Snoring Is No Laughing Matter

1. Snoring Is No Laughing Matter A Primary Care Perspective On Obstructive Sleep Apnea Andrew Okas, D.O.

2. Case Presentation • CC: Wife made me come!! • HPI: A 32 y.o. stubborn male doctor presents to his PCP for the first time in 15 years because his wife (a doctor) threatens to suture his mouth shut because of earth shaking snoring. • Past Medical/Snoring History: • Gets Kicked Out of Medical School Library for snoring and slobering on text books. • In Residency, He Fell Asleep daily on Neurology rotation (while standing) • Residents ban him from ICU call rooms because of sonic boom snoring. The Diagnosis= A FREAK OF NATURE

3. I Am A Snorer

4. Is Snoring Destroying Your Children?

5. Is Snoring Destroying Your Marriage? "Stop snoring week aims to restore happy sex lives" (Telegraph.co.uk) "It's snore fun when you have to sleep all alone" (Scotsman) "SEX IS A REAL SNORE POINT" (Glasgow Daily Record) "Snoring can be the cause of divorce" (Pravda, Russia) "World ; Snoring ruins your sex life!:" (Keralanext, India) "You snore? Don't score?" (Sydney Morning Herald, Australia)

6. Is Snoring Destroying The World? OSA is also associated with a variety of disasters, such as Three Mile Island and Chernobyl. (Research Review, February 2006)

7. Reverend Reggie White (43yo) most likely had a condition (Sarcoidosis and Obstructive Sleep Apnea) resulting in "fatal cardiac arrhythmia," said Dr. Mike Sullivan, the medical examiner for Mecklenburg County and a forensic pathologist "It's scary as hell when it happens to you," Tosti said. OSA caused him to doze off sometimes in the middle of a conversation, at work and, on two occasions, in the car. "We had three of our grandchildren in the back seat. They were singing and the radio was blasting and he went off the road," said his wife, Irene. Is Snoring Destroying Lives?

8. Is Snoring Going To Destroy You? Sleep apnea affects more than twelve million Americans, according to the National Institutes of Health The vast majority of these Americans with sleep apnea have not been diagnosed.

9. Overview of Sleep Disorders100 million AmericansOver 84 Disorders American Academy of Sleep Medicine

10. Obstructive Sleep Apnea syndrome is daytime sleepiness in conjunction with 5 or more episodes of apnea or hypopnea per hour of sleep. Definition • 24% of men and 9% of women (30-60 years of age) have excessive snoring (an apnea/hypopnea index > 5) without daytime hypersomnolence. (Flemons, NEJM 2002). • In Sleep 2003 Punjabi discovered that 20%-25% of the general population screened with Epworth sleepiness scale had excessive daytime hypersomnolence. • According to these criteria, 4% of men and 2% of women who are 30-60 years of age have OSA. (Flemons, NEJM 2002).

12. The Consequences of Sleep Apnea

13. Ischemic Events • CVA: A large observational cohort study published in November 2005 in the New England Journal of Medicine reported that obstructive sleep apnea greatly increases the risk of stroke by a factor of 2-3, regardless of whether a person has high blood pressure. • Coronary Artery Disease - A 2-3 times increased risk of heart attack in patients with OSA. There is speculation that OSA may be one factor in the higher frequency of heart attacks in the early morning hours.

14. Sudden Cardiac Death • Gami, et al, NEJM,March 2005 Observed that people with OSA have a peak in sudden death from cardiac causes during sleeping hours which is significantly higher than the normal population. Severe OSA patients had a 40% higher relative risk.

15. Driving • The Wisconsin Sleep Cohort Study reported that: • Drivers with Mild OSA were 3 times as likely to be involved in a car accident as those without OSA, • Drivers with Moderately Severe OSA were 7 times as likely to be involved in a car accident as those without OSA.

