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AACN Symposium 2016: Does My Patient Have Sleep Apnea?

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1 AACN Symposium 2016: Does My Patient Have Sleep Apnea?
Joseph Roland D. Espiritu, MD, MSPH, FCCP, FAASM Medical Director, SLUCare Sleep Disorders Center Associate Professor of Internal Medicine Division of Pulmonary, Critical Care, and Sleep Medicine Saint Louis University School of Medicine

2 Disclosure Former Member of Speakers’ Bureau for Cephalon
All the honoraria were forwarded to Saint Louis University

3 Learning Objectives Distinguish the different types of sleep-related breathing disorders Identify the risk factors and different mechanisms for sleep-related breathing disorders Identify potential neurocognitive, cardiovascular, & endocrine sequelae of untreated sleep apnea. Discuss the role of the critical care nurse in the identification of patients at risk for sleep apnea. Review the efficacy and benefits of available therapies for sleep-related breathing disorders.

4 II. Sleep Related Breathing Disorders
Obstructive Sleep Apnea Disorders Central Sleep Apnea Syndromes Sleep Related Hypoventilation Disorders Sleep Related Hypoxemia Disorder Isolated Symptoms and Normal Variants International Classification of Sleep Disorders-3 (ICDSD-3)

5 Obstructive Sleep Apnea Syndrome

6 Obstructive Sleep Apnea Syndrome
Most common type of sleep-related breathing disorder Complete or partial upper airway obstruction during sleep resulting in frequent arousals, O2 desaturations, and/or poor sleep quality risk of neurocognitive dysfunction, cardiovascular diseases, metabolic abnormalities, and death

7 Question 1 Which of the following is associated with a reduced risk of obstructive sleep apnea? A. Age B. Male gender C. BMI > 35 kg/m2 D. History of systemic hypertension E. Hormone replacement therapy

8 Risk Factors for OSA

9 Prevalence of OSA by Age
Young T et al. Arch Intern Med 2002;162:893–900

10 Wisconsin Sleep Cohort: Prevalence of OSA
Men Women AHI  5/hr 24% 9% AHI  5/hr plus hypersomnolence 4% 2% AHI = no. of apneas and hypopneas/hr of sleep Hypopneas - 50% reduction in respiratory effort by RIP or - Discernible reduction in effort plus 4% O2 Young T et al. NEJM 1993; 328:

11 Peppard PE et al. Am J Epidemiol 2013;177:1006–1014

12 Prevalence of Moderate-to-Severe (AHI15/h) OSA
10% 17% 3% 9% Prevalence, % Sex and Age Categories Peppard PE et al. Am J Epidemiol 2013;177:1006–1014

13 Prevalence of Moderate-to-Severe SDB (AHI15/h) with Daytime Sleepiness (ESS  10)
Sex and Age Categories Peppard PE et al. Am J Epidemiol 2013;177:1006–1014

14 Prevalence of OSA in Women
Prevalence of OSA per 1000 (CI) Odds Ratio (CI) Premenopausal women 0.6 (0.2, 1.8) 1 Post-menopausal women 1.9 (1.0, 3.6) - Postmenopausal women with HRT 0.5 (0.1, 3.8) 0.5 (0.04, 5.6) Postmenopausal women without HRT 2.7 (1.4, 5.3) 1.9 (0.4, 8.7) Bixler EO et al. Am J Respir Crit Care Med 2001; 163:608-13

15 Prevalence of OSA in African-Americans
Study Population Findings Ancoli-Israel 1995 community-dwelling adults  65 yrs OR of OSA in African-Americans is 2.5x Caucasian Redline 1998 adults < 25 yrs Prevalence of OSA (adjusted for BMI and confounders) in African-Americans > Caucasian Sleep Heart Health Study Young 2002 Middle age adults No difference in prevalence of OSA (adjusted for age, sex, and BMI) between African-Americans and Caucasians

16 Prevalence of OSA in Asians
Prevalence estimates: Middle-aged (Hong Kong) men = % Middle-aged women = % Similar to Caucasian populations Obesity is a risk factor but less prevalent among Asians Craniofacial features make greater contributions in Asians > Caucasians Crowded posterior orophyarnx (Mallampati Score) Steep thyromental plane Lam B et al. In J Tuberc Lung Dis 2007; 11:2-11. Lam B et al. Thorax 2005; 60: Li KK et al. Laryngoscope 1999; 109:

