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SleepDisorders:WhatOptometrists
NeedtoKnowA.PaulChous,MA,OD,FAAO
h(ps://www.disneyclips.com/imagesnewb4/snowwhite-sleepy.html
Disclosures
• Ihavespokenfor,beenonadvisoryboardsfororhavebeenpaidconsultantsfor:
Bausch&Lomb,Genentech,Konan,NovoNordisk,Optos,Optovue,Regeneron,VSP,Zeiss,ZeaVision
MyFocus
• Sleepproblemsareprevalent
• Sleepproblemscontributetoeyedisease&systemicdiseasethatislinkedtoeyedisease
• ECPscanhelppaFentswithsleepproblemsgetdiagnosedandtreated
SleepDisorders–WhatWeThinkOf
It’sNOTJustSleepApnea
• BroaderDefiniVonofSleepDisorders
– Parasomnia:episodicsleepeventsincludingsleepterrordisorder,sleepwalkingandnightmaredisorder
– -Dyssomnia:abnormaliVesintheamount,duraVon,qualityorVmingofsleep;PrimaryvsSecondary
=MostPrevalent
Sleep Walking Talking
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ExplodingheadsyndromeisarareandrelaVvelyundocumentedparasomniaeventinwhichthesubjectexperiencesaloudbangsimilartoabombexploding,agungoingoff,aclashofcymbalsoranyotherformofloud,indecipherablenoisethatseemstooriginatefrominsidethehead.
18%ofWSUstudentsreportedatleast1episodeJSleepRes.2015Aug;24(4):447-9.
Dyssomnia• Primary:Primaryinsomnia,narcolepsy,circadianrhythmdisorders,andsleepdisorderedbreathingincludingsleepapnea(central,obstrucVve,mixedforms)
• Secondary:sleepdisorderscausedbypsychosocialstressors,anxiety,depression,diet(caffeine/alcohol/nicoVne),medicaVons(anV-depressants)
Epidemiology• EsFmatedthat20-40%ofAmericansexperiencesleepproblemseachyear
• 50%ofthose>50yearsold
• 25%offatalmotorvehicleaccidentsareduetosleepinessordriverfaFgue
• SleepdeprivaFonsignificantlyincreasesriskofmedicalerrors– 100Kdeathsin2006;250,000in2016– Commi(eeonSleepMedicine,WashingtonD.C.,TheNaVonlAcademiesPress2006
– SleepReview,February27,2017
MMWRMorbMortalWklyRep.2014;63:557-562.• 17-18.5hoursofwakefulnessimpairsmotorfuncFononaparwithormorethanabloodalcoholcontent(BAC)=0.05%
• 17.74-19.65hourswithoutsleepwasequivalenttoBAC=0.10%
SleepDuraVonAcrosstheLifespanSleepMedRev.2012Jun;16(3):199–201.
Insomnia• Prolongedsleeplatencyand/orreducedduraFonofsleep– Acute:30%ofAmericanseachyear(>1monthduraFon)
– ChronicInsomniaSyndrome:10%eachyear(>3monthsduraFon)
– Ifadjustedfordepression,about6%/year– BydefiniFon,accompaniedbyinterferencewithwakefulacFvity(e.g.excessivedayFmesleepiness-EDS)
JClinSleepMed.2007Aug15;3(5Suppl):S7–S10.
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Hyposomnia:ShortSleep(<7h)inAdults&TeensisCommon
• BehavioralRiskFactorSurveillanceSystem2014• 35%ofUSadults
– 68%ofteensget<8hours(NSFrecommends8.5)
• 46%ofAfricanAmericans&NaFveHawaiians• SignificantlymorecommoninadultswithCAD,stroke,asthma,COPD,diabetes,CKD,depression
PrevalenceofShortSleepDuraFonbyState,2014CDCBRFSSData
AverageSleepDuraFoninUSAdults
2hourreducFonsince1960
Doyougetenoughsleepandisitimportant?
