Admission and Care of Complex

Patients to Your Sleep Lab.

Focus Fall 2016 Conference; The 35th Annual Michael Aeillo Resp Care and

Sleep Medicine Conference

Steven A. Thau MD

October 27th, 2016

Conflicts: Regretfully no signing

bonus in the last hour! JP Morgan Chase Home Mortgage, HELOC

Barnard College

SUNY Binghamton

SAR High school

BCDS

I’m hoping that will change between now

and my 3rd talk!!!

Once Upon a Time…

Every patient had a PSG.

Almost everyone had a CPAP titration.

(needed a therapeutic pressure).

>95% of the sleep studies were done for

people with a high probability of severe

OSA.

Techs complained about split nights. (Yes,

some still do).

Real life- 2016

HST’s siphon off most of the straight

forward OSA’s.

Almost no one under the age of 65 has a

PSG.

Many of the obvious cases have already

been diagnosed but they are still out there.

The age and comorbidities of the patients

having a PSG has increased.

What Makes a Patient

“Complex”?

Clinical conundrums: Why is this patient so

sleepy? What makes the patient so violent at

night? Why does the patient go into asystole

at night?

Comorbidities- Bad brain, bad heart, bad

lungs etc.

Aging population.

Often means sleep apnea other than OSA.

Morbidity of OSA

Cardiac Arrhythmia/MI

Systemic Hypertension

Pulmonary Hypertension

Sleep Fragmentation

Impaired QOL

Increased Mortality- both cardiac and MVA’s

(from decreased reaction time= DWI

Central Sleep Apnea

Hyperventilatory

Hypoventilatory

Hypoventilatory w/ hypoxemia

CPAP, Bilevel w/ Back up rate.

ASV

O2

Chest Wall Disease

Severe kyphoscoliosis.

Malformation, trauma to the rib cage

Severe pectus excavatum

Neuromuscular disease

Completely reversible (Guillain-Barré

syndrome)

Reversible with treatment (MG)

Relapsing (MS)

Relentlessly progressive (ALS)

Difficulty with clearing secretions

Neurologic disease

Post CVA

Dementia

Seizures

Parasomnias

Muscle twitching.

Neurologic disease

RBD

Nocturnal seizures

RLS/PLMD

Concommittant OSA

Cardiovascular Disease

CAD/angina.

Arrhythmias- atrial and ventricular

CHF

Alveolar Hypovetilations

OHS OSA

Bilevel

Bilevel + O2

Capnography/ EtCO2

Transcutaneous capnometry

SUMMARY

Epidemiologic data to support an

association between OSA and multiple

comorbidities and physiologic data that

demonstrates a link.

Positive pressure has been used in ICU’s for

years to treat patients with CHF and

hypoxic resp failure but also used to treat

other conditions since there is more

comfortable non-invasive modality for

“stable”outpatients.

SUMMARY

Good data to support treatment- reverses negative

effects.

Relatively inexpensive when compared with other

modalities. (All the benefits of a beta-blocker

without the impotence! In fact, improves libido.)

Need to ask the questions! Won’t recognize OSA

unless you do. (~ guessing BP)

– DO YOU SNORE?

– IS YOUR SLEEP REFRESHING?

CONCLUSION

Sleep disturbances have huge medical

implications. Over treatment, under

treatment, fractures etc.

Problem will likely get worse since patient

population is aging and most “simple”

patients are getting HST.

It behooves everyone to know about these

other conditions.