Case Sleep Disorders: A Case-based Approach ROS: 30 Lbs wt - - PDF document

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Case Sleep Disorders: A Case-based Approach ROS: 30 Lbs wt - - PDF document

Oct 13, 2022 373 likes •557 views

Case Sleep Disorders: A Case-based Approach ROS: 30 Lbs wt gain/1year Fatigue LeRoy Essig, MD Heart burn Rami Khayat, MD Nasal congestion, dry mouth Reduced concentration/memory Case Case 47 y/o male presents to

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Sleep Disorders: A Case-based Approach

LeRoy Essig, MD Rami Khayat, MD

Case

  • 47 y/o male presents to primary doctor

for annual examination

  • Recently started on citalopram
  • History of hypertension
  • Family history of CAD
  • ROS:

30 Lbs wt gain/1year Fatigue Heart burn Nasal congestion, dry mouth Reduced concentration/memory

Case

  • Social history: School bus driver, 30

p/year

  • Wife complains of husband snoring
  • Meds: Lisinopril, atorvastatin,

hydrochlorothiazide

Case

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Sleep History

  • Struggling to stay awake during

daytime

  • 6 hours of sleep per night with a 1

hour nap in the early afternoon, 2-3 beers/night

  • Watches TV in bed before sleep

Sleep History

  • Awakens 3-4 times at night to use rest

room

  • Persistent loud snoring
  • Leg jerks and kicks, restless sleep
  • Wife “gradually” sleeping in another

room

Physical Examination

  • Exam: Weight 212, BMI 35, BP 147/87
  • Big uvula, nasal passages narrow,

“thick neck”

  • Lungs clear
  • Heart regular, no gallop, clear lungs
  • No peripheral edema
  • Intact sensation and strength in LE’s

What problems did you identify in this patient?

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  • General:

Poorly controlled HTN Cardiovascular risk factors Heartburn

Problems

  • Sleep

Fatigue, depression Snoring, sleepiness Restless sleep/legs Dissatisfied spouse

Problems

Arrange problems in

  • rder of Importance
  • Sleepiness

Professional driver

  • Poorly controlled hypertension
  • Smoking
  • Obesity
  • Depression
  • Restless legs

Problems in Order of Importance

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  • Inadequate sleep time
  • Poor sleep hygiene
  • Obstructive Sleep Apnea
  • Periodic Limb Movement of

Sleep/Restless Leg Syndrome

  • Inadequately treated depression
  • Medication side effects

Differential Diagnosis

Daytime Sleepiness

  • 16% of adults experience excessive

sleepiness that impairs daily functioning (Young, 2004).

  • More than 100,000 automobile accidents

each year are due to drivers falling asleep (National Highway Traffic Safety Administration). 71,000 non-fatal injuries 1500 fatalities 12.5 billion dollars in annual all-cause monetary loss

Daytime Sleepiness

  • Sleep deprivation for 1 day or sleeping 2

hours less/day for a week resulted in the same driving impairment as a blood alcohol level of 0.089 g/dL (Powell, 2001).

  • 2002 NHTSA survey of 4010 adult drivers
  • Of the 11% who admitted to nodding
  • ff while driving in the previous year,

2/3 stated they had ≤ 6 hours of sleep the previous night

Assessment of Sleepiness

The Epworth Sleepiness Scale

SITUATION CHANCE OF DOZING 1-Sitting and reading 2-Watching TV 3-Sitting inactive in a public place (I.e. a theater or a meeting) 4- As a passenger in a car for an hour without break 5- Lying down to rest in the afternoon when circumstances permit 6-Sitting and talking to someone 7-Sitting quietly after lunch without alcohol 8 -In a car, while stopping for a few minutes in traffic

0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing

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What is the most effective next intervention?

  • Evaluate for OSA!

Improved sleep hygiene and expanded sleep alone are unlikely to reduce sleepiness if OSA is untreated OSA is linked to hypertension, cardiovascular disease, periodic limb movement and depression

  • OSA- why should I care?
  • If I have to care, what should

I do about it?

  • Treatment of OSA and CSA in patients

with heart disease is a waste of time !

