The document provides an overview and update on sleep apnea, including its evaluation and treatment. It discusses the definition and types of sleep apnea, risk factors, diagnostic testing options, and treatment approaches such as CPAP, oral appliances, surgery, and lifestyle changes. The key goals in managing sleep apnea are to obtain accurate diagnostic data, educate patients, closely monitor treatment adherence, address any equipment issues, and ensure long-term follow up to optimize outcomes.

1. SLEEP APNEA 2017
UPDATE ON EVALUATION
AND MANAGEMENT
February 22, 2017

2. Disclosures
Marc L Benton, MD, FAASM, FCCP
• Medical Director, The Sleep Disorders Center at
Summit Medical Group, Madison, NJ.
Kerry Kelley, RN, RRT, RPSGT
• Manager – Sleep Services
• The Sleep Disorders Center at Summit Medical
Group, Madison, NJ.

3. Sleep Apnea - 2017 Update
• Introduction
• Demographics
• Pathophysiology
• Risk Assessment
• Evaluation Process
• Treatment Options
• Optimizing Outcomes

4. • Introduction
• Demographics
• Pathophysiology
• Risk Assessment
• Evaluation Process
• Treatment Options
• Optimizing Outcomes
Sleep Apnea - 2017 Update

5. Sleep affects, and in turn is affected by, almost every
physiological and psychological process, i.e.,
 Physical performance – work, school, life
 The ability to socially and emotionally relate to others
 Improving learning and memory
 Reduction in health problems and optimization of health
 Functioning in a safe, efficient and effective way
The Three R’s
Rejuvenate, Restore, Re-energize
Sleep Apnea - Introduction

6. All mammals and birds “sleep” as we know sleep to be.
Sleep has also been observed in reptiles, fish and insects,
although it is differently defined – more as a behavioral
phenomenon, and is less well-understood physiologically
Sometimes sleep needs to be ‘adaptive’, so that other basic needs
can be simultaneously accommodated…
Sleep Apnea - Introduction

7. Dolphins sleep by resting one half of their brain at a
time. This is called “unihemispheric” sleep. The brain
waves of dolphins that have been studied while asleep
demonstrate that one side of the brain is awake while
the other side is in deep sleep. Also, the eye on the
side of the awake-half of the brain is open, while the
other eye is closed.
This assures that dolphins can meet their respiratory
needs while also remaining vigilant enough to protect
themselves from predators even when “asleep”.
Sleep Apnea - Introduction

8. Sleep Needs by Age
Newborns/Infants 0 - 2 months
2 - 12 months
10.5 – 18 hours
14 - 15 hours
Toddlers/Children 12 – 18 months
18 mo. – 3 years
3 – 5 years
5 – 12 years
13 – 15 hours
12 – 14 hours
11 – 13 hours
10 – 11 hours
Adolescents Average 9.25 hours
Adults Average 7 – 9 hours
Older Adults Average Widely variable
Older adults need just as much sleep…they just don’t get it
Less deep sleep = more arousals and awakenings
Medical conditions/pain = more arousals and awakenings
“Sleep Debt” - just like money…
Sleep Apnea - Introduction

9. The average person needs 7 to 9 hours sleep per 24-
hour period.
The “normal” sleep-onset latency is about 10
minutes.
The “normal” sleep stage distribution for young-
middle aged adults is:
• 5% stage I
• 50% stage II
• 15-25% stage III, slow wave or deep sleep
• 20-25% stage REM
Sleep Apnea - Introduction

10. Sleep Apnea - Introduction

11. 84 SLEEP DISORDERS
IMPACTING
OVER 100 MILLION AMERICANS
Sleep Apnea - Introduction

12. Classifications of sleep disorders:
• Sleep-related breathing disorders
• Insomnia
• Central sleep apnea
• Circadian rhythm sleep disorders
• Parasomnias
• Sleep-related movement disorders
• Narcolepsy
Sleep Apnea - Introduction

13. • Introduction
• Demographics
• Pathophysiology
• Risk Assessment
• Evaluation Process
• Treatment Options
• Optimizing Outcomes
Sleep Apnea - 2017 Update

14. • Prevalence:
 True frequency depends upon
definitions/cutoffs
 Increasing incidence from 18-45 y/o
 Plateau incidence over 55 y/o
 Males > Females
 AA > Caucasians - obesity, cardiovascular
disease and hypertension
 Asian = Caucasian despite lower BMI – narrow
anterior airway, recessed lower jaw
Demographics