16. When Is Snoring More Than Just A Snore Point? • You are High Risk for OSA if you have 2 of the 4 following criteria. • 1. Snoring • 2. Anyone who has daytime hypersomnolence or fall asleep while driving (night or day) • 3. Obesity • 4. Hypertension (78-95% sensitivity, Flemons, et al. Sleep Medicine Review 1997)

17. THE EPWORTH SLEEPINESS SCALE (Johns, Sleep 1991)1 = Slight chance of dozing2 = Moderate chance of dozing3 = High chance of dozing 1. Sitting and reading     0 1 2 3 2. Watching TV     0 1 2 3 3. Sitting inactive in a public place (e.g. a theater or a meeting)     0 1 2 3 4. As a passenger in a car for an hour without a break     0 1 2 3 5. Lying down to rest in the afternoon     0 1 2 3 6. Sitting quietly after a lunch without alcohol 0 1 2 3 7. Sitting and talking to someone     0 1 2 3 8. In a car, while stopped for a few minutes in the traffic     0 1 2 3

18. Epworth Sleepiness Scores by Diagnosis • Controls 6.0 ± 2.5 • OSA 11.7 ± 4.6 • Narcolepsy 17.5 ± 3.5 • Insomnia 2.2 ± 2.0 • In OSA, ESS > 16 was only seen in patients with moderate to severe disease.

19. Approach to a Patient with Suspected Sleep Apnea Adjusted Neck Circumference: actual neck size plus • 3cm for snoring • 3cm for choking /gasping, • 4cm for HTN • If score is over 48 then high probability (over 20 times as probable). Respiratory Disturbance Index Apnea/Hypopnea Index Flemons, W. W. N Engl J Med 2002;347:498-504

20. The article "Association of Sleep-Disordered Breathing, Sleep Apnea, and Hypertension in a Large Community-Based Study" published in the Journal of the American Medical Association in April 2000 is the largest published population-based study to provide the breakdown of subjects’ apnea-hypopnea index (AHI) by body-mass index (BMI). According to Nieto et al, the majority of subjects with an AHI ³ 5 are not obese. THE MAJORITY OF OSA PATIENTS ARE NOT OBESE

21. Patient With Suspected Sleep Apnea The Future • A large HMO in Puget Sound, Washington is already using home sleep monitoring as the principal method for diagnosing OSA. • A Continuous Positive Airway Pressure Trial as a Novel Approach to the Diagnosis of the Obstructive Sleep Apnea Syndrome* Oliver Senn, MD University Hospital of Zurich, Switzerland. Chest 2006 suggests empiric trial of cpap for moderate to high risk patients for 2 weeks before doing any sleep studies

22. Polysomnography (Gold Standard) (Over 16 Channels) • 2 - 6 channels of EEG (Electroencephalogram - electrical activity in the brain) which allow the person interpreting the test to determine how the stages of sleep change during the night • 2 channels of EOG (Electrooculogram - movement of the eye) which are used to distinguish so-called REM (Rapid eye movement) sleep from Non-REM sleep • Chin EMG (Electromyography - electrical activity of the chin muscle) which is an indicator of arousal and activation of the upper airway muscles, • Airflow from the nose and mouth • Respiratory effort which is measured with elastic belts around the chest and the abdomen • Body position • 1 channel of ECG (Electrocardiogram) • Oximetry (Recording of the oxygen saturation of the blood) • 2 channels of leg EMG (the electrodes are usually applied to the shins) to record limb movements during sleep. Madison waiting period is 1-2 months. Canadian waiting period is 8 months

23. A 4-channel home sleep study is covered by Unity and Physicians Plus $750. • Madison waiting period less than 1 week

24. 6 Channel Home Sleep Monitor • Single leg activity (Channel 1). • Body position (Channel 2), • Snoring (Channel 3), • Airflow from the nose and mouth (Channel 4), • Chest/Abdomen movement (Channel 5) • Oxygen saturation (Channel 8) • Heart rate (Channel 7)

