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Disease State Crossover Managing the Complex OSA Patient Peter Allen, BSRC, RST, RPSGT RRT-NPS-SDS RRT-NPS-SDS.

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Presentation on theme: "Disease State Crossover Managing the Complex OSA Patient Peter Allen, BSRC, RST, RPSGT RRT-NPS-SDS RRT-NPS-SDS."— Presentation transcript:

1 Disease State Crossover Managing the Complex OSA Patient Peter Allen, BSRC, RST, RPSGT RRT-NPS-SDS RRT-NPS-SDS

2 Conflicts of Interest  Philips Respironics  ResMed Corp  Fisher & Paykel  DeVilbiss  MVAP  Natus  NovaSom  Watermark

3 Content  Co-Morbid disease state descriptions and the workflow of those disease states as they pass through the sleep disorders center.  COPD  Diabetes  Morbid Obesity  Cardiovascular  Stroke  Gastroesophageal Reflux/Gerd  Metabolic Syndrome  Intake, Clinical and Marketing Aspects

4 Learning Objectives  1. Attendee will have a better understanding of the underlying physiology of the co-morbid OSA patient and various aspects of overlap syndrome between disease states.  2. Attendee will be better able to plan and cope with the complex patients in their sleep labs.  3. Attendee will learn to grow clinically while realizing the financial opportunity that these patients represent to their sleep centers.

5 Attendees  Night Technologists  EEG Background  Respiratory Background  Home Care DME  Home Sleep Testing  Lab Managers  Lab Owners  Hospital Administrators  Nursing  Physician Assistants

6 Co-Morbid Condition off Your Wing

7 Introduction   Since 1970 when Stanford opened the first sleep center and Dr. Guilleminault later described Obstructive Sleep Apnea(OSA), many studies have been conducted regarding associated disease states.

8 Introduction Cont’d   Many studies have linked OSA to co-morbid disease states and conditions such as:   Cardiovascular and Pulmonary Disease   Congestive Heart Failure – 76%   A-Fib, - 49%   Diabetes – 48%   Obesity - 77%   Stroke   Spinal Cord Injury   Reflux/Gerd   End Stage Renal – 10 times Greater than General Population   Headaches, COPD, Cancer, Metabolic Syndrome

9 Medicare Readmissions Policy   Many Co-Morbid disease states that are associated with OSA are being targeted by Medicare as criteria, for financial penalties to Medical Centers where readmissions occurs, within 30 days of discharge.   This puts a spotlight on Diagnosis and Treatment of OSA and its associated co-morbid disease states as an integral part of a medical centers financial integrity plan.

10 COPD   Chronic Obstructive Pulmonary Disease   Two Components   Chronic Bronchitis – Productive cough, three months of the year, two or more successive years.   Emphysema - Abnormal enlargement of the airspaces in the lungs with destruction to the cell walls.   Primarily caused by cigarette smoking.

11 COPD Medications   Oxygen – Physician’s Orders   Theophylline   Ipratropium bromide   Advair’   Symbicort   Daliresp   Theophylline   Atrovert   Serevent   Salmeterol   Formeterol   Proventol/Ventolin/Abuterol - Nebulizers

12 COPD Referral Sources   Pulmonologists   Hospitalists   Internal   Family   Internal Medicine   Oncologists

13 COPD Intake Concerns   Oxygen ?   Liter Flow ? Hypoxic Drive Candidate   Mobility ?   Additional Caretakers?   Medications? Nebulizers Short Acting Acute Long Acting Maintenance Recent Hospitalizations??

14 COPD Night of Study   Shortness of Breath (SOB)   Ambulation   Oxygen Protocols   Emergency Protocols   Detailed H&P in Chart   Medication Schedules   Thorough Chart Review Early!!!!!