Obstructive Sleep Apnea

Prevalence of Obstructive Sleep Apnea

The Occurrence of Sleep-Disordered Breathing among Middle-Aged Adults The Wisconsin Sleep Cohort, NEJM 1993

Symptoms of OSA

  • Snoring
  • Excessive daytime sleepiness
  • Witnessed apneas
  • Poor memory and concentration,

irritability or personality changes

  • Other: Dry throat, morning headache,

and nocturia

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Diagnosis

  • History and physical examination
  • Questionnaires
  • Pulse oximetry
  • Portable sleep studies
  • Polysomnography

OSA-Imbalance between Dilating and Constricting Forces of the Upper Airway

  • Dilating forces:

pharyngeal muscle tone Lung volumes

  • Constricting forces:

Negative inspiratory pressure Extra luminal fat

Effects of Sleep

  • n the Upper Airway
  • Loss of tone in genioglossus, palatal,

and pharyngeal constrictor muscles

  • Supine position and reduced lung

volumes

Physical Examination in OSA

  • Neck circumference

> 17 inches in males > 16 inches in females

  • Craniofacial anatomy

Inferiorly positioned hyoid bone Mandibular insufficiency Increased mid-facial height

  • Nasal obstruction
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LOC ROC Chin EMG C3-A2 O2-A1 EKG Nasal flow Chest Abdomen SaO2

Sleep Study- Polysomnography

Case: Results of the Sleep Study

  • Sleep Efficiency: 68%
  • Wakefulness and arousal index: 37/hour
  • Respiratory disturbance index: 42/hour
  • Periodic Limb Movement Index: 32/hour

Why should this patient be treated urgently?

  • Professional driver with sleepiness
  • Poorly controlled hypertension
  • Cardiovascular risk
  • Depression
  • Quality of Life

Prospective Data From Wisconsin Sleep Cohort Study (N=913)

(Young et al, Sleep 20:608, 1997) Any MVA in 5 years (n=165) Increased Relative Risk Men Women No SDB Reference category = 1.0 Snorer, RDI <5 3.4* 0.9 RDI 5-15 4.2* 0.8 RDI >15 3.4* 0.6 *Significant increase compared to reference category INCREASED RISK OF CRASHES EVEN WITH MILD OSA

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Relationship Between Severity pf Sleep Apnea and Crash Risk (N=460, OSA)

(George et al, Sleep 22:790, 1999)

p<0.01

Only increased risk RDI >40

0.02 0.04 0.06 0.08 0.1 0.12 0.14 Control RDI 10-25 RDI 26-40 RDI >40 Crash Rate (Number/Year)

Does Sleep Apnea Increase Crash Rates?

Answer Yes

  • Different data about relationship between

crash risk and severity of illness

  • Severe sleep apnea is a risk factor for ↑

crashes

  • Is mild-to-moderate sleep apnea a risk

factor for ↑ crashes—Not clear

  • Does treatment reduce crash risk? Yes

Derivation of Patient Population Used in Study of CPAP and Crashes

(George, Thorax 56:508, 2001)

Confirmed OSA (n=740) Driving records available (n=582) CPAP treatment (n=317) Clinic follow-up for >3 years (n=210)

Peppard, P. E. et al. Arch Intern Med 2006;166:1709-1715.

Association of OSA and Depression

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The Cardiovascular Consequences of Sleep Apnea

Components of the Cardiovascular Response to Apnea

  • Hypoxia
  • Increased sympathetic activity
  • Blood pressure surge
  • Increased respiratory effort
  • Arousal

Increased Sympathetic Nerve Activity in OSA

(Somers et al J Clin Invest 1995; 96:1897-1904)

Increased Incidence of Coronary Artery Disease in OSA

Pecker et al Eur Resir J 2006

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OSA Can Kill Patients with Coronary Disease

Pecker et al. AJRCC 2005

Respiratory Disturbance Index: an independent predictor of mortality in coronary artery disease

OSA And Hypertension

  • 40% of patients with OSA have

hypertension

  • 50% of patients with hypertension

have OSA

  • OSA patients were more likely to be

nocturnal “non-dippers”

  • Treatment of OSA reduces blood

pressure

0.5 1 1.5 2 2.5 <1.5 (Ref) 1.5-4.9 5-14.9 15-29.9 >30 RDI (episodes/hour) Odds Ratio (OR)

OR adjusted for age, sex, ethnicity OR adjusted for age, sex ethnicity, and BMI

Association of Hypertension and Sleep-Disordered Breathing -- Sleep Heart Health Study

n=6440 p=0.0001 for linear trend

Nieto et al, JAMA 283:1829, 2000

0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 0 (Ref) 0.1-4.9 5.0-14.9 >15 Baseline AHI Odds Ratio (OR) for Hypertension at Follow-up

OR adjusted for baseline hypertension status OR for above + age, gender, BMI, etc.