25. Treatment

26. CONSERVATIVE TREATMENT • Do not drink alcoholic beverages in the evening as this disturbs sleep. • Avoid cafeinated beverages after noontime, as caffeine disturbs sleep. Limit total caffeine consumption to no more than two beverages per day. • Do not smoke just before bedtime or during the night as this disturbs sleep. • Exercise regularly during the day, but avoid exercise in the evening within 3 hours of bedtime. • Maintain a comfortable temperature in the bedroom. • If you're overweight, lose weight. Being overweight is the most common cause of snoring. Flabby throat tissues are more likely to vibrate as you breathe. • Sleep on your side. Lying on your back allows your tongue to fall backward into your throat, narrowing your airway and partially obstructing airflow. To prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top. • Treat nasal congestion or obstruction. Adhesive strips applied to your nose widen nasal passages and may help reduce congestion or obstruction. • Limit or avoid alcohol and sedatives. Sedatives and hypnotics (sleeping pills) and alcohol depress your central nervous system,

28. Dental Devices • Indication: Mild/Moderate OSA • Disadvantage: 1. Cost: Over $700 2. Side effects: Obstruct Breathing, Slober 3. Low compliance

29. Dental Appliances

30. Surgery • Uvulopalatopharyngoplasty (UPPP). Your tonsils and adenoids usually are removed as well. This is the most common type of surgery to treat sleep apnea. • Laser-assisted uvulopalatoplasty (LAUP). this procedure involves the use of a laser to remove part of your soft palate and shorten uvula. • Radiofrequency ablation (RFA). In this office procedure, radiofrequency energy to remove tissue from your uvula, and soft palate. • Both LAUP and RFA Are Not recommended for moderate to severe obstructive sleep apnea.

31. Some studies say that compliance is less than 4 hours per night. Continuous positive airway pressure (CPAP)

32. Atrial Overdrive Pacemakers • NEJM 2002 Atrial overdrive (15 beats above baseline) pacemakers improved both OSA and central sleep apnea

33. The Future • Researchers at the University of Pennsylvania are studying whether serotonin can help English bulldogs, whose facial structure causes them to snore and suffer apnea. • Lab tests show serotonin seems to help keep the bulldogs' throats open during sleep.

34. The Family That Snores Together Slobers Together

36. Upper Airway Resistance Syndrome (UARS) • A "typical" patient with UARS is a slender woman in her 20's - 30's with a small jaw and a high, arched palate. • Some experts also believe that there is a group of patients, mostly female, who are not loud snorers, who do not show evidence of OSA on sleepmonitoring, and yet suffer the symptoms of OSA. In these patients, there is partial airway collapse without detectable change in airflow that results in repeated awakenings during sleep. • The occurrence of these partial airway collapses can be documented by putting a catheter into the esophagus to measure pressure changes in the chest during breathing. These patients show marked changes in pressure during inspiration that are similar to those seen in patients with OSA.

37. SLEEP EVALUATION • 1) Do you sometimes experience a creeping feeling in your legs?     Yes No • 2) Do you or have you ever been told that you kick your legs at night?     Yes No • 3) Do you snore?     Yes No I don't know • If "yes" please continue with #4If "no" or "I don’t know" please continue with #8 • 4) Your snoring is...     softer than talking     as loud as talking     louder than talking • 5) Your snoring occurs...     every/almost every night     a few times each week     once a week or less • 6) Your snoring is also...     frequently interrupted by pauses/choking     occasionally interrupted by pauses/choking     not interrupted as far as you know • 7) Do you snore in every body position?     Yes No I don't know • 8) Do you have, or ever had a bed partner?     Yes No

38. The MSLT measures how easily a person can fall asleep when given the chance across the day. • The MSLT is the gold standard, but this one day test is not an accurate view of daily life. M. W. Johns in The Journal of Sleep Research 2000 showed that the ESS is a more discriminating test of sleepiness in daily life than either the MSLT or the MWT in patients with Narcolepsy.

