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Sleep Apnea Pre-Test Questions. ? 1. BMI only 2. Large neck circumference only 3. BMI and allergies 4.BMI and respiratory disease 5.BMI, Respiratory.

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Presentation on theme: "Sleep Apnea Pre-Test Questions. ? 1. BMI only 2. Large neck circumference only 3. BMI and allergies 4.BMI and respiratory disease 5.BMI, Respiratory."— Presentation transcript:

1 Sleep Apnea Pre-Test Questions

2 ?

3 1. BMI only 2. Large neck circumference only 3. BMI and allergies 4.BMI and respiratory disease 5.BMI, Respiratory disease and large neck circumference Walter is a 42 year old male complaining of daytime fatigue and depression. What additional risk factors should you consider for a diagnosis of sleep apnea?

4 Fred, a 56 year old Asian man, has been diagnosed with diabetes and obstructive sleep apnea. All of the following co-morbidities are likely affected by Freds sleep apnea EXCEPT: 1. Hypertension 2. Asthma 3. Erectile Dysfunction 4. Insulin resistance 5. Heart Failure

5 Jesse is a 52 year old executive who presents with fatigue. His wife has been complaining of his snoring over the past two years. He has been a two- pack a day smoker for 28 years. He weighs 260# and is sedentary. What symptoms would you ask Jesse about to make an initial diagnosis of obstructive sleep apnea? 1.Mild cough and frequent headaches 2.Restlessness and depression 3.Sore throat and difficulty swallowing 4.Dry eyes and shortness of breath

6 You confirm that Jesse has met the conditions for a diagnosis of OSA. What test would most likely confirm this diagnosis? 1.The Epworth Sleepiness Scale (ESS) 2.Polysomnography 3.Nighttime Oximetry 4.None of the above

7 Jesses test confirms OSA. He says he is motivated to lose weight. What other treatment regimens do you prescribe? 1.A beer or other alcoholic beverage at bed time 2.CPAP 3.Prescription sleeping aids and CPAP 4.Smoking cessation and CPAP

8 Understanding, Recognizing and Managing Obstructive Sleep Apnea Federico Cerrone, MD,FCCP,DASSM Director, Center for Sleep Disorders Overlook Hospital, Summit, NJ

9 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).

10 Sleep Apnea

11 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

12 Sleep Apnea is: Common Dangerous Easily recognized Treatable

13 Sleep Apnea Definition Pathophysiology Clinical Features Risk Factors Methods of Diagnosis Treatment

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15 Question 1 What is the definition of obstructive sleep apnea? 1.Patient makes no effort to breathe? 2.Patients oxygen levels and carbon dioxide levels decrease with sleep? 3.There is a reduction in airflow, but patient still makes effort to breathe? 4.Patient has an inability to fall asleep, stay asleep or has early morning awakenings?

16 Types of Sleep Disordered Breathing Apnea –Cessation of airflow > 10 seconds Hypopnea –At least 30% reduction airflow > 10 seconds associated with: Arousal Oxyhemoglobin desaturation

17 Apnea Patterns Obstructive Mixed MixedCentral Airflow Respiratory effort

18 Upper Airway Resistance Syndrome EEG 10 sec Arousal Airflow Effort (Pes) SaO 2 Effort (Abdomen) Effort (Rib Cage)

19 Measures of Sleep Apnea Frequency Apnea Index –# apneas per hour of sleep Apnea / Hypopnea Index (AHI) –# apneas + hypopneas per hour of sleep

20 Severity Criteria Mild: 5-15 events per hour Moderate: 15-30 events per hour Severe: more than 30 events per hour

21 Limitations to Criteria Does not incorporate severity of oxygen desaturation Does not consider non-apneic respiratory events

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23 Question 2 Which of the following statements regarding prevalence of obstructive sleep apnea is true? 1.24% of men and 9% of women have OSAS? 2.4% of men and 2% of women had an AHI5 according to the first major US population-based prevalence study? 3.Prevalence of OSAS will continue to increase as prevalence of obesity continues to rise? 4.Sleep apnea occurs equally in men and women?

24 Prevalence of Sleep Apnea 30-60 year olds Percent of Population Adapted from Young T et al. N Engl J Med 1993;328.

25 Patient # 1 Patient tells you that a couple of drinks increases the snoring He also grinds his teeth per his dentist

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27 Question 3 Which of the following best characterizes the pathogenesis of OSA? 1.Increased genioglossus activity while awake? 2.Reduced tensor palatini activity while awake? 3.Not enough skeletal support of upper airway? 4.Decreased genioglossus activity while awake?