FewerpeoplereporFngEnoughsleepoverFme
Maximalwell-beingscoresAt8hourspernight
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SleepApnea• CessaFonofbreathduringsleep• About20%ofUSadults• Roughly15%ofthesearesymptomaFc
SleepApnea• MostcaseareObstrucFve(OSAS)
– 22%ofmen/17%ofwomenà22millionAmericans
– Ratesincreasewithage&obesityà80%unDx• <10%arecentral-<1%ofpopulaFon
– DecreasedorabsentvenFlatoryeffort(neurologic)
• Apnea:temporarycessaFonofbreathing(>10seconds)duringsleepwithreducedO2saturaFon
• Hypopnea:decreasedairflow>10secwithreducedO2saturaFon(parFalobstrucFon)– ElevatedApnea-HypopneaIndex(AHI)JThoracDis.2015Aug;7(8):1311–1322
AHIapneic+hypopneicepisodes
Fmeasleep(inhours)
• AHI<5=normal• AHI>5<15=mildapnea• AHI>15<30=moderateapnea• AHI>30events/hour=severeapnea
• 15%ofallOSAismoderateorworsebyAHI• MilderOSAfarmorelikelytobeposiFonal
EurRespJ2016;47:23-26 Chest2005Oct;128(4):2130-7
OtherSleepDisorders• RestlessLegSyndrome:legdiscomfortcoupledwithcompulsivemovement;SymptomsworsewhenstaVonary;females>males;5.5%ofthepopulaVon(PLMD=3.9%)
• Narcolepsy:excessivedayVmesleepiness,sleepparalysis,hallucinaVons,+/-cataplexy;males<females;79.4casesper100,000prevalence(0.05%ofthepopulaVon)
Sleep2018;41(suppl1):A227
SleepMed2011;12(7):623-34
BuchfuhrerMJ.Strategiesforthetreatmentofrestlesslegssyndrome.Neurotherapeu*cs.2012;9(4):776–790
• OlenworsenedbyanFhistamines,melatonin,alcohol,SSRIs
• RLSincreasestheriskofsuicideandself-harmbyupto4-foldaleralladjustments– 24+KRLSpaFentsfollowedover8years
JAMANetwOpen.2019;2(8):e199966.Epub2019Aug2
ToolsforAssessingSleepSymptoms• EpworthSleepinessScale(ESS)
– QuesFonsaboutsleepinessduringwakeacFvity
• PinsburghSleepQualityInventory(PSQI)– QuesFonsaboutsleeplatency,quality,breathing
• LinlecorrelaFonbetweenESS&PSQI• BothpoorpredictorsofmilderobstrucFvesleepapnea(OSA)&othersleepdisorders
• BerlinObstrucFveSleepApneaSurvey• STOP-BANGApneaQuesFonnaire(snore/Fred/observed/pressure–BMI/age/neckcircumference/gender)
SleepMed.2014Apr;15(4):422-9.
IntJPrevMed.2018Mar9;9:28
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Polysomnography(PSG)
• Goldstandardfordiagnosisofmostsleepdisorders(exceptRestlessLegSyndrome)
• Overnightmeasurementofbreathing,pulse,P02,EEG,REM,legmovements
• Homesleepstudiesrecordpulse,P02,breathing– GoodcorrelaFonwithPSGforDxofOSA– Costsaretypically$200-500versus$1500-2000
Respirology.2010Feb;15(2):336-42
AcFgraphy• Lower-cost,wearablesensorsformeasuringacVvity,pulseandpulsevariability,breath,oxygenaVonduringwakefulandsleephours– SleepduraVon– Wakefulnessaoersleeponset(WASO)– 7deviceshavepeer-reviewedsleepvalidaVonstudyevidence
– AmericanAcademyofSleepMedicineguidelinesadvocatetheiruseforchronicinsomnia&circadianrhythmsleepdisorders
JClinSleepMed.2018Jul15;14(7):1209-1230.
“Phygama”• AcVgraphicsleepwearusingpressurepointstomeasuremovement,breathandpulseduringsleep
• BallisVcmeasurementswhereembeddedsensorswithintexVlesmeetwearers’skin
Source:UniversityofMassachuse(s,Amherst
ComigtoaBedr
oom
nearyou!
