UPDATES IN SLEEP MEDICINE

MICHELLE ZETOONY, DO, FCCP, FACOI

BOARD CERTIFIED PULMONARY, CRITICAL CARE, SLEEP & INTERNAL MEDICINE

PINELLAS PARK, FL

DISCLOSURE

I have no conflicts that pertain to this lecture.

OBJECTIVES

• Understanding diagnosis and diagnostic testing for obstructive sleep apnea.

• Endpoints for treatment of obstructive sleep apnea

• Insomnia diagnosis and treatments

• Patient engagement in treatment of sleep disorders

• Newer non-medication treatment options

SLEEP APNEA

- The repetitive cessation of breathing noted during sleep.

- Obstructive

- Central

- Mixed

- Periodic breathing

- Abnormal is AHI (apnea-hypopnea index) > 5 in patient with symptoms and > 15 in patient without symptoms

OBESITY SYSTEMIC HYPERTENSION PULMONARY HYPERTENSION ANXIETY PAIN HEADACHES & MIGRAINES REFLUX DISEASE DEMENTIA

GLAUCOMA STROKE MYOCARDIAL INFARCTION ARRYTHMIA DEPRESSION NOCTURIA MALIGNANCY SUDDEN DEATH

OBSTRUCTIVE SLEEP APNEA

DIAGNOSTIC TESTING

HOME sleep testing

IN-LAB sleep testing • HOME=reserved for patients w/ high pretest prob of having OSA

• IN LAB=required for high risk populations including those w/ stroke, congestive heart failure, advanced lung disease, pediatric population and those with intellectual disabilities.

WHICH TEST WOULD BE MOST APPROPRIATE TEST FOR EVALUATING A 47YO MALE PATIENT WHO HAS ATRIAL FIBRILLATION, SNORES AND HAS A BMI OF 32.1 KG/M2. HE WAS RECENTLY HOSPITALIZED FOR SUSPECTED MYOCARDIAL INFARCTION. WHILE HE WAS IN THE HOSPITAL HE HAD PERIODS OF BREATHING WITH WITNESSED PAUSES.

A. In lab testing single night.

B. Home testing single night.

C. Home testing multiple nights.

D. In lab testing multiple nights.

TREATMENT OF SLEEP APNEA

BEHAVIORAL TREATMENTS

• Avoidance of sedatives prior to bedtime (including alcohol)

• Avoidance of supine sleep when possible

• Treatment of snoring and nasal congestion

• Removal of actual obstruction

• Weight loss if BMI > 30

NASAL END EXPIRATORY VALVES & NASAL PRESSURIZED VALVES

• www.proventtherapy.com

A Novel Nasal Expiratory Positive Airway Pressure (EPAP) Device for the Treatment of Obstructive Sleep

Apnea: A Randomized Controlled Trial Berry, RB, Kryger, MH, Massie, CA [SLEEP 2011;34 (4):479-485] (19 Center, 3 Month, Randomized Controlled Trial)

ADJUSTABLE ORAL APPLIANCE

www.ihatecpap.com

THINGS THAT ARE AVAILABLE BUT HAVE NOT BEEN CONSISTENTLY EFFECTIVE OR EVEN DANGEROUS

Getsleepsmart.com/winx

• WINX (apnicure.com) • PILLAR PROCEDURE • POSITIONAL DEVICES • MEDICATIONS (decongestants and sleep aids) • NASAL SURGERIES • ELBOW BY BEDPARTNER

CPAP/BIPAP

CONTINUOUS POSITIVE AIRWAY PRESSURE

• The first CPAP was used in 1981: a pneumatic split on the airway to prevent apnea

• Initial CPAP was nonresponsive and nonreactive

• CPAP – auto

• Responsive to variations in breathing and able to react to resistance

• Different algorithms developed for difference manufacturers

• BIPAP

• Ability for the inhalation pressure to be different from exhalation

• Travel machines and Cleaning machines improve patient compliance

SURGERY (BARIATRIC & NONBARIATRIC) • Surgical weight loss is the

only weight loss that has consistently reduced AHI.