Association Between Sleep Apnea and Incident Hypertension During 4 Year Follow Up Period

Hypertension = BP of at least 140/90 or use

  • f anti-hypertensive

medications

Peppard et al, NEJM 342:1378-1384, 2000

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11 Association of OSA and Type II Diabetes Reichmuth et al AJRCCM 2005 Association of OSA and Type II Diabetes Reichmuth et al AJRCCM 2005

4 year odd ratio of physician diagnosed DM over 4 year of follow up

Obstructive Sleep Apnea and Stroke

Young et al AJRCC 2005

Obstructive Sleep Apnea and Outcome of Stroke

Mohsenin NEJM 2005

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OSA Can Cause Heart Failure

E Shahar, et al, AJRCCM, 2001

0.5 1 1.5 2 2.5 3 3.5 4 4.5 5 I II III IV AHI Interquartile range OR CHF

n=6,424

Higher Prevalence of Predicted OSA in Patients Presenting with AF Compared to General Cardiology Patients

(Gami et al, Circ 110:364, 2004)

Association Between Severe OSA (AHI >30) and Arrhythmias in Sleep Heart Health Study

(Mehra et al, AJRCCM, doi:10.1164/rccm.200509-1442OC)

4.02 (1.03-15.74) 3.85 (1.00-14.93) 5.66 (1.56-20.52) Atrial fibrillation 1.74 (1.11-2.74) 1.81 (1.16-2.84) 1.96 (1.28-3.00) Complex ventricular ectopy 3.40 (1.03-11.2) 3.72 (1.13-12.2) 4.64 (1.48-14.57) Non-sustained ventricular tachycardia Odds Ratio* (95% CI) Adjusted for Age, Sex, BMI, CHD Odds Ratio* (95% CI) Adjusted for Age, Sex, BMI Unadjusted Odds Ratio Arrhythmia Type

BMI=body mass index; CHD=coronary heart disease *Results of logistic regression analysis with SDB as the exposure; N=338 without SDB, N=228 with SDB

Sudden Cardiac Death in OSA

N Engl J Med 2005;352:1206-14.

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OSA Increases Fatal and Non-fatal Cardiovascular Events (Marin et al, Lancet 365:1046, 2005)

OSA is a Cardiovascular Risk Factor

Heart Failure Arrhythmia Hypertension Atherosclerosis

OSA

Pulmonary vasoconstriction Worsening RV function

OSA

Sympathetic activity Hypoxemia Negative intrathoracic pressure Oxidative injury Endothelial dysfunction Afterload SVR RV afterload Atherosclerosis Ischemic heart disease HTN Arrhythmias Diastolic dysfunction Systolic transmural pressure LV afterload Venous return RV overload Impaired LV filling Heart failure Sudden death Stroke LV Hypertrophy LV remodeling Platelet activation

Undiagnosed OSA Kills Patients with Cardiovascular Disease

  • OSA causes sudden death
  • OSA worsens atrial fibrillation
  • OSA worsens Hypertension control
  • OSA promotes stroke
  • OSA worsens outcome of stroke
  • OSA promotes arrhythmia
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OSA is a Cardiovascular Risk Factor

  • OSA is a cardiovascular risk

factor just like high cholesterol and diabetes Certain cardiovascular risk factors are modifiable

OSA is a Cardiovascular Risk Factor

Early identification and treatment of cardiovascular risk factors is the current focus of care Treatment of co-existent OSA in patients with established cardiovascular disease is critical

Case-Continued

  • Patient is started on CPAP, returns

after 6 weeks with:

Complete resolution of snoring Remains restless in sleep Sleepiness is only partially improved Dry mouth in the morning

Why didn’t the treatment of OSA completely reverse sleepiness

  • Is the patient adequately for OSA?

Is the patient using CPAP long enough? Is the mask appropriately fitted? Is there mask leak?

  • Are there other correctable causes of

sleepiness?

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CPAP Limitations

  • Interface
  • Mask issues, claustrophobia
  • Mouth leaks
  • Skin abrasion
  • Pressure-related
  • Intolerance of pressure, flow
  • Rhinitis, sinusitis, headaches

CPAP Limitations

  • Equipment related
  • Noise, smell, condensation
  • Dryness, inadequate humidification
  • Changes in optimal pressure within

night/over time

  • Weight gain
  • Nasal congestion
  • Positional
  • Sleep stage

Assessment of Adequate treatment of OSA

  • Hours of use per night: >4-5 hours
  • Total Sleep time: 7-10 hours
  • Mask fitting (noise, dry eyes, aerophagia)
  • Number of awakening per night

Differential Diagnosis

  • Inadequate sleep time
  • Poor sleep hygiene
  • Obstructive Sleep Apnea
  • Periodic Limb Movement of Sleep/Restless

Leg Syndrome

  • Inadequately treated depression
  • Medication side effects
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Sleep Hygiene Interventions

  • Increase sleep time
  • Avoid Alcohol too close before

bedtime

  • Avoid TV in bed
  • Exercise 4-5 hours before bedtime

Case-Continued

  • Interventions:

Sleep Expansion Sleep hygiene Change Citalopram

Conclusions

  • Excessive Sleepiness is present in

>16% of adults

  • OSA is present in 5-15% middle age

adults

  • OSA increases risk of vehicle

accidents

  • OSA is a cardiovascular risk factor