Dainis Irbe 2

III ESTONIAN SLEEP MEDICINE CONFERENCE: 

III ESTONIAN SLEEP MEDICINE CONFERENCE What is new in sleep medicine 2007? DAINIS IRBE, MD Medical director, Pacific Northwest Sleep Association, USA

Coping with Shiftwork: 

Coping with Shiftwork

Sleep Strategies: 

Sleep Strategies Managing your work time Use naps to improve alertness Create a good sleep environment Establish a regular pre-sleep routine Establish a regular bedtime and wake-up schedule Manage your caffeine intake Other advice: Avoid alcohol Take regular exercise Manage your diet

Managing Your Work Time: 

Managing Your Work Time There are different tips for managing fatigue depending on your shift pattern and the type of shift you have just finished. Example: managing night shifts Go to bed as soon as you get home Have an afternoon nap Avoid exposure to daylight Eat 3 regular meal with “lunch” during your night shift

Creating a good sleep environment: 

Creating a good sleep environment Quiet Dark Warm/cool Comfortable bed that you associate with sleep Fresh air Free from interruptions

Pre-sleep routine: 

Pre-sleep routine You can learn that it is time to relax and go to sleep Establish a pre-sleep routine to provide specific cues: Reading Listening to music Getting dressed for bed Only get into bed when your tired

Napping – Not to be used whilst at work: 

Napping – Not to be used whilst at work Limit naps to about 30 – 45 minutes including the time it takes to fall asleep Naps of 15 – 20 min are most restorative Give yourself time to get over sleep inertia There is no minimum time period for effective napping Improved alertness may last for several hours

Caffeine: 

Caffeine It is a stimulant so it can keep you awake but it can also disrupt sleep Use caffeine in moderation and when it is most needed Avoid it for several hours before sleep Don’t quit “cold turkey”, cut back gradually How much caffeine is okay?

Accidents at Switch to Daylight Savings Time: 

Accidents at Switch to Daylight Savings Time Cohen 1996

Accidents in Fall at Switch to Standard Time: 

Accidents in Fall at Switch to Standard Time Cohen 1996

Slide12: 

Distribution of Age of Driver In Fall-Asleep Crashes (Pack et al, Accid Anal Prev 27:769, 1995) No. of accidents Age 16 25 35 45 55 65 75 85

Slide13: 

Time of Occurrence of Fall-asleep Crashes In Individuals Age 16-25 Years

Slide14: 

Time of Occurrence of Fall-asleep Crashes In Individuals Over 65 Years

Why Do People Have Drowsy Driving Crashes?: 

Why Do People Have Drowsy Driving Crashes? *p<0.05 **p<0.01 * ** ** Hours Awake Before Crash (Compared to Non-Sleep Crash Group)

Why Do People Have Drowsy Driving Crashes?: 

Why Do People Have Drowsy Driving Crashes? *p<0.05 **p<0.01 * ** ** Hours of Sleep Preceding Crash

Slide17: 

Is Crash Risk Related To Severity of Apnea? Conflicting data

Slide18: 

Relationship Between Severity pf Sleep Apnea and Crash Risk (N=460, OSA) (George et al, Sleep 22:790, 1999) p<0.01 Only increased risk RDI >40

Slide19: 

Data On CPAP and  Crashes Study Finding Issue Kreiger et al  crashes Self-report, Chest 112:1561, 1997 recall bias Horstmann et al  crashes Self-report, Sleep 23:383, 2000 recall bias Findley et al  crashes DMV records of AJRCCM 161:857, 2000 crashes

Slide20: 

Most Definitive Study - Crash Rates Before and After CPAP and In Controls (George, Thorax 56:508, 2001) OSA Patients Controls

Recommendations for Evaluation of OSA in Commercial Drivers(Hartenbaum et al, Chest 130:902, 2006): 