15 COPD and the Record   High CO2 – 35 Normal>>>50+   Low Spo2 – 90% to 97%>>>>88% or less   Hypoventilation   Centrals During Titration   Supplemental Oxygen as needed   PVCs, PACs, Uni and Multi-Focal, V-Tach   High Heart Rates   A-Fib

16 COPD OSA “Overlap Syndrome ”   1. Impaired Lungs plus OSA   2. COPD and OSA jointly contribute   3. More nocturnal desaturations   4. Reduction in respiratory drive-HV   5. Chest wall hyperinflation causes muscle fatigue in these patients.   6. COPD has systemic consequences   7. CO2 High(Retainers), Spo2 Low

17 Overlap Syndrome Conclusions   Overlap syndrome increases risk of death and hospitalization due to COPD.   PAP treatment with or without oxygen is associated with better patient outcomes along with decreased hospitalizations.   Less readmissions for these patients

18 Diabetes   Impairment of the body’s ability to use blood sugar for energy.   Type 1- Insulin producing Beta cells in pancreas destroyed.   Type 2- Most common 90% to 95%, Weight, Food Insulin resistance by body, so pancreas overproduces   Gestational - during pregnancy- Usually Temp   Over 6 million in the US alone

19 Diabetes Medications   Type IInsulin – Oral or Injection   Type II   Metformin   Victoza   Glucophage   Amaryl   Glucotrol   Januvia   Novolin

20 Diabetes Referral Sources   Family   Internal Medicine   Endocrinologist   Bariatric Medicine

21 Diabetes Intake Concerns   Type 1:   When do they take their meds?   Reinforce that patient needs to bring meds.   Type II:   When do they take their meds?   Labs are Out-Patient Facilities, So…

22 Diabetes Night of Study   Tech needs to establish med routine   Patient will always self-administer   Refrigeration for meds   Do not let patients “Take a Night Off”   Call to Physician if need be to clarify/safety concerns/patient coherent?

23 Diabetes Sleep Loss Effects   Frequent urination common during PSG   Sleep loss leads to:   Altered glucose and metabolism   Reduced Leptin/Increased Ghrelin   Up regulation of appetite/weight gain   Lower energy = Weight Gain(OSA Factor)   Insulin resistance = Type 2   Increased Risk for Diabetes   Adapted from Parker, K.P. (2011) Sleep disorders and sleep promotion in nursing practice; p. 180

24 Morbid Obesity   Co-Mobidities within a Co-Morbidity   BMI > 32 – Doubles risk of death   High Blood Pressure   Heart Disease – Left and Right side - Lymphedema   High Cholesterol Levels   Diabetes- 10 times- 60% to 80%   Gastroesophageal Reflux   Urinary Stress Incontinence   Degenerative Arthritis-Fall Risk   Skin Infections, Fluid Retention

25 Morbid Obesity Medications   1. Metformin – Type II   2. Diuretics - Lasix   3. Hypertensive Meds – Lisinopril   4. Pillows, Pillows, Pillows,- Orthopnea   5. Insulin – Type 1   6. Lymphedema Meds   7. Oxygen   8. Lipitor   9. Vaso…….Cardio Meds

26 Morbid Obesity Referrals   Family   Internal Medicine   Endocrinologist – Metabolic Syndrome   Bariatric Medicine – Pre and Post Surgical   Nephrologist- Renal Disease   Perioperative Referrals

27 Morbid Obesity Intake   Weight   Bed Limits   Toilet Limits   Chairs   Ambulation?   Medications?   Drs to be copied?   Special Needs?

28 Morbid Obesity Night of Study   PSG Set-Up – Belts, leads, sensors…   Titration Night Mask Fitting Concerns   Headgear Big Enough?- Call Reps   Does your lab have a weight limit?   Bariatric Approved Beds?   Fall Risk?   Culture of Safety Concerns all Around   Meds   Frequent bathroom breaks   Possible Incontinence

29 Morbid Obesity Record   1. Loud Snoring   2. Deep Desaturations   3. Irregular EKG 4. Usually Severe OSA   5. CPAP to BI-Level Protocols?   6. Frequent breaks in recording   7. Artifact, movement, sweat   8. Speaking

