Peter Allen, BSRC, RST, RPSGT RRT-NPS-SDS

AAST Board Member/Director at Large NEPS Conference 2017

Management of Complex Patients

In Your Sleep Lab

Director at Large for the AAST

Clinical Coordinator Main Line Health Sleep Disorders Centers

US Project Manager

Bermuda Center for Sleep Disorders

Co-Morbid disease state descriptions and the workflow of those disease states as they pass through the sleep disorders center.

COPD

Diabetes Non-Ambulatory

Morbid Obesity Psych Special Needs Patients

Cardiovascular Facility Referrals

Stroke

Gastroesophageal/Reflux/GERD

Metabolic Syndrome

Intake, Safety, Clinical, Patient Experience and Revenue Aspects

1. Attendee will have a better understanding of the underlying physiology of the co-morbid OSA patient and various aspects of overlap syndrome between disease states.

2. Attendee will be better able to plan and cope with the complex patients in their sleep labs.

3. Attendee will learn to grow clinically while realizing the financial opportunity that these patients represent to their sleep centers.

Night Technologists EEG Background Respiratory Background Home Care DME Home Sleep Testing Only Lab Managers Lab Owners Hospital Administrators Nursing/CRNP Physicians/Physician Assistants

Since 1970 when Stanford opened the first sleep center and Dr. Guilleminault later described Obstructive Sleep Apnea(OSA), many studies have been conducted regarding associated disease states.

Many studies have linked OSA to co-morbid disease states and conditions such as:

Cardiovascular and Pulmonary Disease

Congestive Heart Failure – 76%

A-Fib, - 49%

Diabetes – 48%

Obesity - 77%

Stroke

Spinal Cord Injury

Reflux/GERD

End Stage Renal – 10 times Greater than General Population

Headaches, COPD, Cancer, Metabolic Syndrome

Many Co-Morbid disease states that are associated with OSA are being targeted by Medicare as criteria, for financial penalties to Medical Centers where readmissions occurs, within 30 days of discharge.

This puts a spotlight on Diagnosis and Treatment of OSA and its associated co-morbid disease states as an integral part of a medical centers financial integrity plan.

Chronic Obstructive Pulmonary Disease

Two Components

Chronic Bronchitis – Productive cough, three months of the

year, two or more successive years.

Emphysema - Abnormal enlargement of the airspaces in the lungs with destruction to the cell walls.

Primarily caused by cigarette smoking.

Oxygen – Physician’s Orders

Theo

Ipratrop

Adv

Symbi

Dalir

Theo

Atro

Sere

Salmet

Formet

Provent/Ventol/Abuter - Nebulizers

Pulmonologists

Hospitalists

Internal

Family

Oncologists

Nursing

Oxygen ?

Liter Flow ? Hypoxic Drive Candidate

Mobility ?

Additional Caretakers?

Medications? ◦ Nebulizers

◦ Short Acting Acute

◦ Long Acting Maintenance

Recent Hospitalizations??

Shortness of Breath (SOB)

Ambulation

Oxygen Protocols

Emergency Protocols

Detailed H&P in Chart, Always

Medication Schedules

Thorough Chart Review Early!!!!!

High CO2 – 35 Normal>>>50+ End Tidal?

Low SpO2 – 90% to 97%>>>>88% or less

Hypoventilation

Centrals During Titration

Supplemental Oxygen as needed

PVCs, PACs, Uni/Multi-Focal, V-Tach

High Heart Rates

A-Fib, flutter

1. Impaired Lungs plus OSA

2. COPD and OSA jointly contribute

3. More nocturnal desaturations

4. Reduction in respiratory drive-HypoV

5. Chest wall hyperinflation causes muscle fatigue in these patients.

6. COPD has systemic consequences

7. CO2 High(Retainers), SpO2 Low

Overlap syndrome increases risk of death and hospitalization due to COPD.

PAP treatment with or without oxygen is associated with better patient outcomes along with decreased hospitalizations.

More readmissions for these patients

Impairment of the body’s ability to use blood sugar for energy.

Type 1- Insulin producing Beta cells in pancreas destroyed.