SleepDisordersAssociatedwithRiskofMulFpleSystemicPathologies
• CardiovascularDisease• Diabetes/InsulinResistance/Obesity• IntesFnalDysbiosis• Hypertension
• Sub-opFmalresponsetotreatmentoftheabove
hnps://www.cdc.gov/sleep/about_sleep/chronic_disease.html
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CVD• ObstrucFvesleepapneaincreasestheriskofstrokeandMImorehan3-fold,butCPAPdoesn’tlowerriskofrecurrenteventspermulFpleanalyses*
• Meta-analysisshowssleepapneadoublestheriskofMACEalerstentplacement
• WomenwithinsomniahavehigherBPandserummarkersofinflammaFon
Medicine(BalVmore).2018Apr;97(17):e0621
EurJClinInvest.2018May;48(5):e12908.
JAmHeartAssoc.2018Jun9;7(12)
*MOREonthisLATER
NappingProtectsAgainstMI?
• OnceortwiceweeklydayVmenappingassociatedwitha48%decreasedriskofMI,stroke&heartfailure– 3400+SwissadultsfreeofCVDfollowed5+years
• Unaffectedbyconfoundersincludingage,HTN,dyslipidemia,OSAS,sleepduraVon
• Morefrequentnapping(6-7/wk)associatedwithincreasedriskbutthiswasa(enuatedaoeradjustmentsforothrriskfactors
pii:heartjnl-2019-314999.doi:10.1136/heartjnl-2019-314999.[Epubaheadofprint]
Diabetes• Shortsleep(<5.5hours)triplesthelikelihoodofT2DMinobservaFonalstudiesalerallcontrols
• SevereobstrucFvesleepapneaincreasedincidentdiabetes71%over13yearsindependentlyofadiposity
• Bothshort(<5.5hrs)andlong(>9hrs)sleepduraFonaresignificantlyassociatedwithadiposity&insulinresistance
CurrDiabRep.2018Aug17;18(10):82.
SleepMed.2016Sep;25:156-161
DiabetesResClinPract.2018May;139:195-202
DiabetesCare2015Mar;38(3):529-537480K+subjects
“SweetSpot”is7.7hours
HTNandOSA• 50%ofhypertensivepaFentshaveOSA• Drug-resistantHTNishighlyassociatedwithsevereOSA
Hypertension.2014Feb;63(2):203–209.
OSA+HighFatDietàDysbiosis,HTN• Ratswithtrachealballoon-inducedapneaandhigh-fatdietdevelopsignificantdecreaseinbutyrate-producingbacterialfloraand29mmHgBPincreaseaoer2weeks
• FecaltransplantaVonintonormalratsresultedina32mmHgincreaseinBPat2weeks
• SuggestsacausalnexusforHTNbetweensleepapnea,dysbiosisandfatintake
Hypertension.2016Feb;67(2):469–474.
ReducFonsinbutyrateproducingbacteriaareprevalentinT2DM&HTN MedSci(Basel).2018Jun;6(2):32
Microbiome.2017;5:14.
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SleepDisordersAssociatedwithMulFple,PrevalentEyeDiseases
• OSA:normotensiveglaucoma,NAION,DR&DME,PoorresponsetoanF-VEGFTxinnvAMD&DME,FloppyEyelidSyndrome
• Insomnia:AMD• Hyposomnia:nvAMD,POAG,dryeye,myopia• Hypersomnia(excessivesleepduraFon):Sight-threateningDR,AMDwithgeographicatrophy,POAG
ApneainDiabeFcReFnopathy/DME• STDRrateswere2-2.5XhigherinT2DMpaVents(n=230)withOSAfollowedfor4yrs
• Aoeralladjustments,OSAincreasedoddsofprogressingtosevereNPDR/PDR5-fold
• AHI>11.9vs<4.8increasedoddsofSTDR7.5-fold• CSMEpaVentswithconfirmedOSA&TxwithgridlasergainedanextralineofVAiftreatedwithCPAP>2.5hrs/night@6months
• DMEpaVents(n=30receivingAvasVn),theprobabilityofOSAsymptomswasdirectlyproporVonaltothe#ofrequiredinjecVons
AmJRespirCritCareMed.2017Oct1;196(7):892-900.
