Sleep Apnea Identification and Treatment

Podcast Transcript

Raed Dweik, MD:

Hello, and welcome to the Respiratory Exchange Podcast. I'm Raed Dweik, chairman of the Respiratory Institute at Cleveland Clinic. This podcast series of short, digestible episodes is intended for healthcare providers and covers topics related to respiratory health and disease.

My colleagues and I will be interviewing experts about timely and timeless topics in the areas of pulmonary, critical care, sleep, infectious disease, and related disciplines. We will share information that will help you take better care of your patients today, as well as the patients of tomorrow. I hope you enjoy today's episode.

Hello, everyone, and welcome to the Respiratory Exchange Podcast. I'm your host, Raed Dweik, chairman of the Respiratory Institute at the Cleveland Clinic. And our guests today are Dr. Loutfi Aboussouan, who is the director of the Neuromuscular Clinic in the Respiratory Institute and Dr. Reena Mehra, who is the director of sleep disorders research in the Neurological Institute with a joint appointment in the Respiratory Institute as well. Our topic is going to be sleep apnea or sleep disordered breathing. Right? So, welcome.

Loutfi Aboussouan, MD:

Welcome. Thank you.

Reena Mehra, MD:

Thank you so much. It's a delight to be here.

Raed Dweik, MD:

Okay. So, let's start with the very basics here. You know, if you're a physician taking care of patients, who do you think of that they have sleep apnea that should be sent for testing, you know? Maybe start with you, Loutfi.

Loutfi Aboussouan, MD:

Yeah. I think it's very important. The most common sleep disordered breathing is sleep apnea, and I think it's very important to consider symptoms. And I think I would urge perhaps physician to include snoring in the review of system. I think it's ignored in there, and I think it would be important to include it there, because that's one of the most important features.

And of course, there are other components of the disorder that may lead someone to think about sleep apnea, gasping or choking at night. Sometimes there are witnessed episodes of apneas by bed partners. Waking up with a dry throat, to me, is an important marker, morning headaches, waking up unrefreshed, and sleepiness, daytime sleepiness. So, to me, those are important features a doctor should be aware of to question the diagnosis.

Raed Dweik, MD:

So that's all history, and anything else, you know, in history, or maybe are there any physical exam features you look for?

Reena Mehra, MD:

Yes. Absolutely. So, we typically will do a thorough upper airway examination to get a sense of soft tissue upper airway anatomy, craniofacial structure. If there's micrognathia or retrognathia, there can be craniofacial structural alterations that lend people to be at increased risk for obstructive sleep apnea.

A nasal exam as well, septal deviation, for instance, nasal obstruction can be part of the pathophysiology of sleep apnea, usually not the entire picture, but can also impact the ability of the individual to tolerate positive airway pressure as well.

So, the symptoms, as Dr. Aboussouan mentioned, and some of the physical examination findings, and of course, obesity, overweight obesity, which can be a risk for sleep apnea. And, in totality, there's a pretest probability that can be ascertained from the STOP-BANG instrument, which is an instrument that we commonly use that encapsulates some of the common symptoms as well as physical examination findings.

Raed Dweik, MD:

Yeah. I'm glad you brought that up, because I'm thinking of a busy clinician, whether a primary care physician or a pulmonary or a specialist. Like, they have so many things they have to go through. So, what's a quick way? It looks like the STOP-BANG is a quick way to assess sleep apnea. Is that any way you can comment on that?

Loutfi Aboussouan, MD:

Yeah. I think the STOP-BANG is an easy tool. It focuses on findings a patient could report to you, so that would be S-T-O-P for the STOP, the snoring, tiredness, observed apnea, or the presence or treatment for blood pressure.

And then the B-A-N-G, BANG would be more exam findings or demographic findings, the body mass index. A cutoff of 35 is a risk. Age. A cutoff of 50 is a risk. The neck circumference, 16 inches for women, 17 inches for men. And the gender. Uh, being a male is a risk factor.

