1. Recognizing and Treating Sleep Apnea in Primary Care Gandis Mazeika, MD President, Sound Sleep Health

2. Goals Review Anatomy and Pathophysiology of OSA Review Anatomy and Pathophysiology of OSA Review the impact of OSA Review the impact of OSA – On Patients – In Primary Care Setting Review Screening and Diagnosis for OSA Review Screening and Diagnosis for OSA Review OSA Physical Exam Review OSA Physical Exam

3. Case History 52 YO married female homemaker Lifelong history of recurrent migraine headache, often present on awaking Now increasingly tired and waking up several times at night. Has been told she snores PMH significant for Breast CA, depression, anxiety, chronic LBP FH: neg for migraines SH: high home stress (2 special needs children)

4. Case History Habits: nonsmoker, no alcohol, 6 cups coffee daily Meds: Subutex for migraines and chronic LBP, omeprazole, vit D, sertraline 100mg VS: 112 lb, 60 in, BMI 21, normotensive, HR 55 Exam: facial, CN, upper airway, heart, lung, extremity exams all unremarkable

5. Case History PSG: AHI 14 (mild), oxyhemoglobin sats dropped to 87% in association with apnea events Treatment Plan: Presented with option of oral appliance vs CPAP; elected to start CPAP therapy. f/u 4 weeks after starting CPAP: headaches fully resolved; tapering Subutex.

6. Myth versus Reality Only obese people have obstructive sleep apnea Only obese people have obstructive sleep apnea Sleep apnea is simple disorder Sleep apnea is simple disorder Sleep apnea is a purely anatomical disorder Sleep apnea is a purely anatomical disorder Sleep apnea is a heterogenous disorder Sleep apnea is a heterogenous disorder Sleep apnea is a complex neurological disorder Sleep apnea is a complex neurological disorder

7. Abnormal breathing events Respiratory Effort Related Arousal (RERA) Respiratory Effort Related Arousal (RERA) – Thoracic negative pressure crescendo with arousal Hypopnea Hypopnea – Obstructive Recommended > 30% reduction in nasal flow + 4% desaturation Recommended > 30% reduction in nasal flow + 4% desaturation Alternate > 50% reduction in nasal flow + 3% desat or arousal Alternate > 50% reduction in nasal flow + 3% desat or arousal At least 10 seconds in duration At least 10 seconds in duration % decrement is an “eyeball” determination = very subjective % decrement is an “eyeball” determination = very subjective Wide interscorer and lab to lab variability Wide interscorer and lab to lab variability – Central – Mixed Apnea Apnea – Obstructive > 90% reduction in nasal flow signal with chest and abdominal effort preserved > 90% reduction in nasal flow signal with chest and abdominal effort preserved > 10 seconds > 10 seconds

8. Basic Concepts The Spectrum of Sleep Disordered Breathing The Spectrum of Sleep Disordered Breathing OSA OSA – UARS: RERAS – Mild OSA AHI 5-15 – Mod OSA AHI 15-30 – Severe OSA AHI>30

9. Respiratory effort related (RERA) Increased respiratory effort illustrated by increasing negative Pes until UARS threshold triggers an arousal Increased inspiratory time, decreased expiratory time = > increased peak negative inspiratory pressure (Pes), increased HR, SV decreased = >arousal at Pes = > sleep fragmentation In children first increase RR to maintain minute ventilation at metabolic cost “Occult” Sleep Disordered Breathing

10. Hypopnea First hypopnea with arousal, second longer in duration with desatuation event

11. Obstructive Apnea Does not have to be associated with arousal

12. Hypopneas not meeting AASM scoring criteria RDI < 5, negative sleep study, clear SDB, clinically EDS, Observed abnormal breathing, sleep maintenance insomnia, hypnotic dependence

13. Severe OSA Notice Severe Desats

14. Severe OSA, treated Regular breathing, improved sats

15. Anatomical Factors Narrowing of upper airway

16. Anatomical Factors Palatal Abnormalities (partial cleft, Marfan’s) Tongue Space Issues (car too big for the garage)

17. Pathophysiology of SDB What happens at sleep onset? What happens at sleep onset? – Decrease in muscle tone – Change in tongue position – Decrease in lung volumes, gravity – Increase airway resistance Airway narrowing Airway narrowing – Snoring – Airway partial closure – Airway total closure – Oxygen desaturation – Micro-arousal

18. Pathophysiology Snoring (and other factors) damage upper airway and cause edema Flow limitation and hypoventilation Chronic hypoxia and hypercarbia Blunted responses to hypoxia and hypercarbia Long term systemic effects

19. Pathophysiology Local tissue and nerve damage, Edema Impaired upper airway and thoracic tone Snoring Noisy breathing Oxygen desaturation Blunted arousal thresholds Metabolic Changes Cardiopulmonary Effects Systemic Diseas e Failure to compensate Partial collapse Hypopnea Nocturnal Hypoxia Hypercapnia Irreversible white matter changes Total Airway Collapse Apnea 1 2 3 Aging Weight gain Co-morbidities

20. Direct Consequences of OSA Sleep Disturbance and/or Sleep Fragmentation Hemodynamic Changes Related to Altered Thoracic Pressure Neuronal Stress Related To Cyclical Hypoxia

21. Sleep Disturbance

22. Ventricular Mass and Ejection Fraction Subjects with uncomplicated OSA showed systolic and diastolic dysfunction LV and LA function corrected following introduction of CPAP Lip et al, Circulation: Heart Failure, 2012

23. Neurodegenerative Changes Veasey et al, Sleep, 2004

24. Indirect Consequences of OSA Increased Frequency of MI and Stroke Insulin Resistance and/or Insulin Failure Leptin Resistance Depression/Anxiety More Frequent Hospital Admissions Longer Average Hospital Stays Higher Overall Cost of Care Increased Absenteesism

25. Cardiovascular Morbidity/Mortality Marin et al, Lancet 2005  Observational, sleep-clinic based study  1651 pts. Followed over 10 years.  Endpoints were fatal and non-fatal cardiovascular events.