ReVna.2014Dec;34(12):2423-30
RespiraVon.2012;84(4):275-82
DR&Hypersomnia
• 1231T2DMpaFentsinSingapore• LongsleepduraFon(>8hrs)&EDSwereindependentlyassociatedwithVTDR(3-fold)
• Hypothesis:ReFnalO2demandispredominantlydrivenbyrodmetabolism;increasedsleepmaybeahypoxicsFmulustoworseningreFnaldisease
PLoSOne.2018;13(5):e0196399
VTDRisProliferaFveReFnopathy(PDR)orcenter-involvedmacularedema(CI-DME)
A novel approach to DR n Inner retinal hypoxia is primarily
responsible for DR and vision loss n Rods are primarily responsible for most
retinal O2 consumption during dark n Limiting rod metabolism with a green LED
reduces hypoxic stress in animals and improved DME in 17/26 eyes versus 3/26 control eyes
Diabetic retinopathy and a novel treatment based on the biophysics of rod photoreceptors and dark adaptation. Editors In: Kolb H, Fernandez E, Nelson R, editors.
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GeographicAtrophy• Aleralladjustments,longsleep(>8hours)increasedtheriskofGA7.1FmescomparedtopaFentswithoutAMD– 1003consecuFveptsinaSanFranciscoreFnapracFcesurveyedaboutsleephistory
– HourssleepingwasnotassociatedwithnvAMD
ReFna.2016Feb;36(2):255-8.
?nvAMD• InacaseontrolstudyofAMDptswithself-reportedshortsleep(<6hours),relaFveriskofCNVMwas3.29v.7-8hrs;2.25for6-7hrs;1.39for>8hrs(n=165)– HR=3.1forshortsleepalerallcontrols
In38paFentswithnvAMDandOSAconfirmedbyPSG,CPAP+AvasFnimprovedVA(20/40vs20/100),CSTby-78μandcutrequiredAVTinhalfcomparedtoAvasFnalone(8vs16injecFons)
ReVna.2016Apr;36(4):791-7.
OphthalmicEpidemiol.2016;23(1):20-6.
PoorResponsetoAVTinUntreatedOSA
Glaucoma• POAGwasassociatedwithshort(<5hrs)andlong(>9hrs)sleepduraFon(p=0.07)
• WhenstraFfiedbyabdominalobesity&BMI,overweightsubjectswere2.4XmorelikelytohavePOAGifsleepduraFonwas>9hrsor<7hrsaleradjustmentsforage/gender/IOP/HTN/smoking/drinking/income/depression(p=0.036)– 9400subjectsfromKNHANES2012
Medicine(BalVmore).2016Dec;95(52):e5704.
‘SweetSpot’’
SleepduraFonsignificantlyassociatedwithPOAGinabdominallyobesesubjects
NormotensiveGlaucoma
• NTGappearstobemoreprevalentinOSA
• PresenceoffloppyeyelidsyndromeinptswithOSAassociatedwitha4-fold+increaseinglaucoma(NTG&POAG)– 23%vs5%p=0.04– 150FESpaFents
JGlaucoma.2014Jan;23(1):e81-5.
JGlaucoma.2007Jan;16(1):42-6BMCOphthalmol.2014Mar10;14:27
MySimpletonConclusion
• SickreFnasandopFcnervesneedtobreathe
• SickreFnasandopFcnervesneedadequatesleep,butnottoomuchortoolinlesleep
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DryEye• ShortandveryshortsleepduraFonincreasedoddsofdryeyesymptoms– HR=1.2(5hrs)and1.29(<4hrs)– 16KfomKNHANES
• ClinicalandsubjecFvedryeyesignificantlymorecommoninpaFentswithpoorPSQIscores– Osakastudyn=672Japaneseofficeworkers– 730ptsatTokyoeyeclinic
SleepMed.2015Nov;16(11):1327-133
ClinOphthalmol.2016;10:1015–1021.NeuropsychiatrDisTreat.2015;11:889–894
Mechanisms?• ExperimentalsleepdeprivaFon(mice)induceslacrimalglandhypertrophyandreducestearproducFonaler10days– Reversedaler14daysofrest
• Sleepapneasignificantlyassociatedwithpersistent/severedryeyesymptomsinastudyof120USVeterans(3.8X)– CPAPusenotreported
ExpMolMed.2018Mar2;50(3):e451
JAMAOphthalmol.2016Dec22.