So, this would be a simple eight item tool that will give you a good probability. If you have three or more of those positive checkpoints, then the probability is high and would warrant an evaluation.

Raed Dweik, MD:

Are these, like, embedded like NEHRS now, at least the symptom part the patient can fill ahead of time, or that we are not there yet?

Reena Mehra, MD:

So, with our sleep study order at the Cleveland Clinic, it is integrated to help then guide even the kind of diagnostic testing you would like to order. So, for instance, it will pull some of the demographic characteristics like age and gender and things like that, and then can help at least fill in some of those fields, and you can complete the rest of it.

And if indeed, as Dr. Aboussouan said, if there are three or more of those characteristics that are positive, that indicates high pretest probability for obstructive sleep apnea. That would then affect which kind of diagnostic testing route you would go in terms of consideration of, for example, home sleep apnea testing or even a split night study, for instance, if there's high pretest probability for obstructive sleep apnea.

Raed Dweik, MD:

Yeah. I'm glad you brought up testing, because that's kind of the next step. First, there's suspicion. You do the history and the exam. You suspect it. So, testing.

So, in a, if you are a generalist, like a pulmonary generalist or primary care physician, should you test for sleep apnea? Or should you refer early? Or is it better to test first? And if you're going to test, what kind of testing would you do?

Loutfi Aboussouan, MD:

A lot of that depends on the comfort of the, uh, practitioner. So, we have a lot of internal medicine doctors who are very comfortable going ahead and proceeding with a test themselves, and a lot of our referrals are actually from, from that.

The sleep studies we read, you know, there's a substantial proportion is not from a specialist sleep but from an internist and sometimes a urologist, for some reason, are picking up on sleep apnea because of nocturia, and they're comfortable ordering the test.

So, it really depends on the level of comfort. So, they're welcome to refer but also doing the test is easy. As Dr. Mehra mentioned, the setup of the order set is very streamlined to guide them as to you know, what you look for. It will immediately pick up certain items of the STOP-BANG and guide them that this may be somebody for whom a home sleep apnea test might be more important or more appropriate than a polysomnogram.

Raed Dweik, MD:

Yeah. For some things, like there are screening tests and then diagnostic tests. Is that something that, that approach exists for sleep apnea? Or do you just go for the whole thing, or not? How do you approach, you know, sleep apnea for diagnosis?

Loutfi Aboussouan, MD:

For diagnosis, we would go with a home sleep test. You know, that's, especially if the pretest probability has determined by the stomp, STOP-BANG three items or more that are positive. If that probability is high, then we would go with a home sleep apnea test.

We do tend to modify that. For example, if you suspect somebody has a significant comorbidity, a heart disease, a neuromuscular problem, COPD, heart failure, so anything that may confound the interpretation of the test, particularly because of hypoxemia or other things, so in which case, we tend to favor a full attended sleep study, the polysomnogram in the lab as opposed to home sleep apnea test.

Raed Dweik, MD:

So, yeah. I'm hearing more and more that these home sleep studies are becoming the standard now. So, is that, is, like, the polysomnogram at the hospital gone? Or is it an option for some patients but not others? What's your approach, Reena?

Reena Mehra, MD:

I think there's a role for both. So there, if there's high pretest probability, and the individual's otherwise healthy, and it's quite straightforward, then doing a home sleep apnea test is most of the time sufficient to really get a sense if there's presence and severity of sleep apnea.

If there is more complexity to the clinical picture c- underlying cardiopulmonary disease, neurologic disease, and complexity there, for which you really need to better ascertain certain aspects of sleep physiology, then polysomnography will serve you better.

And we also advise that, you know, if home sleep apnea testing is not consistent with a diagnosis of obstructive sleep apnea in an individual who you're highly suspecting has sleep apnea, then really, one should proceed to do a full polysomnography, which is a more comprehensive test and gives a better sense of the presence of obstructive sleep apnea.

Raed Dweik, MD:

Yeah. That's a good point. Thank you for clarifying that. So now we suspect sleep apnea. We did sleep study. We diagnosed it. Next steps are treatment. Any one of you to want to take on the treatment approaches?

