1. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

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3. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. in the clinic Obstructive sleep apnea

4. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1.  All adults who answer yes to either question:  Are they dissatisfied with their sleep?  Do they have daytime sleepiness?  Patients with risk factors  Obesity, especially BMI >35 kg/m2  Family history of obstructive sleep apnea  Retrognathia  Treatment-resistant hypertension  CHF, atrial fibrillation, stroke  Type 2 diabetes  Patients with high-risk driving occupations or daytime sleepiness + motor vehicle crash Who should be screened for OSA?

5. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What are the screening tools?  Berlin questionnaire (primary care setting)  10 items  Snoring severity, significance of daytime sleepiness, witnessed apnea, obesity, hypertension  STOP-BANG screening test (preoperative setting)  8 items  STOP: Snoring, Tired, Observed apnea, high blood Pressure history  BANG: elevated BMI, Age > 50, increased Neck circumference, Gender male  Neither tool precludes formal sleep testing

6. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. Can OSA be prevented?  Weight loss can reduce severity  May also achieve remission

7. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. CLINICAL BOTTOM LINE: Screening and Prevention...  Ask all adults about sleep problems or daytime sleepiness  If response is positive: perform OSA screening  Take further clinical history  Use validated questionnaire  Screen is also warranted for all patients with:  Significant obesity  CVD  History of drowsiness while driving

8. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What symptoms should prompt consideration of OSA?  Witnessed episodes of apnea  Loud, frequent, bothersome snoring  Choking/gasping during sleep  Excessive daytime sleepiness  Drowsy driving  Unrefreshing sleep, sleep fragmentation  Insomnia  Nocturia  Morning headaches  Decreased concentration, memory loss  Decreased libido

9. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. In the absence of symptoms, what other diseases should prompt evaluation?  Morbid obesity  If patient scheduled for bariatric surgery  Hypertension  If refractory to medical therapy

10. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What other conditions should be considered?  Chronic sleep deprivation disorder (shift-work disorder)  Circadian rhythm disorder  Depression and anxiety  Hypothyroidism  Obesity hypoventilation syndrome  Central sleep apnea syndrome  Congestive heart failure (Cheyne-Stokes respiration)  Opiate-induced central sleep apnea

11. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What physical exam findings are important?  Respiratory, CV, and neurologic systems  Presence and degree of obesity  Signs of upper airway narrowing  Neck >16” women, >17” men  Mallampati score of 3 or 4  Macroglossia, tonsillar hypertrophy  Enlarged or elongated uvula, high/arched palate  Nasal obstruction  Retrognathia

12. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What type of sleep study should be ordered?  Polysomnography in the sleep laboratory  Standard method for diagnosis and determining severity  Assesses other sleep disorders  Recommended: “full-night” sleep study  Alternative: “Split-night” study  Initial diagnostic recording  Then positive airway pressure titration the same night

13. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What is the role of in-home sleep studies?  Used for uncomplicated cases  Clinical probability high + no cardiopulmonary disease  Validity + utility unclear with serious comorbidities  Convenient and lower cost  May underestimate severity  If test is negative: in-lab sleep study  Definitively exclude diagnosis

14. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What variables are reported on a sleep study report, and what do they mean?  Apnea-hypopnea index (AHI)  Episodes of apnea and hypopnea per hour of sleep  Mild OSA: AHI ≥5 and <15/h  Moderate OSA: AHI ≥15 and <30  Severe OSA: AHI ≥30  Apnea: airflow cessation ≥10 sec  Hypopnea: airflow reduction ≥10 sec plus 3% or 4% OxyHb desaturation or arousal from sleep  Other measures of sleep-disordered breathing, total sleep time, measures of sleep quality  Epileptiform EEG, limb movement, nocturnal arrhythmia

15. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. Do patients need to be seen by a sleep specialist before a sleep study is ordered?  Sleep specialist evaluation recommended  Complex sleep-disordered breathing processes suspected  Other sleep disorder suspected  To ensure proper diagnostic tests ordered  Prior evaluation not needed in other cases  But clinician should discuss options with patient first  Explain OSA therapy and why it may be initiated

16. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. CLINICAL BOTTOM LINE: Diagnosis...  Evaluate patients with symptoms that suggest OSA  Loud snoring, nocturnal choking or gasping  Significant daytime sleepiness, history drowsy driving  Witnessed episodes of apnea  Evaluate patients with no symptoms if  Undergoing bariatric surgery  Have treatment-resistant hypertension  In-lab sleep testing: gold standard  In-home sleep testing: if high clinical suspicion for OSA and no significant cardiopulmonary comorbid conditions

17. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. Which patients with OSA require treatment?  Counsel overweight patients about weight loss  Treat any nasal congestion  Advise alcohol avoidance close to bedtime  Offer trial of therapy (CPAP) if patient has  Daytime sleepiness or frequent nocturnal awakenings  Recent accident or near-miss attributable to sleepiness  Controversial: whether to treat asymptomatic patients with mild or moderate OSA

18. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What is the role of weight loss and exercise?  Helps reduce severity and symptoms  Recommend dietary modification  Recommend regular exercise  Bariatric surgery can reduce severity in morbidly obese

19. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. Can OSA be effectively managed by alterations in sleep position?  If AHI lower when nonsupine: avoid supine position  Up to 1/3 mild or moderate cases are position-dependent  Methods for adherence  Tennis ball strapped to back while sleeping  Wearable positional avoidance devices  Monitors or alarms

20. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. How should CPAP be initiated?  CPAP prescription should include:  Pressure setting  Mask type and size  Heated humidifier  Associated supplies (tube, filters, mask straps)  Traditionally: in-lab overnight titration study  Alternative for uncomplicated OSA: autotitrating CPAP  Educate patients on equipment, maintenance, care  Also: on benefits of therapy and potential problems

21. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What amount of CPAP use constitutes sufficient adherence?  Patients should use CPAP whenever they sleep  CMS: adequate CPAP use ≥4 h/night on 70% of nights  Linear relationship between hours of CPAP use and improvements in:  Sleepiness  Quality of life  Blood pressure

22. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What factors can optimize patient adherence to CPAP therapy?  Early follow-up (within 1–2 weeks of therapy initiation)  Support groups and bed partner support  Cognitive behavioral therapy focused on CPAP  Aid in therapy goal-setting  Support in troubleshooting difficulties  Heated humidification + nasal steroid for congestion  Other PAP modes if patient has intolerance to pressure  Short-term sedative hypnotic (for select patients only)

23. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. How should CPAP masks be chosen?  No one mask type is superior to another  Select mask to maximize patient comfort  Oronasal (“full face”) masks  Patients who sleep with their mouth open  Nasal masks  Better tolerated with claustrophobia  Nasal pillows (sit under the nose and fit in the nares)  Also better tolerated with claustrophobia  Patients with unusual nasal bridge anatomy, facial hair, or absent dentition

24. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What is the role of mandibular advancement devices?  Decrease airway collapsibility and enlarge upper airway  Requires adequate dentition, may exacerbate TMJ  Refer to experienced dentist (sleep dentistry accreditation)  Less effective than CPAP for normalizing the AHI  Mild or moderate OSA: May be reasonable initial therapy  Severe OSA: Not recommended as initial therapy  Patients tend to accept better than CPAP  Follow-up sleep study needed to document adequacy

25. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What is the role of surgical intervention?  Uvulopalatopharyngoplasty (UPPP)  Small reduction in symptoms  Fewer than half of patients have reduction in severity  Tonsillectomy, nasal septoplasty  Increase CPAP tolerability + reduce snoring (not cure)  Maxillomandibular advancement  Invasive procedure with prolonged postop recovery  Cure rate >90%, particularly in nonobese with retrognathia  Tracheostomy  Cures OSA  Can be used in life-threatening situations

26. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. How should treatment be monitored?  Ensure CPAP use during all sleep sessions  Assess symptom resolution  Monitor side effects of CPAP  Assess comorbid conditions associated with OSA  Monitor remission due to weight loss or surgery  Monitor remission in those with history drowsy driving  If relapse occurs, investigate stepwise:  Inadequate therapy adherence  Problems with CPAP delivery  Change in pressure needs  Non-OSA sleep factors

27. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. How should OSA be treated when a patient is admitted to the hospital?  Patients should use their CPAP or MAD in the hospital  Just as they would at home  Use sedative and opiate medications cautiously  If moderate sedation used intraoperatively  Monitor ventilation by continuous oximetry and continuous capnography  Consider CPAP administration during sedation  Beware untreated OSA in periop setting  Higher rate cardiopulmonary complications, ICU transfers

28. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. When should a sleep specialist be consulted for management?  Complicated management situations  CPAP-intolerance  Persistent symptoms despite therapy  Multiple sleep disorders  Complex sleep-disordered breathing

29. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. What should patients know about the effects of medications and supplemental oxygen?  Use sedatives and opiates cautiously (can worsen OSA)  Exogenous testosterone may exacerbate or induce OSA  Don’t use supplemental oxygen as primary therapy  Treats oxyhemoglobin desaturation associated with OSA  Little evidence that it reduces symptoms, BP, CV risk  Some patients require both CPAP and supplemental oxygen

30. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. Can treatment prevent or modify outcomes in other diseases?  CPAP and MAD therapy reduce blood pressure  Degree of adherence correlates with BP response  CPAP therapy may reduce hypertension  Effect of therapy on cardiovascular outcomes unclear  Other diseases may be modified by OSA therapy  May modestly increase ejection fraction in CHF  May reduce likelihood of Afib recurrence

31. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. CLINICAL BOTTOM LINE: Treatment...  Conservative measures: weight loss, avoid alcohol at bedtime  Patients who require CPAP, other therapy (MAD, surgery)  Symptomatic or severe OSA  OSA-related drowsy driving  Benefits of adequate adherence to therapy  Symptom resolution  Reduced cardiovascular risk