Sleep Apnea

Pre-Test Questions

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Understanding, Recognizing and Managing Obstructive

Sleep Apnea

Federico Cerrone, MD,FCCP,DASSM

Director, Center for Sleep Disorders

Overlook Hospital, Summit, NJ

Sleep Disorders - Socioeconomic Consequences

40 million Americans suffer from chronic disorders of sleep and wakefulness.

95% of these remain unidentified and undiagnosed.

The annual direct cost of sleep-related problems is $16 billion, with an additional $50-$100 billion in indirect costs (accidents, litigation, property destruction, hospitalization, and death).

Sleep Apnea

Patient # 1

• 52 year old male with history of borderline hypertension

• Wife complains of his snoring

• His weight has increased 10 pounds over the last year

• Feels tired, but states he is very busy with work and the kids

Sleep Apnea is:

• Common

• Dangerous

• Easily recognized

• Treatable

Sleep Apnea

•Definition

•Pathophysiology

•Clinical Features

•Risk Factors

•Methods of Diagnosis

•Treatment

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Types of Sleep Disordered Breathing

• Apnea–Cessation of airflow > 10 seconds

• Hypopnea–At least 30% reduction airflow > 10

seconds associated with:• Arousal• Oxyhemoglobin desaturation

Apnea Patterns

ObstructiveObstructive MixedMixed CentralCentral

Airflow

Respiratoryeffort

Upper Airway Resistance Syndrome

EEG

10 sec

Arousal

Airflow

Effort(Pes)

SaO2

Effort(Abdomen)

Effort(Rib Cage)

Measures of Sleep Apnea Frequency

• Apnea Index

– # apneas per hour of sleep

• Apnea / Hypopnea Index (AHI)

– # apneas + hypopneas per hour of sleep

Severity Criteria

•Mild: 5-15 events per hour

•Moderate: 15-30 events per hour

•Severe: more than 30 events per hour

Limitations to Criteria

•Does not incorporate severity of oxygen desaturation

•Does not consider non-apneic respiratory events

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Prevalence of Sleep Apnea

0

5

10

15

20

25

AHI > 5 SAS Asthma

Male

Female

U.S. Pop

30-60 year olds

Percent ofPopulation

Adapted from Young T et al. N Engl J Med 1993;328.

Patient # 1

• Patient tells you that a couple of drinks increases the snoring

• He also grinds his teeth per his dentist

?

1

2

3

4

5

6

7

8

9

The Upper Airway

Anatomical Factors

•Collapsible tube

•Changes in upper airway anatomy

•There are increased parapharyngeal fat pads

•Obesity can reduce lung volumes

•Dilator muscles

Control of Dilator MusclesEffects On Pharyngeal Muscle Activity

Normal Subject

Awake

OSA Patient

NREM

Genioglosus EMG

Tensor Palatini EMG

Airflow

Genioglosus EMG

Tensor Palatini EMG

Airflow

Pathophysiology of Apnea

Pathophysiology of Sleep ApneaAwake: Small airway + neuromuscular compensation

Loss of neuromuscular compensation

+Decreased pharyngeal

muscle activity

Sleep Onset

Hyperventilate: connect hypoxia & hypercapnia

Airway opens

Airway collapsesPharyngeal muscle

activity restored

Apnea Arousal from sleep

Hypoxia & Hypercapnia

Increased ventilatory effort

Patient # 1

• The patient upon further questioning

does get tired when driving more than

one hour

• He is on medication for depression

• Sleep study reveals AHI=55 with lowest

oxygen saturation of 80%

Clinical Consequences

Cardiovascular Complications

Morbidity

Mortality

Sleep FragmentationHypoxia/ Hypercapnia

Excessive Daytime Sleepiness

Sleep Apnea

Consequences: Excessive Daytime Sleepiness

• Increased motor vehicle crashes

• Increased work-related accidents

• Poor job performance

• Depression

• Family discord

• Decreased quality of life

Consequences: Automobile Accidents

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

0.4

0.45

No Apnea Sleep Apnea All Drivers

Accident / driver / 5 yrs

Adapted from Findley LJ et al. Am Rev Respir Dis 1988;138.

Consequences: Automobile Accidents

Odds Ratio

0

2

4

6

8

10

12

NO ETOH + ETOH

ETOH On Day of Accident

Risk of Traffic Accident: OSA + ETOH

Adapted from Teran-Santos J et al.

N Engl J Med 1999;340.