Loutfi Aboussouan, MD:

Treatment, well, there are some first line options. Definitely CPAP, uh, PAP therapy is the first line option. Our sleep dentist will say also that an oral appliance may be a first line option, for certain patients. So, we try to tailor a little bit to the patient and their preferences.

If we are talking, though, about a significant morbidity, somebody who has significant impairment, daytime sleepiness, I think the best option to provide them quick and effective treatment would be, would be CPAP. There may be some reluctance on, on the part of some patients.

But it's interesting how many patients actually come in informed. They've spoken to neighbors. They've spoken to friends. They've spoken to others who will relate to them that they've had a good experience or a bad experience with, with CPAP. And they're actually willing to give it a try. Most of them actually come in with the expectation that this will make a big difference in their life.

So, we usually start with CPAP, in part because it's quick. It can achieve control of sleep apnea quicker, whereas oral appliances may require fitting, clearance with insurance, modification of the appliance before they end up at a steady state level.

Raed Dweik, MD:

So, these are the two common modalities to start with, the, the appliances, the mouth appliances, and the CPAP. So, so like the CPAP, let me ask you, Reena, about this.

You know, we all have patients who take the CPAP, and they use it, and they swear by it. It transforms their life. They sleep well. They have more energy the next day. And you know, they travel with it. They take it with them everywhere. And there are these patients who really just, like, can't stand it. So, can you comment on that a little bit, about your experience with those?

Reena Mehra, MD:

Absolutely. It's very interesting, actually, how there's such interindividual variability with the receptiveness to positive airway pressure and then also the benefits of positive airway pressure.

So, and it oftentimes doesn't correlate. One would think that with increasing severity of sleep apnea, one would be able to derive more benefit from the treatment with continuous positive airway pressure. But we oftentimes, interestingly, don't see that.

So, I think really, it is explaining that obstructive sleep apnea is to the patient in terms of, you know, upper airway collapse and the ramifications of lack of treatment of obstructive sleep apnea and how that impacts quality of life and health in terms of trying to overcome any barriers to receptivity.

And in terms of responsiveness, as you mentioned, you know, there really is just such variability. If patients are coming in with symptoms such as profound fatigue, sleepiness, you know, we oftentimes will steer them in the direction of continuous positive airway pressure, because we know that will be effective in splinting all aspects of the airway, irrespective of where the collapse is occurring. We'll address the root cause of the pathophysiology of sleep apnea and then translate it into improvement of any symptoms that are related to that untreated obstructive sleep apnea.

Raed Dweik, MD:

Yeah. Makes, that makes a lot of sense. And you know, you just don't prescribe CPAP and let them go. Right? You have to follow up on the CPAP. There are a lot of issues that come up that you have to deal with. So, can you tell us, like, what are the, some of the issues that come up long term when somebody's on CPAP and how to handle them? Yeah.

Loutfi Aboussouan, MD:

That's a very important point. I think one important thing to realize is that it seems like the adherence or acceptance of CPAP is increasing over time, and that's in face of very objective ways to determine that. The machines are actually reporting this adherence. And, uh, what we see is adherence to the 75 percent range. A few years ago, perhaps it was around 50 percent.

So, there are clear improvements in the adherence, and I think we can attribute that to careful attention to what are the impediments to using CPAP? It could be the mask that's not fitting well. Takes two to three masks perhaps before we find the one that fits the patient.

Treating problems perhaps like septal deviation. This could be, or nasal congestion could be an impediment to that, so we have heat, humidifiers that can help with that. Or other things.

The mask itself. The mask designs now are much better, much more comfortable. The interface touching the skin is actually much more comfortable. The gel they use is more pleasant to feel, so the leaks are much better. So, there are a lot of advances that are helping.