40. If "yes" please continue with #9If "no" please continue with #12 • 9) Has your bed partner ever said that you have pauses in your breathing or periods of stopped breathing during your sleep?     Yes No • 10) Has your bed partner ever commented that you snore?     Yes, loud snoring Yes, soft snoring No • 11) If you snore, is it loud enough to bother her/him?     Yes No • 12) Has anyone besides a bed partner ever commented on your snoring (roommate, neighbor, family, etc.)?     Yes, loud snoring Yes, soft snoring No • 13) Do you feel fatigued or exhausted or tired or not up to par?     nearly every day     3 to 4 times a week     once or twice a week     once or twice a month     never or hardly ever • 14) Do you feel that in some way your sleep is not refreshing or restful?     nearly every day     3 to 4 times a week     once or twice a week     once or twice a month     never or hardly ever • 15) Do you have periods of the day when you have trouble paying attention, remembering things or staying awake?     nearly every day     3 to 4 times a week     once or twice a week     once or twice a month     never or hardly ever • 16) Do you have high blood pressure?     Yes No • If "yes" are you being treated for high blood pressure?    Yes No • 17) Do you wake up during the night or in the morning with headaches?     Yes No • 18) Are you a shift worker?     Yes No • 19) Do you have trouble initiating and/or maintaining sleep?     nearly every day     3 to 4 times a week     once or twice a week     once or twice a month     never or hardly ever • 20) What do you feel is your ideal amount of sleep per day?     2-4 5 6 7 8 9 10 • 21) Estimate the average number of hours of sleep you had per day during the last week.     2-4 5 6 7 8 9 10

41. A number of studies have shown that The number of transient arousal periods and the severity of hypoxia correlate with the severity of hypersomnolence. (Newman et al., Journal of Epidemiology 2001)

42. OSA may be more common in certain ethnic groups such as Black Americans, and Hispanics. It is our impression that the prevalence will be quite high in Sikhs, in certain South Asian populations, and in Coastal Indians.

44. Sleep is usually in a Biphasic circadian pattern with the maximal sleepiness occurring between 2AM and 6AM and from 2 PM and 4PM.

49. In Sleep 2002 Drake and Roehrs discovered that the prevalence of excessive daytime sleepiness in the general population was 13 to 25% if a Multiple Sleep Latency Test (gold standard was used)

50. A Continuous Positive Airway Pressure Trial as a Novel Approach to the Diagnosis of the Obstructive Sleep Apnea Syndrome* • Oliver Senn, MD University Hospital of Zurich, Switzerland. Chest 2006 • Abstract • Objectives: Treatment of obstructive sleep apnea syndrome (OSA) is often delayed because polysomnography, the recommended standard diagnostic test, is not readily available. We evaluated whether the diagnosis of sleep apnea could be inferred from the response to a treatment trial with nasal continuous positive airway pressure (CPAP). • Patients: Seventy-six sleepy snorers consecutively referred for sleep apnea evaluation. • Interventions: CPAP treatment trial over 2 weeks as an initial diagnostic test in comparison with polysomnography, and treatment success over 4 months. • Measurements and results: The main outcome was diagnostic accuracy of the CPAP trial. The trial result was positive if the patient had used CPAP for > 2 h per night and wished to continue therapy. This suggested sleep apnea. The trial was evaluated in terms of predicting an obstructive apnea/hypopnea index (AHI) > 10/h during polysomnography performed for validation, and in terms of identifying sleep apnea patients treated successfully over 4 months. Forty-four of 76 patients (58%) had sleep apnea as confirmed by an AHI > 10/h. The CPAP trial predicted sleep apnea with a sensitivity of 80%, a specificity of 97%, and positive and negative predictive values of 97% and 78%, respectively. In 35 of 76 sleep apnea patients (46%) with positive CPAP trial results, polysomnography could have been avoided. These patients were prescribed long-term CPAP therapy. After 4 months, 33 of 35 patients (94%) still used CPAP, and their symptoms remained improved. These patients were identified by the CPAP trial with positive and negative predictive values of 92% and 100%, respectively. • Conclusions: In a selected population, a CPAP trial may help to diagnose OSA, to identify patients who benefit from CPAP, and to reduce the need for polysomnography.