1. You are here because either your screener was positive or you reported symptoms indicating a high probability for sleep disordered breathing

2. Screener

3. Part 1 A score of 8 or more is indicative of excessive daytime sleepiness. Most people who are well rested and not fighting an illness, will not desire or even be able to sleep during the day after a full nights sleep. The sleep study will help to determine if there are abnormalities in your sleep that cause you to feel sleepy during the day.

4. Part 2 Snoring in its self is not dangerous but those who snore often experiences airway collapse when sleeping. Diabetes, coronary artery disease, high blood pressure and irregular heart rhythm may all result from abnormal breathing patterns in sleep. There is a history of premature death in sleep for those with sleep disordered breathing. If you have a history of this in your family your sleep should be studied.

5. Part 3 If you have sleep disordered breathing your risk for cardiac events is markedly increased. It is not expected that you should awake from sleep with chest pain or gasping for breath. If you have awakened with chest pain or shortness of breath you most likely have sleep disordered breathing causing your airway to collapse and obstruct while sleeping. Stroke, congestive heart failure and atrial fibrillation are all associated with sleep disordered breathing. Your risk of repeat events are increased when sleep disordered breathing is present and/or not treated properly. Large neck size adds resistance to the airway when muscles relax in sleep. This increases your risk for sleep disordered breathing. Taking pain medications increases your risk for sleep disordered breathing and can create delays in arousal following an event.

6. Sleep Apnea High blood pressure 83% of people who are on multiple medications for high blood pressure have sleep apnea 50% of people with high blood pressure have sleep apnea Stroke Almost 70% of people who have had a stroke have sleep apnea Type 2 diabetes 58% of patients with type 2 Diabetes have sleep apnea Obesity 77% of people who are obese (Body Mass Index greater than 30) have obstructive sleep apnea Motor vehicle accidents A person with sleep apnea is 7 times more likely to have a motor vehicle accident. Other risks associated with Sleep Apnea Treating sleep apnea can reduce the risk of developing associated diseases. People with untreated obstructive sleep apnea are More likely to have a heart attack 7 times more likely to suffer a stroke

7. When is a sleep study recommended? There is no single answer that got you here. A test is triggered when parts 1 and 2 equal 3 points or higher or a total of four points on all three parts. The higher your score the higher the probability that you have breathing issues during sleep.

8. Why a Sleep Study The way you breathe when you sleep can increase your risk of developing illnesses such as:  Hypertension  Heart failure  Coronary artery disease  Stroke  Atrial Fibrillation  Diabetes If you already have any of these illnesses the way you breathe when you sleep can worsen these conditions and/or make it harder to treat them. Properly treating sleep disordered breathing will reduce your risk for developing diabetes and heart disease.

9. Sleep Study in the Lab or in the Home As a general rule: If you have heart disease your sleep study will need to be done in a full service sleep center. If you do not have heart disease your sleep study may be done at home. Your insurance carrier may also have input into where your study is done.

10. WHAT DOES IT ALL MEAN You are positive for sleep apnea

11. Airway Events in sleep Review of events specific to what you experienced in your study. There are multiple types of breathing events that happen in sleep. Lets review some pictures that will help you to understand what is happening in your airway.

12. Obstructive Apnea This is a picture of 5 minutes of sleep. The red lines are the airflow pattern. Each hump in the 2 blue lines below are efforts to breathe. This picture shows 5 times in this 5 minutes of recording where there were efforts to breathe but no airflow. This is caused by airway collapse. The yellow marks are arousal. The green marks above the red lines are the drops in oxygen. The green marks below is snoring. These events are obstructive apneas

13. Central Sleep Apnea This picture is a 30 second view from a sleep study. The blue line marks a time when the patient was not breathing. If you look at the two lines below you will see that there was no effort to breathe. The green lines mark where the oxygen levels have dropped because of the lack of breath. This event is a central apnea.

14. Mixed Apnea This is a 2 minute picture. During this 2 minutes breathing stopped 3 times. The gray lines mark periods where there was not airflow. The blue lines below the gray marks show effort to breathe. In this type of event there is a short period without effort to breathe and then when effort to breathe returns the airway obstructs. Green line above shows drops in the oxygen levels. Green lines below mark periods of snoring. This events are mixed apneas.

15. Hypopneas This is a 2 minute picture. There are 2 events in this 2 minute period. The pink lines mark the times when efforts to breathe were decreased causing a decrease in oxygen levels (green marks above). The green lines below mark the time with constant snoring. This are hypopneas.

16. RERA (Respiratory Event Related Arousal) This is a 2 minute picture. During this 2 minutes there are 4 times that breathing was decreased which caused an arousal (yellow marks). The events do not cause oxygen levels to drop significantly however they do disturb sleep. In this 2 minute period this person aroused 3 times. This pattern can cause problems with daytime fatigue and over a period of time can result in illness.