Type 2- Most common 90% to 95%, Weight, Food

Insulin resistance by body, so pancreas overproduces

Gestational - during pregnancy- Usually Temp

Over 6 million in the US alone

Type I Insulin – Oral or Injection

Type II Met

Vict

Gluco

Amar

Gluco

Janu

Novo

Family

Internal Medicine

Endocrinologist

Bariatric Medicine

Diabetes Educators

Nutritionists

Dietician

Type 1:

When do they take their meds?

Reinforce that patient needs to bring meds.

Type II:

When do they take their meds?

Labs are Out-Patient Facilities, So…

Tech needs to establish med routine

Patient caregiver or self-administer

Refrigeration for meds

Cola and crackers that staff will not eat….

Do not let patients “Take a Night Off”

Call to Physician if need be to clarify/safety concerns/patient coherent?

Frequent urination common during PSG

Sleep loss leads to: ◦ Altered glucose and metabolism

◦ Reduced Leptin/Increased Ghrelin

◦ Up regulation of appetite/weight gain

◦ Lower energy = Weight Gain(OSA Factor)

◦ Insulin resistance = Type 2

◦ Increased Risk for Diabetes Adapted from Parker, K.P. (2011) Sleep disorders and sleep promotion in nursing practice; p. 180

Co-Morbidities within a Co-Morbidity BMI > 32 – Doubles risk of death

High Blood Pressure

Heart Disease – Left and Right side - Lymphedema

High Cholesterol Levels

Diabetes - 60% to 80% have OSA

Gastroesophageal Reflux

Urinary Stress Incontinence

Degenerative Arthritis-Fall Risk Protocols?

Skin Infections, Fluid Retention

1. Met – Type II

2. Diuretics

3. Hypertensive Meds

4. Pillows, Pillows, Pillows,- Orthopnea

5. Insulin – Type 1

6. Lymphedema Meds

7. Oxygen

8. Lip

9. Vaso…….Cardio Meds

Family

Internal Medicine

Endocrinologist – Metabolic Syndrome

Bariatric Medicine – Pre and Post Surgical

Nephrologist- Renal Disease

Perioperative Referrals

Surgeons and Anesthesiologists

Weight Bed Limits Toilet Limits Chairs Ambulation? Medications? Drs to be copied? Special Needs?

PSG Set-Up – Belts, leads, sensors… Titration Night Mask Fitting Concerns Headgear Big Enough?- Call Reps Does your lab have a weight limit? Bariatric Approved Beds? Fall Risk? Culture of Safety Concerns all Around Meds Frequent bathroom breaks Possible Incontinence

Loud Snoring

Deep Desaturations

Irregular EKG

Usually Severe OSA

CPAP to Bi-Level Protocols?

Frequent breaks in recording

Artifact, movement, sweat

Speaking while asleep

OSA Influence on other conditions, high

Cardio

Pulmonary

High Blood Pressure

Fluid Retention

Bariatric Surgery or Intensive Lifestyle Changes

Metabolic Syndrome, Insulin Resistance – Type 2

Haines et al. Surgery 2007; 141: 354-8

Look Ahead Research Group, Diabetes Care 2007

70% of patients admitted to the hospital for coronary artery disease were found to have sleep Apnea

Patients with OSA have a 50% risk of hypertension

OSA starves heart of oxygen while making it work harder leading to higher blood pressures through the night.

Untreated OSA is well documented as a factor in causing heart disease

A patient’s chance of having OSA if they have heart disease is very high.

AM J Respir Crit Care Med Vol. 188, P1-P2, 2013

ATS Patient Education Series 2013 Chowdhuri, S., MD, Weingarten, J., MD

Systolic Failure Failure to eject/pump blood out of the heart effectively

Diastolic Failure Heart muscles have become stiff and do not fill easily

Fluid builds up in the lungs, liver, gastrointestinal tract, arms and legs/ankles.

