The Future of Sleep Medicine

1. The Future of Sleep Medicine Barbara Phillips, MD, MSPH, FCCP April 2, 2011

2. Disclosures • Consulting, speaking • Cephalon • Department of Transportation, FMCSA • PriMed funding from ResMed, Respironics • Leadership position • American College of Chest Physicians • National Sleep Foundation • National Board of Respiratory Care

3. Sleep Medicine in the Future • The prevalence and importance of sleep apnea are attracting attention • Training and credentialing have changed • Diagnostic approaches are simplifying and multiplying • Reimbursement will continue to fall. • Treatment approaches are changing • The field is vulnerable

4. Sleep Apnea vs Sleep Disorders • Prevalence of common sleep disorders • Insomnia: 10-30% • Sleep Apnea: 5% • RLS: 10% • Narcolepsy: 0.05% • Diagnoses of patients presenting to sleep centers (Coleman II, 2000) • Sleep apnea: 67.8 • RLS: 4.9% • Narcolepsy 3.2%

5. One Definition of Obstructive Sleep Apnea (OSA) CPAP will be covered for adults with sleep-disordered breathing if: • AHI (or RDI) > 15 OR • AHI (or RDI) > 5 with (“mild, symptomatic”) • Hypertension • Stroke • Sleepiness • Ischemic heart disease • Insomnia • Mood disorders

6. Apnea + Hypopnea Index (AHI), AKARespiratory Disturbance Index (RDI)And Oxygen Desaturation Index (ODI) • AHI = Apneas + Hypopneas Total Sleep Time, in Hours • RDI = AHI, more or less (may include RERA’s) • ODI = Number of 4% desats/hr • SDB = Sleep-Disordered Breathing (What you say when you are not sure what you are including. May include snoring, RERA’s, oxygen desaturation)

7. SHHS’s AHI is really an ODI • All events (apneas and hypopneas) required a 4% oxygen desaturation to be counted because • It was not otherwise possible to achieve acceptable inter-rater reliability based on flow rate or arousals.

8. RERA: Respiratory Effort-related Arousal (Guilleminault, 1993) A sequence of breaths characterized by increasing respiratory effort leading to an arousal from sleep which does not meet criteria for an apnea or hypopnea. These events must fulfill both of the following criteria: • 1. Pattern of progressively more negative esophageal pressure, terminated by a sudden change in pressure to a less negative level and an arousal • 2. The event lasts 10 seconds or longer. UARS (Upper Airway Resistance Syndrome): > 5 RERA’s per hour of sleep

9. What About “Simple Snoring?” • Snoring in pregnancy is associated with increased hypertension and growth retardation, controlling for weight, age, smoking (Franklin, Chest, 2000) • Snoring is associated with cognitive decline (Quesnot, J Am Geriatric Soc, 1999) • Snoring medical students are more likely to fail exams, controlling for BMI, age, sex (Ficker, Sleep, 1999). • Snoring is a risk factor for cardiovascular disease in women. (Hu, J Am Coll Cardiol 2000). • Snoring is a risk for type II diabetes (Al-Delaimy, Am J Epidemiol 2002). • Snoring women have faster progression of CAD (Leineweber C. Sleep 2004)

10. Severity Criteria Based on PSG From the American Academy of Sleep Medicine (Sleep, 1999) • “Mild” sleep apnea is 5-15 events/hr • “Moderate” sleep apnea is 15-30 events/hr • “Severe” sleep apnea is over 30 events/hr • (“Events” includes apneas, hypopneas, and RERA’s)

11. Which Patient Has “Mild” OSA? Patient 1 Patient 2 AHI (events/hr) 40 10 Apnea duration (secs) 10-22 10-90 Lowest Sa02 (%) 90 71 % REM on study 18 0 Arousals/hr 8 80 Cardiac arrhythmias none v tach

12. Disease is a Spectrum…

13. Sleep-Disordered Breathing is a Spectrum

14. Why Sleep Apnea Isn’t Going Away…..

17. SDB with Aging

18. Positive Berlin Scores(Heistand et al, Chest 2006) Percentage at high risk by age category

19. CPAP for OSA: Benefits • Improved cognitive function • Improved quality of life • Reduced daytime sleepiness • Reduced risk of automobile accidents • Reduced health care costs • Reduced blood pressure • Reduced cardiac arrhythmias • Improved glucose tolerance • Reduced mortality rate • Reversal of impotence

20. From JNC7…

21. Marin JLancet2005 Marin J Lancet 2005 N=1751 Controlling for: Smoking ETOH Weight Pre-existing heart disease Age Hypertension Lipid-lowering agents Diabetes

22. SDB and Death in a Population-Based Study (Young T, Sleep 2008) Left: Total sample of1522 SHHS participants and 18 year survival Right: Sample excluding 126 participants who used CPAP

24. Increased Risk of Crash with OSA (FMCSA, 2007)

25. CPAP Treatment Reduces Crash Risk (FMCSA 2007)

26. Sleep Medicine in the Future The prevalence and importance of sleep apnea are attracting attention Training and credentialing have changed Diagnostic approaches are simplifying, and multiplying Reimbursement will fall. A lot. Treatment approaches are changing The field is vulnerable

27. Two Issues for MD’s:Training and Credentialing • Training (Fellowships) • More than 70 ACGME-accredited Sleep Fellowships exist (www.acgme.org) • Credentialing (Board Certification) • Two rounds of ABIM-recognized sleep board examinations have been given (November 2007 and 2009) • There is one more “grandfathering” round in 2011 • Then ACGME fellowship training will be required

28. Who is Eligible?(www.abim.org) • The examination is open to diplomates in internal medicine, pediatrics, neurology, family medicine, psychiatry, or otolaryngology. • CMS is establishing a physician specialty code for Sleep Medicine.