15. • Common factors that impact the frequency and
severity of sleep apnea:
 Body mass index (BMI)
 Physical characteristics – airway structure,
craniofacial abnormalities
 Family history – inherited structural
abnormalities, genetically prone to airway
collapse
 Age – loss of muscle tone
 Medical conditions – respiratory issues, muscular
and diaphragm issues
Demographics

16. • OSA prevalence is estimated to be about
25% in adult males, 9-13% females
• 80-90% OSA currently undiagnosed
• The worsening epidemic of obesity in the
United States guarantees a large at-risk
population
• The prevalence of obesity is still
increasing, although the rate of that
increase is slowing
Demographics

17. Demographics

18. • Introduction
• Demographics
• Pathophysiology
• Risk Assessment
• Evaluation Process
• Treatment Options
• Optimizing Outcomes
Sleep Apnea - 2017 Update

19. Definition of Sleep:
• A normal, reversible, recurring
behavioral state of disengagement and
unresponsiveness to the environment
that is characterized by typical changes
in the electroencephalogram.
Pathophysiology

20. • Apnea: cessation of airflow for at least 10
seconds and an arousal from sleep
• Hypopnea: diminished effort in breathing
lasting at least 10 seconds and associated
with a 3 or 4% oxygen desaturation and an
arousal from sleep
• Respiratory Event-Related Arousal (RERA):
diminished effort in breathing resulting in an
arousal from sleep
Pathophysiology
Respiratory Disturbances - Definitions

21. • Apnea: cessation of airflow for at least 10
seconds and an arousal from sleep
• Hypopnea: diminished effort in breathing
lasting at least 10 seconds and associated
with a 3 or 4% oxygen desaturation and an
arousal from sleep
• Respiratory Event-Related Arousal (RERA):
diminished effort in breathing resulting in an
arousal from sleep
Pathophysiology
Respiratory Disturbances - Definitions

22. • Apnea: cessation of airflow for at least 10
seconds and an arousal from sleep
• Hypopnea: diminished effort in breathing
lasting at least 10 seconds and associated
with a 3 or 4% oxygen desaturation and an
arousal from sleep
• Respiratory Event-Related Arousal
(RERA): diminished effort in breathing
resulting in an arousal from sleep
Pathophysiology
Respiratory Disturbances - Definitions

23. • Apnea: cessation of airflow for at least 10
seconds and an arousal from sleep
• Hypopnea: diminished effort in breathing
lasting at least 10 seconds and associated
with a 3 or 4% oxygen desaturation and an
arousal from sleep
• Respiratory Event-Related Arousal (RERA):
diminished effort in breathing resulting in an
arousal from sleep
Pathophysiology
Respiratory Disturbances - Definitions

24. Apnea-Hypopnea Index (AHI):
• the number of apneas and hypopneas per
hour of sleep
Respiratory Disturbance Index (RDI):
• the number of apneas + hypopneas + RERA’s
per hour of sleep
Pathophysiology
Respiratory Disturbances - Definitions

25. Pathophysiology
Anatomy of Obstructive Apnea

26. Pathophysiology
10 Minute Compressions – Severe Sleep Apnea

27. Pathophysiology
Severe Sleep Apnea

28. • Introduction
• Demographics
• Pathophysiology
• Risk Assessment
• Evaluation Process
• Treatment Options
• Optimizing Outcomes
Sleep Apnea - 2017 Update

29. Common complaints:
• Loud snoring, irregular breathing
• Problems initiating sleep
• Problems maintaining sleep
• Non-restorative sleep
• Early morning awakenings
• Excessive daytime sleepiness
• Nighttime urination
• Restless legs
Risk Assessment

30. Body-type profiling:
• Elevated BMI
• Compromised airway
• Large tongue
• Hypertrophied tonsils
• Recessed jaw
• Broad/short neck
• Family history
Risk Assessment

31. Medical co-morbidities:
• Cardiac disorders
• Endocrine/metabolic disorders
• Neurologic disorders
• Psychiatric disorders
• Pre-operative evaluation
• Chronic pain
• Pregnancy
Risk Assessment

32. Every day problems:
• Motor vehicle accidents – trains, planes,
autos
• Industrial accidents/errors
• High-risk occupations
• Compromised work or school
performance
• Sexual dysfunction
• Athletic performance
Risk Assessment

33. OSA and children:
• Poorly tolerated
• School performance
• Attention deficit disorders
• Learning disorders
• Behavioral disorders
• Attendance problems
• Bedwetting
Risk Assessment

34. Exxon Valdez – Oil
Spill
Chernobyl Nuclear
Disaster
Three Mile Island
Nuclear Meltdown
AA Flight 1420 Crash
Multiple Recent Train
Accidents
Untreated Sleep Apnea?

