Sleep Apnea for Physician Assistants 2025 PDF

Physician Assistant Program SLEEP APNEA Angela Desautels MD, FRCPC January 30th, 2025 OBJECTIVES: OBSTRUCTIVE SLEEP APNEA: 1. Describe the pathophysiology and etiology of obstructive sleep apnea 2. Describe who should be screened for obstructive sleep apn...

Physician Assistant Program SLEEP APNEA Angela Desautels MD, FRCPC January 30th, 2025 OBJECTIVES: OBSTRUCTIVE SLEEP APNEA: 1. Describe the pathophysiology and etiology of obstructive sleep apnea 2. Describe who should be screened for obstructive sleep apnea 3. Describe the common symptoms of obstructive sleep apnea 3. Describe how obstructive sleep apnea is diagnosed 4. Describe the management options for obstructive sleep apnea OTHER SLEEP DISORDERED BREATHING: 1. Identify patients with characteristics of obesity hypoventilation syndrome or central sleep apnea needing sleep medicine assessment EXAM QUESTIONS:  Submitted exam questions will be exclusively from the PowerPoint presentation CASE: 54 year old male commercial truck driver presenting to hospital following a single vehicle accident after falling asleep while driving. You suspect obstructive sleep apnea. What symptoms should you ask about on patient history? What physical exam findings are you assessing for? OBSTRUCTIVE SLEEP APNEA: Definition: “Repetitive episodes of upper airway obstruction that occur during sleep and that are typically associated with oxyhemoglobin desaturations” - American Academy of Sleep Medicine OBSTRUCTIVE SLEEP APNEA PATHOPHYSIOLOGY: Recurrent, functional collapse during sleep of the velopharyngeal and/or oropharyngeal airway, causing substantially reduced or complete cessation of airflow despite ongoing breathing efforts. This leads to intermittent disturbances in gas exchange (e.g. hypercapnia and hypoxemia) and fragmented sleep. ETIOLOGY: Upper airway narrowing due to:  Obesity / increased peripharyngeal fat deposition (see next slide)** MOST COMMON  Retrognathia or micrognathia  Adenotonsillar hypertrophy (especially in children)  Upper airway muscle weakness due to neuromuscular disorders, primary CNS disorders or metabolic disorders Paul GR. Sleep apnea. In: Ferri FF, editor. Ferri’s Clinical Advisor: Elsevier; 2019. COMPLICATIONS OF OSA: 1. Drowsy driving and MVAs 2. Neuropsychiatric dysfunction (inattention, memory, cognitive deficits, moodiness and irritability as well as depression, psychosis, and sexual dysfunction) 3. HTN 4. Coronary artery disease 5. Cardiac arrhythmias 6. Heart failure 7. Stroke 8. Pulmonary Hypertension / Right heart failure 9. Metabolic Syndrome 10. Type 2 diabetes 11. Nonalcoholic fatty liver disease  SCREENING FOR SLEEP APNEA: Epstein LJ, Kristo D, Strollo PJ, Jr., Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med.  WHICH HIGH RISK PEOPLE SHOULD UNDERGO COMPREHENSIVE SLEEP HISTORY AND EXAM? Epstein LJ, Kristo D, Strollo PJ, Jr., Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med.  SYMPTOMS OF OBSTRUCTIVE SLEEP APNEA: Epstein LJ, Kristo D, Strollo PJ, Jr., Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. Mason RJ et al: Murray and Nadel’s textbook of respiratory medicine, ed 5, Philadelphia, 2010, WB PHYSICAL EXAM FINDINGS SUGGESTIVE OF OBSTRUCTIVE SLEEP APNEA 1. Increased neck circumference 6. High arched/narrow hard palate (>17 inches in men and >16 7. Macroglossia inches in women) 8. Tonsillar hypertrophy 2. BMI ≥ 30 kg/m 2 9. Elongated or enlarged uvula 3. Modified Mallampati score of 3 or 4 10. Nasal abnormalities (polyps, deviation, turbinate hypertrophy) 4. Retrognathia 11. Overjet 5. Lateral peritonsillar narrowing Class 1 – Visible parts are soft palate, fauces, tonsillar pillars and uvula Class 2 – Visible parts are soft palate, fauces, and uvula Class 3 – Only soft palate and base of uvula Class 4 – Only hard palate visible Schellenberg, J & Maislin, Greg & J Schwab, R. (2000). Physical findings and the risk for Obstructive sleep apnoea: The importance of oro pharyngeal structures. American journal of respiratory and critical care medicine. 162. 740-8. High arched palate Schellenberg, J & Maislin, Greg & J Schwab, R. (2000). Physical findings and the risk for Obstructive sleep apnoea: The importance of oro pharyngeal structures. American journal of respiratory and  Table 3 Table 2 Table 4 and physical exam Adapted from: Epstein LJ, Kristo D, Strollo PJ, Jr., Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J CASE: Your patient complains of nocturnal awakenings, loud snoring, and excessive daytime sleepiness (ESS 16/24) He has a past medical history of HTN (requiring three agents to control) What is your next step? DIAGNOSIS OF OBSTRUCTIVE SLEEP APNEA: Gold Standard: Nocturnal polysomnography (level 1 sleep study) Monitors sleep stage (EEG and EOG), EMG, ECG (modified lead 2), oxygen saturation, airflow and respiratory effort Events: Apnea: Cessation of breathing lasting 10 seconds or longer. Obstructive: continued respiratory effort Hypopnea: Nasal pressure signal excursions (marker of airflow) drop ≥50% of baseline for at least 10 seconds AND a ≥3% desaturation from pre-event baseline OR the event is associated with an arousal. DIAGNOSIS OF OBSTRUCTIVE SLEEP APNEA: Alternative: Home sleep study (level 3 sleep study) Monitors oxygen saturation, heart rate, airflow and respiratory effort May be used to diagnose OSA when utilized as part of a comprehensive sleep evaluation in patients with a high pretest likelihood of moderate to severe OSA Not indicated in patients with major comorbid conditions including, but not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure, or those suspected of having a comorbid sleep disorder OBSTRUCTIVE SLEEP APNEA (OSA) SYNDROME AASM ICSD- 3 PSG or HSAT demonstrates ≥ 5 obstructive respiratory events per hour of sleep AND The presence of one or more of the following:  The patient complains of sleepiness, non-restorative sleep, fatigue, or insomnia symptoms  The patient wakes with breath holding, gasping or choking  The bed partner or other observer reports habitual snoring, breathing interruptions or both during the patient’s sleep.  The patient has been diagnosed with hypertension, a mood disorder, cognitive dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or type 2 diabetes mellitus OR PSG or HSAT demonstrates ≥ 15 obstructive respiratory events per hour of sleep CASE: PSG results: AHI 61/hr (all obstructive apneas or hypopneas) What are some management options in this patient? MANAGEMENT: BEHAVIOR MODIFICATION Indicated for all patients that have obstructive sleep apnea and a modifiable risk factor:  Overweight or obese patients should be encouraged to lose weight  Positional OSA should change their sleep position  All patients warned that alcohol and certain common medications, such as benzodiazepines, may worsen their OSA WEIGHT LOSS AND EXERCISE AASM Guideline (Morgenthaler et al 2006): 1. Weight loss should be combined with a primary treatment for OSA 2. Bariatric surgery may be used as an adjunctive treatment of OSA in patients with obesity  Weight loss has been shown to improve overall health and metabolic parameters, decrease the apnea-hypopnea index, reduce blood pressure, improve quality of life, and probably decrease daytime sleepiness  Exercise may modestly improve OSA even in the absence of significant weight loss 3. Tirzepatide (glucagon-like peptide-1and glucose-dependent insulinotropic polypeptide (GIP) medication) approved by FDA for treatment of moderate to severe OSA in adults with obesity SLEEP POSITION:  Some patients will be observed to have OSA that develops or worsens during sleep in the supine position  These patients tend to have less severe OSA, to be less obese, and to be younger than non-positional patients AASM Guideline (Morgenthaler et al 2006): 1. Positional therapy, consisting of a method that keeps the patient in a non-supine position, is an effective secondary therapy or can be a supplement to primary therapies for OSA in patients who have a low AHI in the non-supine versus that in the supine position. ALCOHOL AVOIDANCE:  All patients with untreated OSA should avoid alcohol, even during the daytime, because it can depress the central nervous system, exacerbate OSA, worsen sleepiness, and promote weight gain  Acute alcohol consumption often worsens the duration and frequency of obstructive respiratory events during sleep as well as the degree of oxyhemoglobin desaturation and snoring  In patients who snore but do not have OSA at baseline, alcohol consumption can prompt frank OSA CONCOMITANT MEDICATIONS:  Certain medications with inhibitory effects on the central nervous system should be avoided if reasonable alternatives exist  In particular, benzodiazepines should be avoided in untreated patients.  Other medications that may exacerbate OSA and worsen daytime sleepiness include benzodiazepine receptor agonists, barbiturates, other antiepileptic drugs, sedating antidepressants, antihistamines, and opiates. WHAT TO AVOID: AASM Guideline (Morgenthaler et al 2006): No medications are recommended as stand alone primary treatment for OSA Oxygen supplementation is not recommended as a primary treatment for OSA MANAGEMENT: POSITIVE AIRWAY PRESSURE THERAPY Positive airway pressure therapy is the mainstay of therapy for adults with OSA. Mechanism of CPAP involves maintenance of a positive pharyngeal transmural pressure so that the intraluminal pressure exceeds the surrounding pressure CPAP also stabilizes the upper airway through increased end- expiratory lung volume. As a result, respiratory events due to upper airway collapse (eg, apneas, hypopneas) are prevented. POSITIVE AIRWAY PRESSURE: INDICATIONS FOR TREATMENT AASM Guideline (Patil et al 2019): 1. AHI >5 plus one or more clinical (eg. excessive sleepiness) or physiologic sequelae (eg. HTN) attributable to OSA 2. There is insufficient and inconclusive evidence to either recommend or withhold PAP to treat non-sleepy adults with OSA as a means to reduce cardiovascular events or mortality. Other considerations:  Patients who perform mission critical work POSITIVE AIRWAY PRESSURE: EFFICACY  CPAP reduces the frequency of respiratory events during sleep, decreases daytime sleepiness, improves systemic blood pressure and blood glucose control, and improves quality of life across a range of disease severities.  