Disease State Crossover

Managing the Complex OSA Patient

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

Conflicts of Interest



Philips Respironics



ResMed Corp



Fisher & Paykel



DeVilbiss



MVAP



Natus



NovaSom



Watermark

Content

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

 COPD       Diabetes Morbid Obesity Cardiovascular Stroke Gastroesophageal Reflux/Gerd Metabolic Syndrome  Intake, Clinical and Marketing Aspects

Learning Objectives

 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.

Attendees

          Night Technologists EEG Background Respiratory Background Home Care DME Home Sleep Testing Lab Managers Lab Owners Hospital Administrators Nursing Physician Assistants

Co-Morbid Condition off Your Wing

Introduction

 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.

Introduction Cont’d

           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

Medicare Readmissions Policy

 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.

COPD

 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.

COPD Medications

            Oxygen – Physician’s Orders Theophylline Ipratropium bromide Advair’ Symbicort Daliresp Theophylline Atrovert Serevent Salmeterol Formeterol Proventol/Ventolin/Abuterol - Nebulizers

COPD Referral Sources

 Pulmonologists  Hospitalists  Internal  Family  Internal Medicine  Oncologists

COPD Intake Concerns

 Oxygen ?

 Liter Flow ? Hypoxic Drive Candidate  Mobility ?

 Additional Caretakers?

 Medications?

   Nebulizers Short Acting Acute Long Acting Maintenance Recent Hospitalizations??

COPD Night of Study

 Shortness of Breath (SOB)  Ambulation  Oxygen Protocols  Emergency Protocols  Detailed H&P in Chart  Medication Schedules  Thorough Chart Review Early!!!!!

COPD and the Record

 High CO2 – 35 Normal>>>50+  Low Spo2 – 90% to 97%>>>>88% or less  Hypoventilation  Centrals During Titration  Supplemental Oxygen as needed  PVCs, PACs, Uni and Multi-Focal, V-Tach  High Heart Rates  A-Fib

COPD OSA “Overlap Syndrome ”

 1. Impaired Lungs plus OSA  2. COPD and OSA jointly contribute  3. More nocturnal desaturations  4. Reduction in respiratory drive-HV  5. Chest wall hyperinflation causes muscle fatigue in these patients.

 6. COPD has systemic consequences  7. CO2 High(Retainers), Spo2 Low

Overlap Syndrome Conclusions

 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.

 Less readmissions for these patients

Diabetes

 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

Diabetes Medications

 Type I Insulin – Oral or Injection  Type II        Metformin Victoza Glucophage Amaryl Glucotrol Januvia Novolin

Diabetes Referral Sources

 Family  Internal Medicine  Endocrinologist  Bariatric Medicine

Diabetes Intake Concerns

 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…

Diabetes Night of Study

 Tech needs to establish med routine  Patient will always self-administer  Refrigeration for meds  Do not let patients “Take a Night Off”  Call to Physician if need be to clarify/safety concerns/patient coherent?

Diabetes Sleep Loss Effects

 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

Morbid Obesity

  Co-Mobidities within a Co-Morbidity BMI > 32 – Doubles risk of death   High Blood Pressure Heart Disease – Left and Right side - Lymphedema  High Cholesterol Levels  Diabetes- 10 times- 60% to 80%  Gastroesophageal Reflux  Urinary Stress Incontinence  Degenerative Arthritis-Fall Risk  Skin Infections, Fluid Retention

Morbid Obesity Medications

 1. Metformin – Type II  2. Diuretics - Lasix  3. Hypertensive Meds – Lisinopril  4. Pillows, Pillows, Pillows,- Orthopnea  5. Insulin – Type 1  6. Lymphedema Meds  7. Oxygen  8. Lipitor  9. Vaso…….Cardio Meds

Morbid Obesity Referrals

 Family  Internal Medicine  Endocrinologist – Metabolic Syndrome  Bariatric Medicine – Pre and Post Surgical  Nephrologist- Renal Disease  Perioperative Referrals

Morbid Obesity Intake

 Weight  Bed Limits  Toilet Limits  Chairs  Ambulation?

 Medications?

 Drs to be copied?

 Special Needs?