35.  Routine medical/dental provider
evaluation
 Validated questionnaires
 Family/friend concerns
 Occupational/licensing screening
Risk Assessment
Screening Tools

36. • Introduction
• Demographics
• Pathophysiology
• Risk Assessment
• Evaluation Process
• Treatment Options
• Optimizing Outcomes
Sleep Apnea - 2017 Update

37. What testing is appropriate?
• Home/portable vs. in-lab
Who/what decides what testing is done?
• Medical provider
• Insurance company
• Medical conditions
• Prior sleep history
Evaluation Process
Sleep Apnea Testing

38. Evaluation Process
Home Sleep Apnea Testing

39. Evaluation Process
Home Sleep Apnea Testing

40. Evaluation Process
Home Sleep Apnea Testing

41. Evaluation Process
Home Sleep Apnea Testing

42. Evaluation Process
Attended Sleep Testing

43. Types of attended sleep studies
• Diagnostic
• Therapeutic
• Split-night
• NPSG + MSLT
• MWT
• MATRx
Evaluation Process
Attended Sleep Testing

44. • Introduction
• Demographics
• Pathophysiology
• Risk Assessment
• Evaluation Process
• Treatment Options
• Optimizing Outcomes
Sleep Apnea - 2017 Update

45. • Positive Airway Pressure therapy
• Dental appliances
• Surgery
• Weight loss
• Nasal valves
• Positional therapy
• Implantable neurostimulator
• Exercises/Didgeridoo
• Combination therapy
Treatment Options

46. Treatment Options
PAP Therapy

47. Treatment Options
PAP Therapy

48. Treatment Options
Attended testing

49. Treatment Options
Attended testing – pre-treatment

50. Treatment Options
Attended testing – initial treatment titration

51. Treatment Options
Attended testing – successful treatment titration

52. Sleep Apnea – Pathophysiology
10 Minute Compression – Severe Sleep Apnea

53. Sleep Apnea – Pathophysiology
10 Minute Compression – No Sleep Apnea

54. Treatment Options
PAP Therapy - Then and Now

55. Treatment Options
New PAP Devices

56. Treatment Options
PAP Therapy
• Auto-PAP
• CPAP
• CPAP with C-Flex
• BiPAP
• BiPAP with BiFlex
• AVAPS
• BiPAP-SV

57. Treatment Options
Interfaces

58. Treatment Options
PAP Therapy
Upsides:
• Best outcomes, especially in more severe OSA
• Detailed feedback on efficacy and compliance
• Widely varied and customizable treatment options
Downsides:
• Requires maintenance (cleaning and parts replacement)
• Side effects (sinus issues, air-swallowing, dry mouth)
• Problems with equipment suppliers
• Less portable

59. Treatment Options
Oral Appliance Therapy

60. Treatment Options
Oral Appliance Therapy

61. Treatment Options
Oral Appliance Therapy

62. Treatment Options
Oral Appliance Therapy
Upsides:
• Easier to manage
• More portable
• Less likely to exacerbate sinus problems
Downsides:
• Less likely to be effective, especially in more severe cases
• No feedback regarding efficacy
• Provider variability in proficiency
• Cost
• Side effects

63. Sleep 2013 Oct 1;36(10):1517-25, 1525A
Treatment Options
Oral Appliance Therapy - MATRx

64. • Procedures
• Nasal surgery
• Tonsillectomy
• UP3
• LAUP
• Somnoplasty
• Pillar procedure
• Tongue ablation
• Tongue or hyoid advancement
• Mandibular advancement
• Tracheostomy
Treatment Options
Upper Airway Surgery

65. Weight loss strategies
 Bariatric medical evaluation
 Bariatric surgery
• Gastric sleeve
• Lap band surgery
• Roux-en-y gastric bypass surgery
Treatment Options
Weight Loss