observational studies - association between CPAP use and decreased mortality but no randomized trial has demonstrated a mortality benefit MANAGEMENT: ALTERNATIVE THERAPIES  Oral appliances (eg, mandibular advancement devices, tongue retaining devices) are an alternative therapeutic strategy in OSA that may be offered to patients with mild to moderate OSA who decline or fail to adhere to positive airway pressure therapy and who have a preference for such treatment.  A variety of surgical approaches have also been explored in OSA; their role is primarily in patients with severe, obstructing lesions of the upper airway who have failed positive airway pressure therapy and an oral device ALTERNATIVE THERAPIES: ORAL APPLIANCES Designed to either protrude the mandible forward (i.e. mandibular advancement/repositioning splints, devices, or appliances) or hold the tongue in a more anterior position (i.e. tongue retaining device) Both designs holds the soft tissues of the oropharynx away from the posterior pharyngeal wall, thereby maintaining upper airway patency For mild-moderate OSA, PAP is generally more effective than an oral appliance at normalizing respiratory events and oxyhemoglobin desaturation episodes during sleep BUT most patients prefer an oral appliance Oral appliances decrease the frequency of respiratory events, arousals, and episodes of oxyhemoglobin desaturation, compared to no treatment or a sham intervention. Oral appliances may also improve daytime sleepiness, quality of life, and neurocognitive function.  MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA (OUTCOME ASSESSMENT) Epstein LJ, Kristo D, Strollo PJ, Jr., Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-76. OTHER TYPES OF SLEEP DISORDERED BREATHING TO BE AWARE OF: 1. Obesity Hypoventilation Syndrome 2. Central Sleep Apnea OBESITY HYPOVENTILATION SYNDROME: Defn: The presence of awake alveolar hypoventilation in an obese individual which cannot be attributed to other conditions associated with alveolar hypoventilation When to suspect obesity hypoventilation in your patient:  BMI > 50 kg/m2 (but can be seen in patients with BMI > 30 kg/m 2)  Hospital presentation with severe hypoxemic hypercapnic respiratory failure  Elevated serum bicarbonate >27 mEq/L  Hypercapnia (PaCO2 > 45mmHg)  Hypoxemia (PaO2 < 70 mmHg) with normal A-a gradient or unexplained awake RA SPO2≤ 94%  Polycythemia CENTRAL SLEEP APNEA: Defn: Characterized by repetitive cessation or decrease of both airflow and ventilatory effort during sleep. When to suspect central sleep apnea in your patients: Symptoms of disrupted sleep (excessive daytime sleepiness, poor subjective sleep quality, insomnia, inattention, and poor concentration) When a hospitalized patient is being monitored and is noted to have episodic oxyhemoglobin desaturation, pauses in breathing, or nocturnal arrhythmias Known associated medical conditions: Heart failure, Stroke, Atrial Fibrillation, Chronic opioid use REFERENCES: 1. American Academy of Sleep Medicine International Classification of Sleep Disorders. 3rd ed. 2014; (Darien, IL American Academy of Sleep Medicine) 2. Epstein LJ, Kristo D, Strollo PJ, Jr., Friedman N, Malhotra A, Patil SP, et al. Clinical guideline for the evaluation, management and long- term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-76. 3. Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R, Ramar K, Harrod CG. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3):479–504. 4. Mason RJ et al: Murray and Nadel’s textbook of respiratory medicine, ed 5, Philadelphia, 2010, WB Saunders. 5. Mokhlesi B. Obesity hypoventilation syndrome: a state-of-the-art review. Respir Care. 2010;55(10):1347-62; discussion 63-5. 6. Morgenthaler TI; Kapen S; Lee-Chiong T et al. Practice parameters for the medical therapy of obstructive sleep apnea. SLEEP 2006;29(8):1031-1035 7. Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2019;15(2):335–343. 8. Paul GR. Sleep apnea. In: Ferri FF, editor. Ferri’s Clinical Advisor: Elsevier; 2019. 9. Schellenberg, J & Maislin, Greg & J Schwab, R. (2000). Physical findings and the risk for Obstructive sleep apnoea: The importance of oro pharyngeal structures. American journal of respiratory and critical care medicine. 162. 740-8.