• Maxillomandibular advancement

• Tongue reduction surgery

• Genioglossus advancement

• Uvulopalatopharyngoplasty

• Nasal surgeries

• Hypoglossal nerve stimulators

GOALS OF APNEA TREATMENT

• Resolution of sleep apnea (AHI < 5 events per hour).

• Improvement in sleep quality

• Possible increase in sleep quantity

• Improvement in health related measures

INSOMNIA

• Acute (less than 4 weeks) or chronic (> 3 months with at least 3x/week symptoms)

• Etiology may be important for management in acute insomnia but less so for chronic forms of insomnia

• Daytime impairment due to trouble falling asleep (DIS), trouble maintaining sleep (DIM) and/or early morning awakenings (EMA)

Insomnia will impact most people at some point in their lives.

INSOMNIA IMPACT

• Most patients don’t see sleep problems as a medical problem

• 11% will use alcohol to get to sleep at least twice a month

• Patients seeking medical professions help specifically for a sleep problem already have a comorbid condition that often is being seen as the PRIMARY COMPLAINT

• i.e. anxiety, pain, palpitations, headaches, poor memory

• Severity of sleep problem is more severe (or perceived as more severe) if seeing a specialist for sleep (or even a physician)

• Community awareness and priority is IIMPERATIVE!!

NSF Survey 2005

INSOMNIA TREATMENT

• Patient’s goals need to be aligned

• falling asleep within 15-30 minutes

• Sleeping in at least 4 hour blocks

• Improving quality of sleep, often in patients with pain component there is reduction in pain intensity

• Treatment requires behavioral changes

• Insomnia medications (including supplements are not intended for chronic use)

• Cost of treatments (covered versus not covered by medical insurance)

• Medication studies often are sponsored by pharmaceutical companies

• Pharmaceutical industry makes more than $4.5 billion dollars on treatment of insomnia

12YO HIGH-FUNCTIONING FEMALE WITHOUT SIGNIFICANT MEDICAL HISTORY PRESENTS WITH COMPLAINTS OF INSOMNIA FOR THE LAST 6 WEEKS. SHE SAYS THAT SHE HAS NO PROBLEM GETTING TO SLEEP BUT AFTER ABOUT A FEW HOURS SHE IS AWAKE. “I CAN’T GET BACK TO SLEEP.” DURING THE DAY SHE IS FALLING ASLEEP AT SCHOOL. WHAT IS THE NEXT BEST DIAGNOSTIC STEP?

• A) Nocturnal Sleep study

• B) Sleep log/diary for 2 weeks

• C) Actigraphy

• D) Blood tests including drug screen

• E) History and physical

COGNITIVE BEHAVIORAL THERAPY (CBT-I)

• A therapy method to overcome emotional distress by challenging irrational thoughts through practice (verbally or written often when starting)

• Helps patient develop healthier thoughts

• Helpful for overcoming “all or nothing” thoughts and “overgeneralization” • The components :

• Sleep hygiene education

• Cognitive therapy

• Relaxation therapy

• Stimulus-control therapy

• Sleep-restriction therapy

LIMITATIONS OF CBT-I

• Providers must be trained in its use

• Technique is time consuming

• average of 5.7 sessions over 6.5 weeks, with each session lasting at least 20-40 minutes

• Edinger et al showed that a total of 4 biweekly individual treatments represents the optimal dosing of CBT.

• NOT practical for most primary care providers or neurologists.

• Efficacy is UNKNOWN when CBT is administered by a non-psychologist

ALPHA STIM THERAPY

FDA approved device to treat insomnia/pain/anxiety and depression, 250microAmp

IMPROVEMENT IN SLEEP

• Improves metabolic function

• Improves psychologic function

• Improves memory

• Improves daytime fatigue and sleepiness

• Decreases rate of accidents and use of psychoactive drugs (including caffeine)

• Decreases incidence of chronic medical conditions

SUMMARY

• Obstructive sleep apnea is a condition that affects many people and occurs more commonly in those with risk factors.

• Diagnostic testing is available and easier for patients.

• There are a number of treatment options to help the patient have resolution to their OSA.

• Treatment of sleep disorders is imperative to improve health related outcomes and modify other disease states.

THANK YOU!

QUESTIONS?

Feel free to contact me: Michelle Zetoony, DO

drzetoony@gmail.com