Clinical Pearls in Sleep Medicine

1. Clinical Pearls in Sleep Medicine Tareq m. Abu-Salah, M.D. Pulmonary, Critical Care & Sleep Medicine

2. Objectives • Overnight Oximetry • How to read a sleep report • Compliance Report • Sleep Disorders Clinic • Atrial Fibrillation and OSA

3. Oximetry patterns

4. Question • 55 year old male nuclear medicine physician comes for evaluation of excessive daytime sleepiness during the day for the last 2 years. He sleeps 7-8 hours every night. He has no other symptoms and has no known medical problems. He has never smoked and does not drink alcohol. His physical examination is significant for a BMI 36.6. He undergoes an overnight oximetry over 6 hours and 40 minutes.

6. Your best next step in management is: • 1. Start oxygen 2L/minute at bedtime and refer to pulmonary for further evaluation • 2. Counsel the patient to lose weight and follow up in 3 months with a repeat oximetry. • 3. Repeat another oximetry on room air during the first half of the night and on oxygen 1-2 L/minute in the second half of the night. • 4. A decision can not be made based on the data available.

7. Your next step in management is: • 1. Start oxygen 2L/minute at bedtime and refer to pulmonary for further evaluation • 2. Counsel the patient to lose weight and follow up in 3 months with a repeat oximetry. • 3. Repeat another oximetry on room air for the first half of the night and on oxygen 1-2 L/minute on the second half. • 4. A decision can not be made based on the data available.

9. Oxygen desaturation Index • ODI= 290/ 6 .67 = 43.5 ( ? AHI ) • On room air, oxygen, breathing device. • Alcohol, sleeping pills, benzodiazepine…etc. • Compare with the patient’s sleep diary.

12. Case 2 • 42 year old IT Helpdesk technician comes for evaluation of excessive daytime sleepiness. He has borderline hypertension and diabetes and is on metformin 500 mg twice a day and Maxzide 37.5-25 mg daily. He denies any other symptoms. His physical exam is significant for a neck circumference of 50 cm, a BMI 47.3 and a BP 146/98. His PCP orders an overnight oximetry.

15. Case 3 • You are called to see a 60 year old male patient from Bosnia who does not speak English and has OSA. He does not have a copy of his sleep study. The interpreter is not available for 2 days. The patient has his CPAP machine with him but the primary team is concerned that his CPAP pressure is inadequate because he was admitted with altered mental status.

16. What is the best next step in management? • 1. Order a split night study with diagnostic polysomnography in the first half of the night and a CPAP titration the second half of the night. • 2. Order a blood gas on room air • 3. Order a nocturnal oximetry on room air • 4. Order an oximetry while the patient is using his CPAP machine.

17. What is your next step? • 1. Order split night study with diagnostic polysomnography in the first half of the night and a CPAP titration the second half of the night. • 2. Order a blood gas on room air • 3. Order a nocturnal oximetry on room air • 4. Order an oximetry while the patient is using his CPAP machine.

20. Compliance Reports

25. CPAP masks

26. Sleep Clinic • Trouble shooting for lack of compliance • Risks of untreated OSA • Other sleep disorders • Overnight oximetry • Parasomnias

27. Trouble shooting • Still sleepy • Compliance • Can’t have anything on my face ( mask, humidity, desensitization) • Can’t breath ( sinus , Ramp, EPR) • Leak ( mask ) • Wakes up and my mask is not on ( humidity) • When I wake up, putting it back is a hassle • Desensitization ( in sleep lab and before sleep) • Hose • Cleaning mask, humidifier and hose • Medicare rules • Failure of CPAP therapy and other options

28. Compliance CPAP

30. The Problem • 2 million people are affected AF, prevalence & mortality increasing • OSA is more prevalent in AF • Bitter studied 150 patients with AF and found a higher prevalence of OSA • Gami studied 151 consecutive patients with AF about to undergo cardioversion and 312 patients with no history of AF ( OSA was present in 49% in patients with AF compared with 32% in those without AF). • Braga found OSA in 81.6% in patients with AF compared with 60% in those without • Individuals with OSA 4X risk for AF compared with those without OSA (Sleep Heart Study)

31. Pathophysiology • Normal Sleep  decreased HR, CO, PVR, BP and symp output. • OSA hypoxia, hypercapnia, increased symp output and excitation of chemoreceptors, PVR, HR, BP. • OSA inspiration against collapsed pharynx left vent transmural P. that results in increasing afterload LVHatrial remodellingarrythmia • Hypoxia and Hypercapnia can cause directly arrythmia ( Hypoxia  IC Ca) • Sympathetic system activation decreases atrial cycle length • OSA arterial stiffness increased left atrial diameter Increased risk for AF

32. OSA as a RF for Initial AF Onset • A retrospective Cohort study of 3543 patients with current AF or a history of AF showed that OSA, age, gender, HTN and smoking were predictors for AF in patients younger than 65 whereas CHF was the only predictor after the age of 65. • All patients of the study were referred to the sleep clinic and so it may not represent the general population Gami et al. Obstructive sleep apnea, obesity, and the risk of incident atria fibrillation. J Am Coll Cardiol. 2007;49:565–581.

33. Patients with OSA have a 25% greater risk of AF recurrence after catheter ablation than those without OSA. • Subgroup analysis showed that OSA diagnosed using polysomnography is a strong predictor of AF recurrence but not when OSA was diagnosed using the Berlin questionnaire • Conclusion: Patients with OSA have significantly greater AF recurrence rates after pulmonary vein isolation. Am J Cardiol 2011;108:47–51

34. 61 patients ( mean age 62) treated with AAD for symptomatic AF underwent overnight polysomnography. • 24 patients had severe OSA. • Nonresponders were more likely to have severe OSA than milder disease • Patients with severe OSA were less likely to respond to AAD

35. Conclusions: • Despite a high prevalence of SDB in this population with AF, most patients do not report EDS. • EDS does not appear to correlate with severity of SDB or to accurately predict the presence of SDB. • Further research is needed to determine whether EDS affects the natural history of AF or modifies the response to SDB treatment.

36. Questions ?