Zee, P & Naylor, E http://www.medscape.org/viewarticle/491026

Shortness of Breath

RLS Symptoms

Diuretics = Increased Bathroom Breaks

OSA and CSA

Insomnia – Daytime Sleepiness

Short Sleep Duration

Lisin

Aten

Dio

Norv

Clonid

Azo

Verapa

Furose

Las

Cor

Zest

Vaso…

Lopres

Leva

……anybody

Family

Internal Medicine

Cardiology

Surgeons - Perioperative

Hospitalist

CRNP & PA

Oxygen?

Get both Family and Specialists

Last Hospitalization?

Medications and average BP

BP Pre and Post Study – Both Arms

Ask when they last took their medications

DeFib Unit Operational – Signed off on?

Room Temp Important if Sweating

Note any swelling in arms or legs

Note Pacemaker and Type – Constant/As Need

BLS, ACLS, PALS

911 , 711 depending on hospital/freestanding

Irregular EKG

PVCs, PACs, V-Tach, A-Fib, Flutter, Systole/Pauses

Full or Partial Heart Block

Breaks in record-Diuretics Insomnia from Anxiety

Cheyne Stokes Breathing Pattern – 73% in CHF patients

Left ventricular dysfunction-Hyper and Hypo ventilation

Waxing and Waning breathing pattern

ASV Considerations?

Pacing Spikes

OSA and CSA

CSA sometimes evoked by O2 and PAP = Auto Servo Ventilation

Elevated Blood Pressure during Sleep Elevated Sympathetic Tone leads to HBP. About 30% of patients with hypertension have OSA. Congestive Heart Failure well documented connection Left ventricle enlargement/increased workload/events. Effects are both acute and chronic. Cessation of airflow and subsequent desaturation starves

heart of oxygen. PAP Treatment is shown to have positive effect on all. Heart Failure associated with Cheyne Stokes Pattern OSA occurs in 50% of atrial fibrillation patients.

Hemorrhagic-Vessel breakdown

Ischemic-transient ischemic attack (TIA) Narrowing

Embolic-Clot local or from other area blocks flow

OSA and SDB contributes to increased risk of stroke.

Stroke can contribute to OSA or CSA

Reduced muscle tone and control of upper airway

Sudden Slurring of Speech

Muscle control deficit in face/body affecting one side or bilaterally

Time = Brain

Anti-platelet Aspirin

Plav/Clop

Tic/Ticio

Anti-clot War/Coum

Hepar-Hospital via IV

Acute Phase Thrombolytic Agents-”Clot Busters”

Family

Internal Medicine

Neurology

Hospitalist

Case Managers

CRNPs

Hemorrhagic

Ischemia (TIA) or Embolic

Left or Right Side Deficit

Speech?

Ambulatory ?

Aide or Family Member

Time of Day or Night –Triggers

Left side Right side?

Full 10/20??

Fall Risk?

Medication Schedule?

BP in the evening and morning

Medical Director Parameters for BP

What time of the day/night did stroke occur?

Left Side or Right Side EEG differences

Non-Homologous electrodes cause voltage asymmetries.

Measure, Measure, Measure

Do not eye-ball EEG set-up

Full 10/20 frequently ordered

OSA increase risk of stroke, independent of other risk factors.

Males with mild sleep apnea have doubled stroke risk

Stroke patients-63% have SDB Stroke patients w SDB have higher mortality, 1yr

Even higher frequency of SDB in stroke patients with high BMI

and Type 2 Diabetes.

Human PH – 1 TO 14 Arterial PH – Normal 7.35 – 7.45 Stomach PH – 4 or less Adults and Infants Apnea causes Reflux or is Reflux causing Apnea? Heartburn most common symptom Chronic Illness 5-7% Worldwide Middle Age-Esophageal Valve Weakens Opening pressure of that valve?? PAP concerns?

Zan Reg Nex Pepto Ranit Lanso Famo Simeth Gav Maa Myl Prev Pep Tu

Family

Internal Medicine

Cardiology

Gastroenterologists

Neonatologists

Pediatricians

CRNPs

Medication Schedule

Physicians orders regarding meds

Hospitalizations?

Barrett’s esophagus or other Upper GI?