17 Risk Factors for OSA in Asians
Systematic review with 47,957 subjects (26,042 men and 21,915 women) OSA prevalence ranged from 3.7% to 97.3%. Risk factors: Male gender Older age BMI waist:hip ratio neck circumference Arterial hypertension Smoking Snoring Daytime sleepiness Mirrakhimov et al. BMC Pulmonary Medicine 2013, 13:10

18 Prevalence of OSAS in Chinese Elderly
Ng SSS et al. PLoS One 2015; 16; 10:e

19 Prevalence in OSAS in Chinese Elderly
Ng SSS et al. PLoS One 2015; 16; 10:e

20 Prevalence of OSAS in South Asians
308 patients (72.7% women; 13% South Asian), mean age 46 ± 12 yr and BMI 49 ± 8 kg/m2 South Asians vs White Europeans: prevalence of OSA (85% vs. 66% [p = 0.017]) prevalence of severe OSA (42.5% vs 21.6% [p = 0.015]) minSpO2 (76%, IQR 64-84% vs 83%, IQR 77-87%; p < 0.01) time SpO2<90% (8.4%, IQR % vs 2.4%, IQR %; p=0.03) Independent OSA risk factors: Age BMI Male gender Leong WB et al. J Clin Sleep Med 2013; 9:

21 Weight and OSA 10% body weight  30% AHI
Young T et al. Am J Respir Crit Care Med 2002;165:

22 Craniofacial Features in OSA
Neck circumference: men  17 inches women  16 inches Enlarged nasal turbinates Deviated nasal septum Narrow mandible Narrow maxilla Dental overjet and retrognathia Crossbite and dental malocclusion (class 2) High and narrow hard palate Elongated and low-lying uvula Prominent tonsillar pillars Enlarged tonsils and adenoids Macroglossia Multiple references

23 Adenotonsillar Hypertrophy and OSA

24 Retrognathia and Micrognathia

25 Moderate Alcohol Intake and OSA
Vodka (40% ethanol) 1.5 mL/kg (0.5 g·kgBW) White wine (0.5 g·kgBW) 7.1‹±1.9/hr 9.7±2.1/hr 3.3±1.2 vs 4.5±1.7 3.3±1.2 vs. 4.5±1.7 3.3±1.2 vs 3.1±1.1 3.3± ±1.1 Scanlan MF et al. Eur Respir J 2000; 16: 909±913 Teschler H et al. Eur Respir J 1996; 9:2371–2377

26 Medications That Affect Pharyngeal Muscles
Benzodiazepines Flurazepam - AHI, nocturnal desaturations, and duration of apneas1 Triazolam -  arousal threshold, apnea duration and nocturnal desaturations2 Narcotics (opioids) IV morphine produces central and obstructive apneas after upper abdominal surgery3 1. Dolly et al. AJM 1982 2. Berry et al. AJRCCM 1995 3. Robinson et al. Chest 1987

27 Pathophysiology of OSA
White DP. Am J Respir Critical Care Med 2005; 172:

28 Symptoms of OSA Respiratory Neurocognitive Hypersomnolence Fatigue
Loud persistent snoring Snort arousals Choking Gasping Gagging Apneas Other Nocturia -  atrial natriuretic peptide Hypersomnolence Fatigue Insomnia Depression Impaired memory Decreased vigilance


30 Physical Examination in OSA
BP (hypertension) BMI > 28 kg/m2 ENT Exam Mallampati score Neck circumference Cardiopulmonary exam

31 Modified Mallampati Score
Comparison of Friedman tongue position (FTP) and Mallampati classification (MC).

32 STOP-BANG Scoring System
S = Snoring T = Tiredness O = Observed apnea P = Pressure (systemic hypertension) B = BMI > 35 kg/m2 A = Age > 50 yrs N = Neck circumference > 16 inches (40 cm) G = Gender (male) High risk for OSA ≥ 3 Low risk for OSA < 3 Chung F et al Anesthesiology 2008; 108:

33 Netzer NC et al. Annals of Internal Medicine 1999; 131:485-91
Chung Fe et a. Anesthesiology 2008; 108:

34 Home Sleep Apnea Test Retrieved from _enUS492US502&biw=1366&bih=599&source=lnms&tbm=isch&sa=X&ved=0ahUKEwjgh8Cix6_ LAhXFlIMKHU-jD6oQ_AUICCgD#imgrc=G4yyzG8amR5eRM%3A