Consequences: Cardiovascular

• Systemic hypertension

• Cardiac arrhythmias

• Myocardial ischemia

• Cerebrovascular disease

• Pulmonary hypertension / cor pulmonale

Consequences: MortalityEffect of Al on Mortality

He J et al. Chest 1988;94.

(Untreated, age<50)

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

Entry 1 2 3 4 5 6 7 8 9

AI < 20

AI > 20

Cu

mu

lati

ve S

urv

ival

Interval (Years)

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Consequences: Hypertension

Shepard JW Jr. Med Clin North Am 1985;69.

Cardiovascular Consequences: Hypertension

Odds Ratio

0

0.5

1

1.5

2

2.5

3

0 0.1 - 4.9 5 - 14.9 > 15

Apnea / Hypopnea Index (AHI)

Prospective Study of Association Between OSA and Hypertension

Adjusted

for age, sex, BMI, neck circ., cigs., ETOH, baseline Htn

Adapted from Peppard PE et al. N Engl J Med 2000;342.

Consequences: Arrhythmias

Shepard JW Jr. Clin Chest Med 1992;12.

EEG

LOC

EMG

CHIN

EKG

SAO2

FLOW

PNT

EFFABDEFF

SUM

EFFRC

Atrial Fibrillation

•Decrease in oxygen saturation may be the best predictor of risk

Gami,JACC,2007

Stroke

•Increased severity of obstructive sleep apnea increases risk of stroke

Yaggi et al: NEJM 2005

Consequences: Cardiovascular Disease

Odds Ratio

Cross Sectional Study of Association Between OSA and CVD

Adjusted for age, sex, race, BMI, Htn, cigs., chol.

0

0.5

1

1.5

2

2.5

CAD HF CVA

0 - 1.3

1.4 - 4.4

4.5 - 11.0

> 11.0

AHI

Adapted from Shahar E et al.Am J Respir Crit Care Med 2001;163.

Metabolic Consequences

•OSA is linked to glucose intolerance and increased leptin levels

•Leptin mediates appetite suppression

•Obese patients have increased leptin levels but are resistant to the appetite suppressant effects

•OSA patients have higher leptin levels than similarly obese pts without OSA

•CPAP reduces leptin levels and improves glucose tolerance

Barkoukis: Review of Sleep Medicine,2007

Patient # 2

• 55 year old female post-menopause complains of insomnia

• Extreme fatigue during the day

• Interrupted sleep at night

• Normal blood pressure

• BMI 24 (normal)

• Moderate overbite

• Sleep study with AHI=8, RDI=30, oxygen saturation low 94%

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Sleep Apnea Risk Factors-Patient # 1

• Obesity

• Increasing age

• Male gender

• Anatomic abnormalities of upper airway

• Family history

• Alcohol or sedative use

• Smoking

• Associated conditions

Risk Factor: Obesity

Davies RJ et al. Eur Respir J 1990;3.

0

10

20

30

40

50

60

70

80

70 80 90 100 110 120 130 140

>4%

Art

eria

l sat

ura

tio

n d

ipa

h-1

% Predicted normal neck circumference

Risk Factor: Age

0

5

10

15

20

25

30

35

30-39 Yrs 40-49 Yrs 50-60 Yrs

Female

Male

% with AHI > 5

Adapted from Young T et al. N Engl J Med 1993;328.

Age

•Prevalence plateaus after age 65

•Is sleep apnea different in older people?

Young; 2002 Arch Intern Med

Risk Factor: Gender

Millman RP et al. Chest 1995;107.

0

20

40

60

80

100

120

0 20 40 60 80 100 120 140

Ap

nea

/Hyp

op

nea

Ind

ex

Skinfold Sum (mm)

Male

Female

Risk Factor: Anatomic Abnormality

Suratt PM et al. Chest 1986;90.

0

5

10

15

20

25

30

35

40

45

50

Nose Open Nose Occluded

Ap

ne

as

& H

yp

op

ne

as

pe

r h

ou

r o

f s

lee

p 75 6

4

8

5

1

2

7

3

Adapted from Redline S et al. Am J Resp Crit Care Med 1995;151.

Likelihood of Sleep Apnea as Function of Family Prevalence

Risk Factor: Family History

(Adjusted forage, race, sex,BMI)

Odds Ratio

0

0.5

1

1.5

2

2.5

3

3.5

4

1 2 3 Relative Relatives Relatives

Risk Factor: Sedatives

Sanders MH. In: Principles and Practice of Sleep Medicine. Philadelphia: W.B. Saunders Company, 1994.