So, I think what we need to be careful about is, okay, you're having trouble using CPAP. Tell me exactly what's wrong. Why is it you're not using it? Is the pressure too high? Are you finding there's too much leak? Is the mask coming off your face at night? Maybe it's not fitting right. Is it uncomfortable because it's putting pressure at the bridge of the nose? And for each of those, we have solutions that we can investigate.

Raed Dweik, MD:

Has the technology also gotten better, like things like DPAP and stuff? Can you speak how the ramping up and ramping down, is that, has that helped in any way.

Reena Mehra, MD:

So, yes. There's different ways and modalities with continuous positive airway pressure to administer it. So, there's the standard static pressure that can be administered.

And more recently, we are starting to use auto positive airway pressure device approaches, so the devices work through different algorithms to detect the resistance in the airway. And once it detects that resistance, if that is high, it can adjust the pressure accordingly to address any obstruction in the airway.

So theoretically, this may allow the patients to be more adherent, be more comfortable with the device. If they perhaps have more positional sleep apnea where sleep apnea is worse on their back or worse during REM sleep, in particular, then the device can make these adjustments when the sleep apnea is more prominent and go down on the pressure when the sleep apnea is not as present.

Raed Dweik, MD:

That's great. I think that's probably more comfortable, you know, for the patients and staff. So, you know, as a physician, you've, you know, suspected. You identified. You treated with CPAP. Is there any reason to refer to a sleep specialist? You know, where's the role of the sleep specialist here?

You know, clearly a lot of, there's a lot of sleep apnea out there. A lot of it is taken care of by primary care physicians and, you know, general pulmonary practitioners. When is the time to refer to somebody like you, who you do this, like, for a living?

Loutfi Aboussouan, MD:

Yeah. I think what's important there is the follow up, but because we just prescribed CPAP and we delivered it to the patient, and the patient is using it, doesn't mean we stop there. Perhaps this is where the sleep specialist comes in.

The machine, as I said before, actually provides a lot of information. They provide adherence data, but also, they provide information on whether sleep apnea is controlled, whether there are leaks from the mask.

They also, for some machines, will kind of categorize the types of residual events that are occurring, central apneas, obstructive apnea, vibratory snore, flow limitations. These are all flagged by the machines.

And I think the fine reading of these little details may be better in the hands of a, of a sleep specialist. They're difficult to obtain. This information may not be readily available to a general practitioner. But these are things we routinely do in our clinic and they're important. They do make a difference in the way we treat these patients, so they're important.

So that's where I think seeing the patients perhaps after they've been set up, just to make sure everything is okay, and of course, if there's a problem, if the patient isn't accepting the device for one reason or another, then I think a referral to us would be important, because the first experience with CPAP, the early experience with CPAP can be a determinant of long-term acceptance. So, the sooner they adapt to it, the better they are.

Reena Mehra, MD:

If I could also add, I think it depends a lot on the comfort level of the primary provider. There are some primary providers who are very comfortable managing standard obstructive sleep apnea if it is very straightforward.

And then, if there are major issues with adherence that they're not able to overcome, or if there's complexity of underlying pulmonary or cardiac disease that is complicating a kind of straightforward obstructive sleep apnea picture, say central apnea concomitant with obstructive apnea or treatment emergent central apnea, for instance, then when it gets more complex, they'll refer to a sleep specialist. So, I think it really depends upon the comfort level of the provider.

Raed Dweik, MD:

So, I'm hearing there's no general rule about referral to a sleep specialist. It depends on the level of the comfort of the practitioner, you know, but also how well the patient is doing, I guess, like almost like any other specialty. Just, you know, go to the specialist when you're having difficulty managing the patient.

What about follow-up studies? Like now a patient is being treated with CPAP or an oral device and coming along and stuff. Do you have to repeat the sleep study every year, every few years, or only when there's an event or change of status? What's your approach to that?

Loutfi Aboussouan, MD:

The devices we have, the modern devices, are almost equivalent to running a titration every night, in a way. It's not exactly that, but the machine is reporting control. And so, I personally do not feel a need to repeat the sleep studies very frequently.