Morbid Obesity Night of Study

 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

Morbid Obesity Record

 1. Loud Snoring  2. Deep Desaturations  3. Irregular EKG 4. Usually Severe OSA  5. CPAP to BI-Level Protocols?  6. Frequent breaks in recording  7. Artifact, movement, sweat  8. Speaking

Morbid Obesity OSA Overlap

 1. OSA Influence on other conditions, high  2. Cardio  3. Pulmonary  4. High Blood Pressure  5. Fluid Retention  6. 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

Cardiovascular

 1. 70% of patients admitted to the hospital for coronary artery disease were found to have sleep Apnea  2. Patients with OSA have a 50% risk of hypertension  3. OSA starves heart of oxygen while making it work harder leading to higher blood pressures through the night.

    4. Untreated OSA is well documented as a factor in causing heart disease 5. A patient’s chance of having OSA if they have heart failure 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

Congestive Heart Failure

 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

CHF and Sleep

 Shortness of Breath  RLS Symptoms  Diuretics = Increased Bathroom Breaks  OSA and CSA  Insomnia – Daytime Sleepiness  Short Sleep Duration

Cardiovascular Medications

               1. Lisinopril 2. Atenolol 3. Diovan 4. Norvasc 5. Clonidine 6. Azor 7. Verapamil 8. Furosemide 9. Lasix 10.Coreg

11. Zestril 12. Vasotec 13. Lopressor 14. Levatol 15. ……anybody

Cardiovascular Referral

 Family  Internal Medicine  Cardiology  Surgeons - Perioperative  Hospitalist

Cardiovascular Intake

 Oxygen?

 Get both Family and Specialists  Last Hospitalization?

 Medications and average BP

Cardiovascular Night of Study

 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

Cardiovascular Record

    Irregular EKG PVCs, PACs, V-Tach, A-Fib, Pauses Full or Partial Heart Block Breaks in record-Diuretics/Lazix Insomnia from Anxiety   Cheyne Stokes Breathing Pattern – 73% in CHF patients Left ventricular dysfunction-Hyper and Hypo ventilation Waxing and Waning breathing pattern   Pacing Spikes OSA and CSA  CSA sometimes evoked by O2 and PAP, Auto Servo Ventilation

Cardiovascular OSA Overlap

          1. Elevated Blood Pressure during Sleep 2. Elevated Sympathetic Tone leads to HBP 3. About 30% of patients with hypertension have OSA 4. Congestive Heart Failure well documented connection 5. Left ventricle enlargement/increased workload/events 6. Effects are both acute and chronic 7. Cessation of airflow and subsequent desat starves heart of oxygen. 8. PAP Treatment is shown to have positive effect on all 9. Heart Failure associated with Cheyne Stokes Pattern 10. OSA occurs in 50% of atrial fibrillation patients

Stroke

 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

Stroke Onset Symptoms

 Sudden Slurring of Speech  Muscle control deficit in face/body affecting one side or bilaterally

Stroke Medications

 Anti-platelet    Aspirin Plavis/Clopidogrel Ticlid/Ticiopidine  Anti-clot   Warfarin/Coumadin Heparin-Hospital via IV  Acute Phase  Thrombolytic Agents ”Clot Busters”

Stroke Patient Referral Sources

 Family  Internal Medicine  Neurology  Hospitalist  Case Managers  CRNPs

Stroke Intake

 1. Hemorrhagic  2. Ischemia (TIA) or Embolic  3. Left or Right Side Deficit  4. Speech?

 5. Ambulatory ?

6. Aide or Family Member 7. Time of Day or Night –Triggers

Stroke Night of Study

 Left side Right side?

 Full 10-20?

 Fall Risk?

 Medication Schedule?

 BP in the evening and morning  Medical Director Parameters for BP  Time of Day/Night-Triggers

Stroke Patient Record Aspects

 1. Left Side or Right Side EEG differences  2. Non-Homologous electrodes can cause voltage asymmetries.  3. Measure, Measure, Measure  4. Do not eye-ball EEG set-up  5. Full 10/20 frequently ordered

Stroke Patient OSA Overlap

 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.

