Transcript Sleep Disorders in the Hospital Setting: What You Should Know

Sleep Disorders in the Hospital Setting: What
You Should Know
Michael A Lucia, MD, FCCP, DABSM, FAASM
Asst. Clinical Professor, University of Nevada School of Medicine
Diplomat, American Board Of Sleep Medicine
ABMS Board-Certified: Pulmonary & Sleep Medicine
Normal Sleep: Adults
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Sleep latency:
<20 minutes
Total Sleep Time(TST)
7.5-8.5 hrs
Sleep efficiency:
>90%
Arousals:
<5/hr
Apnea/Hypopnea Index (AHI)<5/hr
REM:
20-25% TST (q 90
min)
• Stage 1 & 2
30-60% TST
• Stage 3 & 4 (SWS)
25-40% TST
Normal Sleep Architecture
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Sleep-Wake Cycle: Two Process Model
Homeostatic
Sleep Drive
Circadian
Alerting
Signal
(SCN)
9 a.m.
Awake
Melatonin
3 p.m.
9 p.m.
3 a.m.
9 a.m.
Asleep
Adapted from Kilduff TS, Kushida CA. Sleep Disorders Medicine: Basic Science,
Technical Considerations, and Clinical Aspects; 1999; and Kennaway DJ, Voultsios A. J
Clin Endocrinol Metab. 1998.
Clinical Spectrum of SDB
Increasing Airway Resistance/Obstruction
NL
Snorer
UARS
PSA
OSA
Chemoreceptor Dysfunction
Low
OHS
NL
High
CSA
Cheyne-Stokes
Airway Architecture
Airway Architecture
Interactions Between Bones and Pharynx
Cervical Spine
Bony Box
Tonsil
Uvula
Cervical
fat pad
Soft
Tissue
Tube
Tongue
Hyoid
Mandible
Dilator Muscles
of the Pharynx
Effect of CPAP
OSA: Consequences
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Impaired cognitive function & short term memory
Impaired vigilance/increased accidents
HTN/A-fib/CAD/Stroke
Increased CRP/endothelial dysfunction
Alterations in mood/depression/anxiety
Nocturia
Chronic cough/dyspnea
Depressed immune function
Increased insulin resistance/Metabolic syndrome
Chronic headaches/migraines
Proteinuria
Continued wt gain/elevated grehlin
CPAP and Atrial Fibrillation
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Percent in A-fib at 1
year
NonOSA
OSA
CPAPtreated
OSA
Circulation 2003;107:2589-94
Stroke (CVA) and OSA
• 63% of CVA patients exhibit Sleep Disordered
Breathing
• OSA > Mixed Apnea > Central Apnea
• Episodes can persists up to 6 months post CVA
• Hospital course, death rate, pneumonia rate all
worse in CVA pts with OSA
OSA and
Mortality
CPAP Use = Improved Survival
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96.4
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91.3
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Percent Survival
85.5
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0-1
1-6
>6
hrs/night hrs/night hrs/night
Campos-Rodriguez, Chest
2007;132(6):1847-52
Tools of The Trade
The Simple 7 Screening for Snorers
• BMI > 30
• Neck > 17 inches in men, 16 inches in
women
• Mallampati score = 3-4
• Snoring
• Witnessed apnea
• Daytime sleepiness or fatigue
• HTN, A-fib, CVA, CHF, CAD
Mallampati Scale
On average, the odds of having OSA increase more
than 2-fold for every 1-point increase in Mallampati
score.
Class I
Class II
Nuckton TJ, et al. Sleep. 2006;29:903-908.
Class III
Class IV
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STOP BANG Questionnaire
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S – Snoring
T – Tired
O – Observed apnea
P – Blood Pressure
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B – BMI > 35
A – Age > 50
N – Neck > 40cm
G – Gender = male
Sensitivity/specificity for mod/severe
OSA = 74%/93%
CPAP In The Hospital
• All pts with OSA should be allowed to use their
home CPAP
• All Pts should be advised to bring the CPAP to the
hosp even for minor procedures
• All pts with a strong suspicion of OSA should be
screened for OSA before any elective surgery
• Oxygen is not a substitute for an airway!
