1. Sunil Sharma MD

2. Diagnosis: History Snoring (loud, chronic) Snoring (loud, chronic) Nocturnal gasping and choking Nocturnal gasping and choking Ask bed partner (witnessed apneas) Ask bed partner (witnessed apneas) Excessive daytime sleepiness Excessive daytime sleepiness Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.

3. Epworth Sleepiness Score SITUATION CHANCE OF DOZING SITUATION CHANCE OF DOZING Sitting and reading --- Sitting and reading --- Watching TV ---- Watching TV ---- Sitting inactive in a public place (e.g a theater or a meeting) ---- Sitting inactive in a public place (e.g a theater or a meeting) ---- As a passenger in a car for an hour without a break ---- As a passenger in a car for an hour without a break ---- Lying down to rest in the afternoon when circumstances permit--- Lying down to rest in the afternoon when circumstances permit--- Sitting and talking to someone ---- Sitting and talking to someone ---- Sitting quietly after a lunch without alcohol ----- Sitting quietly after a lunch without alcohol ----- In a car, while stopped for a few minutes in traffic ---- In a car, while stopped for a few minutes in traffic ---- 0 = no chance of dozing 0 = no chance of dozing 1 = slight chance of dozing 1 = slight chance of dozing 2 = moderate chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing 3 = high chance of dozing

4. Unusual Presentation of OSA Uncontrolled HTN Uncontrolled HTN Recurrent Pulmonary edema / CHF Recurrent Pulmonary edema / CHF Uncontrolled Asthma Uncontrolled Asthma Insomnia Insomnia Nocturnal angina Nocturnal angina Nocturia Nocturia Uncontrolled diabetes/ metabolic syndrome Uncontrolled diabetes/ metabolic syndrome Memory loss/ Loss of focus Memory loss/ Loss of focus Pulmonary Hypertension Pulmonary Hypertension Hyperactivity / Poor academic performance (Children) Hyperactivity / Poor academic performance (Children)

5. Diagnosis: Physical Examination Upper body obesity / thick neck Upper body obesity / thick neck > 17” males > 16” females Hypertension Hypertension Obvious airway abnormality Obvious airway abnormality

6. Neck circumference Contd.. Massive Tonsils BMI Massive uvula Contd..

7. Elongated palateHigh palate and narrow arch over jetMassive tongue Contd..

8. Mallampati score Class I: soft palate, fauces, uvula, pillars Class II: soft palate, fauces, portion of uvula Class III: soft palate, base of uvula Class IV: hard palate only Class I: soft palate, fauces, uvula, pillars Class II: soft palate, fauces, portion of uvula Class III: soft palate, base of uvula Class IV: hard palate only

9. SCREENING TOOLS

10. Berlin Questionnaire High Risk: if there are 2 or more Categories where the score is positive

12. INVESTIGATIONS

13. Polysomnography

14. Patil, S. P. et al. Chest 2007;132:325-337 A summary hypnogram and oximetry tracing in a patient with severe OSA (AHI, 84/h)

15. Type III devices

16. Patient /physician education HTN/ DM/ Afib/ MI/ CHF/ stroke/post-op complications Impotence, reduced memory Increased mortality Increased deaths after angioplasty and increased risk of blockage after angioplasty

17. Why treat OSA Improve neurocognitive symptoms Improve neurocognitive symptoms Improve bed-partners QOL Improve bed-partners QOL Prevent cardiovascular complications Prevent cardiovascular complications

18. General treatment measures Avoid alcohol before bedtime Avoid alcohol before bedtime Avoid sedatives Avoid sedatives Improve sleep hygiene Improve sleep hygiene Treat nasal congestion Treat nasal congestion Encourage weight loss/exercise Encourage weight loss/exercise Education Education Consequences of EDS Consequences of EDS Impact on CVS Impact on CVS Impact on professional / personal life Impact on professional / personal life