66. Treatment Options
Positional Therapy

67. Treatment Options
Inspire Implantation

68. "In a study published in the
British Medical Journal, 25
patients with sleep apnea who
practiced playing it for about
30 minutes a day, six days a
week for four months, significantly
reduced the number of apneas they
had during sleep; daytime sleepiness
also decreased. Scientists believe the
breathing technique required to play
the didgeridoo strengthens the upper
airway and makes it less likely to
collapse."
Treatment Options
Exercises, Didgeridoo

69. Treatment Options
Alternative Facts

70. • Introduction
• Demographics
• Pathophysiology
• Risk Assessment
• Evaluation Process
• Treatment Options
• Optimizing Outcomes
Sleep Apnea - 2017 Update

71. • Good data, good decisions
• Education, education, education
• Close follow-up through initial phases of
therapy
• Compliance tracking
• Manage the home care (DME) issues
• Train and utilize Compliance Specialists
• Long term follow-up
Optimizing Outcomes

72. • Get good data, make good decisions
 The correct treatment of the wrong problem is
the incorrect treatment
 Perform high-quality diagnostic and
therapeutic sleep studies, and make sure the
results are consistent with clinical
expectations
 Getting prior test results and treatment
information can be very useful
 Know when an attended sleep study is
necessary, and fight to get it done
Optimizing Outcomes

73. • Education, education, education
 For the patient, for the providers, and the staff
 The better-informed the patient is, the better
patient they will be (usually)
 Education can help the patient assume some
ownership of the problem, which should
facilitate better outcomes
 Providing regular and constructive feedback to
the patient can be invaluable
Optimizing Outcomes

74. • Close follow-up through initial phases of
therapy
 Performance in the first week and first month
most commonly predict long-term outcomes
 You cannot find solutions until you are aware
that there is a problem
 Fixing problems earlier rather than later
improves patient satisfaction, outcomes, and
retention
 Early feedback and additional education help
prevent the development of behavior patterns
that undermine successful treatment
Optimizing Outcomes

75. • Compliance tracking
 The ability to obtain accurate
usage/compliance and treatment efficacy data
has revolutionized the treatment of OSA
 Patient’s subjective assessments of their
status is often useful but frequently incorrect
 Acquiring compliance and efficacy data, and
acting on it as needed is the current standard-
of-care in sleep medicine
 Acquiring and integrating real-time compliance
data into the patient record is becoming easier
and more beneficial to patients and providers
Optimizing Outcomes

76. • Manage the equipment issues
 This is often the weak link in managing OSA
treatment
 This is by far the most common thing that
patients complain about
 It contributes to poor outcomes, abandoned
therapy, and patient migration to other doctors
 Investing the time and effort in knowing which
companies to use, which to avoid, and how to
get the patients the services that they need is
key
Optimizing Outcomes

77. • Train and utilize Compliance Specialists
 In order to optimize outcomes and patient
satisfaction, it is necessary to have personnel
who are able to turn failures into successes,
and problems into solutions
 This requires expertise, experience, insight,
observational and communication skills, along
with the time and tools to perform the work
that is required
 Developing and customizing algorithms,
cultivating relationships with patients and
being accessible and helpful will always result
in a better product
Optimizing Outcomes

78. Treatment Options
Nasal Masks

79. Treatment Options
Nasal Pillows

80. Treatment Options
Full Face Masks

81. Optimizing Outcomes

82. Optimizing Outcomes

83. Optimizing Outcomes

84. Optimizing Outcomes

85. % Nights CPAP Used: 90%, % Nights Used > 4 hrs: 10%, Ave. Daily Usage: 2h:17m
Optimizing Outcomes

86. % Nights CPAP Used: 90%, % Nights Used > 4 hrs: 10%, Ave. Daily Usage: 2h:17m
Optimizing Outcomes
% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 60%, Ave. Daily Usage: 4h:35m

87. % Nights CPAP Used: 90%, % Nights Used > 4 hrs: 10%, Ave. Daily Usage: 2h:17m
Optimizing Outcomes
% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 60%, Ave. Daily Usage: 4h:35m
% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 87%, Ave. Daily Usage: 5h:24m
% Nights CPAP Used: 100%, % Nights Used > 4 hrs: 90%, Ave. Daily Usage: 5h:44m

88. • Long term follow-up
 People change – medications, new medical
problems, lifestyles, priorities – and treatments
often need to be modified
 Successfully treated patients can slowly drift
away from those successes if they are not
periodically monitored
 The condition that is being treating will evolve
over time, and it may require different therapy
 New treatments, better ideas, and different
approaches need to be integrated into
management plans over time
Optimizing Outcomes