2. Sleep Apnea And Conditions seen in the ICU

3. Sleep Basics Some Definitions

4. Sleep Basics Obstructive Sleep Apnea OSA Central Sleep Apnea CSA Excess Daytime Somnolence EDS Polysomnography PSG (Sleep Study) Continuous Positive Airway Pressure CPAP Epworth Sleepiness Scale a screening questionnaire ESS Berlin Screen a set of questions to determine the risk of OSA

5. SLEEP IS ESSENTIAL TO HEALTH MOST OF US SPEND ONE THIRD OF OUR LIVES ASLEEP PS WHAT IS 1/3 OF 24 HOURS (HINT IT IS NOT 4 OR EVEN 6)

6. Normal Sleep times Infant 16 Hours One Year 13 Hours Two Years 12 Hours Ten Years 9-10 Hours Adolescents 9-10 Hours Adults 7-8 Hours

7. DAYTIME SOMULENCE THERE ARE SCALES SUCH AS THE EPWORTH SLEEPINESS SCALE TO QUANTIFY THIS SYMPTOM. THE EPWORTH SCALE ASKS YOU TO QUANTIFY HOW LIKELY YOU ARE TO DOZE OFF IN SITUATIONS SUCH AS READING, WATCHING TV, RIDING IN A CAR, SITTING QUIETLY AFTER LUNCH. THE MOST COMMON CAUSE OF TIREDNESS IS INSUFFICIENT OR POOR QUALITY SLEEP YOUR SLEEP AMOUNT IS ADEQUATE WHEN YOU CAN GET THROUGH YOU DAY WITHOUT TIREDNESS

8. Sleep Hygiene Stable bed time and awakening time Morning Bright Light (Sun works) Daily activity (exercise in AM or before dinner) Dark and comfortable bed room, avoid TV, computers, phones, games Only relaxing activities before bed

9. Sleep Hygiene What Not to Do Naps Alcohol, caffeine, nicotine Evening bright light Exercise within 3 hours of bed Big meals within 3 hours of bed Noise or excessive heat/cold in bedroom Use bed for anything other than sleep or sex Clock watching or trying to force sleep

10. COPD And Sleep Apnea

11. Groups at Risk COPDOSA Prevalence 7-19% worldwide (1/5 > 30 who have smoked over 10 years) Men: Women 2:1 Lifetime Risk ¼ Age > 50 years Prevalence 4% men, 2%women 75% undiagnosed Weight 10% weight gain gives 6 fold rise in OSA Middle age up to 65 is peak Obese teens can need CPAP

13. Definitions COPD Obstructive Sleep Apnea Airflow Obstruction Low FEV 1 Nocturnal Desaturation Daytime Hypoxemia Pulmonary Hypertension Repetitive airflow cessation or reduction Airway collapse Nocturnal desaturations Pulmonary Hypertension

14. Overlap Syndrome Of patients with OSA 10-15% will have the overlap syndrome Spirometry shows Obstruction Rates of hypoxemia, hypercarbia and Pulmonary hypertension are all increased over uncomplicated OSA patients Hypercarbia occurs at a lower BMI and AHI than Obesity Hypoventilation Hypercarbia occurs at a higher FEV 1 than in pure COPD Intermittent hypoxemia promotes atherosclerosis Lee,R. McNicholas, W.T Cur Opin Pulm Med 2011, 17(2) 79-83.

15. Stroke And Sleep Apnea

16. Stroke and Sleep Apnea Sleep Heart Health Study 5422 Participants over 40 followed for 8.7 yrs. Stroke risk almost 3 times higher for men with AHI above 19. In men the risk increased as the AHI increased. Women had an increased risk if the AHI was above 25 These numbers held up when controlled for other stroke risk factors (Am J Resp Crit Care Med. 4/25/10)

17. Stroke and Sleep Apnea Sleep Apnea is found in 9% of acute stroke patients in some studies In a MRI study of Clinically Silent Infarcts 58% had severe OSA. In fact the higher the AHI the more likely they were to have CSI With Chronic Microvascular Changes on MRI 38% had Severe OSA (High Rate of Sleep Apnea in Patients with Silent Strokes. Medscape. Feb 02, 2012)

18. Congestive Heart Failure And Sleep Apnea

19. CHF and OSA Sleep Heart Health Study In men 40-70 with AHI above 30: 68% more likely to develop CHD (MI, Revascularization or death) This same group was 58% more likely to get CHF than those without OSA (The Sleep Heart Health Study, Circulation 2010)

20. CHF and OSA Sleep Disordered Breathing is identified in 70% of Decompensated CHF patients Central Sleep Apnea predicted elevated readmission rates at 3 and 6 months and a 2/3 increase in 3 year mortality Sleep Apnea worsens Acute HF outcomes: testing for it at Admission proposed. Medscape. Oct4, 2013. Abstract from Heart Failure Society of America Meeting 9/23/2013;Orlando FL.

