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Obstructive Sleep Apnea: Diagnosis and Management

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Obstructive Sleep Apnea: Diagnosis and Management Obstructive Sleep Apnea: Diagnosis and Management Kunal Agarwal, MD, FAAFP ACTIVITY DISCLAIMER The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. 1 DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Kunal Agarwal, MD, FAAFP Medical Director, Nanticoke Sleep Disorders Center, Seaford & Millsboro, Delaware Dr. Agarwal received his Bachelor of Arts degree in Neuroscience from Johns Hopkins University in Baltimore, Maryland and his medical degree from Ross University School of Medicine in Portsmouth, Dominica. He completed his residency in family medicine at Western Michigan University School of Medicine in Kalamazoo and a fellowship in sleep medicine at Henry Ford Hospital in Detroit, Michigan. Board certified in both family medicine and sleep medicine, Dr. Agarwal is a member of the AAFP, the American Academy of Sleep Medicine (AASM), the American College of Chest Physicians, and the American Association of Physicians of Indian Origin (AAPI). Dr. Agarwal practices family medicine and sleep medicine in Seaford, Delaware. At the Nanticoke Sleep Disorders Centers, he sees adult and pediatric sleep patients, and he developed an inpatient sleep apnea screening program. He serves as a member of the Nanticoke Leadership Council, Pharmacy and Therapeutics Committee, and is vice chairman of the Provider Wellness Committee. He also serves as the physician advisor to the Polysomnogram Advisory Council at the Delaware Department of State Division of Professional Regulation. Dr. Agarwal has been named as Top Doctor by Delaware Today in 2017, 2018 (featured on cover), and 2019. 2 Learning Objectives 1. Identify patients, based on risk factors, who need to be evaluated for obstructive sleep apnea. 2. Consider OSA in the differential diagnosis of a variety of clinical presentations including new onset hypertension and daytime fatigue. 3. Counsel patients to make lifestyle modifications that may relieve mild obstructive sleep apnea. 4. Counsel patients on strategies to encourage compliance with CPAP therapy for obstructive sleep apnea, and mandibular advancement devices as an alternative. Audience Engagement System Step 1 Step 2 Step 3 3 Outline •Definition •Epidemiology •Risk factors •Screening •Diagnosis •Polysomnogram and Home Sleep Study •Sleep Apnea and other medical conditions •Treatment •Questions Definition •Episodes of complete or partial collapse of airway are translated to # of apnea and hypopnea events (AHI). •Apnea = cessation of airflow > 10 seconds •Hypopnea = Decreased airflow > 10 seconds associated with: •Arousal •Oxyhemoglobin desaturation 4 Epidemiology 33% of adults are at risk for •Men: women =2:1 OSA •80‐90% undiagnosed •Prevalence of 20‐30% males and 10‐15% females in North America •Higher prevalence in African Americans, compared to Caucasians <35 years of age •Similar prevalence in Asia to USA, despite lower obesity •18 million suffer (prevalence similar to Diabetes) •Can affect children 5 OSA Treatment Economic Analysis • Annual per patient diagnosis and treatment costs are 67% less than leaving patients undiagnosed • Diagnosing and treating all 29.4M Americans with OSA could save $100.1 billion • Biggest opportunity cost involves lost workplace productivity ($ 86.9 Billion) © American Academy of Sleep Medicine 2016 USPSTF Recommendation •Current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults. (I statement) •No evidence that detecting OSA through screening among individuals who do not present with symptoms yields any benefit. •Should have low threshold for screening 6 Sleep and Primary Care • Nearly 50 percent of adult patients visiting primary care physicians are at risk for OSA • 30% to 40% of patients who see their PCP regularly are at high risk for OSA • Only 20% of them spontaneously report their sleep symptoms • Complete review of systems, should include specific questions about sleep (snoring, sleepiness, apneas) • Few pediatricians (18%) had ever received formal training on sleep disorders. Sleep and Primary Care • Data from the 2015 National Ambulatory Medical Care Survey indicates that family physicians make a diagnosis of OSA in over 775,762 office visits annually • Studies suggest that OSA can be effectively managed in the primary care office setting • 92,608 total boarded family medicine physicians • 173 are also boarded in sleep medicine 7 African Americans and OSA • Less likely to receive OSA evaluation and treatment, even though they are at greater risk than their Caucasian counterparts • Misconception that OSA was synonymous with insomnia • Misconception was that OSA was a natural process of aging • Belief OSA was caused by: • eating certain foods, • eating too late or immediately before bedtime, • not doing enough activities during the day and therefore not being tired enough at the end of the day Screening for OSA •American Academy of Sleep Medicine (AASM) suggests three opportunities to screen for OSA: •At routine health maintenance visits •If the patient reports clinical symptoms of OSA •If the patient has risk factors. 8 STOP BANG score • Snoring • Each 1 point • Tired, fatigued, or sleepy • Low Risk : 0 – 2 • Observed apneas • Intermediate Risk :3 – 4 • Pressure (hx of high blood pressure) • High Risk : 5 – 8 • BMI > 35 • Age >50 • User friendly – 5th grade reading level • Neck size > 16 inches • Sensitivity of 93% at AHI of 15 • Gender: Male • Specificity of 43% at AHI of 15 • Validated in preoperative setting Berlin Questionnaire BERLIN Questionnaire Validated in primary care settings. The BQ for OSA (5). The questionnaire incorporates questions about snoring (category 1), daytime somnolence (category 2), and hypertension and BMI (category 3). BQ, Berlin questionnaire; OSA, obstructive sleep apnea; BMI, body mass index. Copyright © 2019 North American Neuro‐Ophthalmology Society 18 9 Epworth Sleepiness Scale: Measures average sleep propensity (chance of dozing) over 8 common situations that almost everyone encounters. Score greater than 10 is significant Situation Chance of Dozing •Sitting and reading 0-3 •Watching T.V. 0-3 •Sitting inactive in a public place (i.e., theater, 0-3 meeting) •As a passenger in a car for 1 hour without a 0-3 break 0-3 •Lying down to rest in the afternoon when circumstances permit 0-3 •Sitting talking to someone 0-3 •Sitting quietly after lunch without alcohol 0-3 •In a car while stopped for a few minutes in traffic 0-24 (0-10 normal) Total 3= High chance of dozing; 2=moderate; 1=slight; 0=never Poll Question 1 Which of the following is NOT a high risk factor for OSA? A. Congestive heart failure B. Thyroid disorder C. Stroke D. Atrial fibrillation E. They are ALL high risk factors 10 Risk Factors • Male • Postmenopausal women • Overweight BMI>30 • Over 40 years of age • Neck size 17 inches or greater in men; 16 inches in females • Family history of OSA • Smoking • Excessive alcohol use • Ethnic origin: African American, Hispanic, Asian • Small oral pharynx – crowded airway High risk for OSA • Obesity (BMI > 35) • Congestive heart failure • Atrial fibrillation • Resistant hypertension • Type 2 diabetes • Nocturnal dysrhythmias • Stroke • Pulmonary hypertension • High‐risk driving populations • Preoperative for bariatric surgery 11 Common Signs of Sleep Apnea Sleep Disturbance Medical Issues • Loud or disruptive snoring • Dry or sore throat • Gasping or choking during sleep • Depression, irritability or difficulty concentrating • Witnessed apneas • High blood pressure • Restless sleep • Nocturia Daytime function • Weight gain • Loss of energy/unexplained fatigue • Decreased libido • Memory loss
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