1. OVERVIEW OF SLEEP AND SLEEP APNEA David Claman, MD Professor of Medicine Director, UCSF Sleep Disorders Center

2. SLEEP HYPNOGRAM

4. SLEEPY FIREFIGHTER? 45 year old firefighter complains of daytime sleepiness; “Doctor: I snore – could I have sleep apnea? I sleep alone so no one can tell me.” Reports “sleep hours 11 pm – 7 am” Real schedule is 24 hr at work, then 48 hrs off –At work sleep 2-4 hrs (no reports of apnea) –1 st night after work: 10 pm – 8 am –2 nd nightafter work: 1 am – 5:15 am (up early to drive to work!)

6. CIRCADIAN RHYTHM DISORDERS Sunlight is main “Zeitgeber”; meals, exercise, & social activities can also shift sleep rhythms Internal Clock located in Suprachiasmatic nucleus (SCN) of hypothalamus Jet lag: light and social stimuli help shift internal biological clock 1-2 hrs / day Shift work: light and social stimuli are in conflict with work schedule; may lead to poor sleep quality, insomnia and chronic fatigue

7. JET LAG Start trip sleep deprived Dehydration on plane worsened by caffeine and alcohol Circadian rhythm “out of phase” Flying West is easier –delay sleep schedule by 1-2 hr/d Flying East is harder –advance sleep schedule by 0.5-1 hr/d

8. JET LAG INTERVENTIONS Avoid sleep deprivation before trip –Consider daytime flight –Avoid important meetings the morning of arrival Adjust schedule before trip –1-2 hours per day, for 1-2 days before trip Avoid alcohol and caffeine Bright light –In morning when flying east (to advance schedule) –In afternoon/evening when flying west (to delay) Hypnotic prn (zolpidem or melatonin)

9. SHIFT WORK DISORDER Shift Work Disorder (SWD) is characterized by complaints of insomnia, excessive sleepiness and impaired performance that occur when work hours are scheduled during the usual sleep period 20% of workforce in industrialized countries are shift workers, & 40-80% of night workers report sleep difficulties

10. SHIFT WORK DISORDER Most common schedule is to work Mon through Fri nights 11 pm – 7 am, but to sleep during those same hours on Sat / Sun Since sunlight is strongest stimulus of circadian rhythms, the body’s preferred sleep schedule stays oriented for the hours 11 pm – 7 am

11. SHIFT WORK DISORDER Interventions: –Optimal approach is to stay awake at night on non- working days and always sleep on the same schedule –If patient continues to alternate their sleep schedule, try to maximize overlap between weekday and weekday schedules (if 7a-2p weekdays, then 3a-10a weekends) –Avoiding sunlight on drive home at 7 am (using “glacier” sunglasses) may also be helpful

12. DDx of Insomnia Psychiatric / psychological Medical Drugs (especially caffeine and alcohol) Psychophysiological insomnia –Somatized tension and anxiety causing insomnia Poor sleep hygiene –Maladaptive coping mechanisms are common Circadian rhythm issues

13. SLEEP HYGIENE Keep regular bedtime and wake-up time Keep bedroom quiet, comfortable, & dark Relaxation technique for 10-30 min before bed Get regular exercise Don’t nap Don’t lie in bed feeling worried, anxious, or frustrated Don’t lie awake in bed for long periods of time Don’t use alcohol, caffeine, or nicotine

16. DEFINITIONS:  Apnea: complete cessation of airflow lasting 10 second or more  Hypopnea: reduced airflow for 10 seconds or more, associated with 4% oxygen desaturation (4% is classical definition)  Apnea-hypopnea index (AHI): average number of apneas & hypopneas per hour of sleep l AHI < 5 is normal l AHI 5-15 is mildly elevated l AHI 15-30 is Moderate l AHI > 30 Severe

17. CLINICAL PREDICTORS OF OSA  Sleep Heart Health: Clinical predictors of AHI > 15:  Male gender, older age, higher BMI, larger neck girth, snoring & episodes of witnessed apnea  Young T et al. Arch Intern Med 2002 Apr 22;162(8):893-900

18. Young T et al. Excess weight and sleep-disordered breathing. J Appl Physiol 2005;99(4):1592-9.

19. Wisconsin OSA prevalence by gender and BMI Young T. J Appl Physiol 2005;99(4):1592-9

20. HYPERCAPNIA IN OSA French Multicenter Study; n=1141 from database Excluded those with FEV1<80% Overall prevalence of 11% with PaCO2 >45 BMI < 30 – prevalence 7.2% BMI 30-40 – prevalence 9.8% BMI > 40 – prevalence 23.6% Laaban J-P et al. Chest 2005;127:710-715

21. OSA TREATMENT  Weight loss (10% weight loss reduces AHI 25%)  Avoid alcohol and sedatives  Postural training (side sleeping since apnea worse on back)  Nasal patency (treat allergies?)  CPAP (also autoCPAP & Bi-level)  Oral (dental) appliances  ENT surgery:  Tonsillectomy in kids  UPPP in adults 50% success; mandibular surgery 80-90% success  Nasal expiratory resistor (Provent)  Nasal bandaid with microvalve – delivers approx 5 cm pressure

22. CPAP – Site Non-specific

23. LONGTERM USE OF CPAP Best compliance if AHI >30 & ESS >10 McArdle N et al. AJRCCM 1999;159:1108-1114

24. PROFESSIONAL DRIVERS Hours of Service Rules –10-11 hr driving limit; 14-15 hr on-duty limit –http://www.fmcsa.dot.gov/rules-regulations/topics/hos/index.htm Sleep Deprivation –Common in truck drivers; 35% up before 6 am Sleep Apnea – age and obesity major risks –Effect similar to being over legal alcohol limit in simulator –Pack & Dinges: OSA prevalence Mild 17%, Moderate 5.8%, Severe 4.7% www.fmcsa.dot.gov/facts-research/research-technology/tech/Sleep-Apnea-Technical-Briefing.htm

25. National Transportation Safety Board Sleep Apnea Alert October 2009 Recommend “screening” but no regulations in place Federal Motor Carrier Safety Administration –Trucks, buses, trains US Coast Guard – ship pilots FAA – airline pilots

26. DRIVER SAFETY In California, if patient has caused an accident by falling asleep at the wheel in the last 3 years, then Dept of Public Health must be notified If patient reports concerns about sleepiness while driving, chart should document: “Patient was advised not to drive if he / she is drowsy.”

27. SLEEP HISTORY!!!

28. REFERENCES Behavioral and pharmacological therapies for late-life insomnia. CM Morin et al. JAMA 1999;281:991-9 Cognitive Behavioral Therapy and Pharmacotherapy for Insomnia Jacobs GD; Arch Intern Med 2004;164:1888-1896 Principles and Practice of Sleep Medicine. 4th Edition. Kryger, Roth, & Dement. 2005 Jet lag and shift work sleep disorders: How to help reset the internal clock. Kolla BP & Auger RR. Cleveland Clinic J of Med 2011;78(10):675-684 Circadian Rhythm Sleep Disorders. Lu BS & Zee PC. CHEST 2006;130:1915-1923 Marin JM et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea: an observational study. Lancet. 2005;365(9464):1046-53