Recommendations for Evaluation of OSA in Commercial Drivers (Hartenbaum et al, Chest 130:902, 2006) IN SERVICE EVALUATION for OSA recommended if one of the following (3 month maximum certification) Sleep history suggestive of OSA Two or more of the following: BMI >35 kg/m2 Neck circumference >17 inches in males and >16 inches in females Hypertension (new, uncontrolled) Epworth Sleepiness Score >10 and <16 Diagnosed OSA but no compliance data

Recommendations for Evaluation of OSA in Commercial Drivers(Hartenbaum et al, Chest 130:902, 2006): 

Recommendations for Evaluation of OSA in Commercial Drivers (Hartenbaum et al, Chest 130:902, 2006) OUT OF SERVICE EVALUATION – immediate if driver meets one of the following: Observed unexplained excessive sleepiness, e.g., in waiting room Confessed excessive sleepiness Crash (run off road, at fault, rear end) likely related to falling asleep Epworth Sleepiness Score ≥16 Previous diagnosis of OSA – not compliant with CPAP Apnea-hypopnea index >30 on previous study

Recommendations for Commercial Drivers (Treated with CPAP)(Hartenbaum et al, Chest 130:902, 2006): 

Recommendations for Commercial Drivers (Treated with CPAP) (Hartenbaum et al, Chest 130:902, 2006) AHI <5 episodes/hour on therapy Minimally acceptable use is average of 4 hours of CPAP/24 hours Reassessed at a minimum of 2 weeks, but within 4 weeks of starting therapy, compliance checked (see full article for other recommendations)

Slide24: 

Department of Motor Vehicles (As of 1995) Sleep Apnea and Narcolepsy (2 states) California and Texas Narcolepsy Alone (4 states) Maryland, North Carolina, Oregon, Utah Sleep Apnea (proposed; 1 state) Maine Way out of date – have things changed? KNOW THE REGULATIONS IN YOUR STATE

A More Recent Task Force Report From Europe(McNicholas et al, Eur Respir J 20:1594, 2002): 

A More Recent Task Force Report From Europe (McNicholas et al, Eur Respir J 20:1594, 2002) Shows wide variability in approaches in European countries Advocates education of policy makers for drivers licenses Regulations should be shared responsibility of physician, patient and licensing authority Advocates more strict regulations for commercial drivers “Imperative that practical and realistic guidelines be implemented” Does not, however, propose any guidelines

What About Use of Performance Tests in Commercial Drivers?: 

What About Use of Performance Tests in Commercial Drivers? Maintenance of Wakefulness Test (MWT) seems to be used in practice No data that MWT is predictive of crash risk No normative data for MWT in general population No basis to assess result of MWT NOT RECOMMENDED IN RECENT GUIDELINES (NO EVIDENCE)

Across Country Viewpoints on Sleepiness During Driving(George et al [includes L. Findley], Am J Respir Crit Care Med165:746-749, 2002) : 

Across Country Viewpoints on Sleepiness During Driving (George et al [includes L. Findley], Am J Respir Crit Care Med 165:746-749, 2002) Case: Mr. Z—OSA (AHI=54 episodes/hour) Intermittent CPAP use (3-4 nights/week; nights used = 3.8 hours) Salesman – drives 20,000-40,000 miles No fall-asleep crashes Drowsy driving – pulls over to nap

Across Country Viewpoints on Sleepiness During Driving(George et al, Am J Respir Crit Care Med 165:746-749, 2002): 

Across Country Viewpoints on Sleepiness During Driving (George et al, Am J Respir Crit Care Med 165:746-749, 2002) Canadian Viewpoint (C. George) Patient education Discussion of warnings, e.g, fall-asleep at red lights No test predictive of crash risk Notifies state – tells patient that he is doing so Mr. Z has OSA Mr. Z is under treatment If Mr. Z is compliant with CPAP therapy, not at risk Shifts burden to patient