Pea

k In

teg

rate

d a

ctiv

ity

(% c

on

tro

l)

Minutes after injection

Diazepam Injection

Hypoglossal Nerve

Phrenic Nerve

0 5 15 3060

150

100

50

0

Risk Factor: Alcohol

Bonara M et al. Am Rev Respir Dis 1984;130 © American Lung Association.

Before Alcohol

Blood Alcohol = 83 mg/dl

Blood Alcohol = 134 mg/dl

Phrenic

Hypoglossal

Phrenic

Hypoglossal

Phrenic

Hypoglossal

Risk Factor: Smoking

0

1

2

3

4

5

Adjusted Odds Ratio for Sleep Apnea (AHI > 15) in Former & Current Smokers vs Nonsmokers

Adapted from Wetter DW et al. Arch Intern Med 1994:154 ©1994 American Medical Association.

Former Current Smokers Smokers

(Adjusted for age, race, sex, BMI)

Odds Ratio

Risk Factor: Associated Conditions

• Hypothyriodism

• Acromegaly

• Amyloidosis

• Vocal cord paralysis

• Marfan syndrome

• Down syndrome

• Neuromuscular disorders

Patient # 3

• 42 year old male weight lifter

• Girlfriend states he holds his breath during sleep

• He is not aware of this

• No complaints of tiredness

• Epworth Sleepiness Scale 11

Diagnosis: History

• Snoring (loud, chronic)

• Nocturnal gasping and choking

– Ask bed partner (witnessed apneas)

• Automobile or work related accidents

• Personality changes or cognitive problems

• Risk factors

• Excessive daytime sleepiness

Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.

Diagnosis: Assessing Daytime Sleepiness

• Often unrecognized by patient

– Ask family members

• Must ask specific questions

– Fatigue vs. sleepiness

– Auto crashes or near misses

– Sleep in inappropriate settings

• Work

• Social situations

0 = would never doze or sleep.1 = slight chance of dozing or sleeping2 = moderate chance of dozing or sleeping3 = high chance of dozing or sleeping

Situation Chance of Dozing or Sleeping

Sitting and reading ____

Watching TV ____

Sitting inactive in a public place ____

Being a passenger in a motor vehicle for an hour or more

____

Lying down in the afternoon ____

Sitting and talking to someone ____

Sitting quietly after lunch (no alcohol) ____

Stopped for a few minutes in traffic while driving

____

Total score (add the scores up)(This is your Epworth score)

____

Epworth Sleepiness Scale

Patient # 3

• Blood pressure 140/85

• His neck size is 18 inches

• Tonsils are 4+

• Rest of exam unremarkable

• Sleep study with AHI of 25

• Lowest oxygen saturation 92%

Diagnosis: Physical Examination

• Upper body obesity / thick neck

> 17” males

> 16” females

• Hypertension

• Obvious airway abnormality

Exam: Tonsillar Hypertrophy

Shepard JW Jr et al. Mayo Clin Proc 1990;65.

Oropharynx With Tonsillar Hypertrophy

Normal Oropharynx

Exam: Oropharynx

Patient With the Crowded Oropharynx

Physical Examination

Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978.

Structural Abnormalities

Practice Recommendation

• Practice Recommendation: The risk for obstructive sleep apnea correlates on a continuum with obesity, large neck circumference, and hypertension. Combinations of these factors increase the risk for OSAHS in a non-linear manner.

• Evidence-Based Source: Institute for Clinical Systems Improvement

• Web Site of Supporting Evidence: http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html

• Strength of Evidence: Class A: Randomized, controlled trial; Class B: Cohort study; Class C: Non-randomized trial with concurrent or historical controls, Case-control study, Study of sensitivity and specificity of a diagnostic test, Population-based descriptive study; Class D: Cross-sectional study, Case series, Case report; Class R: Consensus statement, Consensus report, Narrative review

Diagnosis: Pediatric Apnea

• Presentation– Behavioral problems / irritability– Poor school performance– Enuresis– Snoring

• Cause– Adenotonsillar hypertrophy– Craniofacial abnormality– Frequently not obese

Pediatric Sleep Apnea

Child with Sleep ApneaChild’s Enlarged Palatine &

Adenoidal Tonsils

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Why Get a Sleep Study?

• Signs and symptoms poorly predict disease severity

• Appropriate therapy dependent on severity

• Failure to treat leads to:

– Increased morbidity

– Motor vehicle crashes

– Mortality

• Other causes of daytime sleepiness

What Test Should be Used?