28 1 2 3 4 5 6 7 8 9 The Upper Airway

29 Anatomical Factors Collapsible tube Changes in upper airway anatomy There are increased parapharyngeal fat pads Obesity can reduce lung volumes Dilator muscles

30 Control of Dilator Muscles Effects On Pharyngeal Muscle Activity Normal Subject Awake OSA Patient NREM Genioglosus EMG Tensor Palatini EMG Airflow Genioglosus EMG Tensor Palatini EMG Airflow

31 Pathophysiology of Apnea

32 Pathophysiology of Sleep Apnea Awake: Small airway + neuromuscular compensation Loss of neuromuscular compensation + Decreased pharyngeal muscle activity Sleep Onset Hyperventilate: connect hypoxia & hypercapnia Airway opens Airway collapses Pharyngeal muscle activity restored Apnea Arousal from sleep Hypoxia & Hypercapnia Increased ventilatory effort

33 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%

34 Clinical Consequences Cardiovascular Complications Morbidity Mortality Sleep Fragmentation Hypoxia/ Hypercapnia Excessive Daytime Sleepiness Sleep Apnea

35 Consequences: Excessive Daytime Sleepiness Increased motor vehicle crashes Increased work-related accidents Poor job performance Depression Family discord Decreased quality of life

36 Consequences: Automobile Accidents Accident / driver / 5 yrs Adapted from Findley LJ et al. Am Rev Respir Dis 1988;138.

37 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.

38 Consequences: Cardiovascular Systemic hypertension Cardiac arrhythmias Myocardial ischemia Cerebrovascular disease Pulmonary hypertension / cor pulmonale

39 Consequences: Mortality Effect of Al on Mortality He J et al. Chest 1988;94. (Untreated, age<50) AI < 20 AI > 20 Cumulative Survival Interval (Years)

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41 Question 4 Back to our patient in Case 1: Which of the following is correct regarding the relationship between OSA and hypertension? 1.Prospective observational cohort studies have not demonstrated an increased risk of htn associated with OSA 2.Systemic htn is not on the causal pathway between OSA and stroke? 3.Blinded RCT have shown that CPAP reduces blood pressure in htn patients with sleep apnea?

42 Consequences: Hypertension Shepard JW Jr. Med Clin North Am 1985;69.

43 Cardiovascular Consequences: Hypertension Odds Ratio 0 0.5 1 1.5 2 2.5 3 00.1 - 4.95 - 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.

44 Consequences: Arrhythmias Shepard JW Jr. Clin Chest Med 1992;12. EEG LOC EMG CHIN EKG SAO2 FLOW PNT EFF ABD EFF SUM EFF RC

45 Atrial Fibrillation Decrease in oxygen saturation may be the best predictor of risk Gami,JACC,2007

46 Stroke Increased severity of obstructive sleep apnea increases risk of stroke Yaggi et al: NEJM 2005

47 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 CADHFCVA 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.

48 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

49 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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51 Question 5 Which one of the following is a known risk factor of OSA? 1.Decreased neck circumference 2.The Premenopausal status 3.Presence of Retronagthia 4.Longer thyromental distance

52 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

53 Risk Factor: Obesity Davies RJ et al. Eur Respir J 1990;3. >4% Arterial saturation dipa h -1 % Predicted normal neck circumference

54 Risk Factor: Age % with AHI > 5 Adapted from Young T et al. N Engl J Med 1993;328.

55 Age Prevalence plateaus after age 65 Is sleep apnea different in older people? Young; 2002 Arch Intern Med

56 Risk Factor: Gender Millman RP et al. Chest 1995;107. Apnea/Hypopnea Index Skinfold Sum (mm) Male Female

57 Risk Factor: Anatomic Abnormality Suratt PM et al. Chest 1986;90. Apneas & Hypopneas per hour of sleep 75 6 4 8 5 1 2 7 3

58 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 for age, race, sex, BMI) Odds Ratio 1 2 3 Relative Relatives Relatives

59 Risk Factor: Sedatives Sanders MH. In: Principles and Practice of Sleep Medicine. Philadelphia: W.B. Saunders Company, 1994. Peak Integrated activity (% control) Minutes after injection Diazepam Injection Hypoglossal Nerve Phrenic Nerve 05153060 150 100 50 0

60 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

61 Risk Factor: Smoking 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

62 Risk Factor: Associated Conditions Hypothyriodism Acromegaly Amyloidosis Vocal cord paralysis Marfan syndrome Down syndrome Neuromuscular disorders

63 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

64 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.

