Sleep Apnea C Tyler Sleep Apnea Kaiser SF

Sleep Apnea: • C Tyler

Sleep Apnea Kaiser SF Sleep Lab a. k. a. ‘apnea clinic’ Part 4 C Tyler, Sep 2016 Medical Director Kaiser, San Francisco

Alternative Therapies: • CPAP – Gold Standard – Most effective – Titratable (auto) – Verifiable (compliance) – Safe Positional Therapy Weight Loss Smoking Cessation Treat Allergy Treat Acromegaly Treat Hypothyroid Oral Appliance (M. A. D. ) Provent Surgery

Weight Loss

Positional Therapy

Allergy Rx / Stop Smoking

Provent

Surgery: UPPP • • • Irreversible Pain, Death Oro-nasal reflux Voice change 50% “effective” Surgical Literature: – ‘Efficacy’ = 50% reduction in AHI

Genioglossus advancement

Maxillo-mandibular advancement

Oral Appliances • • Mechanical Mandibular Advancement - ‘Jaw Thrust Efficacy - 50% Compliance - ? Better ? Complications - TMJ, discomfort….

Oral Appliance • AASM recommendations: – mild-to-moderate OSA (AHI < 25), – severe OSA who are intolerant or refuse CPAP • Good dentition: no periodontal disease • $1600 vs $800 for CPAP • 50% effective 50% of the time

Hypoglossal Nerve Stimulator • • Recently FDA approved Propofol Endoscopy $40, 000 No long term data

Benefits of Treatment: • Sleep Quality • Quality of wakefulness (and of life) • Cardiovascular risk reduction

OSA as a Cardiovascular Risk Factor • Hypoxia • Adrenergic discharge • Sleep Fragmentation

HTN • ? 70% with essential HTN have OSA • ? 80% with refractory HTN have OSA • ? 50% with HFr. EF or HFp. EF have OSA

Hypertension and OSA

Cardiovascular Events in untreated OSA • 7 year follow up study of healthy middle aged men • Event = new CAD, HTN, MI, Stroke, CV Death

OSA+CHF: Probability of hospitalization or death in 5 years

CSA + SHF: CPAP responders vs non-responders

Cardiovascular Endpoints: • • CONCLUSIONS Therapy with CPAP plus usual care, as compared with usual care alone, did not prevent cardiovascular events in patients with moderate-to-severe obstructive sleep apnea and established cardiovascular disease. • • Average CPAP use < 4 hr per night Inadequate treatment = no benefit

Summary: • OSA causes sleep deprivation • OSA causes oxidative vascular injury • Treatment of OSA – reduces risk of cardiovascular events – reduces motor vehicle accidents • CPAP is the Gold Standard • Alternative treatments exist – for those intolerant of CPAP

Thank you - Chris Tyler

Quiz: • How long do Ducks sleep? • Stanley Kubrick’s work on crime and punishment. • Over geologic and evolutionary time, days are getting (longer: shorter)? • The supra-chiasmatic nucleus responds to (light, melatonin, a $100, 000 drug) • Caffeine antagonizes adenosine (yes/no)

The End

CPAP and Heart Failure • CANPAP trial: no benefit to CPAP in CHF+CSR • f/u paper showed improved outcome IF marked reduction in AHI

Cheyne-Stokes respirations – Crescendo-decrescendo – Arousal at peak hyperpnea – PLM coexists in 85% – 20 -40% of HFr. EF – Hypocapneic (high loop gain) – Resolves in REM sleep (reduced loop gain) – CPAP reduces catechol levels and increases LVEF

Hypoventillation Syndromes • Ondine’s Curse: Central Congenital Hypoventillation • Primary Alveolar Hypoventillation

Central Apnea: • Periodic breathing at altitude • Sleep transition apneas – Any fragmentation of sleep • (insomnia, PLMS, pain, ) • Treatment emergent central apneas – CO 2 falls below apnea threshold – Frequently resolves with time • narcotic-induced central apnea

Future Opportunities: • Linkage to Obesity Efforts – nutritionist, metabolic clinic, etc. • Regional Registry • Population Management Tools • Comprehensive follow-up program – – – Questionnaire Oximetry, Repeat diagnostics Re-titrations Compliance checks New technologies - ie telephonic monitoring

MRI x-section

Cheyne-Stokes Resp • • Periodic Breathing Arterial BP Sympathetic activity (note: C-S resp is not a hypercarbic condition)

Prevalence of OSA/CSA in SHF • Prevalence is higher in men

CHF: Cheyne-Stokes Resp • Modest hypoxemia • Not associated with hypercarbia

Prevelence of CSA in LV dysfunction

CSA and probability of death

Rx of SRBD in Systolic HF • • • Optimize HF Rx O 2 Resp stimulants (CO 2? ? ) CPAP/Bi. PAP adaptive pressure support servoventilation

NC O 2 reduces AHI in SHF

CPAP troubles: air leak

When REM goes Bad Figure: Neuropharmacologic and neurochemical control of cataplexy and excessive daytime sleepiness. Cataplexy, like REM sleep, regulated by balance of adrenergic and cholinergic tone.

• preoptic area (POA) lesions – loss of circadian sleep – Sustained wake state

Encephalitis Lethargica

• Pharmacologic – Amphetamine – blocks DA/NE reuptake – Caffeine – antagonized Adenosine – Modafinil - – blocks DA/NE reuptake

Follow-up and Compliance • • • Annual checks (ideal) If significant weight gain or loss (+/- 10%) Return of symptoms Machine / mask problems Compliance Check: – AHI, hrs of use, average use – Questionnaire: sx, sleep quality, problems

Sleep Latency (MSLT) and sleep deprivation

OSA epi-phenomena • REM rebound • Sleep transition phenomena