• In-laboratory full night polysomnography

–Split night studies

• Home diagnostic systems

–Oximetry to full polysomnography

Polysomnography

Polysomnogram

Polysomnography in OSA

Full-Night In-Laboratory Polysomnography

• Pro

– Full set of variables obtained

– Equipment problems can be repaired

– Technician can address patient problems

• Con

– Cost

– Accessibility

– Patient sleeps away from home

• Pro– Reduced cost– Patient may be studied only once– Reduces time to treatment initiation

• Con– Diagnostic time may be inadequate– Treatment time limited– Difficult decisions required of technicians

Split-Night In-Laboratory Polysomnography

Cases

• Some cases can be misleading and you can miss serious cases if you just use oximetry

• It is important to conduct the proper study

Oximetry

• Pro– Inexpensive–Simple to perform–Little patient discomfort–Widely available

• Con– Interpretation not standard–Poor sensitivity – missed diagnosis–Specificity controversial

Home Study Tracing

Redline S et al. Chest 1991;100.

Home Study

• Pro

– Potentially less expensive

– Patient sleeps at home

• Con

– Generally fewer signals are recorded

– Equipment cannot be adjusted

– Technician cannot assist patient

Diagnosis of Sleep Apnea

• In-laboratory polysomnography

–Gold standard

–Assess severity

– Initiate treatment

Diagnostic Conclusions

• Signs and symptoms

– Excessive daytime sleepiness

– Hypertension and other cardiovascular sequelae

• Sleep study results

– Apnea / hypopnea frequency

– Sleep fragmentation

– Oxyhemoglobin desaturation

Treatment Objectives

• Reduce mortality and morbidity

–Decrease cardiovascular consequences

–Reduce sleepiness

• Improve quality of life

Therapeutic Approach

• Risk counseling

– Motor vehicle crashes

– Job-related hazards

– Judgment impairment

• Apnea and comorbidity treatment

– Behavioral

– Medical

– Surgical

The High-Risk Driver

• Educate patient

• Document warning

• Resolve apnea quickly

• Follow-up

– Effectiveness

– Compliance

Behavioral Interventions

• Encourage patients to:

–Lose weight

–Avoid alcohol and sedatives

–Avoid sleep deprivation

–Avoid supine sleep position

–Stop smoking

Weight Loss

• Should be prescribed for all obese patients

• Can be curative but has low success rate

• Other treatment is required until optimal weight loss is achieved

Weight Loss and Sleep Apnea

-4

-20 to <-10%

-10 to <-5%

-5% to <+5

+5 to +10%

+10% to +20

-3

-2

-1

0

1

2

3

4

5

6

Change in Body Weight

Adapted from Peppard PE et al. JAMA 2000;284.

Mean Change in AHI, Events/hr

Practice Recommendation

• Practice Recommendation: Lifestyle modifications, particularly weight loss and reduced alcohol consumption can play a significant role in the reduction of severity of sleep apnea

• Evidence-Based Source:Institute for Clinical Systems Improvement

• Web Site of Supporting Evidence:http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html

• Strength of Evidence:Class A: Randomized, controlled trial; Class B: Cohort study; Class C: Non-randomized trial with concurrent or historical controls, Case-control study, Study of sensitivity and specificity of a diagnostic test, Population-based descriptive study; Class D: Cross-sectional study, Case series, Case report; Class R: Consensus statement, Consensus report, Narrative review

Sleep-Position Training

Medical Interventions

• Positive airway pressure

–Continuous positive airway pressure (CPAP)

–Bi-level positive airway pressure

• Oral appliances

• Other (limited role)

–Medications

–Oxygen

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Positive Airway Pressure

Positive Airway Pressure

Benefits of CPAP: Mortality

He J et al. Chest 1988;94.

1 2 3 4 5 6 7 8 9

CPAP

(AI > 20, All Ages)C

um

ula

tive

Su

rviv

al

Interval Years

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0

** ** ** **Control

Benefits of CPAP: Sleepiness

0

3

6

9

12

15

Pre Post

1 night14 nights

42 nights

CPAP TreatmentL

aten

cy t

o S

leep

(m

in)

Adapted from Lamphere J et al. Chest 1989;96.

Benefits of CPAP: Performance

0

5

10

15

20

25

30

35

Before CPAP After CPAP No Apnea

Ob

stac

les

hit

in 3

0 m

in.

Adapted from Findley L et al. Clin Chest Med 1992;13.