35 Home Sleep Apnea Test for OSA
Indications Contraindications High pretest probability of moderate to severe OSA. In-laboratory PSG is not possible by virtue of immobility, safety, or critical illness. Monitor the response to non-CPAP treatments for sleep apnea. Significant comorbid medical conditions that may degrade the accuracy of the test CHF decompensation Advanced pulmonary disease Suspected comorbid sleep disorders Periodic limb movements Narcolepsy Screening of asymptomatic populations Collop NA et al. J Clin Sleep Med 2007;3(7):

36 Polysomnography Retrieved from popups/polysomnography/

37 Polysomnography Electroencephalography (EEG) Extraoculography (EOG)
Chin Electromyography (EMG) Leg EMG Electrocardiography Body position Supine Lateral Prone Infrared camera

38 Polysomnography Snore microphone Airflow parameters
Nasal pressure transducer Oronasal thermistor Respiratory inductive plethysmography Chest Abdomen Oximetry [Capnography] [End-tidal CO2 levels (ETCO2)] [Transcutaneous CO2 (TCO2)]

39 Split-night PSG in Patient with OSA
Espiritu JD.  Sleep Apnea and Sleep-Related Breathing Disorders.  In: Malhotra R ed. Sleepy or Sleepless:  A Clinical Approach to the Sleep Patient.  


41 30%  airflow 3-4%  SpO2

42 Question 2 Which of the following conditions has not been demonstrated to be associated with OSA? A. Cardiovascular disease B. Metabolic dysfunction C. Motor vehicle accidents D. Autoimmune disorders E. Death

43 OSA and Risk for Motor Vehicle Collisions
Review of 40 published studies 2 to 3 times increased risk of crashes in noncommercial drivers with sleep apnea 1 of 3 studies showed an increased crash risk in commercial drivers Sleep apnea treatment improved both noncommercial and commercial driver performance There is extensive literature on the relationship between sleep-disordered breathing and the risk of having a motor vehicle accident. This slide shows a summary of the systematic review from 40 pertinent studies looking at the relationship between the presence of sleep disordered breathing, sleepiness and risk of motor vehicle crashes in commercial and non commercial drivers. For studies investigating the relationship in noncommercial apneic drivers, the majority (23 of 27 studies and 18 of 19 studies with control groups) found a statistically significant increased risk, with many of the studies finding a 2 to 3 times increased risk. For commercial drivers, only 1 of 3 studies found an increased crash rate, with this association being weak (odds ratio of 1.3). The evidence was mixed regarding whether the risk of crash involvement is proportional to the severity of the sleep apnea, with only about half of the studies finding a statistically significant increased risk with increased severity. Correlation with subjective daytime sleepiness and crash risk was also found in only half of the studies reviewed. Ellen RL, Marshall SC, Palayew M, Molnar FJ, Wilson KG, Man-Son-Hing M. Systematic review of motor vehicle crash risk in persons with sleep apnea. J Clin Sleep Med Apr 15;2(2): Ellen RL, et al. JCSM :193 Ellen RL, et al. JCSM :193

44 Sleep Heart Health Study: Prevalence of Cardiovascular Diseases
Quartile AHI I <1.3 II III 4.4-11 IV >11 p CAD 1.0 1.01 1.2 1.22 0.08 CHF 1.19 1.96 2.20 0.008 CVD 1.24 1.38 1.55 0.06 Shahar et al. Am J Respir Crit Care Med 2001; 163: 19-25

45 OSA and Risk of Hypertension
AHI (1/hr) Odds Ratio (95% CI) 1.0 1.42 ( ) 5-14.9 2.03 ( ) 15 2.89 ( ) Peppard PE et al. N Engl J Med 2000; 342:

46 Busselton Study: OSA and Risk of Diabetes Mellitus
Incidence of DM Fully Adjusted Odds Ratio of DM (95% CI) No sleep apnea 2.2% Ref. Mild sleep apnea 3.4% 1.51 (0.25, 9.12) Moderate to severe sleep apnea 20% 13.45 (1.59, ) Marshall NS et al. J Clin Sleep Med 2009; 5:15-20.