30 Morbid Obesity OSA Overlap   1. OSA Influence on other conditions, high   2. Cardio   3. Pulmonary   4. High Blood Pressure   5. Fluid Retention   6. Bariatric Surgery or Intensive Lifestyle Changes   Metabolic Syndrome, Insulin Resistance – Type 2   Haines et al. Surgery 2007; 141:   Look Ahead Research Group, Diabetes Care 2007

31 Cardiovascular   1. 70% of patients admitted to the hospital for coronary artery disease were found to have sleep Apnea   2. Patients with OSA have a 50% risk of hypertension   3. OSA starves heart of oxygen while making it work harder leading to higher blood pressures through the night.   4. Untreated OSA is well documented as a factor in causing heart disease   5. A patient’s chance of having OSA if they have heart failure is very high.   AM J Respir Crit Care Med Vol. 188, P1-P2, 2013   ATS Patient Education Series 2013 Chowdhuri, S., MD, Weingarten, J., MD

32 Congestive Heart Failure   Systolic Failure   Failure to eject/pump blood out of the heart effectively   Diastolic Failure   Heart muscles have become stiff and do not fill easily   Fluid builds up in the lungs, liver, gastrointestinal tract, arms and legs/ankles.   Zee, P & Naylor, E

33 CHF and Sleep   Shortness of Breath   RLS Symptoms   Diuretics = Increased Bathroom Breaks   OSA and CSA   Insomnia – Daytime Sleepiness   Short Sleep Duration

34 Cardiovascular Medications   1. Lisinopril   2. Atenolol   3. Diovan   4. Norvasc   5. Clonidine   6. Azor   7. Verapamil   8. Furosemide   9. Lasix   10.Coreg   11. Zestril   12. Vasotec   13. Lopressor   14. Levatol   15. ……anybody

35 Cardiovascular Referral   Family   Internal Medicine   Cardiology   Surgeons - Perioperative   Hospitalist

36 Cardiovascular Intake   Oxygen?   Get both Family and Specialists   Last Hospitalization?   Medications and average BP

37 Cardiovascular Night of Study   BP Pre and Post Study – Both Arms   Ask when they last took their medications   DeFib Unit Operational – Signed off on?   Room Temp Important if Sweating   Note any swelling in arms or legs   Note Pacemaker and Type – Constant/As Need   BLS, ACLS, PALS   911, 711 depending on hospital/freestanding

38 Cardiovascular Record   Irregular EKG   PVCs, PACs, V-Tach, A-Fib, Pauses   Full or Partial Heart Block   Breaks in record-Diuretics/Lazix Insomnia from Anxiety Cheyne Stokes Breathing Pattern – 73% in CHF patients   Left ventricular dysfunction-Hyper and Hypo ventilation   Waxing and Waning breathing pattern   Pacing Spikes   OSA and CSA   CSA sometimes evoked by O2 and PAP, Auto Servo Ventilation

39 Cardiovascular OSA Overlap   1. Elevated Blood Pressure during Sleep   2. Elevated Sympathetic Tone leads to HBP   3. About 30% of patients with hypertension have OSA   4. Congestive Heart Failure well documented connection   5. Left ventricle enlargement/increased workload/events   6. Effects are both acute and chronic   7. Cessation of airflow and subsequent desat starves heart of oxygen.   8. PAP Treatment is shown to have positive effect on all   9. Heart Failure associated with Cheyne Stokes Pattern   10. OSA occurs in 50% of atrial fibrillation patients

40 Stroke   Hemorrhagic-Vessel breakdown   Ischemic-transient ischemic attack (TIA) Narrowing   Embolic-Clot local or from other area blocks flow   OSA and SDB contributes to increased risk of stroke.   Stroke can contribute to OSA or CSA   Reduced muscle tone and control of upper airway

41 Stroke Onset Symptoms   Sudden Slurring of Speech   Muscle control deficit in face/body affecting one side or bilaterally

42 Stroke Medications   Anti-platelet   Aspirin   Plavis/Clopidogrel   Ticlid/Ticiopidine   Anti-clot   Warfarin/Coumadin   Heparin-Hospital via IV   Acute Phase   Thrombolytic Agents-”Clot Busters”