SleepDeprivaFonDryEye(SDE)• SDEresultsfromchangesinmorphologyofcornealepithelialmicrovilliandêtearstabilityresulVngfrominhibiVonoftheproteinPPAR-α (mousemodel)
• Topicalfenofibrate(anV-lipidagentTricor™)acVvatesPPAR-α andnormalizesmicrovilli&tearfilmstability
InvestOphthalmolVisSci.2018Nov1;59(13):5494-5508
CPAPuse&OSD• ConjuncFvalsquamousmetaplasiaincreased&TBUTdecreasedinrighteyesonlyaler4monthsofCPAP(n=80)– PosiFonaleffect?(maskvshabitualsleepposiFon);maskleakage,maskdisplacement,nasolacrimalairflow
Cornea.2012Jun;31(6):604-8
EyeEco’sEyeseals4.0.
SleepReview2016InterviewofArtEpstein,OD,FAAO
DoesCPAPIncreaseIOP?
• NodifferenceinmeanIOPatbaselineandaler7hoursin31subjectswOSA+/-CPAP
• NocturnalIOPwassignificantlyhigherin21CPAPsubjectsmeasuredQ2h– Meantrough/peakspreadincreasedfrom6.7to9.0mmHgaler1month
– DecreasedIOPwasseenaler30minutesCPAPcessaFon
GraefesArchClinExpOphthalmol.2015Dec;253(12):2263-71
InvestOphthalmolVisSci.2008Mar;49(3):934-40.
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TimeforanAnecdote• OSAwaspresentin46%of200consecuFveT1DMpaFents(30%normalweight/60%overweight/obese)
• 54yomalewT1DM:AHI=18.3events/hr• BaselineIOP19mminAMx3mornings• Aler6hrsCPAP,IOPincreasedto23-26mmwithmeanCPApressureof11mmHg(AHImean=3.4)
• AddiFonoforalappliancetoCPAPreducedIOPtobaseline,meanCPApressureto5mm,&AHImean=0.5)
JDiabetesComplicaVons.2017Jan;31(1):156-161
Hyposomnia&Myopia
• 3625Koreanadolescents(12-19yo)• MyopiawasinverselyassociatedwithsleepduraFonalercontrols(0.1D/hour)
• Comparedtosubjectsge|ng<5hrs,ORformyopia>-0.50D<6.00Dinthosege|ng>9hrswas0.59(p=0.006)
• NorelaFonshipwasseenformyopia>6diopters
ActaOphthalmol.2016May;94(3):e204-10.
ActaOphthalmol.2016May;94(3):e204-10.
Comba|ngPoorSleep• Removelocalfactors(quiet/darkroom;avoidcaffeine/nicoFne/alcohol&lightatnight)– Bluelightsuppressesmelatonin,impairssleeplatency,duraFonofREM–559studiesin5yrs
• IdenFfy&treatpsycho-socialstressors(anxiety/depression)
• Avoidnapping,shilworkandvariablebed/wakingFmes
• PhysicalacFvity• IdenFfy&treatOSA
NaVonalSleepFoundaVon
�DrugTherapyinsomniaàSonata,Lunesta
nightterrorsàclonazepamRLSàcarbidopa,gabapenFn,Fe
IsCaffeineReallyProblemaFc?• JacksonHeartSleepStudy
– 785AfricanAmericansusingacVgraphy(wearableacVvitymonitor)x1week
• Self-reporteduseofalcohol,nicoVneand/orcaffeinatedbeverageswithin4hoursofbedVme
• BothnicoVneandalcoholsignificantlydisruptedsleep,butlow-dosecaffeinedidnot(<1cupofcaffeinatedcoffee/tea)
Sleep.2019Aug6.pii:zsz136
Caffeinecntd• ThereisconsiderablevariabilityincaffeinemetabolismandsensiVvity– Modulatedbygenesinfluencingdopamineandadeninereceptors
• Cross-secVonalAnalysisof880collegestudents– CaffeineconsumpVonaoer6PMhadnoeffectonself-reportedsleepquality(PSQI)
– HigherweeklycaffeineconsumpVonaffectedsleepqualityONLYinthoseNOTconsumingaoer6PM
– àhypersensiFvesubjectsself-selectedfornoeveningconsumpFon
JSleepRes.2018Oct;27(5):e12670.Psychopharmacology(Berl).2010Aug;211(3):245-57
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BonomLine• AvoidalcoholannicoFnebeforebed
• AvoidcaffeineconsumpFonbeforebed,especiallyifitexperienFallyinterfereswithyourindividualsleepquality
AvoidLight-at-Night• LANdisruptsthecircadianrhythmandmetabolism,increasingratesofobesityandmetabolicdisorders
• IndoorandoutdoornighFmelighFngaffectssleepqualityandquanFty
EndocrRev.2014Aug;35(4):648-70.