26. Cardiovascular Morbidity/Mortality Wisconsin Cohort Study Wisconsin Cohort Study Severity of OSA inversely correlated to survival Severity of OSA inversely correlated to survival Young et al, Sleep, 2008

27. Diagnosis of OSA

28. Common Risk Factors for OSA Snoring Witnessed apnea Sleepiness or fatigue HTN or GERD or treated for these Overweight Facial or upper airway anatomy Nocturia Morning Headaches Erectile Dysfunction

29. Other High-Risk Groups for OSA Diabetes Atrial Fibrillation Pulmonary HTN History of MI or stroke COPD or restrictive lung disease Chronic pain - on opioids Neuromuscular disease Family History of OSA/loud snoring ADHD

30. Screening for OSA OSA Risk Questionnaires – Easy to Administer and Score – Limited Accuracy (But Not Bad) – Less Convincing to the Patient Sleep Studies – Complicated to Administer and Score At Present, Required By Insurance Companies – Cost Considerations – Require Input From a Boarded Sleep Specialist – More Convincing to the Patient

31. GASP: An Apnea Risk Questionnaire YesNoNot Sure 1.  Have you been told (or noticed on your own) that you snore on most nights? 2.  Have you been told (or noticed on your own) that you stop breathing or struggle to breathe in your sleep? 3.  Are you tired, fatigued or sleepy on most days? 4.  Do you have acid indigestion or high blood pressure (OR use medication to control either of these conditions)? 5.  Are you overweight? + =012345

32. GASP Questionnaire Yes and Maybe Answers = 1 No Answers = 0 Score Range Between 0 and 5 Score of 4 or Higher: 85 - 90% PPV Score of 1 or Lower: 85 – 90% NPV

33. Portable Monitoring Positives: Positives: Easy Learning Curve for Pts Easy Learning Curve for Pts Use At Home Use At Home Relatively Inexpensive Relatively Inexpensive Negatives: Negatives: 5 – 15% Failure Rate 5 – 15% Failure Rate Less Sensitive Than In-Lab Less Sensitive Than In-Lab Brain Activity Not Recorded Brain Activity Not Recorded Not Indicated In Some Pts Not Indicated In Some Pts

34. Facility-Based Sleep Studies Positives: Positives: More Sensitive More Sensitive Measure Brain and Muscle Activity Measure Brain and Muscle Activity Failures are Rare Failures are Rare Negatives: Negatives: Longer Waits Longer Waits More Expensive More Expensive Performance Anxiety Performance Anxiety

35. OSA Examination Facial physiognomy Facial physiognomy Nasal airflow Nasal airflow Occlusion Occlusion Tongue Tongue Hard palate Hard palate Soft palate Soft palate Uvula Uvula

36. General Observations Voice quality Voice quality – Nasal – Hoarse SOB/dyspnea SOB/dyspnea

37. Facial physiognomy Long narrow face Long narrow face Short stout neck with redundant tissue Short stout neck with redundant tissue

38. Occlusion Overjet Overjet

39. Mandible Recessed mandible with type II occlusion Recessed mandible with type II occlusion Large mandible Large mandible

40. Tongue Size/shape Size/shape – Elongated or Broad Scalloping Scalloping

41. Tongue Activation Following Apnea

42. Nasal airflow Laterality Laterality Nasal valve characteristics Nasal valve characteristics

43. Hard Palate Tori Tori Dome shape Dome shape

44. Soft Palate Mallampati Class Mallampati Class

45. Uvula Size, shape Size, shape

46. Posterior Oropharynx/Tonsils Tonsillar Hypertrophy Tonsillar Hypertrophy Crowding From Lateral Pharyngeal Walls Crowding From Lateral Pharyngeal Walls

47. Therapeutic Options

48. Weight Loss Strong Correlation with Reduced Apnea Severity Strong Correlation with Reduced Apnea Severity Tuomilehto et al, AJRCCM, 2009

49. Positive Pressure Therapy

50. Oral Appliance Therapy

51. Oral Appliance Outcomes Post-treatment AHI Pre-treatment AHI

52. ProVent

53. Airway And Nasal Surgery

54. Other Therapies Hypoglossal Nerve Stimulation Hypoglossal Nerve Stimulation Palate Strengthening Exercises Palate Strengthening Exercises Tricyclic Antidepressants and Other Meds Tricyclic Antidepressants and Other Meds

55. Adjunctive Measures Avoid Sleeping On Back Avoid Sleeping On Back Moderation of Alcohol Intake Moderation of Alcohol Intake Salt Restriction Salt Restriction Change From Opioids to NSAIDS or Other Pain Management Strategies Change From Opioids to NSAIDS or Other Pain Management Strategies

56. Clinical Pearls The Reluctant Patient – Discuss long term consequences of untreated OSA – Lots of treatment options – Spouse is often the source of referral Managing Expectations – Many pts hope to feel dramatically better with therapy Not all fatigue is the result of OSA Not all fatigue is the result of OSA Treatment of OSA doesn’t always result in relief Treatment of OSA doesn’t always result in relief

57. Summary Most Sleep Disorders Present Straightforwardly – Symptoms Of Sleepiness, Fatigue, Sleep Fragmentation – Reports of Bed Partner Obstructive Apnea Can Be More Subtle – Risk Questionnaires Are Helpful – Upper Airway Exam Contributes To Risk Assessment