43 Stroke Patient Referral Sources   Family   Internal Medicine   Neurology   Hospitalist   Case Managers   CRNPs

44 Stroke Intake   1. Hemorrhagic   2. Ischemia (TIA) or Embolic   3. Left or Right Side Deficit   4. Speech?   5. Ambulatory ? 6. Aide or Family Member 7. Time of Day or Night –Triggers

45 Stroke Night of Study   Left side Right side?   Full 10-20?   Fall Risk?   Medication Schedule?   BP in the evening and morning   Medical Director Parameters for BP   Time of Day/Night-Triggers

46 Stroke Patient Record Aspects   1. Left Side or Right Side EEG differences   2. Non-Homologous electrodes can cause voltage asymmetries.   3. Measure, Measure, Measure   4. Do not eye-ball EEG set-up   5. Full 10/20 frequently ordered

47 Stroke Patient OSA Overlap   OSA increase risk of stroke, independent of other risk factors.   Males with mild sleep apnea have doubled stroke risk   Stroke patients-63% have SDB   Stroke patients w SDB have higher mortality, 1yr   Even higher frequency of SDB in stroke patients with high BMI and Type 2 Diabetes.

48 Gastroesophageal Reflux(Gerd)   1. Human PH – 1 TO 14   2. Arterial PH – Normal 7.35 – 7.45   3. Stomach PH – 4 or less   4. Adults and Infants   5. Apnea causes Reflux or is Reflux causing Apnea?   6. Heartburn most common symptom   7. Chronic Illness 5-7% Worldwide   8. Middle Age-Esophageal Valve Weakens   9. Opening pressure of that valve?? PAP concerns?

49 Reflux/Gerd Medications   1. Zantac   2. Reglin   3. Nexium-Purple Pill   4. Pepto-Bismol   5. Ranitidine   6. Lansoprazole   7. Famotidine   8. Simethicone   9. Gavison   10. Maalox   11. Mylanta   12. Prevacid   13. Pepcid   14. Tums

50 Reflux/Gerd Referral Sources   Family   Internal Medicine   Cardiology   Gastroenterologists   Neonatologists   Pediatricians

51 Reflux/Gerd Intake Concerns   1. Medication Schedule   2. Physicians orders regarding meds   3. Hospitalizations?   4. Barrett’s esophagus or other Upper GI?

52 Reflux/Gerd Night of Study   1. Dr’s Orders Followed?   2. Last Meal time documented   3. Last Med   4. Does patient have a logbook?   5. Flat or Raised?   6. Document Patients Snacking/Eating   7. Spicy, acidic, fried foods, tomato based

53 Reflux/Gerd Record Aspects   1. Infant Study- Arousals, Body Posture   2. Adults- Arousals, Frequent breaks   3. Document Patient Observations   4. GERD with OSA events?   5. Choking Aspiration Risk?   6. Upright Posture   7. Left side/Right side/Recovery Position   8. Dr’s orders regarding food/meds/body position

54 Reflux/Gerd OSA Overlap   1. Not a clear causal relationship   2. Chicken/Egg or Egg/Chicken   3. Hard breathing during events?   4. Different mechanisms can cause both   5. Multifactorial Origin – Shared risk factors   6. Aspiration risk at end of apnea is of concern to the technologists.

55 Metabolic What???

56 Metabolic Syndrome   1. Systemic rather than local disorder   2. OSA & Metabolic = Syndrome Z   3. Causal Relationship Probable   4. Repetitive Hypoxia   5. Adipokines and Inflamatory Cytokines   6. Estimated 24% of US Population

57 Metabolic Syndrome   Three of the following five variables:   Hypertension   Insulin resistance – Type 2   Low high-density lipoprotein cholesterol   Elevated serum triglyceride   Abdominal Obesity-Visceral Fat

58 Metabolic Syndrome   Multiple studies have shown that association between OSA plus Metabolic Syndrome increases as severity of the patient’s OSA increases.   PAP has been shown to improve high blood pressure but not insulin resistance or lipid profiles.   Coughlin et al.