65 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

66 0 = would never doze or sleep. 1 = slight chance of dozing or sleeping 2 = moderate chance of dozing or sleeping 3 = high chance of dozing or sleeping SituationChance 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

67 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%

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

69 Exam: Tonsillar Hypertrophy Shepard JW Jr et al. Mayo Clin Proc 1990;65. Oropharynx With Tonsillar Hypertrophy Normal Oropharynx

70 Exam: Oropharynx Patient With the Crowded Oropharynx

71 Physical Examination Guilleminault C et al. Sleep Apnea Syndromes. New York: Alan R. Liss, 1978. Structural Abnormalities

72 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

73 Diagnosis: Pediatric Apnea Presentation –Behavioral problems / irritability –Poor school performance –Enuresis –Snoring Cause –Adenotonsillar hypertrophy –Craniofacial abnormality –Frequently not obese

74 Pediatric Sleep Apnea Child with Sleep Apnea Childs Enlarged Palatine & Adenoidal Tonsils

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76 Question 6 What is the Gold Standard for diagnosing OSA? 1.Overnight home oximetry? 2.History from a bed partner? 3.Overnight sleep study? 4.Physical exam with obesity, increased neck size and history of daytime sleepiness?

77 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

78 What Test Should be Used? In-laboratory full night polysomnography –Split night studies Home diagnostic systems –Oximetry to full polysomnography

79 Polysomnography

80 Polysomnogram Polysomnography in OSA

81 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

82 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

83 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

84 Oximetry Pro –Inexpensive –Simple to perform –Little patient discomfort –Widely available Con –Interpretation not standard –Poor sensitivity – missed diagnosis –Specificity controversial

85 Home Study Tracing Redline S et al. Chest 1991;100.

86 Home Study Pro –Potentially less expensive –Patient sleeps at home Con –Generally fewer signals are recorded –Equipment cannot be adjusted –Technician cannot assist patient

87 Diagnosis of Sleep Apnea In-laboratory polysomnography –Gold standard –Assess severity –Initiate treatment

88 Diagnostic Conclusions Signs and symptoms –Excessive daytime sleepiness –Hypertension and other cardiovascular sequelae Sleep study results –Apnea / hypopnea frequency –Sleep fragmentation –Oxyhemoglobin desaturation

89 Treatment Objectives Reduce mortality and morbidity –Decrease cardiovascular consequences –Reduce sleepiness Improve quality of life

90 Therapeutic Approach Risk counseling –Motor vehicle crashes –Job-related hazards –Judgment impairment Apnea and comorbidity treatment –Behavioral –Medical –Surgical

91 The High-Risk Driver Educate patient Document warning Resolve apnea quickly Follow-up –Effectiveness –Compliance

92 Behavioral Interventions Encourage patients to: –Lose weight –Avoid alcohol and sedatives –Avoid sleep deprivation –Avoid supine sleep position –Stop smoking

93 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

94 Weight Loss and Sleep Apnea -4 -20 to <-10% -10 to <- 5% -5% to <+5 +5 to +10% +10% to +20 -3 -2 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

95 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

96 Sleep-Position Training

97 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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99 Question 7 A young adult male has htn and daytime sleepiness and is diagnosed with severe OSA. He will be starting CPAP therapy. He believes all his problems will be solved. In addition to resolving his breathing events, CPAP is most likely to improve: 1.Hypertension 2.Daytime sleepiness 3.Depression 4.Memory issues

100 Positive Airway Pressure

101

102 Benefits of CPAP: Mortality He J et al. Chest 1988;94. CPAP (AI > 20, All Ages) Cumulative Survival 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

103 Benefits of CPAP: Sleepiness CPAP Treatment Latency to Sleep (min) Adapted from Lamphere J et al. Chest 1989;96.

104 Benefits of CPAP: Performance Obstacles hit in 30 min. Adapted from Findley L et al. Clin Chest Med 1992;13. (n=6) (n=6) (n=12)

105 Positive Airway Pressure: Problems Patient Acceptance Claustrophobia Aerophagia Chest Discomfort Mask Discomfort

106 Positive Airway Pressure: Problems

107 CPAP Compliance Patient report: 75% Objectively measured use > 4 hrs for > 5 nights / week: 46% Asthma-medicine compliance: 30%