Sometimes, we run into inevitable insurance roadblocks. A sleep study was done before Medicare on a patient with a certain criterion, and now Medicare is asking for different criteria. Sometimes this may trigger a study to requalify the patient.

But in general, once the patient is smooth sailing with a CPAP, I prefer not to order another, another sleep study, as long as I'm getting reliable information from the device on control and leaks.

Reena Mehra, MD:

And patients will follow up with us if they're smooth sailing, usually every six to 12 months. So that provides the opportunity to pick up on any, say, worsening of symptoms. Say they initially derive benefit, no longer deriving benefit, or the data from their downloads suggests that they're not being optimally treated for their sleep apnea any longer.

Or if there's a change in weight or change in health status factors, for example, heart failure that becomes a new diagnosis or new pulmonary diagnosis, for example, then it requires kind of a clinical reassessment of the situation and then determining if we need to do another sleep study to better figure out what's going on with the physiology.

Raed Dweik, MD:

That's great. I think change of status in general is time to reevaluate and decide. So we focused our treatment option on CPAP, which clearly is the most common and seems the most beneficial. But, uh, I heard from you earlier about the oral devices. But what are the other alternatives to CPAP that we have for treatment options for sleep apnea?

Reena Mehra, MD:

So oral appliances are an option, and in particular an option for mild obstructive sleep apnea. Once obstructive sleep apnea is more on the moderate to severe degree, then it tends to not be as effective.

So, the oral appliances are typically these mandibular advancement devices that work by pulling the mandible forward by increments, and then in an effort to open up the posterior airway. And some individuals will do fine.

Now, if somebody's edentulous, for example, they're not a candidate for an oral appliance, so there are factors to take into consideration. And it is a process, so there's gradual sort of adjustments that are being made to the device, and then a reassessment to see whether or not those adjustments are effective in treating the sleep apnea.

Other treatment options include hypoglossal nerve stimulation or the Inspire device is the trade name. And that essentially involves an implantable device that has a lead that goes to the nerve that enervates the tongue to help stimulate the nerve to keep the airway open. So that is now becoming more of an option for our patients, in particular who have severe obstructive sleep apnea and who meet other criteria.

Raed Dweik, MD:

Yeah. I'm sure that probably there's a lot of interest in hearing about this. Maybe you can elaborate on this device. I don't know if either one of you can elaborate more on what it takes to have one. Who's the candidate? What does it involve? You know, is it covered by insurance? Maybe things like that. Can we talk more about that?

Loutfi Aboussouan, MD:

Yeah. I think maybe one of the most important qualifications for that is the type of collapse, the way the collapse occurs. So, the patient will require direct evaluation of the airway under anesthesia, so an ENT physician will do that to look at the pattern of the airway collapse.

So of course, because the device advances the tongue forward, it's a hypoglossal nerve stimulation, you want to have a predominant, anterior posterior collapse. That's how it works best. So, if there's concentric collapse of the airway, the patient may not be a candidate, because there's a sideway collapse of the airway as well. So that's one of the qualifications.

And I think we still follow the guidelines from the original study where they identified the inclusion criteria, so the BMI would have to be 135. There has to be a certain degree of sleep apnea as well. But I think and, and I feel that as the comfort with this device increases, those parameters will probably, probably change as well.

Raed Dweik, MD:

How long has this been around? Is this sort of a newer therapy?

Loutfi Aboussouan, MD:

The first study was 2014, I think.

Raed Dweik, MD:

Yeah.

Reena Mehra, MD:

Yes. The pivotal trial was published in 2014, and then different institutions have established these centers of excellence, so it really requires a multidisciplinary approach to the implantation of the device and then follow up in terms of the management of the device and any changes in the voltage or parameters that need to be made to make sure that there's effective treatment of the obstructive sleep apnea.

Raed Dweik, MD:

So, it's really a surgical procedure, right? You have to be implanted as it takes surgery, right? Usually, ENT surgeons do this?

Loutfi Aboussouan, MD:

Usually it's an outpatient, same-day procedure, from what I understand.