29. Training and Credentialing for Sleep Techs • Currently, there is a chronic shortage of qualified sleep techs. • Sleep tech licensing bills that require a RPSGT or RT credential have proliferated. • Competition and acrimony have escalated between accrediting bodies • The NBRC now offers a Sleep Disorders Specialist tech examination for RT’s (SDS). • AASM has announced a plan for a certifying exam for techs.

32. How is the NBRC examination different than the RPSGT examination? • The Specialty Examination for Respiratory Therapists Performing Sleep Disorders Testing and Therapeutic Intervention is for respiratory therapists already having earned the CRT or RRT credentials. • Content of this specialty examination is focused on sleep focused testing and intervention conducted by respiratory therapists and requires respiratory therapy education for eligibility.

33. Comparison of the SDS and RPSGT Exam

35. What the Future Holds • The NBRC has been accredited by the National Commission of Certifying Agencies (NCCA). • This opens the door to acceptance as a credential for sleep laboratory accreditation through the AASM and the Joint Commission. • The AASM’s entry on the scene will shake things up. • This may help reduce the tech shortage.

36. Sleep Medicine in the Future The prevalence and importance of sleep apnea are attracting attention Training and credentialing have changed Diagnostic approaches are simplifying, and multiplying Reimbursement will continue to fall. Treatment approaches are changing The field is vulnerable

37. How does this sound to YOU? • “You have a life-threatening condition that can cause car crash, hypertension, stroke, cognitive dysfunction and many other consequences. Effective treatment is available. And, after several weeks, a couple of nights in the sleep laboratory, and several thousand dollars, we may be able to get you started on that treatment.”

39. Portable Monitoring (or oximetry) is to in-lab PSG as… • CXR is to CT scan (lung cancer) • Pre-post spirometry is to methacholine challenge (asthma) • Fasting glucose is to oral glucose challenge test (diabetes)

41. Counting up sleepers..? Just how do we do it…? Really quite simple. There’s nothing much to it. We find out how many, we learn the amount By an Audio Telly-o-Tally-o Count. We have a machine in a plexiglass dome Which listens and looks into everyone’s home. Theodore Geisel, 1962

42. Outcomes of Home-Based Diagnosis and Treatment of Obstructive Sleep Apnea Chest 2010; 138: 257-263 • Home testing and autoCPAP resulted in the same results in sleepiness, adherence, blood pressure and QoL as in-lab testing. • “It is really not about the technology; it is about the initial and then chronic care of the patient….” (Dr N Collop, editorial)

44. The Use of Clinical Prediction Formulas in the Evaluation of Obstructive Sleep Apnea (Rowley J, Sleep 2000) Crocker et al, Am Rev Respir Dis 1990 age, BMI, witnessed apneas, hypertension Maislin et al, Sleep 1995 sex, BMI, age, snorting, snoring, witnessed apneas Flemons et al, Am J Respir Crit Care Med, 1994 Neck circumference, hypertension, habitual snoring, choking Viner et al Ann Intern Med 1991 Sex, age, snoring, BMI

45. The Berlin Questionnaire(Netzer et al. Ann Intern Med 1999) N=100 Multicenter trial Berlin questionnaire: queries about snoring, sleepiness, obesity, hypertension Being identified as “high risk” predicted an RDI > 5 sensitivity 86 % specificity 77 % PPV 89 %

46. CPAP as a Therapeutic Trial (Senn O Chest 2006, n= 33) • Autotitrating CPAP, 4-15 cm H20, was used as the therapeutic trial • A successful trial was “yes” to • Are you willing to continue CPAP treatment? • Was objective CPAP use > 2 hours/night? • All underwent PSG; sleep apnea was considered an AHI of > 10 • Excluded were those with CHF, OHS, underlying lung disease, prior CPAP Rx, psych or illness, language problems • Those who were diagnosed with OSA on basis of TT had same outcomes as in-lab diagnosed.

47. A Few More Observations • Most folks wind up on 10 + 2 cm H20 CPAP. • Heavier people need more pressure • Checking the mask may be more cost-effective than repeating the titration • There is no substitute for following the patient clinically!

48. An Outrageous Premise • The CPAP titration is a highly over-rated, overpriced, overused, frequently unsuccessful gimmick whose main function is to keep sleep lab beds full. • Fewer titrations will be done, and this will be mostly for those with CSA.

49. Sleep Medicine in the Future The prevalence and importance of sleep apnea are attracting attention Training and credentialing have changed Diagnostic approaches are simplifying, and multiplying Reimbursement will continue to fall. Treatment approaches are changing The field is vulnerable