17. AHI – Number of apnea and hypopneas/hour of sleep RDI- number of apneas, hypopneas and RERA’s/hour of sleep Tallying the Findings

18. REI - Respiratory events occurring during sleep periods in a home sleep study. Average number of events per hour. Insurance is currently asking for the AHI but may begin to ask for the REI. REI - Respiratory Event Index

19. What is Sleep Disordered Breathing Sleep Disordered Breathing is a sleep disorder where there is intermittent loss of breathe. This is most often caused by narrowing of the airway and/or airway collapse. In your study your airway was compromised ____ times during the night. Other names for Sleep Disordered Breathing include:  Sleep Apnea  Obstructive Sleep Apnea  Obstructive Sleep Apnea Hypopnea Syndrome

20. When breathing stops.. Oxygen levels drop Breathing is disturbed and after some time 10 to 60 seconds or more you have an arousal and breathing returns. You fall back asleep and difficulty breathing returns Breathing is disturbed and after some time 10 to 60 seconds or more you have an arousal and breathing returns. This can happen hundreds of times per night. The decrease in oxygen caused by not breathing and the increased heart rate caused by the sudden awakenings put stress on the heart. This pattern has been documented to cause the blood pressure to rise which leads to hypertension.

21. Blood pressure goes up … When the blood pressure is increased like this at night it continues into the day. Medications for high blood pressure may work for a while but over time more or different medications will be required, if the source of the problem (the sleep disordered breathing) is not corrected. The high blood pressure and the low oxygen levels increase the work of the heart and do damage to the arteries increasing the incidence of coronary artery disease.

22. You develop Coronary Artery Disease… Coronary Artery Disease is the foundation for heart attack. People with coronary artery disease have narrowing of the arteries that feed oxygen to the heart muscle. Sleep disordered breathing events damage the arteries and decrease the availability of oxygen demanded to the heart during periods when the need for oxygen is increased. Research has shown that treating sleep disordered breathing reduces death due to coronary artery disease. A blocked coronary artery is a heart attack. The amount of damage done depends on which vessel is blocked. Some people will go on to develop heart failure as a result of this breathing pattern.

23. You develop heart failure… In heart failure the ability for the heart to pump the volume of blood needed to supply your body is diminished. People who have Congestive Heart Failure are more likely to have pauses in breathing that are not associated with snoring or airway obstruction. Treating the central apnea can make it easier to live with congestive heart failure.

24. Stroke.. If the blockage is in a artery that feeds oxygen to the brain then this is called a stroke. Treatment of Sleep Disordered Breathing has been shown to reduce the incidence of repeat strokes.

25. Understanding your sleep study results. Mild Moderate or Severe Your AHI was: _____ Your RDI was: _____ Your sleep disordered breathing is considered to be __________. Mild = airway partially or completely closes 5 -15 times per hour of sleep. Moderate = airway partially or completely closes 16-29 times per hour of sleep. Severe = airway partially or completely closes more than 30 times per hour of sleep.

26. Possible effect of your sleep disordered breathing and snoring on you and your bed partner. People who have poor sleep habits are at greater risk for becoming overweight or obese and developing type 2 diabetes, according to several studies. Chronic sleep deprivation may lead to insulin resistance, which can result in high blood sugar and diabetes. Some studies show that chronic sleep deprivation can affect hormones that control appetite. Recent findings link inadequate sleep with lower levels of the hormone leptin, which helps control the metabolism of carbohydrates.leptinmetabolism Low levels of leptin have been shown to increase the body's craving for carbohydrates regardless of the amount of calories consumed. Treatment of snoring and sleep disordered breathing can increase your bed partner’s total sleep time by 1+ hours according to recent studies.

27. Diabetes Patients who spend greater than 3% of their total sleep time with saturations less that 90% are at an increased risk for cardiac events and insulin resistance. 48% of type 2 diabetes sufferers have sleep apnea OSA may have a causal role in the development of type 2 diabetes OSA is associated with insulin resistance 30% of patients presented to a sleep clinic have impaired glucose intolerance Mild forms of sleep disordered breathing may be important in predicting risk of pre-diabetes 86% of obese type 2 diabetic patients suffer from sleep apnea 80% of all diabetes sufferers die of cardiovascular disease

28. Coronary Artery Disease and Heart Attack CAD is the most common type of heart disease. In the United States, CHD is the #1 cause of death for both men and women. Sleep disordered breathing increased the risk of coronary artery disease and heart attack. OSA presents in 70% of heart attack patients with AHI >5 and 52% of heart attack patients with AHI > 10. Treating sleep disordered breathing decreases the risk of new cardiac events.

29. Hypertension Studies have shown that sleep apnea is an independent risk factor for hypertension 30–83% of patients with hypertension have sleep apnea 43% of patients with mild OSA and 69% of patients with severe OSA have hypertension American Heart Association guidelines on drug-resistant hypertension have shown treatment of sleep apnea likely to improve blood pressure control

30. Arrhythmia (Irregular Heart Rhythm) Arrhythmias are noted in 50–75% of OSA patients (Somers 2004). And are noted in 30% of cardiovascular patients (Schafer 1999) OSA presents in 70% of heart attack patients with AHI >5 and 52% of heart attack patients with AHI > 10.