Sleep.2016Jun1;39(6):1311–1320
RGCs in control
• ipRGCs – Intrinsically photosensitive retinal
ganglion cells (1-3% of RGCs) – The 3rd photoreceptor containing the
photopigment, melanopsin – Synchronize circadian rhythms to the
24-hour dark/light cycle – Regulate pupil size in ambient light
ipRGCs Respond to Blue Light
• Contain the photopigment, melanopsin with peak spectral sensitivity of 460-520 nm
• Blue light absorption by ipRGC melanopsin down-regulates production of melatonin by the pineal gland
• Melatonin suppression results in increased wakefulness and alertness
Light At Night (LAN)
• Increased blue light exposure during the evening meal increases hunger & decreases insulin sensitivity x 2 hours
• Increased light at night exposure significantly elevated BP 4/3 mm Hg in Japanese subjects – 6% increased mortality -10K additional
deaths • Increased LAN also significantly associated
with increased rates of obesity and dyslipidemia independently of melatonin levelsà affects microbiome activity
Am Acad Sleep Med 2014
J Clin Endocrinol Metab. 2013 Jan;98(1):337-44
Chronobiol Int. 2014 Jul;31(6):779-86
Cell.2016Dec1;167(6):1495-1510
BacterialmetabolitesaffecthostenergymetabolismandappeFte….
• RecognizedasessenFalhostenergysourcesandactassignaltransducFonmoleculesviaG-proteincoupledreceptors(FFAR2,FFAR3,OLFR78,GPR109A),asepigeneFcregulatorsofgeneexpressionbytheinhibiFonofhistonedeacetylase(HDAC),anddirectlyinfluenceappeFteviaPepFdeYY
Nutrients.2015Apr;7(4):2839–2849.ProcNutrSoc.2015Aug;74(3):328-36.
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ImprovingAdolescentHyposomnia
SchoolStartTimes• TheAmericanSocietyofPediatricsrecommendsthatmiddleandhighschoolsstartnoearlierthan8:30AM
• Veryfewschoolsdoso
ImprovingAdolescentHyposomnia• Passivelighttherapy:3msflashQ20secondsx2hrs@4-6AM(programmablebridgebeacon)– IncreasedsleepinessbutnotsleepduraVon(n=72)
• Lighttherapy+4sessionsofcogniVvebehavioraltherapy(CBT)– Self-selectedgoalofimprovingacademics,athleVcperformance,physicalappearance
– Teensslept43minuteslonger,wenttobed50minutesearlier&were6XmorelikelytomaintainconsistentbedFmeswithdualTx
StanfordMedicine.(2019,September25).Teenssleep43moreminutespernightaoercombooftwotreatments.ScienceDaily.RetrievedOctober5,2019fromwww.sciencedaily.com/releases/2019/09/190925113000.htm
TreaFngOSA• CPAPisthegoldstandard,butcomplianceratesarelow(50%disconFnuewithinthefirstyearandanother25%byyear3)
• Females,>55yoandimproveddayFmesleepiness(ESS)predictcompliancepast6mos
• CPAPdidNOTimproveMACEormortalityinptswithestablishedCVD(meannightlyuseonly3.3hrson70%ofnights)
RespirCare.2010Sep;55(9):1230-9
SleepApnea.NEnglJMed.2016Sep8;375(10):919-31
TreaFngOSA• CPAPisthegoldstandard,butcomplianceratesarelow(50%disconFnuewithinthefirstyearandanother25%byyear3)
• Females,>55yoandimproveddayFmesleepiness(ESS)predictcompliancepast6mos
• CPAPdidNOTimproveMACEormortalityinptswithestablishedCVD(meannightlyuseonly3.3hrson70%ofnights)
RespirCare.2010Sep;55(9):1230-9
SleepApnea.NEnglJMed.2016Sep8;375(10):919-31
SAVETrial(n=2717)SleepApneacardioVascularEventstrialMeannightlyusewasonly3.3hrson70%ofnights!