47 OSA and Arrhythmias Mehra R et al. Archives of Internal Medicine 2009; 169:

48 OSA and Stroke Author Year Type of Study Subjects SDB Prevalence
Risk Estimate (95% CI) Arzt 2005 Population-based 30-60 years old 7% OR = 4.48 ( ) Yaggi 2005 Clinic-based Suspected SDB 66% HR = 1.97 ( ) Munoz 2006 Non-institutionalized years old 25% HR = 2.25 ( ) Valham 2008 Symptomatic angina and CAD 54% HR = 2.89 ( ) Dyken ME et al. Chest. 2009; 136:

49 Wisconsin Sleep Cohort: OSA and Survival
Young T et al. Sleep 2008; 31:1067-8

50 ICU Mortality in OSA Patients
Bolona E at al. J Crit Care 2015; 30:178–180

51 Risk Factors for OSA Post-CABG
Amra B et al. Int J Prev Med 2014; 5:1446–1451

52 OSA Risk and Post-CABG Complications
Amra B et al. Int J Prev Med 2014; 5:1446–1451

53 ICU Mortality in OSA Patients
Bolona E at al. J Crit Care 2015; 30:178–180


55 Hypoxemia in ICU Patients with OSA
Gaddam S et al. Sleep Breath 2014; 18:615–633

56 Reintubation in ICU Patients with OSA
Gaddam S et al. Sleep Breath 2014; 18:615–633

57 Postoperative Respiratory Complications in ICU Patients with OSA
Gaddam S et al. Sleep Breath 2014; 18:615–633

58 Postoperative Cardiac Complications in ICU Patients with OSA
Gaddam S et al. Sleep Breath 2014; 18:615–633

59 Postoperative Neurologic Complications in ICU Patients with OSA
Gaddam S et al. Sleep Breath 2014; 18:615–633

60 Postoperative ICU Transfer in ICU Patients with OSA
Gaddam S et al. Sleep Breath 2014; 18:615–633

61 Postoperative Cardiac Complications in ICU Patients with OSA (No Confounders)
Gaddam S et al. Sleep Breath 2014; 18:615–633

62 Difficult Intubation in the ICU and the Macocha Score
De Jong A et al. Am J Respir Crit Care Med 2013; 187, Iss. 8, pp 832–839

63 Difficult Intubation in the ICU and the MACHOCHA Score
De Jong A et al. Am J Respir Crit Care Med 2013; 187, Iss. 8, pp 832–839

64 Difficult Intubation and ICU Complications
De Jong A et al. Am J Respir Crit Care Med 2013; 187, Iss. 8, pp 832–839

65 Question 3 What is the treatment of choice for obstructive sleep apnea in adults? A. Weight loss B. CPAP C. Oral appliance therapy D. Uvulopalatopharyngoplasty E. Positional therapy

66 AASM Practice Guidelines 2006
CPAP is treatment of choice for adult s with OSA Dietary weight loss may improve AHI in obese OSA but it should be combined with a primary Rx for OSA Bariatric surgery can be used as an adjunct SSRI, protriptyline, theophylline, and estrogen are not recommended as primary treatment Modafinil (and armodafinil) can be used to treat residual sleepiness in OSA patients with adequate CPAP adherence Nasal steroids are a useful adjunctive treatment for OSA but nasal decongestants are not recommended. Supplemental O2 is not a primary treatment for OSA Positional therapy can be used as secondary therapy for positional OSA

67 Effects of CPAP on Neurocognitive Function in OSA
 sleep quality  arousal index  Stage 1 sleep  Stages 3 & 4 sleep  sleep efficiency  daytime sleepiness  driving simulator performance  vigilance  subjective work performance  self-reported health status

68 Cardiovascular Effects of CPAP in Patients with OSAS
 systemic hypertension LV systolic and diastolic function LV end-diastolic diameter pulmonary hypertension Bazzano LA et al. Hypertension 2007; 50:  Kaneko Y et al. N Engl J Med 2003;348: Oliveira W et al. Sleep Med 2012; 13: Arias MA et al. Eur Heart J 2006; 27: Parra O et al. J Sleep Res 2015; 24:47-53

69 Positional Therapy

70 Positional Therapy for Positional OSA
Jokic R et al. Chest 1999; 115:771-8.

71 Oral Appliances and OSA
Mandibular advancing device Tongue-retaining device Deane SA et al. Sleep 2009; 32:648-53

72 Oral Appliance Therapy Effects on the Upper Airway
Repositions the mandible into a more anterior position Lifts the tongue away from the posterior pharyngeal wall Expands the cross-sectional area of the oropharynx as well as the velopharynx Elevates the hyoid bone Longterm success rate = 63% Ferguson KA et al. Sleep 2006; 29: Walker-Engström M et al. Chest 2002;121:

73 Oral Pressure Therapy (Winx)
Retrieved from may-explain-why-the-results-have-not-been-as-good-as-anticipated/

74 Oral Pressure Therapy for OSA
Colrain IM et al. Sleep Med 2013; 14: 830–837.

75 Hypoglossal Nerve Stimulation for OSA
Electrical signals are generated by an implanted neurostimulator and delivered to the ipsilateral HGN via an implantedcuff electrode. Respiration is monitored via implanted thoracic leads that sense changes in bioimpedance with chest wall motion, delivering stimulation immediately prior to and during the inspiratory phase of respiration, when the upper airway is most vulnerable to sleep related narrowing and collapse. Eastwood PR et al. SLEEP 2011; 34:

76 Hypoglossal Nerve Stimulation for OSA
Eastwood PR et al. SLEEP 2011; 34:

77 Hypoglossal Nerve Stimulation for OSA
Eastwood PR et al. SLEEP 2011; 34:

78 Surgical Therapies for OSA
“More Efficacious” “Less Efficacious” Bariatric surgery Tonsillectomy and adenoidectomy (T&A) Uvulopalatopharyngoplasty (UPPP) Uvulopalatal flap +/-tonsillectomy Maxillomandibular advancement (MMA) Pillar Procedure Distraction osteogenesis (DOG) Tracheotomy Nasal reconstruction Laser-assisted uvulopalatoplasty (LAUP) Radiofrequency surgery of the soft palate, tonsils, or base of the tongue Hyoid suspension Laser midline glossectomy Tongue suspension Genioglossus advancement Multi-level surgery Randerath WJ et al. Eur Respir J 2011; 37: 1000–1028

79 Uvulopalatopharyngoplasty
Long-term success rate = 33% Walker-Engström M et al. Chest 2002;121:

80 Tracheostomy for OSA Mean AHI decreased from 92.0 ± 34.8 to 17.3 ± 20.5/h (p< 0.0001) Mortality with tracheostomy (1.7%) compared with untreated OSA subjects (13.8%, p = 0.019) ODI : 78.2 ± 25.8/h  20.8 ± 25.5/h Camacho M et al. Laryngoscope 2014;124(3):803-11

81 Central Sleep Apnea

82 Central Sleep Apnea Syndromes
Central Sleep Apnea Due to Cheyne Stokes Breathing Pattern Central Sleep Apnea Due to a Medical Condition Without Cheyne Stokes Central Sleep Apnea Due to High Altitude ( 8,202 ft) Periodic Breathing Central Sleep Apnea Due to Medication or Substance Primary Central Sleep Apnea Primary Sleep Apnea of Infancy Primary Sleep Apnea of Prematurity Treatment-emergent Central Sleep Apnea ICSD 3

83 Cheyne-Stokes Breathing Pattern

84 Question 4 The ventilatory chemoresponsiveness in central sleep apnea Cheyne-Stokes breathing pattern is: A. Increased B. Decreased C. Unchanged D. Variable E. Unknown

85 Ventilatory Response to CO2 in Central Sleep Apnea
Javaheri, S. N Engl J Med 1999;341:949-54

86 Pathophysiology of Central Sleep Apnea
Hyperventilation (Intermittent) PaCO2 Central apnea- hypopnea Chemoreceptor susceptibility PaO2 PaCO2 Arousal Sympathetic nerve activity & cathecholamine release Köhnlein et al. Thorax 2002; 57:547-54

87 Loop Gain in Central Sleep Apnea
White DP. Am J Respir Crit Care Med 2005; 172:

88 Proposed Therapies for Central Sleep Apnea Syndrome
Optimize CHF treatment Avoid or minimize opioid analgesics Descent to low altitude O2 supplementation if hypoxemic Acetazolamide – carbonic anhydrase inhibitor CPAP – no survival benefit1 Adaptive support servo-ventilation – not recommended due to increased mortality2 CO2 – stimulates ventral medullary ventilatory center Atrial pacing for patients with bradyarrhythmia 1Bradley TD et al. N Engl J Med 2005; 353: 2Cowie MR et al. E-published on September 1, 2015DOI: /NEJMoa