(n=6) (n=6)

(n=12)

Positive Airway Pressure: Problems

Patient Acceptance Claustrophobia Aerophagia Chest Discomfort

Mask Discomfort

Positive Airway Pressure: Problems

CPAP Compliance

• Patient report: 75%

• Objectively measured use

> 4 hrs for > 5 nights / week: 46%

• Asthma-medicine compliance: 30%

CPAP Compliance: Apnea Severity

Engleman HM et al. SLEEP 1993;16.

0

2

4

6

8

10

12

14

CP

AP

Ru

n H

ou

rs/N

igh

t

Apneas and Hypopneas/Hr.

20 40 60 80 100 120

Practice Recommendation

• Practice Recommendation:Polysomnography is the accepted standard test for the diagnosis of obstructive sleep apnea syndrome. The benefit of using attended polysomnography for diagnosis is the ability to establish a diagnosis and ascertain an effective CPAP treatment pressure.

• Evidence-Based Source:Institute for Clinical Systems Improvement

• Web Site of Supporting Evidence: http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_and_treatment_of_obstructive_.html

• Strength of Evidence: Class C: Non-randomized trial with concurrent or historical controls, Case-control study, Study of sensitivity and specificity of a diagnostic test, Population-based descriptive study; Class D: Cross-sectional study, Case series, Case report; Class M: Meta-analysis, Systematic review, Decision analysis, Cost-effectiveness analysis; Class R: Consensus statement, Consensus report, Narrative review

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Strategies to Improve Compliance

• Machine-patient interfaces–Masks–Nasal pillows–Chin straps

• Humidifiers• Ramp• Desensitization• Bi-level pressure

CPAP Masks

Bi-level Positive Airway Pressure

Positive Pressure Therapy

15

CPAP Bi-level

10

5

0

Pressure

FlowInsp

Exp

Compliance: CPAP Vs. Bi-Level PAP

Reeves-Hoché MK et al. Am J Respir Crit Care Med 1995;151 © American Lung Association.

0

1

2

3

4

5

6

1 2 3 4

Compliance: CPAP vs Bi-level Positive Pressure

CPAP Bi-level

Mean hours of

use

8

7

6

5

4

3

2Visit

12 weeks

Visit 2

4-8 weeks

Visit 4

24-28 weeks

Visit 3

8-12 weeks

Visit 5

52 weeks

Oral Appliances

• Indications

–Snoring and apnea (not severe)

• Efficacy

–Variable

• Side effects

–TMJ discomfort, dental misalignment, and salivation

Oral Appliance: Mechanics

Supplemental Oxygen

• Not a primary treatment for sleep apnea

• Does not improve daytime sleepiness

• May prolong apneas

• Reduces oxygen desaturation during apneas

• Reduces arrhythmias

Pharmacologic Treatment

• Limited Role

–Protriptyline or fluoxetine

–Decongestants

–Nasal steroids

–Antihistamines

–Other

Surgical Alternatives• Reconstruct upper airway

– Uvulopalatopharyngoplasty (UPPP)– Laser-assisted uvulopalatopharyngoplasty

(LAUP)– Radiofrequency tissue volume reduction– Genioglossal advancement– Nasal reconstruction– Tonsillectomy

• Bypass upper airway– Tracheostomy

Sites of Airway Narrowing

Adapted from Morrison DL et al. Am Rev Respir Dis 1993;148.

Collapse at softpalate only

Multiple sites ofcollapse

18%

82%

Uvulopalatopharyngoplasty (UPPP)

• Usually eliminates snoring

• 41% chance of achieving AHI < 20

• No accurate method to predict surgical success

• Follow-up sleep study required

Uvulopalatopharyngoplasty (UPPP)

Radiofrequency Tissue Volume Reduction

• Radiofrequency energy delivered to palate or tongue

• Causes tissue scarring / retraction

• Relatively painless

• Office vs O.R. procedure

• FDA approved for snoring and sleep apnea

• Role unclear - limited efficacy data

Staged Surgical Procedures

Primary Care Management

• Risk counseling

• Behavior modification

• Monitor symptoms and compliance

– Monitor weight and blood pressure

– Ask about recurrence of symptoms

– Evaluate CPAP use and side effects

Sleep Apnea: Is Your Patient at Risk? NIH Publication No.95-3803.

Primary Care Management

• Reasons for lack of improvement

– Noncompliance

– Alcohol and sedative use

– Depression

– Poor sleep habits

– Nonapneic sleep disorder

• Persistent or recurrent symptoms

– Consider referral to sleep specialist

Sleep Apnea

• Common

• Dangerous

• Easily recognized

• Treatable

Sleep Apnea

Sleep Apnea

Post-Test Questions

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