Gastroesophageal Reflux(Gerd)

         1. Human PH – 1 TO 14 2. Arterial PH – Normal 7.35 – 7.45

3. Stomach PH – 4 or less 4. Adults and Infants 5. Apnea causes Reflux or is Reflux causing Apnea?

6. Heartburn most common symptom 7. Chronic Illness 5-7% Worldwide 8. Middle Age-Esophageal Valve Weakens 9. Opening pressure of that valve?? PAP concerns?

Reflux/Gerd Medications

              1. Zantac 2. Reglin 3. Nexium-Purple Pill 4. Pepto-Bismol 5. Ranitidine 6. Lansoprazole 7. Famotidine 8. Simethicone 9. Gavison 10. Maalox 11. Mylanta 12. Prevacid 13. Pepcid 14. Tums

Reflux/Gerd Referral Sources

 Family  Internal Medicine  Cardiology  Gastroenterologists  Neonatologists  Pediatricians

Reflux/Gerd Intake Concerns

 1. Medication Schedule  2. Physicians orders regarding meds  3. Hospitalizations?

 4. Barrett’s esophagus or other Upper GI?

Reflux/Gerd Night of Study

 1. Dr’s Orders Followed?

 2. Last Meal time documented  3. Last Med  4. Does patient have a logbook?

 5. Flat or Raised?

 6. Document Patients Snacking/Eating  7. Spicy, acidic, fried foods, tomato based

Reflux/Gerd Record Aspects

        1. Infant Study- Arousals, Body Posture 2. Adults- Arousals, Frequent breaks 3. Document Patient Observations 4. GERD with OSA events?

5. Choking Aspiration Risk?

6. Upright Posture 7. Left side/Right side/Recovery Position 8. Dr’s orders regarding food/meds/body position

Reflux/Gerd OSA Overlap

 1. Not a clear causal relationship  2. Chicken/Egg or Egg/Chicken  3. Hard breathing during events?

 4. Different mechanisms can cause both  5. Multifactorial Origin – Shared risk factors  6. Aspiration risk at end of apnea is of concern to the technologists.

Metabolic What???

Metabolic Syndrome

 1. Systemic rather than local disorder  2. OSA & Metabolic = Syndrome Z  3. Causal Relationship Probable  4. Repetitive Hypoxia  5. Adipokines and Inflamatory Cytokines  6. Estimated 24% of US Population

Metabolic Syndrome



Three of the following five variables:

 Hypertension  Insulin resistance – Type 2  Low high-density lipoprotein cholesterol  Elevated serum triglyceride  Abdominal Obesity-Visceral Fat

Metabolic Syndrome

 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.

Metabolic Syndrome

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

Metabolic Syndrome

 The Sleep Heart Health Study found a significant association between the respiratory disturbance index and waist to hip ratio, hypertension, and hypercholesterolemia in men, and low HDL-C, and hypertriglyceridemia in women.

 A matched control study found that OSA was associated with insulin resistance, total cholesterol, HDL-C and Leptin. A Japanese study showed that OSA may promote metabolic dysfunction and fat maldistribution.

Metabolic Syndrome

 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%.

Metabolic Syndrome

         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.

Metabolic Syndrome

       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

Monocyte Responds

Macrophage Engulphs Pathogen

Exploding Macrophages

Metabolic Syndrome

 Patients with sleep apnea have reduced Leptin levels.

 Sleep deprivation unto itself,,, alone,,, contributes to increased levels of Ghrelin, increased appetite, higher glucose levels, insulin resistance, and therefore a higher risk of diabetes.

 OSA compounds and contributes to most any other disease state a patient has. (Allen, P. et al)  Normalization of metbolic parameters often occurs after PAP tx.

Metabolic Syndrome Conclusion

 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.

Overall Summary/Conclusions



Sleep Technologists

 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

References

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

References Cont’d

   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

References Cont’d

 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 Ciculation 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

References Cont’d

 Javaheri, Shahrokh, MD. Feb 19 th Failure” Cardiosource.org

2013 “Basics of Sleep Apnea and Heart  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

References Cont’d

     

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

References Cont’d

 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 manifistation 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

Thank You



Peter Allen, BSRC, RRT-NPS-SDS,



RST, RPSGT



[email protected]