Cardiac Rehab with OSA PP pres

Sleep, Sleep Disorders and What to Do About It…: 

Sleep, Sleep Disorders and What to Do About It… Sadie Olson, RPSGT Upland Hills Health Sleep Disorders Center

Overview:: 

Overview: Normal sleep and breathing NPSG’s –Nocturnal Polysomnograms Common sleep disorders seen at UHH SDC Sleep Disordered Breathing Risks, Signs and Treatments Determining who is at risk. 2

Normal Sleep: 

Normal Sleep So what is it? 3

Typical Adult: 

Typical Adult 7-8 hours of sleep Sleep cycle: Light sleep (N1 and N2), deep sleep or SWS (delta N3) and REM sleep. Lasts 70-90 minutes. 4-5 cycles is the norm Beginning of night, normal adult’s deep sleep periods are longer and get shorter where REM sleep periods start shorter and get longer. 4

Polysomnography : 

5 Polysomnography EOG - Electrooculogram EEG - Electroencephalogram EMG - Electromyogram EKG - Electrocardiogram Tracheal noise Nasal and oral airflow Thoracic and abdominal respiratory effort Pulse oximetry

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6 C3 O1 Electroencephalography in the Overnight Sleep Study G1 G2 Paper or computer screen A2 Differential Amplifier C3-A2 O1-A2 G1 G2

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7 Left and Right Electrooculogram LOC ROC Eye Blinks Electrooculography picks up the inherent voltage of the eye. The cornea has a positive voltage output, while the retina has a negative polarity. Sleep Academic Award 7

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8 Differential Amplifier G1 G2 Combination of two dissimilar metals Voltage changes are seen with exhalation and inhalation Thermocouple- Oronasal airflow

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9 Differential Amplifier Differential Amplifier Differential Amplifier Tracheal Sound Respiratory Effort Leg movement

Overnight PSG: 

10 Overnight PSG You expect me to sleep with this?????

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11 EEG EOG Chin EMG Snore Mic EKG Leg EMG SpO2 Airflow Respiratory Effort Chest Abdomen C2 F2 O2 30 second view/epoch

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Common Sleep Disorders:: 

Common Sleep Disorders: Sleep Disordered Breathing (SDB) Obstructive Sleep Apnea Syndrome (OSAS) Sleep Hypopnea Syndrome (SHS) Central Sleep Apnea Syndrome (CSA) Complex Sleep Apnea Syndrome ( CompSA ) Obesity Hypoventilation Disorder AKA Pickwickian Syndrome 16

Others:: 

Others: Restless Leg Syndrome (RLS) Periodic Limb Movement Disorder (PLMD) REM Behavior Disorder (RBD) Narcolepsy 17

Slide 18: 

“ My wife sent me here !”

Mechanism of OSAS/SDB: 

19 Mechanism of OSAS/SDB The upper airway dilating muscles,like all striated muscles-normally relax during sleep. In OSAS/SDB, the dilating muscles can no longer successfully oppose negative pressure in the airway during inspiration. Apneas and hypopneas are caused by the airway being sucked and closed on inspiration during sleep.

Anatomy of OSA/SDB: 

20 NORMAL SNORING SLEEP APNEA Anatomy of OSA/SDB

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23 Two minute view

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24 One Minute View

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Pickwickian Syndrome : 

26 Pickwickian Syndrome Obstructive sleep apnea was called the Pickwickian syndrome in the past because Joe the Fat Boy who was described by Charles Dickens in the Pickwick papers had typical features with snoring, obesity, sleepiness and “dropsy”.

Pickwickian Syndrome Today : 

27 Pickwickian Syndrome Today Classified today as:

Symptoms of SDB: 

28 Symptoms of SDB Daytime Early morning headaches Fatigue Daytime sleepiness Poor memory, concentration or motivation Unproductive at work Falling asleep during driving Depression GERD

Symptoms of SDB: 

29 Symptoms of SDB Night time Snoring Witnessed apnea Frequent nocturnal awakenings Waking up choking or gasping for air Unrefreshed sleep Restless sleep nocturia Dry mouth decreased libido

Predisposing Factors of SDB: 

30 Predisposing Factors of SDB male gender prior to females reaching menopause age obesity (defined by a high body mass index) Increased waist/hip ratio (apple bodies) smoking Shortening of the mandible and/or maxilla (the change can be subtle and familial) Hypothyroidism & acromegaly by narrowing the upper airway with tissue infiltration Myotonic dystrophy, Ehlers- Danlos

The Problem: 

31 The Problem Obstructive Sleep Apnea Syndrome (OSAS )/SDB is one of the most important conditions identified in the last 50 years. OSAS/SDB is characterized by recurrent episodes of complete or partial upper airway obstruction during sleep, along with daytime sleepiness

Prevalence of OSAS/SDB: 

32 Prevalence of OSAS/SDB In USA, prevalence of OSAS/SDB among middle-aged men and women (30-60 y/o) were 4 %-10% and 2 %-5% (Young et al ) One study reports that among people who are 65 to 95 years old, 70% of the men and 56% of the women had periods of stopped breathing or reduced airflow to the lungs 10 or more times per hour.