Raed Dweik, MD:

Yeah. Okay. But then you have to qualify. You have to be the right, have the right disease. But I'm sure there's some insurance issues that you have to clear through as well.

Yeah. All right. This has been great, and we went to great lengths into how to suspect sleep apnea, how to diagnose it, and how to treat it, and newer options. Maybe just go back to the beginning and just talk about how common it is and what are the health effects, firstly? Why should we even treat it in the first place? I don't know if either one of you wants to take that on, how common it is and, you know, why should we be treating it? Yeah.

Loutfi Aboussouan, MD:

Yeah. So, it's actually quite common, and it seems like the prevalence is increasing. There are some studies showing a 26 percent prevalence of sleep apnea and consequential sleep apnea, maybe as much as 10 percent. There are recent epidemiological studies. And I've seen one saying that a billion people on the planet have sleep apnea.

Raed Dweik, MD:

Whoa. That's a big number.

Loutfi Aboussouan, MD:

Yeah. So, you can imagine the consequence of that is that it's significantly underdiagnosed. Right? So, a high index of suspicions is needed. Patients need to be aware of that. I was recommending inclusion of snoring in the review of system; I think just to catch more people.

And I think the tools we have now, particularly home sleep apnea tests, allow us to perhaps cast a wider net to be able to catch this diagnosis. And the consequences, you know, maybe Dr. Mehra can address that. She's very adept at a lot of the research in that area.

Raed Dweik, MD:

Yeah.

Reena Mehra, MD:

Yes. So, with an upper airway occlusion, when the airway collapses, then there's these intermittent bouts of hypoxemia that occur in even the reoxygenation phase, which is thought to be a phase where there can be increased oxidative stress.

Autonomic nervous system fluctuations can also occur where there's enhanced parasympathetic tone during the event and sympathetic surges after the event. Changes in our intrathoracic pressures, which can basically affect mechanically the heart and have an impact in particular on the thin-walled atria. And then rises in CO2.

And then this intermittent sort of nature of these respiratory events as they're happening during sleep also add to the pathophysiology of sleep apnea, and therefore, the long-term health consequences in terms of increased cardiovascular risk, increased neurologic disease risk as well.

Raed Dweik, MD:

Yeah. It has a lot of negative consequences, so it's very important to treat. So, thank you both. This was really very informative. I'm trying to kind of see if we have some takeaway messages for our listeners here.

One, I think, we start from the very end, that sleep apnea or obstructive sleep apnea is a very common disease, like I heard, like the first time I heard a billion people on the planet may have it. That's a lot.

It has major health effects, so that's very important to have a high index of suspicion. And we talked about the STOP-BANG approach too for physicians to recognize sleep apnea in patients. The mainstay of diagnosis is either home sleep study or a full-fledged polysomnogram in the hospital.

And CPAP is the mainstay of therapy. There are other options like oral devices, and also most recently, hypoglossal nerve stimulation. So, there are options to treat sleep apnea. Anything else to add, either one of you?

Loutfi Aboussouan, MD:

One of the consequences, of course, is excessive daytime sleepiness. We talk a lot about the long-term consequences of obstructive sleep apnea, the cardiovascular consequences, but the short-term consequences, of course, are excessive daytime sleepiness and the increased risk of car accidents. So, I think, uh, that is consequential too. We need to be aware that's a big problem.

Raed Dweik, MD:

Thank you both and thank you to our listeners today. Again, this is Raed Dweik, chairman of the Respiratory Institute at the Cleveland Clinic. Our topic today was obstructive sleep apnea, and my guests were Dr. Reena Mehra who's the director of the sleep disorder research at the Cleveland Clinic, and Dr. Loutfi Aboussouan, who is the director of the neuromuscular program. So, thank you both and thank you to our listeners for listening. Have a great day.

Thank you for listening to this episode of the Respiratory Exchange Podcast. For more stories and information from the Cleveland Clinic Respiratory Institute, you can follow me on Twitter @raeddweikmd.