19. Are there any co-existent sleep related issues? Insufficient sleep/circadian rhythm dis Insufficient sleep/circadian rhythm dis Depression Depression Narcolepsy Narcolepsy Idiopathic hypersomnolence Idiopathic hypersomnolence Poor insight in his medical condition Poor insight in his medical condition Medications Medications

20. PAP therapy. Who should be treated? Most effective therapy-splits airway open Most effective therapy-splits airway openIndications All patients with AHI>15 All patients with AHI>15 AHI of 5 -15 with symptoms or underlying CVD AHI of 5 -15 with symptoms or underlying CVD

21. Modes of PAP BiPAP W/WO back-up Auto- PAP ASV

22. When to use bipap Obesity hypoventilation syndrome Intolerance to cpap ( high pressure) COPD+OSA Chronic Respiratory failure Neuro-muscular disorders

23. services 2 weeks chief technologist Adjusted hospital/ home trial 2 monthly Compliance data review Over-read and consultation 50% off for physicians Rental basis

25. Compliance improvement model Involve the partner! Involve the partner! EDUCATION!! –cardiovascular and cognitive implications EDUCATION!! –cardiovascular and cognitive implications Watch for red flags Watch for red flags Poor sleep efficiency on CPAP trial Poor sleep efficiency on CPAP trial Low EPS Low EPS Symptoms of claustrophobia Symptoms of claustrophobia Consider compliance clinics or frequent follow-ups in the first 4 weeks! Consider compliance clinics or frequent follow-ups in the first 4 weeks! Mask acclimitization before instituting therapy Mask acclimitization before instituting therapy OSA related literature to patients OSA related literature to patients Encourage grp sessions or support grps Encourage grp sessions or support grps Troubleshoot interphase related problems/nasal symptoms Troubleshoot interphase related problems/nasal symptoms Pay attention to cultural beliefs and ethnic differences. Pay attention to cultural beliefs and ethnic differences. Consider management under one roof. Consider management under one roof.

26. Dental devices Two main types Two main types Mandibular repositioning appliances ( MRA) Mandibular repositioning appliances ( MRA) Protrude the mandible forward Protrude the mandible forward Tongue repositioning devices Tongue repositioning devices Protrude the tongue Protrude the tongue

27. Indications for Dental devices Mild – moderate OSA Mild – moderate OSA UARS UARS Snoring Snoring As adjunct to CPAP for Severe OSA As adjunct to CPAP for Severe OSA * useful in pts. With micrognathia, overbite, retrognathia * useful in pts. With micrognathia, overbite, retrognathia

28. Contra-indications Severe SDB Severe SDB Nocturnal desaturations Nocturnal desaturations Poor dentition * Poor dentition * Severe nasal obstruction Severe nasal obstruction ? Bruxism ? Bruxism Dementia/ stroke Dementia/ stroke * Use tongue repositioning device

29. MY TOP TEN reasons to get Sleep evaluation in patients with CVD/ DM EDS with snoring or witnessed apneas EDS with snoring or witnessed apneas Newly diagnosed HTN Newly diagnosed HTN Too young or too old! Too young or too old! Family h/o SDB or no family h/o HTN Family h/o SDB or no family h/o HTN Associated obesity, snoring or signs of OSA Associated obesity, snoring or signs of OSA Uncontrolled HTN Uncontrolled HTN CHF CHF Nocturnal dyspnea, excessive daytime fatigue despite optimal management of CHF Nocturnal dyspnea, excessive daytime fatigue despite optimal management of CHF CAD- nocturnal angina, SOB, EDS CAD- nocturnal angina, SOB, EDS Uncontrolled diabetes/ insulin resistance/metabolic syndrome Uncontrolled diabetes/ insulin resistance/metabolic syndrome Strokes- excessive daytime fatigue/ snoring Strokes- excessive daytime fatigue/ snoring Arrhythmias- ventricular irritability/ atrial fibrillation Arrhythmias- ventricular irritability/ atrial fibrillation Pulmonary HTN Pulmonary HTN ESRD with EDS/snoring ESRD with EDS/snoring