“I’m Not Anxious”
High-Risk Patients
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CHF
Stroke
CAD
Atrial Fibrillation
Post-op
Neuromuscular disease
Recommendations: OSA
American Society of Anesthesia 2007
• All elective surgery pts should be screened for OSA
• All existing OSA pts should be allowed to use CPAP
• High-risk hospitalized pts should be screened for OSA and
treated with CPAP empirically
• Opioids, paralytics and sedation should be minimized in
high risk patients
• Head and body positioning should be used to maximize
airway patency
• Oximetry and capnography should be utilized for high risk
pts
Comorbidities & OSA
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Hypertension
CHF
Ischemic Heart Disease
Atrial fibrillation
Pulmonary Hypertension
Stroke
Metabolic Syndrome
Bariatric Surgery
GERD
63-83%
76%
38%
49%
90%
71-90%
50%
71%
60%
Perioperative Risks in OSA
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Difficult airway
Post-op hypoxia
Pneumonia
Delirium
Hypoxia
Prolonged ICU and hosp stays
Death (found “dead in bed”)
Post-Op Management
• Monitored
setting/capnography/oximetry/ECG
• Overnight hospital observation
• Reduce IV opiods & sedation
• Use of pt CPAP & 02
Causes Of Sleep Deprivation
Poor Sleep
Environmental
Physiological
Psychological
Sleep In The Hospital
Sleep In The ICU
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REM Sleep
NREM Sleep
Arousals
Awake Time
Total Sleep
Sleep In The ICU
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40% reduction in total sleep time
Half of all sleep occurs in daytime
Half of arousal were from noise
Less than 5% of REM on average
Complete loss of circadian rhythm/melatonin
secretion
• Sleep disruptions persist for up to 6 months after
ICU stay
Perception VS Reality
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Sleep Time (hrs)
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Nurse Report
Patient EEG
The ICU Environment
Conducive to
Sleep
Conducive to
Assimilation
Leave Me Alone!
• 40-60 direct patient contacts per night in the ICU
• 10% of all awakenings due to pt care contact
• Average sleep duration between interruptions is 530 min
• Staff talking was the most commonly remembered
complaint by the pt (46%)
Causes of Sleep Disruption In The ICU
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Vital checks
Blood draws
Noise
Tests
Nursing Care
Light
Medication administration
Noise in the ICU
Primary Noise Makers
Noise In The ICU: Everybody’s Stress
Noise In The ICU: Everybody’s Stress
Noise & Light = Stress
Medication Effects
• Sedation = Sleep
• Most meds (benzos, narcotics, pressors) suppress
REM and SWS
• SSRI’s strongly suppress REM
• Opioids completely suppress REM in the post-op
period for up to 2-3 days
• Opioids, benzos, paralytics, propofol ALL worsen
OSA
Melatonin: The Time Keeper
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Secretion is enhanced by critical illness
Circadian rhythm is lost
Sleep is enhanced with exogenous administration
Minimal risk/side effects
No vasoactive effects
Improves free radical scavenging
Improves survival from sepsis
Parallels TNF and IL-1 secretion
Can be measured in urine
Vents and Sleep
• Pressure support associated with worse sleep than
Assist Control
• Likely due to over-ventilation of the pt with sleep
and poor coordination with sleep respiration
control
• More central apnea noted with PSV
• Proportional Assist Ventilation led to best sleep
• PAV > AC > PSV
Recommendations For Improved Sleep:
Noise
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Limit noise, esp staff talking
Change alarm settings
Close doors
Beepers & cell phones to vibrate
Adhere to visiting hours
Use ear plugs & eye masks
Add white noise
Recommendations For Improved Sleep:
Patient Care
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Minimize nighttime nursing care
Decrease vital checks in stable pts
Schedule procedures during waking hrs
Minimize sedation, esp benzo’s & use short acting
Consider melatonin
Treat pain & anxiety adequately
Light exposure from 6am – 10pm
Adjust ventilator settings to AC and avoid
weaning