA Asian and Japanese patients have craniofacial geometries and smaller airway passages that may predispose OSA African Americans typically have more severe OSA than whites even when adjusting for BMI, gender and age. African Americans typically have more severe OSA than whites even when adjusting for BMI, gender and age.

11. Prevalence of OSA What role does obesity play?

12. Prevalence of OSA BMI = Weight(kg)/Height(m) 2 = (lbs./in. 2 )x 705 B ODY M ASS I NDEX

13. Prevalence of OSA BMI Indicators Acceptable Range 18.5 – 24.9 Overweight25.0 – 29.9 Obese30.0 – 34.9 Severe Obesity35.0 – 39.9 Morbid Obesity40.0 – 49.9 Super-Morbid Obesity> 50

14. BMI CHART (Sample Portion) 200205210215220225230235240245250255260265 4’104243444546474849505152535456 5’0”3940414243444546474849505152 5’2”3738 3940414243444546474849 5’4”34353637383940 414243444546 5’6”3233343536 37383940 414243 5’8”3031323334 353637 383940 5’10”2930 3132 333435 3637 38 6’0”272829 3031 32333435 3637 6’2”26 2728 2930 3132 33 34 Height Overweight Class I Obesity Class II Serious Obesity Class III Morbid Obesity Weight

15. Role of obesity in OSA BRFSS, 1985 Role of obesity in OSA BRFSS, 1985 No Data <10% 10%–14% (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)

16. Role of obesity in OSA BRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

17. One in five people in the United States is obese One in five people in the United States is obese Three in five Americans are either overweight or obese Three in five Americans are either overweight or obese In the past 20 years, In the past 20 years, obesity among adults has doubled Source: The Surgeon General’s Call to Action to Prevent Overweight and Obesity. A Rapidly Expanding Problem The Obesity Crisis

18. Role of obesity in OSA http://www.google.com/imgres?q=bmi+and+obstructive+sleep+apnea&um=1&hl=en&biw=1280&bih=649&tbm=isch&tbnid=ev_aW35 GBInbaM:&imgrefurl=http://journal.publications.chestnet.org/article.aspx%3Farticleid%3D1085729&imgurl=http://journal.publications. chestnet.org/data/Journals/CHEST/22068/zcb0100712270004.jpeg&w=1800&h=982&ei=CMlIUPzgE83GqAGz5oHYAw&zoom=1&iac t=hc&vpx=933&vpy=368&dur=20240&hovh=166&hovw=304&tx=219&ty=148&sig=108640793115164267964&page=2&tbnh=95&tbn w=174&start=18&ndsp=24&ved=1t:429,r:17,s:18,i:184 accessed on 6 Sept 2012

19. Role of obesity in OSA Potentially life-threatening sleep apnea is unrecognized without aggressive evaluation Hallowell et al, The American Journal of Surgery 193: 364-367. 2007 Expert Panel Recommendations Obstructive Sleep Apnea and Commercial Motor Vehicle Safety http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep- MEP-Panel-Recommendations-508.pdf accessed on 6 Sept 2012 http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep- MEP-Panel-Recommendations-508.pdf http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep- MEP-Panel-Recommendations-508.pdf

20. Role of obesity in OSA Expert Panel Recommendations http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep- MEP-Panel-Recommendations-508.pdf accessed on 6 Sept 2012 http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep- MEP-Panel-Recommendations-508.pdf http://www.fmcsa.dot.gov/rules-regulations/TOPICS/mep/report/Sleep- MEP-Panel-Recommendations-508.pdf Initially considered anyone with BMI > 30 kg/m 2 to be screened for OSA over 41% of the drivers would need screened BMI cutoff raised to 33 kg/m 2, only 24% of drivers need screened

21. Implications of OSA So they snore

22. Implications of OSA Cumulative survival Interval (years) * * * ** Chest 88:9-14, 1988 Effect of apnea index on mortality

23. Implications of OSA  CAD ACS ACS Angina Angina  HTN Systemic HTN Systemic HTN Pulmonary HTN Pulmonary HTN  Ventricular hypertrophy and dysfunction  Cardiac dysrhythmias Bradycardia Tachycardia  Atrial fibrillation  CVA

24. Implications of OSA  OSA is strongly linked to CVD CAD appears associated with OSA CAD appears associated with OSA Up to 46% of patients presenting with an acute cardiac event had OSAUp to 46% of patients presenting with an acute cardiac event had OSA Moderately severe OSA (AHI > 20) is an independent risk factor for MIModerately severe OSA (AHI > 20) is an independent risk factor for MI Skinner et al Chest 127(1): 2005 Schafer et al Cardiol 92(2): 79-84 1999

