Portable Polysomnography and Positive Airway Pressure Titration Home Sleep Home?

1. Portable Polysomnography and Positive Airway Pressure Titration Home Sleep Home? Lee Dresser, M.D. Medical Director St. Francis Hospital Sleep Center

3. Mental fatigue, poor decision-making, impaired learning, increased seizures and migraines occur when we are sleep deprived. • Why does normal brain function deteriorate with prolonged waking and require (Good) sleep to be restored?

4. Recent study showed waste products of brain metabolism are removed from brain of mice during sleep. • Sleep therefore maybe required to clear potentially toxic metabolites from the brain. This may lead to feeling of refreshment.

5. Sleep Drives Metabolite Clearance from the Adult Brain Lulu Xie1,*Maiken Nedergaard1,† SCIENCE; October 2013 Theconservation of sleep across all animal species suggests that sleep serves a vital function. We here report that sleep has a critical function in ensuring metabolic homeostasis. Using real-time assessments of tetramethylammonium diffusion and two-photon imaging in live mice, we show that natural sleep or anesthesia are associated with a 60% increase in the interstitial space, resulting in a striking increase in convective exchange of cerebrospinal fluid with interstitial fluid. In turn, convective fluxes of interstitial fluid increased the rate of β-amyloid clearance during sleep. Thus, the restorative function of sleep may be a consequence of the enhanced removal of potentially neurotoxic waste products that accumulate in the awake central nervous system.

6. SLEEP 2008;31(8):1071-1078.

7. Up to 17% Adults in US may Have Some Form Sleep Disordered Breathing (SDB) Up to 6% Have Moderate to Severe Apnea

8. Up to 75% of SDB Patients are Undiagnosed

9. Many Studies Link SDB to: • Hypertension • Heart Disease • Stroke • Depression • Motor Vehicle Accidents • Cognitive Impairment • Decreased Quality of Life

10. Daytime Impairment Due to OSA May Decrease Motivation to Maintain Healthy Lifestyle and Diminish Compliance with Therapy for Comorbid Conditions

11. Sleep Disordered Breathing Obstructive Sleep Apnea defined as reduction of airflow by 90% or more for at least 10 seconds. Obstructive Hypopnea defined as either decrease in airflow by at least 50% with reduction of oxygen saturation by 3% or Decrease in airflow with reduction of oxygen saturation by 4%

12. Mild SDB: AHI > 5 < 15 Moderate SDB: AHI > 15 < 30 Severe SDB: AHI > 30

15. Severe Sleep Disordered Breathing Was Associated with Increased Mortality, Even in Non-sleepy Patients

16. Association of SDB with Death Much Stronger After Excluding Patients Using CPAP Thus, CPAP Appears to Prevent Death in Patients With Severe SDB

17. Conclusion: Good Quality Sleep is Good For the Body, Brain and Long Life

18. Reasons for Home Sleep Studies: • Decrease Wait Time • Patient Unable, Unwilling to go to Lab • $$ More Attractive to patients with High Deductibles and to Insurance Companies

19. CMS Payments for PSGs 2001: $62 Million 2011: $565 Million

20. PSGHST • Medicare: $598 $186 • Highmark: $1306 $226 • BC/BS

21. Centers for Medicare and Medicaid (CMS)Guidelines for Home Sleep TestsWill pay for Types I, II, III and IV Studies* Note CMS Type I-IV studies are different from AASM Type I-IV studies

22. Type I Studies • Attended • EEG • EOG • Heart Rate • Chin EMG • Limb EMG • Respiratory Effort at Thorax and Abdomen • Air Flow • Pulse Oximetry

23. Type II • Unattended with minimum 7 Channels • Must Include: • EEG • EOG • Heart rate • EMG • Airflow • Respiratory Effort • Oxygen Saturation

24. Type III • Unattended with minimum 4 Channels • Must Include: • 2 Respiratory/Flow • Heart rate • Oxygen Saturation

25. Type IV Unattended with minimum 3 Channels Must include channels that allow direct calculation of AHI or RDI through measurement of Thoracoabdominal Movement of Airflow CMS will also allow studies done with PAT (Peripheral Arterial Tone) device