59 Metabolic Syndrome   Studies are showing that OSA and Metabolic Syndrome are not separate co- morbidities but actually linked to each other very closely.

60 Metabolic Syndrome   The Sleep Heart Health Study found a significant association between the respiratory disturbance index and waist to hip ratio, hypertension, and hypercholesterolemia in men, and low HDL-C, and hypertriglyceridemia in women.   A matched control study found that OSA was associated with insulin resistance, total cholesterol, HDL-C and Leptin. A Japanese study showed that OSA may promote metabolic dysfunction and fat maldistribution.

61 Metabolic Syndrome   Linkage between OSA and Diabetes is very well documented and appears to play a role in Metabolic Syndrome.   Prevalence of OSA in obese Type 2 Diabetic patients with moderate to obstructive severe sleep apnea has been reported as high as 70%.

62 Metabolic Syndrome   Hypothalmic-pituitary-Adrenal(HPA) Axis   Cortisol – Hormone/Steroid is released – Adrenal Gland   Cortisol secretion was increased by sleep apnea   Study shows that obese men with OSA have abnormally higher sympathetic nervous system activity and HPA.   Autonomic(ANS), Sympathetic(SNS), Parasympathetic(PNS)   OSA has inflamatory cascade component, although linkage to OSA is still unclear.   Repetitive hypoxia and reoxygenation lead to oxidative stress   Oxidative stress appears to be a consequence of metabolic syndrome and visceral obesity.   Oxidative stress activates an inflammatory response.

63 Metabolic Syndrome   Inflammatory responses activate Cytokines.   Inflammation, metabolic syndrome ties in with atherosclerosis.   Biomarkers are used by researchers to track the bodies inflammatory responses and associate them with OSA.   Obesity is the common factor that connects OSA TO Metabolic syndrome.   Monocytes and Macrophages abound and increase through what is known as the “Cascade”. Monocytes>>Macrophages eat/destroy   Adipokines-Fat derived Cytokines-One is Leptin. Leptin plays a role in appetite and energy.   Ghrelin-Hormone that also regulates appetite. High levels after weight loss. CPAP reduces

64 Monocyte Responds

65 Macrophage Engulphs Pathogen

66 Exploding Macrophages

67 Metabolic Syndrome   Patients with sleep apnea have reduced Leptin levels.   Sleep deprivation unto itself,,, alone,,, contributes to increased levels of Ghrelin, increased appetite, higher glucose levels, insulin resistance, and therefore a higher risk of diabetes.   OSA compounds and contributes to most any other disease state a patient has. (Allen, P. et al)   Normalization of metbolic parameters often occurs after PAP tx.

68 Metabolic Syndrome Conclusion   Metabolic syndrome consists of a systemic and complicated chain of events and components, one of which can be the presence of Obstructive Sleep Apnea.   Research is showing that Sleep Disorder Medicine will be playing a major role in the diagnosis and treatment of patients with Metabolic Syndrome or Syndrome Z.

69 Overall Summary/Conclusions   Sleep Technologists   You will be seeing more complex patients   Get as much additional training as you can   Is your sales department, physician liaison, lab owner, hospital focusing on these patients?   They Should Be For Economic Survival of Your Sleep Lab

70 References AM j Resp Crit Care Med 2010 Aug 1;182(3): Int J Chron Obstruct Pulmon Dis. Dece. 2008: 3(4): Adaptation from Parker, K.P. (2011) Sleep disorders sleep, nursing P180 ATS J Vol; 181, Issue 5(March1, 2010) Impact of Untreated OSA on Glucose Control in Type 2 Diabetes Grimaldi, D. et al. Diabetes Care February 2014 vol. 37 no Glycemic Control in Type 2 Diabetes Grimaldi, D. et al. Diabetes Care February 2014 vol. 37 no Glycemic Control in Type 2 Diabetes University of Chicago, et al., Sleep Diagnosis and Therapy “Sleep Apnea Can Worsen Blood Sugar Control in People with Type 2 Diabetes” WebMD, Mann, Denise, Smith, Michael, MD Reviewed Jan10th 2010 “The Sleep-Diabetes Connection Coughlin, et al. Eur Heart J International Diabetes Foundation Brussels Einhorn et al. Edocr Pract Resmed.com Woidtke, Robyn, APSS Boston 2012