25. Implications of OSA  OSA is strongly linked to CVD Hypertension appears exacerbated by OSA Hypertension appears exacerbated by OSA Increased activation of sympathetic nervous systemIncreased activation of sympathetic nervous system Vascular endothelial dysfunctionVascular endothelial dysfunction Somers et al J Clin Invest 96(4): 1897-1904 1995

26. Implications of OSA  OSA is strongly linked to CVD OSA exacerbates CHF OSA exacerbates CHF Treatment of OSA results in improvement in LVEF and improved QOF on SF36 and chronic heart failure questionnaires. Treatment of OSA results in improvement in LVEF and improved QOF on SF36 and chronic heart failure questionnaires. Kaneka et al, N Engl J Med 348(13): 1233-1244 2003

27. Implications of OSA  OSA is strongly linked to CVD Almost 60% of patients with OSA have dysrhythmias Almost 60% of patients with OSA have dysrhythmias Both tachy and brady dysrhythmias Both tachy and brady dysrhythmias Up to 10% of patients develop transient heart blockUp to 10% of patients develop transient heart block Hoffstein et al Chest 106: 466-471 1994 Harbison et al Chest 118: 591-595 2000

28. Implications of OSA  OSA is strongly linked to CVA Up to 60% of stroke patients have OSA Up to 60% of stroke patients have OSA The Sleep Heart Health Study demonstrated that OSA was associated with an increased prevalence of stroke The Sleep Heart Health Study demonstrated that OSA was associated with an increased prevalence of stroke Kaneko et al Sleep 26: 293-297 2003 Shahar et al Am J Respir Crit Care Med 163: 19-25 2001

29. Implications of OSA Sleep disordered breathing linked to apnea- induced hyperglycemia in diabetes Nocturnal glucose values significantly higher in patients with OSA compared to those without OSA Nocturnal glucose values significantly higher in patients with OSA compared to those without OSA European Association for the Study of Diabetes meeting May 2007

30. Obstructive Sleep Apnea OSA isn’t just snoring  Think systemic….. Hypertension, ischemic heart disease, stroke, pulmonary hypertension, cor pulmonale, right heart failure

31. Obstructive Sleep Apnea

32. Implications of OSA  Over time, OSA gets worse Am J Respir Crit Care Med 2002;165:1217-1239

33. Implications of OSA The economic cost of sleep disorders SLEEP 2006;29(3):299-305  Evaluation of the direct and indirect costs attributable to sleep disorders Work related accidents, MVC, productivity lossesWork related accidents, MVC, productivity losses

34. Implications of OSA SLEEP 2006;29(3):299-305

35. Implications of OSA SLEEP 2006;29(3):299-305

36. Implications of OSA  Untreated OSA adversely affects worker productivity Excessive sleepiness, cognitive dysfunction, increased irritability and reduced vitality results in 30% reduction in productivity Excessive sleepiness, cognitive dysfunction, increased irritability and reduced vitality results in 30% reduction in productivity Effect spans job salary levels Effect spans job salary levels American Academy of Sleep Medicine reported by New York Times June 14, 2011

37. Treatment  Lifestyle Avoid alcohol, sedatives, sleep on your side, decongestants, quit smoking Avoid alcohol, sedatives, sleep on your side, decongestants, quit smoking  Mouthpieces  Breathing devices (CPAP)  Surgery (UP3)

38. Treatment

39. Treatment Am J Respir Crit Care Med 2002;165:1217-1239

40. OSA and workplace safety  Why would employers be concerned about OSA?

41. OSA and workplace safety  Happier employees Untreated OSA is associated with depression and chronic fatigue Untreated OSA is associated with depression and chronic fatigue

42. OSA and workplace safety  Happier employees Untreated OSA is associated with depression and chronic fatigue Untreated OSA is associated with depression and chronic fatigue  Healthier employees Less time off work Less time off work

43. OSA and workplace safety  Happier employees Untreated OSA is associated with depression and chronic fatigue Untreated OSA is associated with depression and chronic fatigue  Healthier employees Less time off work Less time off work  Less expensive By keeping overall employee health optimized, heath care costs may be reduced By keeping overall employee health optimized, heath care costs may be reduced

44. OSA and workplace safety  Untreated, OSA causes reduced psychomotor function, cognition which is directly related to accidents MVC’s are particularly a concern MVC’s are particularly a concern J Clin Sleep Med 2009;5(6):573-581

45. Conclusions  OSA is a life threatening medical condition  Untreated OSA causes many other medical conditions  Untreated OSA is associated with increased health care costs and reduces worker productivity  Untreated OSA threatens worker safety  OSA can be effectively treated