31. Stroke 65% of stroke patients have sleep disordered breathing. Up to 70% of patients in rehabilitation therapy following stroke have significant SDB (AHI >10) People with untreated sleep apnea are 7 times more likely to suffer a stroke

32. Congestive Heart Failure 4.7 million people in the US have heart failure Approximately 50% of HF patients have SDB

33. Untreated OSA Risk The chances of developing coronary artery disease, stroke, high blood pressure, congestive heart failure and type 2 diabetes more than doubles for a person suffering from OSA. The deaths of the NFL athlete, Reggie White as well as the Canadian comedian John Candy were both caused by OSA. Reggie White was believed to have died in his sleep from untreated OSA as he was not able to use a CPAP due to claustrophobia. John Candy had OSA most of his adult life and died from a heart attack. It is estimated that about 50% of individuals who have cardiovascular disease also suffer from OSA.

34. YOUR TREATMENT OPTIONS ARE INFLUENCED BY THE SEVERITY OF YOUR SLEEP DISORDERED BREATHING Treatment Options Oral Appliance – Mild to Moderate, Snoring/RERA’s CPAP Therapy – Mild, Moderate and Severe Craniofacial Surgery – Mild, Moderate, Severe with craniofacial abnormalities Oral Surgery – Snoring and/or RERA’s Airway Surgery – Snoring and/or RERA’s

35. How the Oral Appliance Works Repositions the lower jaw, tongue, soft palate and uvula. Stabilizes the lower jaw and tongue. Increases the muscle tone of the tongue

36. Pros Cons Oral appliances are comfortable and easy to wear. Most people find that it only takes a couple of weeks to become acclimated to wearing the appliance. Oral appliances are small and convenient making them easy to carry when traveling. Treatment with oral appliances is reversible and non-invasive Effectiveness of the appliance cannot be determined prior to use. Not indicated as a first line of treatment for severe sleep apnea. Oral Appliance

37. How CPAP Works A cushion of air is maintained in the back of the throat that will keep the airway from collapsing during sleep. CPAP – Continuous positive airway pressure.

38. Pros Cons A sleep study done in a sleep lab can determine the effectiveness of CPAP in a single night. The titration allows for adjustment to be made as needed. Pressure on the face caused by the mask. In lab study for titration. Drying of the airway cause by the flow from machine. May be impossible to use when you are sick. (nasal congestion). Heavy to travel with. CPAP

39. Nasal Airway – Deviated Septum or polyps Oral Airway - UPPP UPPP - A procedure used to remove excess tissue in the throat to widen the airway. The uvula (small finger-shaped piece of tissue that hangs down from the back of the roof of the mouth into the throat), part of the roof of the mouth (soft palate) and excess throat tissue is removed (the tonsils the adenoids and the pharynx). Airway Surgery An incision made inside the nostril, the tissue covering the septum is lifted up to reveal the bone and cartilage. The deviated portions of the bone and cartilage are then either removed or reshaped, leaving behind enough non-deviated bone and cartilage to maintain the shape of the nose.

40. Maxillomandibular Advancement (MMA) - the upper (maxilla) is moved forward and stabilized with plates or lower jaw (mandible) is broken and a plate is inserted which and moves the lower jawbone forward. Hyoid advancement surgery - the movable bone underneath the chin is brought forward, pulling the tongue muscle along with it which widens the airway. Craniofacial Surgery

41. Maxillary or Genioglossus (tongue advancement), in which an opening is cut where the tongue joins the jawbone and the area is pulled forward. Genioplasty, which is plastic surgery on the chin. The chin is sliced and the lower part is moved forward thus moving the tongue forward and enlarging the airway. Oral Surgery

42. Pros Cons Widens the airway to minimize the risk of airway collapse. Reduces excess tissue. May control snoring. May control apnea. If the procedure is effective the need for other therapy is avoided. It may be very difficult to breathe, chew and/or swallow after the procedure. Swelling in the throat/airway which may result in the need for placement of a tube in the neck for breathing. Risk related to anesthesia use. Infection It takes about 3-8 weeks to recover from surgery. Limited physical activity, including vigorous sports, for several weeks after surgery to minimize swelling and promote healing. Only 60% of those having surgery say they would undergo it again. May not be effective and need for other therapy will remain. Surgery

43. Pros Cons Once in Treatment is in place. No external device to be used. Cannot have and MRI with the device in place. Requires Anesthesia during the evaluation and during the treatment portion of the process. Cannot be used if BMI is above 32. Follow-up every 6 months for device checks. No guarantee that the device will work prior to surgery. UAS _Upper Airway Stimulation