71 References Cont’d   Resnick HE, Redline S, Share E, Gilpin A, ET al.   NM: Heart Health Study. Diabetes and Sleep Disturbances   Diabetes Care 2003;26(3):702-9   Meslier N, et al. Impaired glucose-insulin metabolism in males with obstructive sleep apnoea syndrome Eur Respir J 2003;229(1):   O’keeffe T, et al. “Evidence supporting routine polysomnography before bariatric surgery” Obesity Surgery 2004; 14(1):23-6   Foster, Gary, PhD, Temple University School of Medicine Diabetes Care. Net “Obstructive Sleep Apnea and Diabetes” 6/21/2010   Look AHEAD Research Group Diabetes Care 2007

72 References Cont’d   Hanes et al., Surgery 2007; 141:354-8“Change in OSA Following Bariatric Surgery”   WebMD Drugs & Medications Search March 2004   Sleep Apnea and Heart Failure-ResMed Corp   Ferreira, S et al. BMC Pulm Med 2010   Lanfranchi, PA et al Ciculation 2003   Javeheri, S et al. AM Col Cardiol   Garcia-Touchard, A. et al. Chest   Joseph et al. Tex Heart Inst   SDB and Hypertension-ResMed Corp   Peppard, PE. Et al. N Eng J Med 2000   Lavie P et al. BMJ 2000   Nieto, FJ, Young TB et al. JAMA 2000  

73 References Cont’d   Javaheri, Shahrokh, MD. Feb 19 th 2013 “Basics of Sleep Apnea and Heart Failure” Cardiosource.org   Wuhl, J., MD “Obstructive Sleep Apnea’s Cardiovascular Effects” MLH 2/21/2012   Weingarten, J MD et al., Am j Respir Crit Care Med Vol 188, P1-P2, 2013 “Obstructive Sleep Apnea and Heart Disease”   Zee, P 7 Naylor, E medscape.org/viewarticle/ ‘Congestive Heart Failure”   Mark D. Elay, MS, RST, RPSGT, RRT-NPS, RPFT “Obstructive Sleep Apnea and Comorbidities: A Survey of Current Information” A2Zzz 23.1 March 2014

74 References Cont’d   SDB and Stroke ResMed Corp   Johnson, KG, et al. Clin Sleep Med   Martinez-Garcia MA, et al. AM J Resp Crit Care Med 2009   Wessendorf TE, et al. J Neurol 2000   Drager, LF, et al. Chest 2011   Jelic S, Trends Cardiovasc Med 2008   Kirschheimer, S. WebMD Health News “Are GERD and Sleep Apnea Related” 2014   “Gerd and Sleep” National Sleep Foundation   Morse ca, et al. “Is there a relationship between obstructive sleep apnea and gastroesophageal reflux disease?” Clin Gastroenterol Hepatol 2004 Sep;2(9):761-8

75 References Cont’d   Calvin, Andrew, D., et al. “Obstructive Sleep Apnea, Inflammation, and the Metabolic Syndrome” Mtab Syndr Relat Discord. Aug 2009; 7(4):   Vgontzas, AN. Et al. “Sleep apnea is a manifistation of the metabolic syndrome” Sleep Med Re Jun;9(3): Abstract   Obesity and Inflammation APSS 2012 Boston   Fantuzzi j All Clin Imunol 2005; 115:911-9   Christiansen, et al. Int J Obes Relat Metab Discord 2004; 29:   Robker, et al. OBES Res 2004; 12:936-40

76 Thank You  Peter Allen, BSRC, RRT-NPS-SDS,  RST, RPSGT 


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