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Surgery for Sleep Apnea and Snoring and Considerations for Managing Insomnia in Older Adults: Safe and Effective Treatment Eric J

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Surgery for Sleep Apnea and Snoring and Considerations for Managing Insomnia in Older Adults: Safe and Effective Treatment Eric J Surgery for Sleep Apnea and Snoring and Considerations for Managing Insomnia in Older Adults: Safe and Effective Treatment Eric J. Kezirian, MD, MPH Professor and Vice Chair, Otolaryngology – Head & Neck Surgery Past President, International Surgical Sleep Society Board-Certified in Otolaryngology and Sleep Medicine Sleep-Doctor.com [email protected] http://sleep-doctor.com/blog Disclosures Medical Advisory Board ReVENT Medical Medical Advisory Board Pillar Palatal Medical Advisory Board Cognition Life Science Medical Advisory Board CryOSA Research Funding Inspire Medical Systems Consultant Nyxoah Consultant Split Rock Scientific Intellectual Property Rights Magnap, Endoscope Consultant, IP Rights Berendo Scientific Consultant Gerard Scientific http://sleep-doctor.com/blog Snoring No good measures of quantification Smartphone apps: SnoreLab ($10) Behavioral: sleep disruption Association with carotid intima-media thickening and atherosclerosis No association with femoral IMT, atherosclerosis ? Clinical relevance (low levels) http://sleep-doctor.com/blog Obstructive Sleep Apnea (OSA) Symptomatic, repeated upper airway obstruction during sleep Severity quantified: apnea-hypopnea index (AHI) Mild (>5-15), Moderate (>15-30), Severe (>30) Behavioral: sleep disruption Health-related: cardiovascular, endocrine National Institutes of Health – OSA affects 18-20 million American adults http://sleep-doctor.com/blog Marin Lancet 2005 Prospective cohort study CV events only in untreated severe OSA Odds of CV death increased (adjusted OR 2.87; 95% CI 1.17- 7.51) http://sleep-doctor.com/blog OSA Risk Factors Male Age—children, older adults Overweight / Obese Neck circumference >16 inches W, >17 inches M Structural abnormalities Large tonsils or adenoids Large tongue Craniofacial abnormalities Disruptive snoring Daytime sleepiness http://sleep-doctor.com/blog Sleep Studies Necessary for diagnosis of OSA In-laboratory polysomnogram Home sleep apnea test Payors prefer home tests In-lab needed for concerns about central sleep apnea; insomnia; or cardiac, pulmonary, or neurologic disease http://sleep-doctor.com/blog Snoring and OSA Treatment Behavioral measures Weight loss Avoid supine body position Avoid alcohol and sedatives PAP Surgery Oral appliances http://sleep-doctor.com/blog OSA Treatment Positive airway pressure CPAP BPAP APAP http://sleep-doctor.com/blog Common Role of OSA Surgery Adults unable to tolerate PAP therapy (30-50%) In addition to behavioral measures, options: No treatment Surgery Oral appliances Goal is resolution of OSA, although may accept improvement, based on belief that partial treatment better than none http://sleep-doctor.com/blog Uvulopalatopharyngoplasty (UPPP) http://sleep-doctor.com/blog Surgery Does Not Work? 137/337 = 40.7% Table 8 Level 4 Sher, Sleep 1996;19:156-177 http://sleep-doctor.com/blog OSA Surgical Procedures and Outcomes Surgery = Anatomy Effective surgery directed at site(s) of obstruction Nasal Region Palate Region Tongue Region http://sleep-doctor.com/blog Palate Procedures Uvulopalatopharyngoplasty Expansion Sphincter Pharyngoplasty Lateral Pharyngoplasty Uvulopalatal Flap Relocation Pharyngoplasty Transpalatal Advancement Pharyngoplasty Z-Palatoplasty Pillar Procedure Palate Radiofrequency Laser-assisted Palatoplasty Injection Snoreplasty Others (CAPSO, variations) http://sleep-doctor.com/blog Pillar Procedure PTFE (Dacron) implants placed into soft palate Office procedure Stiffen palate by: • implant stiffness • natural healing process (muscle growing into spaces in implants) http://sleep-doctor.com/blog