PtswithsevereO2desaturaFonAnddayFmesleepinesswereexcluded
Allsubjectshadestablishedcoronaryarteryand/orcerebrovasculardisease
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DoseMayBeCriFcalforCPAP
• TheSAVEStudydidshowa44%reducFoninstrokeriskforthosewith‘goodcompliance’– >4hrson70%ofnights
• CPAPuse>4hours/nightdoessignificantlyreduceMACEinmeta-analysis– 4RCTs,3780paFentsp=0.02
AmJCardiol.2017Aug15;120(4):693-699
OtherOSATxOpFons• MandibularAdvancementDevices(MAD)
– comparabletoCPAPformildOSA(50-60%lowerAHI)
• Uvulopalatopharyngoplasty(UPPP)– removaloftonsils,posteriorsolpalate,uvula
• TargetedHypoglossalNeurosFmulaFon– improvestonguemuscletonus
• Playingadouble-reedinstrument– lowerprevalenceofOSA
• Playdidgeridoo– comparabletoCPAPformild-moderateOSA
• WeightLoss BMJ.2006Feb4;332(7536):266-70.
JClinSleepMed.2012Jun15;8(3):251-5.
DtschArzteblInt.2018Mar;115(12):200–207MayoClinProc.2009Sep;84(9):795–800.Sleep.2015Oct1;38(10):1593–1598JClinSleepMed.2012Jun15;8(3):251–255BMJ.2006Feb4;332(7536):266–270
UPPP
THN Oboe Didgeridoo
MAD
MandibularAdvancementDevices(MAD)
• ReducerequiredposiVveairwaypressurewhenusedincombinaVonwithCPAP
• ComboTxbe(ertoleratedbymanypaVents• PaFentswithoutsevereupperairwaycollapsibilityandwithaweakerreflexofthroatmusclesweremorelikelytobenefitfromMAD(measuredbyPSG)– 93adultswithmoderatetosevereOSA– OSASseverity&BMIdidNOTpredictresponsetoMAD
AnnalsoftheAmericanThoracicSociety,2019;DOI:10.1513/AnnalsATS.201903-190OC
PLoSOne.2017Oct26;12(10):e0187032.
Excess Body Weight
Sleep Disorders NatSciSleep.2013;5:27–35
WeightLossImprovesDysomnia• Overweight/ObeseT2DMpaFents(meanBMI=36.7)andOSAwholost30lbsover1yearreducedtheirmeanAHIfrom23.2to13.5
• ImprovedOSAscorespersistedaler4yrs(meanchangeAHI=-7.7)despite(mean=15lbs)weightgain
• Decreasedvisceralfat(600Kcaldeficit+/-exercise)significantlyimprovedsleepsymptoms(insomnia,EDS,apnea)inoverweight/obese
ArchInternMed.2009Sep28;169(17):1619–1626.
Sleep.2013May1;36(5):641-649A
BehavSleepMed.2016May-Jun;14(3):343–350.
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Conclusions• Sleepdisordersareprevalentandcontributetovisionlossandmortality
• ECPsshouldaskpts/partnersaboutsleepquality/quanFty(STOP-BANG)
• ECPsshouldiniFatereferralforDxofhigh-riskpaFents
• ECPsshouldassess/treatocularsequelaeofsleepdisordersaswellaspossibleCPAP-relatedocularadverseevents
• ECPsshouldeducateonsleephygiene&therapies
Summary
ThankYou!
PaulChous