89 Sleep Related Hypoventilation
Obesity Hypoventilation Syndrome Congenital Central Hypoventilation Syndrome Late-onset Central Hypoventilation with Hypothalamic Dysfunction Idiopathic Central Alveolar Hypoventilation Sleep Related Hypoventilation Due to a Medication or Substance Sleep Related Hypoventilation Due to a Medical Disorder ICSD-3

90 Question 5 Sleep related hypoventilation syndrome is associated with:
A.  PaCO2 B.  PaO2 C.  serum HCO3 D.  ventilatory chemoresponsiveness E.  ventilatory loop gain

91 General Criteria for Sleep Related Hypoventilation
PaCO2 (or surrogate) > 55 mmHg for ≥ 10 min or ≥ 10 mmHg  in PaCO2 (or surrogate) during sleep (in comparison to an awake supine value) to > 50 mmHg for ≥ 10 minutes. ICSD-3 AASM Manual for the Scoring of Sleep and Associated Events Version 2.0

92 Pathophysiology of Sleep-related Hypoventilation Syndrome
Decreased alveolar ventilation (PaCO2 and PaO2) due to: Blunted ventilatory chemoresponsiveness Pulmonary parenchymal, obstructive, or vascular disease Chest wall or neuromuscular disorder ICSD 2

93 Sleep Related Hypoventilation Syndrome*
*Cystic fibrosis patient Milross MA et al. Chest. 2001;120:  

94 Causes of Hypoventilation
Anatomic Site of Ventilatory Disorder Examples of Causes of Sleep-Related Hypoventilation Ventral medulla Congenital central hypoventilation syndrome Sedative medications (e.g, benzodiazepines) Cervical spinal cord (C3,C4, C5) Severe whiplash injury Motor neurons Amyotrophic lateral sclerosis Poliomyelitis Phrenic and intercostal efferent nerves Cardiothoracic surgery Central venous catheter insertion Critical illness polyneuropathy Medications (e.g., paralytic agents) Subacute inflammatory demyelinating polyneuropathy Neuromuscular junction Curare Lambert-Eaton Syndrome Myasthenia gravis Diaphragm and accessory respiratory muscles Critical illness myopathy Muscular dystrophies Systemic corticosteroids Lungs Obstructive lung disease (e.g., COPD) Restrictive lung disease (e.g., pulmonary fibrosis) Thorax Kyphoscoliosis Miscellaneous Obesity-hypoventilation syndrome

95 Obesity Hypoventilation Syndrome
Pickwickian Syndrome Criteria A-C must be met PaCO2 > 45 mm Hg during wakefulness Obesity (BMI > 30 kg/m2; > 95th percentile for age and sex for children). Hypoventilation is not primarily due to other causes Auchinchloss et al. J Clin Invest 1955; 34:1537 ICSD-3

96 Obesity Hypoventilation Syndrome in the ICU
61 (8%) out of all patients admitted to our ICU over an 8-month period, had a BMI > 40 kg/m² and a PaCO₂ > 45 mm Hg. Exclusions criteria: musculoskeletal disease, intrinsic lung disease, and >20 pack-yr smoking Demographics: Mean BMI was 48.9 ± 8.6 kg/m². Mean age was 59 ± 11 yrs 47 (77%) were women 56 (92%) were Black. Marik PE et al. J Intensive Care Med 2013; 28:124-30

97 Obesity Hypoventilation Syndrome in the ICU
All admitted to the ICU with hypercapnic respiratory failure Admitted an average 6x over 2 yrs 75% erroneously diagnosed/treated for COPD/asthma 86% treated with diuretics for CHF All had type 2 diabetes and the metabolic syndrome. 3 had a tracheotomy in place at admission and required mechanical ventilation. All of the remaining patients were treated with BPAP: 23 patients failing BPAP and requiring mechanical ventilation. 7 patients had a tracheotomy performed Marik PE et al. J Intensive Care Med 2013; 28:124-30

98 Obesity Hypoventilation in the ICU
39 patients (64%) had NASH PFT: restrictive pattern in all patients 2d echo: 43 (71%) patients had LVH and 37 (61%) had LV diastolic dysfunction. 47 (77%) patients had pulmonary hypertension, with RVSP > 45 mm Hg in 25 cases. All had an elevated CRP (9.4 ± 6.9 mg/dL) All but 1 were vitamin D deficient (13.5 ± 8.5 ng/mL). 11 patients (18%) died during the index hospitalization. Marik PE et al. J Intensive Care Med 2013; 28:124-30