Dr’s Orders Followed? Last Meal time documented Last Med Does patient have a logbook? Flat or Raised? Document Patients Snacking/Eating Spicy, acidic, fried foods, tomato based

Infant Study - Arousals, Body Posture Adults- Arousals, Frequent breaks Document Patient Observations GERD with OSA events? Choking Aspiration Risk? Upright Posture Left side/Right side/Recovery Position Dr’s orders regarding food/meds/body position

Not a clear causal relationship

Chicken/Egg or Egg/Chicken

Hard breathing during events?

Different mechanisms can cause both

Multifactorial Origin – Shared risk factors

Aspiration risk at end of apnea is of concern to the technologists.

Intake is paramount here

Most cases have a caregiver

Out-Patient Hotel Setting Stressed

Must bring everything needed

Safety, Safety, Safety

Again Intake

Handling the Surprise Drinker

Systemic rather than local disorder

OSA & Metabolic = Syndrome Z

Causal Relationship Probable

Repetitive Hypoxia

Adipokines and Inflammatory Cytokines

Estimated 24% of US Population

Three of the following five variables:

Hypertension

Insulin resistance – Type 2

Low high-density lipoprotein cholesterol

Elevated serum triglyceride

Abdominal Obesity-Visceral Fat

Multiple studies have shown that association between OSA plus Metabolic Syndrome increases as severity of the patient’s OSA increases.

PAP has been shown to improve high blood pressure but not insulin resistance or lipid profiles.

Coughlin et al.

Studies are showing that OSA and Metabolic Syndrome are not separate co-morbidities but actually linked to each other very closely.

Linkage between OSA and Diabetes is very well documented and appears to play a role in Metabolic Syndrome.

Prevalence of OSA in obese Type 2 Diabetic patients with moderate to obstructive severe sleep apnea has been reported as high as 70%.

Hypothalmic-pituitary-Adrenal(HPA) Axis

Cortisol – Hormone/Steroid is released – Adrenal Gland

Cortisol secretion was increased by sleep apnea

Study shows that obese men with OSA have abnormally higher sympathetic nervous system activity and HPA.

Autonomic(ANS), Sympathetic(SNS), Parasympathetic(PNS)

OSA has inflamatory cascade component, although linkage to OSA is still unclear.

Repetitive hypoxia and reoxygenation lead to oxidative stress

Oxidative stress appears to be a consequence of metabolic syndrome and visceral obesity.

Oxidative stress activates an inflammatory response.

Inflammatory responses activate Cytokines.

Inflammation, metabolic syndrome ties in with atherosclerosis.

Biomarkers are used by researchers to track the bodies inflammatory responses and associate them with OSA.

Obesity is the common factor that connects OSA TO Metabolic syndrome.

Monocytes and Macrophages abound and increase through what is known as the “Cascade”. Monocytes>>Macrophages eat/destroy

Adipokines-Fat derived Cytokines-One is Leptin. Leptin plays a role in appetite and energy.

Ghrelin-Hormone that also regulates appetite. High levels after weight loss. CPAP reduces

Metabolic syndrome consists of a systemic and complicated chain of events and components, one of which can be the presence of Obstructive Sleep Apnea.

Research is showing that Sleep Disorder Medicine will be playing a major role in the diagnosis and treatment of patients with Metabolic Syndrome or Syndrome Z.

Sleep Technologists/Sleep Medicine Field

You will be seeing more complex patients Get as much additional training as you can

Is your sales department, physician liaison, lab

owner, hospital focusing on these patients?

