Epidemiology and diagnosis of sleep apnea · Lancet Resp Med, June 17th 2016. 25 Estimated...
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Epidemiology and diagnosis of
sleep apnea
Dr Raphael Heinzer, MD MPH
Center for Investigation and research in Sleep
Lausanne University Hospital (CHUV)
Switzerland
Joint annual meeting SSC/SSCS-SSP 2016
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Wisconsin Sleep Cohort Study
Apnea hypopnea index > 5/h Men 27%
Women 9%
Sleep apnea syndrome Men 4%
(AHI>5/h + Sleepiness) Women 2%
Young NEJM 1993
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Lancet Respiratory Medicine 2015
2162 subjects aged 40 to 85 yrs have a full
polysomnography at home
- EEG/EOG/EMG (sleep structure)
- Nasal pressure, chest and abdominal movements
and SaO2
- Legs EMG
- ECG (1 channel)
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HypnoLaus Cohort study
Parameters Value
n 2162
Age (y) 58.5 ± 11.0
Gender 50.4 % females
Body mass index (kg/m2) 26.2 ± 4.4
Epworth score (Mean± SD) 6.2 ± 3.9
Neck circumference (Mean± SD) 36.9 ± 3.9
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Prevalence of sleep disorderdbreathing in the general population
%
HypnoLaus Cohort (N = 2121) aged 40-85 years old
83.8
49.7
22
60.9
23.4
7.6
0
10
20
30
40
50
60
70
80
90
>5/h >15/h >30/h
Men
Women
Heinzer et al Lancet resp med 2015
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Prevalence of sleep apnea syndrome(sleep disordered breathing + Epworth >10)
18.9
11.5
5
10.8
4.8
1.8
0
2
4
6
8
10
12
14
16
18
20
AHI > 5/h AHI > 15/h AHI > 30 /h
Males
Females%
HypnoLaus Cohort (N = 2121)
Heinzer et al Lancet resp med 2015
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Wisconsin-HypnoLaus differences
Wisconsin 1993 HypnoLaus 2015
Subjects nb 602 2162
Selection State employees80% snorers
General population
Age Range 30-60 40-85
Setting Sleep laboratory Home
Hypopnea Discernible reductionin airflow + ≥ 4% O2
desaturation
AASM 2013 (Chicago, AASM 07 rec)
Sleepiness 3 questions Epworth
Airflow signal Thermocouple and end-tidal CO2
Nasal pressure
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Thermistor
Nasal pressure
Nasal pressure vs. thermistor
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JACC 2016
- 6,876 patients with stable chronic heart failure (LVEF < 45%)
- Prevalence of Sleep disordered breathing (AHI >15/h)
-36% in women (n: 1,448)
-49% in men (n: 5,428)
NB: No assessment of central vs obstructive sleep apnea
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Arzt et al JACC 2016
Sleep disordered breathing in stable heart failure
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Arzt et al JACC 2016
SDB according to LV ejection fraction
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Diagnostic of sleep disordered
breathing
• Oximetry/Apnealink
• Respiratory polygraphy
• Polysomnography
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X-flow
Abdomen
Thorax
Saturation O2
Obstructive apnea Obstructive apnea
Nasal pressure
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Central apnea
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Cheyne Stokes
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Oximetry
100 sec
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Polygraphy
Nasal pressure (Airflow)
SaO2
Thorax + abdomen
100 sec
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Polysomnography
Nasal pressure (airflow)
SaO2
Thorax + abdomen
100 sec
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Screening scores for SDB ?
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Berlin questionnaire
High risk of OSA If 2 of the 3 categories are positive
Category 1: Snoring Category 2: Fatigue Category 3: BMI and HT
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STOP-BANG
S = Snoring
T = Tired
O = Observed apnea
P = Pressure (high blood pressure)
B = BMI > 25 kg/m2
A = Age > 50 ans
N = Neck circumference > 40 cm
G = Gender (men)
A score ≥ 3 is considered positive (High risk for OSA)
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STOP BANG score in a clinical population
El Sayed EJCDT 2012
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“NoSAS” score
Neck circumference > 40
cm
4 points
Obesity
BMI ≥ 25 kg/m2 and <
30 kg/m2
3 points
BMI ≥ 30 kg/m2 5 points
Snoring (self-reported) 2 points
Age > 55 years 4 points
Sex Male 2 points
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NoSAS ≥ 8 High probability of SDB
Lancet Resp Med, June 17th 2016
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Estimated
prevalence
AUC Sensitivity Specificity PPV NPV
HypnoLaus (40 80 y.o.)
NoSAS 43·3 0·74 0·79 0·69 0·47 0·90
STOP-Bang 69·0 0·67 0·94 0·40 0·35 0·95
Berlin 24·8 0·63 0·41 0·81 0·43 0·79
EPISONO (20-80 y.o)
NoSAS 11·4 0·81 0·85 0·77 0·33 0·98
STOP-Bang 11·6 0·68 0·72 0.64 0·21 0·95
Berlin 11·5 0·65 0·61 0·68 0·20 0·93
Lancet Resp Med, June 17th 2016
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Estimated
prevalence
AUC Sensitivity Specificity PPV NPV
HypnoLaus (40 80 y.o.)
NoSAS 43·3 0·74 0·79 0·69 0·47 0·90
STOP-Bang 69·0 0·67 0·94 0·40 0·35 0·95
Berlin 24·8 0·63 0·41 0·81 0·43 0·79
EPISONO (20-80 y.o)
NoSAS 11·4 0·81 0·85 0·77 0·33 0·98
STOP-Bang 11·6 0·68 0·72 0.64 0·21 0·95
Berlin 11·5 0·65 0·61 0·68 0·20 0·93
Lancet Resp Med, June 17th 2016
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0.50
0.55
0.60
0.65
0.70
0.75
0.80
AHI > 5 AHI > 10 AHI > 15 AHI > 20 AHI > 25 AHI > 30
Are
a u
nd
er
the
cu
rve
NoSAS
STOP-Bang
Berlin
Lancet Resp Med, 2016
Performance of the scores according to different
AHI thresholds
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28
Free «NoSAS» application available for iphones and Android smartphones
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Conclusion
- Sleep disordered breathing is highly prevalent in the middle to older age general population
- SDB is frequent in stable heart failure patients (LVEF <45%)
- Polygraphy (with respiratory effort channels) isthe minimum standard to diagnose SDB
- Screening scores/oximetry can help decidingwhich patients should be sent for PG/PSG
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HypnoLaus Team
José Haba-Rubio
Sopharat Vat Nadia Tobback
Mehdi Tafti
Daniela Andries
Supported by:
Leenaards foundation, Fond national suisse, GSK, Ligue pulmonaire vaudoise
Helena Marti-Soler