99 Congenital Central Hypoventilation Syndrome
Criteria A and B must be met: A. Sleep related hypoventilation B. Mutation of the PHOX2B gene Onset: infancy but may occur later in life Abnormal brainstem integration of chemoreceptor afferents Associated abnormalities: Hirschsprung’s disease (16%) Autonomic dysfunction Neural tumors Swallowing dysfunction Ocular abnormalities ICSD 3

100 NIV in Morbidly Obese Patients in ARF
In decompensated OHS, NIV rarely failed in reversing ARF. Morbidly obese patients with early NIV failure had a severity score and a HCO3 level at admission, and likely have hypoxemic ARF caused by pneumonia. Factors associated with a successful response to NIV included PaCO2 at admission and a diagnosis of idiopathic hypercapnic decompensation of OHS. > 50% of hypercapnic patients with decompensated OHS exhibited a delayed response to NIV. Lemyze M et al. PLoS One ; 9(5):e97563

101 Treatment of Sleep-related Hypoventilation Syndromes
Treat underlying cause Weight loss for obesity Inhaled steroids and bronchodilators for COPD Anticholinesterase (i.e., pyridostigmine) for myasthenia gravis Noninvasive ventilation (i.e., Bilevel PAP)

102 Sleep Related Hypoxemia Disorder
Criteria A and B must be met SpO2 during sleep of ≤ 88% in adults or ≤ 90% in children for ≥ 5 minutes. B. Sleep related hypoventilation is not documented. ICSD-3 Ramsey R et al. Chest. 2007; 132(3): 852–859.

103 Obstructive vs Central Sleep Apnea
Type Risk Factors Mechanism Diagnosis Obstructive Sleep Apnea Age Gender Race (?) Menopause Obesity Narrow oropharynx Neck circumference Imbalance between factors that promote airway patency and collapse 1. RDI ≥ 15/h or 2. RDI ≥ 5/h with neurocognitive symptoms, mood disorder, cardiovascular comorbidities, or diabetes Central CHF Chronic long-acting opioid medication High-altitude ventilatory Chemoresponsiveness (loop gain) Central apnea index  5/h or Cheyne-Stokes breathing pattern Espiritu JD.  Sleep Apnea and Sleep-Related Breathing Disorders.  In: Malhotra R ed. Sleepy or Sleepless:  A Clinical Approach to the Sleep Patient.  

104 Sleep-Related Hypoventilation vs Hypoxemia
Type Risk Factors Mechanism Diagnosis Sleep-Related Hypoventilation Obesity Sedating medications Lung disease CNS disorders Neuromuscular disease Blunted ventilatory chemoresponsiveness Restrictive ventilatory abnormality Elevated PaCO2 >55 mmHg lasting >10 min during sleep Hypoxemia Obstructive airway diseases Pulmonary parenchymal disease Pulmonary vascular disease VQ mismatch Shunt Deadspace Diffusion abnormality SpO2 of ≤88% for ≥5 min during sleep, in the absence of hypoventilation Espiritu JD.  Sleep Apnea and Sleep-Related Breathing Disorders.  In: Malhotra R ed. Sleepy or Sleepless:  A Clinical Approach to the Sleep Patient.  

105 Summary OSA disorders result from an imbalance between factors that promote airway collapse and patency. CSA syndromes are characterized by periodic and/or Cheyne-Stokes breathing due to underlying heightened ventilatory chemoresponsiveness (high loop gain). SRHV disorders cause sustained hypercapnia during sleep due to blunted ventilatory chemoresponsiveness and/or a restrictive ventilatory defect resulting from neuromuscular disorders, pulmonary disease, skeletal abnormalities, or obesity. SRHO disorder is characterized by sustained hypoxemia due to gas-exchange abnormalities with an elevated alveolar-arterial O2 gradient during sleep.

106 Summary SRBDs are associated with significant neurocognitive dysfunction, cardiovascular co-morbidity, and even increased mortality. Management of SRBDs requires treatment of the underlying condition as well as various modes of PAP, O2, and/or other therapies that correct the underlying sleep-related breathing abnormality.

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