Across Country Viewpoints on Sleepiness During Driving(George et al, Am J Respir Crit Care Med 165:746-749, 2002): 

Across Country Viewpoints on Sleepiness During Driving (George et al, Am J Respir Crit Care Med 165:746-749, 2002) United States (L. Findley) Provides written statement – shifts burden to patient. You have been diagnosed with sleep apnea, a condition which may adversely affect your driving. People with sleep apnea often have a three to four increased rate of motor vehicle crashes or other accidents. These accidents may cause serious injury or death to you or others. If you have had an accident or frequent near accidents due to sleepiness or inattention, you should stop driving or operating dangerous machinery until your sleep disorder has been treated and you are no longer sleepy or inattentive while driving. It is your responsibility not to drive if you are inattentive while driving. If you drive or fly professionally, you must report your sleep disorder to the doctor who certifies you fit for this profession.

Across Country Viewpoints on Sleepiness During Driving(George et al, Am J Respir Crit Care Med 165:746-749, 2002): 

Across Country Viewpoints on Sleepiness During Driving (George et al, Am J Respir Crit Care Med 165:746-749, 2002) United States (L. Findley) Does not report to state In Colorado, no protection from litigation for disclosing private medical information Legal advice – not to report without patients written permission

Across Country Viewpoints on Sleepiness During Driving(George et al, Am J Respir Crit Care Med 165:746-749, 2002): 

Across Country Viewpoints on Sleepiness During Driving (George et al, Am J Respir Crit Care Med 165:746-749, 2002) United Kingdom (Hack) Informs Mr. Z of risks related to driving Informs Mr. Z if he has crash – police can access medical records Does battery of performance tests Accepts no validity Reassurance, if normal If remains excessively sleepy/non-compliant Informs patient Reports to motor vehicle authorities Breach of confidentiality protected in UK – if protects others from potential harm

Across Country Viewpoints on Sleepiness During Driving(George et al, Am J Respir Crit Care Med 165:746-749, 2002): 

Across Country Viewpoints on Sleepiness During Driving (George et al, Am J Respir Crit Care Med 165:746-749, 2002) Australian Viewpoint (McEvoy) Informing patient of risk Better risk assessment ?Near-miss/?crashes ?Falls asleep at red lights If higher risk  limit driving If no, inform patient he should report himself to state If no, seek consent to report If no, report (All states in Australia, except Tasmania, protect physician in this case)

Key Aspects: 

Key Aspects Key is informing patient of risks and documenting this Better risk assessment Know your state laws Engage council for general advice about what to do in your state If you plan to report somebody to state, discuss with lawyer (i.e., hospital lawyer) in advance

Obstructive Sleep Apnea (OSA): 

Hypertension Sleepiness Insulin resistance Atherosclerosis ? Increased risk for: Genes 1 Genes 2 Genes 3 Genes 4 CAN WE DETERMINE WHO IS MOST LIKELY TO DEVELOP THESE CONSEQUENCES BY KNOWING GENOTYPE? AREA OF INTEREST FOR US OSA Obstructive Sleep Apnea (OSA)

Many Sleep DisordersHave a Genetic Component: 

Many Sleep Disorders Have a Genetic Component Obstructive sleep apnea Restless legs syndrome Parasomnias Narcolepsy (remarkable recent discoveries) Insomnia Circadian rhythm disorders Determining genes conferring risk for sleep disorders is a major opportunity for our field No shortage of opportunity

Studies in Iceland Offer Another Unique Approach: 

Studies in Iceland Offer Another Unique Approach Being used for both obstructive sleep apnea (Pack, Gislason, Stefansson) and restless legs syndrome (Rye, Stefansson) Why Iceland?