108 CPAP Compliance: Apnea Severity Engleman HM et al. SLEEP 1993;16. CPAP Run Hours/Night Apneas and Hypopneas/Hr. 20 40 60 80 100 120

109 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_obstru ctive_.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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111 Question 8 A 50 yo male with OSA is started on CPAP at 12 cm H2O at home. He returns 2 weeks later and is having trouble tolerating CPAP. Which of following has been shown to help compliance? 1.Zolpidem 5 mg at bedtime 2.Add ramp system 3.Heated humidification 4.Add chinstrap

112 Strategies to Improve Compliance Machine-patient interfaces –Masks –Nasal pillows –Chin straps Humidifiers Ramp Desensitization Bi-level pressure

113 CPAP Masks

114 Bi-level Positive Airway Pressure Positive Pressure Therapy 15 CPAPBi-level 10 5 0 Pressure Flow Insp Exp

115 Compliance: CPAP Vs. Bi-Level PAP Reeves-Hoché MK et al. Am J Respir Crit Care Med 1995;151 © American Lung Association. Compliance: CPAP vs Bi-level Positive Pressure CPAP Bi-level Mean hours of use 87654328765432 Visit 1 2 weeks Visit 2 4-8 weeks Visit 4 24-28 weeks Visit 3 8-12 weeks Visit 5 52 weeks

116 Oral Appliances Indications –Snoring and apnea (not severe) Efficacy –Variable Side effects –TMJ discomfort, dental misalignment, and salivation

117 Oral Appliance: Mechanics

118 Supplemental Oxygen Not a primary treatment for sleep apnea Does not improve daytime sleepiness May prolong apneas Reduces oxygen desaturation during apneas Reduces arrhythmias

119 Pharmacologic Treatment Limited Role –Protriptyline or fluoxetine –Decongestants –Nasal steroids –Antihistamines –Other

120 Surgical Alternatives Reconstruct upper airway –Uvulopalatopharyngoplasty (UPPP) –Laser-assisted uvulopalatopharyngoplasty (LAUP) –Radiofrequency tissue volume reduction –Genioglossal advancement –Nasal reconstruction –Tonsillectomy Bypass upper airway –Tracheostomy

121 Sites of Airway Narrowing Adapted from Morrison DL et al. Am Rev Respir Dis 1993;148. 18% 82%

122 Uvulopalatopharyngoplasty (UPPP) Usually eliminates snoring 41% chance of achieving AHI < 20 No accurate method to predict surgical success Follow-up sleep study required

123 Uvulopalatopharyngoplasty (UPPP)

124 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

125 Staged Surgical Procedures

126 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.

127 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

128 Sleep Apnea Common Dangerous Easily recognized Treatable

129 Sleep Apnea

130 Post-Test Questions

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132 1. BMI only 2. Large neck circumference only 3. BMI and allergies 4.BMI and respiratory disease 5.BMI, Respiratory disease and large neck circumference Walter is a 42 year old male complaining of daytime fatigue and depression. What additional risk factors should you consider for a diagnosis of sleep apnea?

133 Fred, a 56 year old Asian man, has been diagnosed with diabetes and obstructive sleep apnea. All of the following co-morbidities are likely affected by Freds sleep apnea EXCEPT: 1. Hypertension 2. Asthma 3. Erectile Dysfunction 4. Insulin resistance 5. Heart Failure

134 Jesse is a 52 year old executive who presents with fatigue. His wife has been complaining of his snoring over the past two years. He has been a two- pack a day smoker for 28 years. He weighs 260# and is sedentary. What symptoms would you ask Jesse about to make an initial diagnosis of obstructive sleep apnea? 1.Mild cough and frequent headaches 2.Restlessness and depression 3.Sore throat and difficulty swallowing 4.Dry eyes and shortness of breath

135 You confirm that Jesse has met the conditions for a diagnosis of OSA. What test would most likely confirm this diagnosis? 1.The Epworth Sleepiness Scale (ESS) 2.Polysomnography 3.Nighttime Oximetry 4.None of the above

136 Jesses test confirms OSA. He says he is motivated to lose weight. What other treatment regimens do you prescribe? 1.A beer or other alcoholic beverage at bed time 2.CPAP 3.Prescription sleeping aids and CPAP 4.Smoking cessation and CPAP


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