Modified Expansion Sphincter Pharyngoplasty, aka Functional Expansion Pharyngoplasty http://sleep-doctor.com/blog OSA ≠ OSA ≠ OSA: Patients Are Different http://sleep-doctor.com/blog Drug-Induced Sleep Endoscopy (DISE) Developed in Europe (1991) Used in several centers around the world but less commonly in U.S. Fiberoptic endoscopy of sedated patient Goal: reproduce SDB seen on sleep study VOTE Classification Kezirian Eur Arch ORL 2011 DISE associated with surgical outcomes Green Laryngoscope 2019 http://sleep-doctor.com/blog Velum (Palate) http://sleep-doctor.com/blog Oropharyngeal Lateral Walls http://sleep-doctor.com/blog Tongue http://sleep-doctor.com/blog Epiglottis http://sleep-doctor.com/blog Hypopharyngeal Procedures Tongue radiofrequency Genioglossus advancement Tongue stabilization Hyoid suspension Midline glossectomy Maxillomandibular advancement http://sleep-doctor.com/blog Tongue Radiofrequency Many areas of the body Heart, prostate, oncology Energy delivered to create injury, then fibrosis http://sleep-doctor.com/blog Midline Glossectomy http://sleep-doctor.com/blog Maxillomandibular Advancement http://sleep-doctor.com/blog Hypoglossal Nerve Stimulation Inspire Upper Airway Stimulation • Inspire therapy: Stimulation – Fully implanted lead – Senses breathing – Mild stimulation to key airway muscles via hypoglossal nerve Generator – Turns on with a sleep remote Sensing lead http://sleep-doctor.com/blog What Do I Do?: Structure-Based Approach Velum/Palate UPPP ± tonsillectomy Other palate procedures (ESP and LP) Oro LW ? Hyoid suspension, ESP, LP, MAD/MMA Tongue Genioglossus advancement Tongue RF Tongue stabilization Tongue resection (BMI >30/32) Upper Airway Stimulation (BMI<32; multi) Epiglottis Hyoid suspension vs. Partial epiglott Maxillofacial MMA Counseling patients key: BMI, AHI, mandible (SNB), ?age http://sleep-doctor.com/blog Conclusions Evaluation of the pattern of upper airway obstruction may enable: Targeted, more effective treatment of OSA Development of new devices or procedures Poor outcomes have always been considered a failure of surgical technique/skill Selection of appropriate procedures may be just as important http://sleep-doctor.com/blog Insomnia ≥3 months of difficulty with sleep initiation, maintenance, duration, or quality despite adequate opportunity Prevalence 15-24% High-risk: older adults, woman, shift workers, medical or psychiatric disorders Causes: caffeine (lasts 8-12 hours), corticosteroids, beta-agonists, antidepressants http://sleep-doctor.com/blog Melatonin Important in Older Adults (Karasek Exp Gerontol 2004) http://sleep-doctor.com/blog Treatments Sleep aids (alcohol, antihistamines – not good) Cognitive-behavioral therapy (CBT-I) • Sleep hygiene • Stimulus control • Relaxation training – breathing, meditation • Cognitive therapy – education to correct dysfunctional beliefs • Sleep restriction – 5-6 hours, increase slowly Specific training – MD/DO, Psychologist, NP/PA Internet-based CBT-I (not available): Sleepio, SHUTi http://sleep-doctor.com/blog Medications (Winkelman NEJM 2015) http://sleep-doctor.com/blog Medications Benzodiazepines: bad for anyone Sedative-hypnotics (Z drugs): bad for older adults --independent association with risk of falls (Kolla 2013) Adjusted OR 4.37 (3.34-5.76) Melatonin – dose? timing? 10 mg x 1 month? Ramelteon ( Cannabinoids – research in infancy Herbal medications – research favors placebo Mind-body (meditation, acupuncture, Tai chi, yoga) – small studies http://sleep-doctor.com/blog Prolonged Release Melatonin 2 mg: self-reported sleep (WADE BMC Medicine 2010) http://sleep-doctor.com/blog Conclusions Insomnia is common Different types of insomnia Options include sleep hygiene alone, medications (not ideal for long-term use, except for melatonin which seems safe), and CBT-I Melatonin may be good place to start for older adults http://sleep-doctor.com/blog.
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