Apnea-Hypopnea Index: 

33 Apnea-Hypopnea Index Apnoea-hypopnoea index (AHI)= number of apneas/ hypopneas per hour of sleep (each event lasts 10 sec or longer during sleep) AHI<5 Normal AHI 5-15 Mild OSA AHI 15-30 Moderate OSA AHI >30 Severe OSA

SDB and DM: 

34 SDB and DM Patients from the sleep clinic with AHI>10 are much more likely to have impaired glucose tolerance and diabetes (Meslier et al Eur Respir J 2003)

SDB & Cardiovascular Diseases: 

35 SDB & Cardiovascular Diseases Uncontrolled HTN- 70-83 % have OSA/SDB Acute coronary syndrome- 40-50% has OSA/SDB Cardiac arrhythmias mostly AF – 40% have OSA/SDB Heart Failure Sudden cardiac death Stroke

SDB and CAD: 

SDB and CAD SDB causes increases in b/p, decrease in O2 and there is ample reason to believe that it could adversely affect left ventricular function in those with an already failing heart. People with coronary artery disease whose blood oxygen is lowered by sleep disordered breathing may be at risk of ventricular arrhythmias and nocturnal sudden death. CPAP treatment may reduce this risk. Sleep disordered breathing may cause coronary artery disease and hypertension. Additional research is needed to determine if treatment of the sleep disordered breathing can prevent these impacts but it is known to control and improve the condition. 36

Which Came First?? CAD or SDB?: 

Which Came First?? CAD or SDB? Bear in mind the important point that just because there is an association between the prevalence of two conditions that does not mean that one causes the other. There are other factors that may be causing both! There are still several studies trying to determine if SDB is the cause, risk factor or merely a marker for CAD. 37

CPAP Treatment Benefits: 

CPAP Treatment Benefits 38 Hypertension alone can be controlled with CPAP use in some studies. CPAP-treated patients showed a 9% improvement in left-ventricular ejection fraction and reduced daytime systolic blood pressure and heart rate compared with control patients who demonstrated no changes. It is reasonable to assume (though it is not proven) that treatment with continuous positive airway pressure (CPAP) would minimize the episodes of hypoxia and therefore the potential for ischemia. In that case routine use of CPAP should largely abolish the danger of ventricular arrhythmias and nocturnal sudden death.

Incidence of coronary artery disease, hypertension and other vascular disease in patients with SDB : 

Incidence of coronary artery disease, hypertension and other vascular disease in patients with SDB It again seems quite clear that patients with SDB are more likely to develop any of the above disorders. There is evidence that other factors predispose to SDB, but there nevertheless is adequate evidence to suggest that SDB may be an independent predictor of the development of vascular disease even in when these confounding factors are excluded. What all patients with SDB should be advised is to ensure that all other risk factors are avoided (smoking, obesity, hypertension, hyperlipidemia, diabetes etc) so that the chances of developing coronary disease are minimized. 39

The triangle of good health!: 

The triangle of good health! 40 Nutrition Activity Sleep

Preach good sleep…: 

Preach good sleep… Sleep hygiene… Bedtime routine, bedroom is for sleeping and intimacy – it is not our office, tv room, etc. Quantity 7.5-8.5 hours is the average that we should be shooting for Quality (do they need a sleep study?) 41

Quality… Do you need a sleep study?: 

Quality… Do you need a sleep study? Do you sleep well through the night or do you toss and turn, have frequent awakenings, experience nocturia? Do you feel refreshed upon awakening? Are you tired during the day? Do you snore or have witnessed apneas? 42

Tools to Use…: 

Tools to Use… After further investigating a person’s sleep, it may be appropriate to have him or her fill out a Berlin Questionnaire and the Epworth Sleepiness Scale. If any are positive – consider referring for a sleep study to r/o SDB. 43

Berlin and Epworth: 

Berlin and Epworth Berlin: Follow Scoring Categories Rules Epworth: 9 or above is abnormal. Keep in mind if these are negative or within normal limits, this does not dismiss the fact that he/she may still have SDB. I.e. – low Epworth, but pt uses caffeine and or nicotine to mask sleepiness. 44

Diagnosis: 

45 Diagnosis A good sleep history Assessment of obesity, oral cavity Assessment of possible predisposing causes and comorbidities : HTN, hypothyroidism , heart disease, diabetes, depression, stroke. Polysomnography : gold standard tool

Sleep History: “BEARS”: 

46 Sleep History: “BEARS” B edtime (address sleep hygiene) E xcessive daytime sleepiness A wakenings: night wakings early morning waking R egularity and duration of sleep S noring

Current Treatment for OSA: 

APB 16/03/09 Current Treatment for OSA NON - SURGICAL Wt loss CPAP Positional Tx Oral appliances Drugs SURGICAL Tracheostomy UPPP Glossectomy Hyoid advancement Mandibular advancement

Weight Loss: 

48 Weight Loss Peppard PE et al. JAMA 2000; 284: 3015-21 10% weight loss predicted a 26% reduction in AHI

Body Position: 

49 Body Position Raise HOB Avoid supine position Strategies- Tennis ball in pajamas Backpacks

CPAP Therapy: 

50 CPAP Therapy Works as a pneumatic Splint 1 st choice of treatment in moderate to severe OSAHS Success rate 95-100% Long term compliance 60-70% Retitrate pressure if needed

CPAP Therapy- Side Effects: 

51 CPAP Therapy- Side Effects Nasal congestion Rhinorrhoea Oronasal dryness Skin abrasions/ rash Conjunctivitis from air leak Chest discomfort Claustrophobia

Be a part of the team!!: 

Be a part of the team!! Get help from your sleep center to start a screening and referral process for all rehab patients. Follow up with the patient to make sure they are “on board” with the plan. Actually doing the sleep study and treatment if necessary. Work with his/her doctor to assure CPAP compliance is at it’s best. 52

Conclusion: 

53 Conclusion With the increasing problem of heart disease along with predisposing factors, the impact of undetected OSAS/SDB as a public health burden cannot be undermined among our population. It merits appropriate preventive and treatment strategies.

Links and Credits…: 

Links and Credits… http://www.healthyresources.com/sleep/apnea/contrib/heart.html Berlin questionnaire developed by several doctors at a sleep conference in Berlin, Germany. Epworth Sleepiness Scale developed and introduced by a doctor at the Epworth Hospital in Australia. 54