1. OSA Pathogenesis, Co-morbidities and Outcomes John Reid, MD FRCP(C) RMGIM Conference, Banff November 24, 2012

2. Disclosures I have no conflicts of interest to declare, financial or otherwise I have no conflicts of interest to declare, financial or otherwise

3. Objectives Brief discussion of OSA Brief discussion of OSA Epidemiology Epidemiology Pathogenesis Pathogenesis Co-morbidities Co-morbidities Treatment outcomes Treatment outcomes Discuss controversies or clinical dilemmas Discuss controversies or clinical dilemmas Question/ Discussion Question/ Discussion

4. OSA - Prevalence OSA Syndrome: OSA + Daytime Sleepiness OSA Syndrome: OSA + Daytime Sleepiness 4% of adult males 4% of adult males 2% of adult females 2% of adult females AHI > 5 AHI > 5 24% of adults males 24% of adults males 9% of adult females 9% of adult females <50% of cardiac patients may have Sleep Apnea <50% of cardiac patients may have Sleep Apnea

5. OSA Other associated complaints include: Other associated complaints include: Sleep fragmentation Sleep fragmentation Insomnia of sleep maintenance Insomnia of sleep maintenance Un-refreshing sleep Un-refreshing sleep Morning headaches Morning headaches Tiredness / fatigue Tiredness / fatigue Memory / mood problems Memory / mood problems

6. OSA - Implications Poor quality sleep, EDS Poor quality sleep, EDS HTN (1-3 X ↑) HTN (1-3 X ↑) CAD (30 – 40% ↑) CAD (30 – 40% ↑) Stroke (50% ↑) Stroke (50% ↑) DM ? DM ? Neuropsychological morbidity Neuropsychological morbidity Pulmonary HTN, Right heart failure Pulmonary HTN, Right heart failure Motor vehicle and other accidents (3-10 X) Motor vehicle and other accidents (3-10 X) Estimated increase risk of death of 1%/yr vs treated OSA ( Sassani A, et al. Sleep. 2004: 27;453-8) Estimated increase risk of death of 1%/yr vs treated OSA ( Sassani A, et al. Sleep. 2004: 27;453-8)

7. OSA: Co-morbidities Children Children ADHD ADHD Growth Restriction Growth Restriction Poor school performance Poor school performance Academic achievement Academic achievement Long-lasting consequences? Long-lasting consequences?

8. OSA - Implications Symptoms generally more severe in patients with more severe disease Symptoms generally more severe in patients with more severe disease However, symptoms do not always correlate with AHI (eg UARS) However, symptoms do not always correlate with AHI (eg UARS) AHI does not always correlate with hypoxemia AHI does not always correlate with hypoxemia

9. OSA Pathogenesis Repetitive collapse of upper airway during sleep, resulting in arousals and/or hypoxemia Repetitive collapse of upper airway during sleep, resulting in arousals and/or hypoxemia Excessive Daytime sleepiness often arises from sleep loss/fragmentation Excessive Daytime sleepiness often arises from sleep loss/fragmentation Cardiovascular consequences of repetitive arousals, hypoxemia,  catecholamines & cortisol & inflammatory cytokines Cardiovascular consequences of repetitive arousals, hypoxemia,  catecholamines & cortisol & inflammatory cytokines

10. OSA Pathogenesis

11. OSA- Area of Collapse

12. OSA - Definitions Apnea Apnea Absence (<20% of baseline) of airflow for 10 s Absence (<20% of baseline) of airflow for 10 s Hypopnea Hypopnea Reduction in airflow (30%, 50%?) from baseline for 10 s AND followed by an EEG arousal or desaturation Reduction in airflow (30%, 50%?) from baseline for 10 s AND followed by an EEG arousal or desaturation RERA RERA No reduction in airflow, but evidence of progressively increasing respiratory effort, followed by an EEG arousal No reduction in airflow, but evidence of progressively increasing respiratory effort, followed by an EEG arousal

15. OSA Normal Normal < 5 per hour (AHI, RDI) < 5 per hour (AHI, RDI) Mild Mild 5 - 15 5 - 15 Moderate Moderate 15 - 30 15 - 30 Severe Severe > 30 > 30

16. Partial Sleep Report

17. Oximetry

18. Oximetry - Severe OSA

19. Apneas – Mild Desaturation

20. Respiratory Event Related Arousal (RERA)

21. OSA - Treatment Conservative Therapy Conservative Therapy Weight loss, positional therapy, avoidance of alcohol, stop smoking, treat nasal congestion Weight loss, positional therapy, avoidance of alcohol, stop smoking, treat nasal congestion Specific Therapy Specific Therapy CPAP CPAP Dental Appliance Dental Appliance Oropharyngeal Surgery Oropharyngeal Surgery Pillar® Procedure Pillar® Procedure Nasal EPAP (Provent®) Nasal EPAP (Provent®) Hypoglossal Nerve Stimulation Hypoglossal Nerve Stimulation

22. CPAP Therapy Improves neurophysiologic symptoms, including EDS, in patients with severe OSA Improves neurophysiologic symptoms, including EDS, in patients with severe OSA Data inconclusive in patients with mild to moderate OSA – significant variability Data inconclusive in patients with mild to moderate OSA – significant variability Modest benefit shown in patients with moderate OSA Modest benefit shown in patients with moderate OSA

23. Dental Appliances Recommended for mild - moderate patients and those who cannot tolerate CPAP Recommended for mild - moderate patients and those who cannot tolerate CPAP Improves OSA and hypoxemia in mild- moderate patients Improves OSA and hypoxemia in mild- moderate patients Not as effective as CPAP Not as effective as CPAP Not as extensively studied as CPAP Not as extensively studied as CPAP 1/3 of all patients may have clinical or structural contraindications 1/3 of all patients may have clinical or structural contraindications

24. Dental Appliances

25. Oropharyngeal Surgery Tonsillectemy & Adenoidectemy Tonsillectemy & Adenoidectemy Uvulapalatopharyngeoplasty (UPPP) Uvulapalatopharyngeoplasty (UPPP) Rhinoplasty and Nasal septalsurgery Rhinoplasty and Nasal septalsurgery Maxillo-mandibular (Bimaxillary) advancement Maxillo-mandibular (Bimaxillary) advancement

26. Surgery T&A - first line for children T&A - first line for children UPPP - a consideration for carefully selected patients - less effective than CPAP UPPP - a consideration for carefully selected patients - less effective than CPAP LAUP - for primary snoring only, not a treatment of OSA LAUP - for primary snoring only, not a treatment of OSA

27. Pillar Procedure

28. Nasal EPAP – Provent®

29. Summary OSA is very common and increasing in prevalence OSA is very common and increasing in prevalence Caused by repetitive collapse of the upper airway during sleep Caused by repetitive collapse of the upper airway during sleep Significant health consequences Significant health consequences Oximetry has limitations as screening tool, not sensitive enough to rule out OSA Oximetry has limitations as screening tool, not sensitive enough to rule out OSA

30. Summary Treatment Treatment Most often CPAP Most often CPAP Consider dental appliance Consider dental appliance Maybe consider surgery Maybe consider surgery Pillar ®, Provent®? Pillar ®, Provent®? Always include conservative measures Always include conservative measures

31. Discussion Points CPAP alternatives CPAP alternatives What to do about non-sleepy OSA patients What to do about non-sleepy OSA patients Peri-operative management Peri-operative management Retesting Retesting License regulation License regulation Your questions? Your questions?