They Should Be For Economic Survival of Your Sleep Lab

AM j Resp Crit Care Med 2010 Aug 1;182(3):325-31

Int J Chron Obstruct Pulmon Dis. Dece. 2008: 3(4): 671-682

Adaptation from Parker, K.P. (2011) Sleep disorders sleep, nursing P180

ATS J Vol; 181, Issue 5(March1, 2010) Impact of Untreated OSA on Glucose Control in Type 2 Diabetes

Grimaldi, D. et al. Diabetes Care February 2014 vol. 37 no. 2 355-363 Glycemic Control in Type 2 Diabetes

University of Chicago, et al., Sleep Diagnosis and Therapy “Sleep Apnea Can Worsen Blood Sugar Control in People with Type 2 Diabetes”

WebMD, Mann, Denise, Smith , Michael, MD Reviewed Jan10th 2010 “The Sleep-Diabetes Connection

Coughlin, et al. Eur Heart J. 2004 International Diabetes Foundation Brussels

Einhorn et al. Edocr Pract. 2007

Resmed.com

Woidtke, Robyn, APSS Boston 2012

Resnick HE, Redline S, Share E, Gilpin A, ET al.

NM: Heart Health Study. Diabetes and Sleep Disturbances

Diabetes Care 2003;26(3):702-9

Meslier N, et al. Impaired glucose-insulin metabolism in males with obstructive sleep apnoea syndrome Eur Respir J 2003;229(1):156-60

O’keeffe T, et al. “Evidence supporting routine polysomnography before bariatric surgery” Obesity Surgery 2004; 14(1):23-6

Foster, Gary, PhD, Temple University School of Medicine Diabetes Care. Net “Obstructive Sleep Apnea and Diabetes” 6/21/2010

Look AHEAD Research Group Diabetes Care 2007

Hanes et al., Surgery 2007; 141:354-8“Change in OSA Following Bariatric Surgery”

WebMD Drugs & Medications Search March 2004

Sleep Apnea and Heart Failure-ResMed Corp

Ferreira, S et al. BMC Pulm Med 2010

Lanfranchi, PA et al Circulation 2003

Javeheri, S et al. AM Col Cardiol. 2007

Garcia-Touchard, A. et al. Chest. 2008

Joseph et al. Tex Heart Inst. 2009

SDB and Hypertension-ResMed Corp

Peppard, PE. Et al. N Eng J Med 2000

Lavie P et al. BMJ 2000

Nieto, FJ, Young TB et al. JAMA 2000

Javaheri, Shahrokh, MD. Feb 19th 2013 “Basics of Sleep Apnea and Heart Failure” Cardiosource.org

Wuhl, J., MD “Obstructive Sleep Apnea’s Cardiovascular Effects” MLH 2/21/2012

Weingarten, J MD et al., Am j Respir Crit Care Med Vol 188, P1-P2, 2013 “Obstructive Sleep Apnea and Heart Disease”

Zee, P 7 Naylor, E medscape.org/viewarticle/491026 ‘Congestive Heart Failure”

Mark D. Elay, MS, RST, RPSGT, RRT-NPS, RPFT “Obstructive Sleep Apnea and Comorbidities: A Survey of Current Information” A2Zzz 23.1 March 2014

SDB and Stroke ResMed Corp

Johnson, KG, et al. Clin Sleep Med. 2010

Martinez-Garcia MA, et al. AM J Resp Crit Care Med 2009

Wessendorf TE, et al. J Neurol 2000

Drager, LF, et al. Chest 2011

Jelic S, Trends Cardiovasc Med 2008

Kirschheimer, S. WebMD Health News “Are GERD and Sleep Apnea Related” 2014

“GERD and Sleep” National Sleep Foundation

Morse ca, et al. “Is there a relationship between obstructive sleep apnea and gastroesophageal reflux disease?” Clin Gastroenterol Hepatol 2004 Sep;2(9):761-8

Calvin, Andrew, D., et al. “Obstructive Sleep Apnea, Inflammation, and the Metabolic Syndrome” Mtab Syndr Relat Discord. Aug 2009; 7(4): 271-277

Vgontzas, AN. Et al. “Sleep apnea is a manifestation of the metabolic syndrome” Sleep Med Re. 2005 Jun;9(3):211-24. Abstract

Obesity and Inflammation APSS 2012 Boston

Fantuzzi j All Clin Imunol 2005; 115:911-9

Christiansen, et al. Int J Obes Relat Metab Discord 2004; 29:146-50

Robker, et al. OBES Res 2004; 12:936-40

Peter Allen, BSRC, RRT-NPS-SDS, RST, RPSGT

petersleep@comcast.net