Restless Legs Syndrome: 

Restless Legs Syndrome "Familial" cases have earlier age of onset compared to sporadic Segregation analysis (Winkelmann et al, Ann Neurol 52:297, 2002) separated families based on age of onset of disease Group A (n=75 pedigrees) – mean age of onset 30 years Model suggested: major gene, autosomal dominant Group B (n=163 pedigrees) – mean age of onset >30 years Model: no evidence of genetic component Genetic RLS – early age of onset

Restless Legs Syndrome in Monozygotic Twins – Age of Onset(Ondo WG, et al, Neurol 55:1404, 2000): 

Restless Legs Syndrome in Monozygotic Twins – Age of Onset (Ondo WG, et al, Neurol 55:1404, 2000) n/a n/a

Restless Legs Syndrome: 

Restless Legs Syndrome Several regions of the genome are linked to restless legs syndrome No gene yet determined Anticipate discovery of genes conferring risk for restless legs syndrome in the near future

Genes and Narcolepsy: 

Genes and Narcolepsy Canine narcolepsy (autosomal recessive) related to mutation in orexin 2 receptor (Lin et al, Cell 98:365, 1999) Orexin knockout mice have narcolepsy phenotype (Chemelli et al, Cell 98:437, 1999)

Genes and Narcolepsy: 

Genes and Narcolepsy Patients with narcolepsy with cataplexy are more likely to be orexin-deficient (CSF) (Ripley et al, Neurology 57:2253, 2001) No association between polymorphisms of orexin receptors or orexin and narcolepsy (Olafsdottir et al, Neurol 57:1896, 2001; Hungs et al, Neurol 57:1893, 2001) Only single case of early onset narcolepsy with mutation in orexin described (Peyron et al, Nat Med 6:991, 2000)

Genes and Narcolepsy: 

Genes and Narcolepsy Strong association with HLA DQBI*0602 (Figure from Chabas et al, Ann Rev Genomics Hum Genet 4:459, 2003)

Potential Implications of Association with HLA DQBI*0602: 

Potential Implications of Association with HLA DQBI*0602 Narcolepsy is an autoimmune disease HLA type confers susceptibility to unknown environmental challenge (even with HLA type – low prevalence of narcolepsy) There are other susceptibility genes that interact with HLA gene to produce disorder (even with HLA type – low prevalence of narcolepsy)

Slide45: 

4 minute screenshot of patient with abnormal pulse oximetry. Patient is actually having very frequent central apneas and very fragmented sleep pattern.

Central Sleep Apnea and CHF: 

Central Sleep Apnea and CHF

Cheyne-Stokes Breathing: 

Cheyne-Stokes Breathing Unstable ventilatory control seen in the setting of CHF

CSB / Pathophysiology: 

CSB / Pathophysiology Episodic hypoxia Arousals Periodic breathing Oscillations in BP and HR ↑ Sympathetic nervous system activity

PSG: 

PSG CPAP 8-9 cm 4.3-3.6 hours daily use

Cardiac Function: 

Cardiac Function

Comments: 

Comments CSB not fully controlled with CPAP May need a better treatment Improved medical therapy may have lessened effect of CPAP CPAP may have a detrimental effect in some patients Not enough patients enrolled

Adapt Servo Ventilation: 

Adapt Servo Ventilation Variable bi-level device Base pressure 9/5 Adjusts IPAP to supplement ventilation when < 90% of average ventilation Initiates breath if no effort Airflow VPAP Adapt SV (ASV on) RESMED

Adapt Servo Ventilation: 

Adapt Servo Ventilation 25 patients with stable CHF-CSR randomized to ASV or CPAP Evaluated AHI, Compliance, QOL at 3 and 6 months, LVEF at 6 months Phillippe C. Heart. 2006 Mar;92(3):337-42

Adapt Servo Ventilation: 

Adapt Servo Ventilation Phillippe C. Heart Online June 2005.

Summary: 

Summary CSA /CHF and cardiovascular disease CSA is associated with increased mortality Studies with CPAP have shown improvement in CSA, cardiac function, and sympathetic activity ASV is a promising new therapy for CSA/CHF