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OBSTRUCTIVE SLEEP Lapses in Concentration: big increase if 6 hours - - PDF document

Dec 26, 2023 443 likes •520 views

Chronic Sleep Deprivation (0 v 4 v 6 v 8 hrs) OBSTRUCTIVE SLEEP Lapses in Concentration: big increase if 6 hours (Van Dongen Sleep 2003) APNEA and WORK Treatment Update David Claman, MD Professor of Medicine Director, UCSF Sleep Disorders

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OBSTRUCTIVE SLEEP APNEA and WORK Treatment Update

David Claman, MD Professor of Medicine Director, UCSF Sleep Disorders Center 415-885-7886 Disclosures: None Chronic Sleep Deprivation (0 v 4 v 6 v 8 hrs)

Lapses in Concentration: big increase if ≤ 6 hours

(Van Dongen Sleep 2003)

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DEFINITIONS:

u Apnea: complete cessation of airflow lasting 10 second or

more

u Hypopnea: reduced airflow for 10 seconds or more,

associated with 4% oxygen desaturation

u 3% is AASM recommendation; 4% is Medicare definition

u Apnea-hypopnea Index (AHI): average number of apneas &

hypopneas per hour of sleep

  • AHI < 5 is normal
  • AHI 5-14 - Mild OSA
  • AHI 15-29 - Moderate OSA
  • AHI >= 30 - Severe OSA
  • Wisconsin Sleep Cohort: prevalence of 2% women and 4% in men based on

AHI > 5 and symptoms of daytime sleepiness; NEJM 1993; 328(17):1230-5.

CLINICAL PREDICTORS OF OSA

  • Screening questionnaires
  • Epworth Sleepiness Scale: range 0-24 for 8 questions

– Normal score < 10 – In OSA population, score correlates with AHI

– SLEEP 1991; 14(6):540-5

  • Berlin 10 questions validated in primary care

– Snoring, apnea, fatigue, sleepiness at wheel, Hypertension – Ann Intern Med. 1999 Oct 5;131(7):485-91

  • STOP-BANG used in Anesthesia

– Snoring, Tired, Observed apnea, Pressure (HTN), BMI 35, Age 50, Neck circumference 40 cm (15.75 inches), Gender (male) – Arch Otolaryngol Head Neck Surg. 2010 Oct: 136(10):1020-4

EPWORTH SLEEPINESS SCALE

https://www.slhn.org/docs/pdf/neuro-epworthsleepscale.pdf Score < 10 is normal; 10-15 is situational sleepiness; 15 > excessive

CLINICAL PREDICTORS OF OSA

http://www.stopbang.ca/osa/screening.php

  • STOPBANG – 8 Questions
  • High risk: yes to 5-8 questions; Medium risk

yes on 3-4;Low risk yes on 0-2

  • Snoring
  • Tired (fatigue)
  • Observed Apnea
  • Pressure (Hypertension)
  • BMI >35 ( ≥ 30 is considered obese)
  • Age >50
  • Neck size > 17 inches for men or >16 inches for women
  • Gender male
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COMPARISON OF QUESTIONNAIRES

GE Silva et al. J Clin Sleep Med. 2011; 7(5): 467–472

PREVALENCE OF SLEEP APNEA

u 602 working subjects, age 30-60, studied

by overnight polysomnography

u Obstructive sleep apnea defined as both

AHI > 5 and hypersomnolence

u 9% of women had AHI >5; 22% c/o

hypersomnolence; yields 2% prevalence

u 24% of men had AHI >5; 15% c/o

hypersomnolence; yields 4% prevalence

T Young; NEJM 1993;328:1230-5

Cumulative Percentage of New Fatal (A) & non-Fatal (B) Cardiovascular Events

JM Marin et al. Lancet. 2005 Mar 16;365(9464):1046-53

KEY POINTS:

  • 1. Increased mortality seen if

AHI>30

  • 2. CPAP reduced this risk

CPAP as Secondary Prevention of Cardiovascular Events in OSA

Randomized trial CPAP v usual care; n=2717

  • Age 61; 80% men; AHI 29; BMI 28
  • Pre
  • existing CAD or cerebrovascular disease

Mean f/u 3.7 years; CPAP use 3.3 hrs

  • No change in primary cardiovascular outcomes
  • CPAP did improve quality of life measures
  • McEvoy RD et al. NEJM 2016;375:919

–

  • 931
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CPAP to Prevent Cardiovascular Events

  • McEvoy RD et al. NEJM 2016;375:919-931

OSA TREATMENT

u Weight loss (10% weight loss reduces AHI 25%) u Avoid alcohol for 3+ hour before bed u Postural training (side sleeping since apnea worse on back) u Nasal patency (treat allergies) u CPAP (including autoCPAP; Bi-level less common) u Oral (dental) appliances u ENT surgery:

u Tonsillectomy in kids u UPPP in adults <50% success u Hypoglossal nerve stimulator now FDA approved

u Nasal expiratory resistor (Provent)

u Nasal adhesive micro-valve resistor – delivers approx 5 cm pressure

WHY TREAT SLEEP APNEA?

  • Improve patient’s

daytime alertness (big motivator!)

  • Reduce cardio-

vascular risk

– Still debated

  • Improve partner’s

sleep

MANDIBULAR ADVANCEMENT DEVICES

Advancement of mandible Enlarge airway behind tongue, but may also enlarge airway behind palate

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ORAL APPLIANCE THERAPY: ANTERIOR MANDIBULAR REPOSITIONING

Ferguson;Chest 1996;109:1269-75

WHEN TO USE ORAL APPLIANCES?

  • Mild to moderate OSA (AHI <30)
  • Intolerant of CPAP
  • After failed UPPP
  • Significant overbite
  • Must have teeth!
  • Relative contraindications:

– Severe OSA with severe oxygen desaturation – TMJ symptoms

CPAP – Site Non-specific CPAP: Nasal Mask or Pillows

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LONGTERM USE OF CPAP

Best compliance if AHI >30 & ESS >10

McArdle N et al. AJRCCM 1999;159:1108-1114

SURGICAL THERAPY

(primarily if non-compliant with CPAP)

  • Nasal Surgery
  • Tonsillectomy: if 3-4++, can be 80-90% success

(common approach in kids)

  • Uvulopalatopharyngoplasty (UPPP) reduces AHI by

50% in 40-50% of patients

  • For snoring: laser or radiofrequency
  • Mandibular advancement

– Genioglossus advancement with hyoid – Mandibular-maxillary osteotomy & advancement

  • Hypoglossal Nerve Stimulator
  • Tracheotomy remains gold standard

Question 1

  • Based on sleep deprivation data, when do

shorter sleep hours cause more symptoms?

  • A. ≤ 8 hours
  • B. ≤ 7 hours
  • C. ≤ 6 hours
  • D. ≤ 4 hours

Question 2

  • Which of the following is NOT part of

STOPBANG?

– A. BMI – B. Alcohol – C. Hypertension – D. Observed apnea