21. Cardiovascular Mortality and OSA In a recently published Korean Study the Hazard Ratio for Cardiovascular Mortality was elevated 4.66 times by an AHI >30. All cause Mortality in the same group was elevated 2.47 times. Lee, J.E. et al. J. Clin Sleep Med 2013, 9(10) 997-1002

22. Atrial Fibrillation And Obstructive Sleep Apnea

23. Atrial Fibrillation and OSA Do they Coexist or is there a Causative Effect Severe OSA patients are more likely to have AF than would be predicted by chance. Range Gami 17% > controls, Bitter 42.7% OSA prevalence in AF patients, Braga 81.6% OSA patients are more likely to have recurrent AF and it recurrence post cardioversion.

24. Atrial Fibrillation and OSA CPAP treatment decreases recurrence post cardioversion rates The worse the OSA the higher the recurrence rate CPAP reduces the recurrence rate by half Even with catheter ablation OSA patients have a 40% recurrence rate (Lettieri, Christopher. The Relationship Between OSA and AF:Guidance for Clinicians. Medscape. Dec 19, 2012.

25. Sleep Apnea and Obesity We all know that Obesity can lead to OSA But Just as likely OSA may worsen OBESITY OSA worsens how the liver handles glucose and is linked to glucose intolerance. It is also linked to disorders of fat metabolism. Intermittent hypoxemia can promote insulin resistance and hyperlipidemia

26. Sleep Apnea and Obesity New Data Leptin (from fat cells and signals the brain you are full) Ghrelin (from your stomach tells your brain you are hungry) When you are sleep deprived your Leptin is reduced and your Ghrelin is elevated) So you eat and you crave high fat and high calorie foods

27. Traffic Accidents And Sleep Apnea

28. Traffic Accidents and OSA Remember 92% of OSA patients are undiagnosed It may Occur in 24% of Adult Males Tiredness affects reaction time, lane position and steering OSA patients are 2-15 time as likely to have an accident as the general population With an AHI of 10 or more the risk of an accident goes up 6.3 times The FAA says the performance degradation of mild to moderate OSA can equal BAL 0.08% Teng and Won. Clin in Chest Med 33(2012) 731- 44.

29. Traffic Accidents and OSA In a recent Australian Study there was an increased rate of near-misses in men and women with untreated obstructive sleep apnea. The risk of motor vehicle crashes was higher in men. The higher the sleepiness score the higher the risk of crashes. Ward, KL et al. J. Clin Sleep Med 2013 9(10) 1013-1021.

31. References Gottleib, DJ et al. Prospective Study of OSA and Incident Coronary Artery Disease and Heart Failure. Circulation 2010:(122)352-360 Nainggolan, L. Sleep apnea Linked to Heart Failure in Men, But Not Women. Medscape. Jul 14, 2010. Stiles, S. Sleep Apnea Worsens Acute HF Outcomes; Testing for it at Admission Proposed. Medscape Oct 4, 2013. Lettieri, C. The relationship Between Obstructive Sleep Apnea and Atrial Fibrillation: Guidance for Clinicians. Medscape. Dec 19, 2012.

32. References Lee, J. et al. Mortality of Patients with Sleep Apnea in Korea. J. Clin Sleep Med 2013:9(10) 997-1002. Lee, R., McNicholas, WT, Obstructive Sleep Apnea in COPD patients. Cur Opin Pulm Med. 2011:17(2):79-83. Teng, AY and Won, C., Implications of OSA on Work and Work Disability Including Drivers. Clin Chest Med: 33(2012) 731- 44.

33. References Anderson, P.: High Rate of Sleep Apnea in patients with Silent Strokes. Medscape. Feb 2, 2012. Kelly, J.C.: Mild to Moderate Sleep Apnea Increases Stroke Risk. Medscape. April 15, 2010. Ward, KL et al. Excessive Daytime Somnolence Increases the Risk of Motor Vehicle Crash in Obstructive Sleep Apnea. J Clin Sleep Med2013,9(10) 1013-1021.