26. Most HST Devices Rely Upon • 3 Signals to Diagnose OSA • Nasal/Oral Airflow • Respiratory Effort • Oximetry

27. Other Channels Commonly Added: Pulse, Position, TST

31. Important That Patient Be Well Educated How to Use HST Device • Must be Able to Review Raw Data • Must Be Interpreted by Well Trained Sleep Specialist in Context Comprehensive Sleep Evaluation

32. Home Sleep Test • Advantages: • Patient can sleep at home • Good for immobile, reluctant patients • Financially attractive to patients and insurers

33. Home Sleep Test • Disadvantages: • May Underestimate OSA Severity • 3-18% Failure rate. Artifact • Not suitable for central apnea, significant CHF or COPD, morbid obesity • Miss PLMs, RBD, Seizures

34. What is Evidence Regarding Home Sleep Studies?

35. Noninferiority of Functional Outcome in Ambulatory Management of Sleep Apnea Samuel T. Kuna, et al. Am J. Respir. Crit. Care Med.; 183, 1238-1244, 2011 • Compared HST and Auto-PAP to In Lab PSG and CPAP Titration • Randomized, Controlled Trial 296 Patients • VA Study, 95% Male • 15% Failure Auto-PAP • Compared Productivity, Vigilance, Activity Level, Intimacy and Sexual Relationships, Compliance with CPAP between Two Groups

36. Noninferiority of Functional Outcome in Ambulatory Management of Sleep Apnea Samuel T. Kuna, et al. Am J. Respir. Crit. Care Med.; 183, 1238-1244, 2011 • RESULTS: • Functional Outcomes Improved Equally in Both Groups • CPAP Compliance the same in Both Groups at 3 Months

37. SLEEP 2012;35(6):757-767

38. Selected patients with moderate to severe OSA • Used “Adjusted Neck Circumference” >/= 43 cm • To Neck Circumference Add: • Habitual Snoring: 3 cm • HTN: 4 cm • Witnessed Apnea, Gasping Most Nights: 3 cm • To Be Included in Study Needed Adjusted Neck Circumference >/= 43 cm AND ESS >/= 12

39. Used Embletta HST. Measured Airflow, Chest and Abdominal Movements, Pulsox, ECG and Body Position • Adjusted Neck Circumference Gave 50% Pretest Probability of AHI > 15

40. HST and Auto-PAP were Equivalent to In Lab Studies In: • Tolerance of CPAP • Time to Beginning Therapy • Reduction in Hypersomnolence • Adherence at 3 Months Better in HST Patients

41. 23/74 Patients with Home AHI < 15 Had In Lab AHI > 15 • Despite Rigorous Education, Acclimatization, Ongoing Support only 30% Lab and 40% Home Groups were Compliant with CPAP at One Month According to Medicare Guidelines

43. Physician Credentials for Interpretation HST • and Ordering PAP Devices • Board Certified By ABSM or Member of • American Board of Medical Specialties; or • Completed Sleep Fellowship; or • Active Staff Member AASM or Joint Commission Accredited Sleep Center

44. Automatic Titrating CPAP Most Studies Excluded Patients with CHF, COPD and Central Apnea Designed to Increase Pressure to Maintain Airway Patency and Decrease Pressure if No Events Detected in Certain Period of Time

46. Automatic Titrating CPAP • Auto-PAP Devices Measure • Different Variables: • Snoring • Apnea, Hypopnea • Airflow Limitation • Or Combination

47. Automatic Titrating CPAP • Advantages: • Increase Patient Compliance by Increasing • Pressure only as Needed, i.e. in REM and when Supine • Adjust if patient gains/loses weight

48. Automatic Titrating CPAP Can Keep Patient on APAP or Determine P90 or P95 and Set CPAP at That Pressure

49. Automatic Titrating CPAP • Many Studies Show Reduction of • AHI < 5 with Auto-PAP • One Review of 30 Studies on Auto-PAP • Showed No Clear Increase Acceptance • or Compliance with Auto-PAP vs CPAP

50. Conclusions • HSTs are Accurate at Diagnosing OSA, • Especially if Patients Well Screened to • Have Moderate to Severe Disease • Certain Patient Populations Require • In Lab Studies (Demented Patients, Morbidly Obese, With Severe Coexistent Medical Problems, Suspect PLMs or RBD