Part 1: OSA Basics

Dr. Jessica Vensel Rundo, MD, MS, explains OSA results from airway collapse and obstruction during sleep, which often causes the person to wake up with or without oxygen desaturation.

As the director of the Sleep Fellowship Program at Cleveland Clinic’s Neurological Institute’s Sleep Disorders Center, Dr. Rundo gives an overview of the basics of OSA, including how it is defined and characterized. With an overall understanding of the key factors that play a role in OSA, the public can be better informed to diagnose and appropriately treat OSA.

Additionally, Dr. Rundo states the prevalence of OSA is underestimated and underdiagnosed – despite known risk factors and comorbid conditions. In the article, she details OSA symptoms, risk factors, gender, age, race, obesity, comorbidities, screening and diagnostic criteria in the article.

“Screening for OSA with a sleep history, simple upper airway examination, and quick validated screening tools aid in identifying the need for testing for OSA,” Dr. Rundo states in the article.

Learn more from Dr. Rundo, here: bit.ly/OSA_Basics

Part 2: Sleep apnea and the heart

Dr. Reena Mehra, MD, MS, Director of the Sleep Disorders Research Program of the Sleep Disorders Clinic at Cleveland Clinic’s Neurological Institute, explains the correlation between sleep apnea and the heart.

A person’s normal sleep-wake cycle is characterized by daily variations in blood pressure, heart rate and cardiac events. However, when someone has sleep apnea, it disrupts the sleep-heart interaction, affecting their pathophysiology, according to Dr. Mehra.

“OSA (obstructive sleep apnea) is a nocturnal physiologic stressor that is highly prevalent and under recognized,” Dr. Merha states in the article. “It affects approximately 17 percent of the adult population and the prevalence is increasing with the obesity epidemic. Nearly 1 in 15 individuals is estimated to be affected by at least moderate OSA.”

If left untreated, sleep apnea may increase the risk of chronic cardiovascular events, such as heart failure, stroke and obesity, the article states. Sleep apnea can also increase the risk of cardiac arrhythmia due to higher levels of inflammation, intrathoracic pressure and carbon dioxide.

“The increase in inflammation and oxidative stress is thought to alter the cardiac electrophysiology of the heart and contribute to structural remodeling of the heart that increases the risk of cardiac arrhythmia,” Dr. Mehra explained.

Using a CPAP with continuous positive airway pressure may help to reduce the risk of cardiac events associated with sleep apnea.

Learn more from Dr. Mehra, here: bit.ly/OSA_Heart

Part 3: Beyond heart health: Consequences of OSA

Dr. Harneet Walia, MD, FAASM, an associate professor at Cleveland Lerner College of Medicine of Case Western Reserve, goes beyond heart health and explores additional health concerns related to sleep apnea in part three of the series.

“Obstructive sleep apnea (OSA) is a serious condition that impacts quality of life and causes drowsy driving and depression,” Dr. Walia, a staff member of the Sleep Disorders Center at Cleveland Clinic’s Neurological Institute, stated in her report within the five-part supplement article to the Cleveland Clinic Journal of Medicine, titled “Obstructive Sleep Apnea: A wake-up call for better outcomes.” Additionally, “poor quality of life, metabolic disease and cognitive impairment” are also negative consequences of obstructed sleep apnea.

Several proposed factors are possible explanations between sleep apnea and depression, including: poor quality of sleep, frequent arousal and fragmented sleep. Sleep apnea may also cause metabolic syndrome and hypertension, which lead to an increased risk of cardiovascular disease and overall mortality.

“Recent data points toward the bidirectional relationship between sleep and Alzheimer’s disease in that excessive and prolonged neuronal activity in the absence of appropriately structured sleep may be the reason for both Alzheimer’s disease and OSA,” Dr. Walia reported. “Treatment of OSA improves many of these health consequences, emphasizing the need for OSA treatment.”

Learn more from Dr. Walia, here: http://bit.ly/OSA_Consequences

Part 4: Positive airway pressure: Making an impact on sleep apnea

Dr. Colleen Lance, MD, medical director at Sleep Laboratory at Hillcrest Hospital, Sleep Disorders Clinic Center, Neurological Institute, Cleveland Clinic, explains how positive airway pressure is making an impact on sleep apnea.

“Positive airway pressure (PAP) devices deliver a pressurized column of air to open the airway in patients with sleep apnea,” Lance stated in her portion of the report.

“For patients with moderate to severe sleep apnea, PAP therapy is the gold standard for treatment, with demonstrated improvements in daytime sleepiness and cardiovascular measures that are superior to conservative treatments,” Lance added.

The American Academy of Sleep Medicine practice guidelines for PAP conclude that a CPAP (continuous positive airway pressure) is the superior conservative treatment that eliminates respiratory disturbances, reduces the apnea-hypopnea index, the arousal index, and daytime sleepiness, as well as increases the total amount of slow-wave sleep.

However, adhering to PAP therapy is a challenge for many patients for a variety of reasons, the largest being comfort, which results in decreased frequency and duration of use. Common complaints include facial discomfort, lack of humidity and pressure intolerance.

“Today’s PAP devices have features designed to make them easier to use and more comfortable to improve adherence to therapy,” Lance said. “Facial interference options, heated humidifiers, tubing accessories, cleaning devices, reporting of compliance data via telecommunication, and pressure adjustment features of PAP devices may improve patient adherence and comfort.

Lance goes on to say that other innovative strategies, like motivational enhancement, desensitization protocols and advanced device features are being used to address issues with adherence.

Learn more from Dr. Lance, here: http://bit.ly/PAP_Impact

Part 5: Alternative intervention for obstructive sleep apnea

Dr. Tina Waters, MD, Sleep Disorders Center, Neurological Institute, Cleveland Clinic, shares insight about alternative interventions for obstructive sleep apnea for patients who cannot use PAP (positive airway pressure) therapy.

While PAP therapy is considered the “gold standard” for OSA treatment and has been shown to positively impact quality of life and cardiovascular outcomes, not all patients with OSA can tolerate PAP therapy.

“Alternative interventions to PAP include lifestyle measures, surgical interventions, hypoglossal nerve stimulation (HNS), oral appliance therapy (OAT) and expiratory PAP (EPAP) devices for OSA,” Waters said.

Lifestyle interventions may include weight loss, exercise, avoiding alcohol and other non-related medications. Additionally, certain sleep positions may also help OSA.

Waters explained there are several surgical interventions, such as those that target the location of upper airway obstruction, that may also improve OSA. These may include removing the tonsils, the posterior surface of the soft palate and uvula and closing the tonsillar pillars, as well as bariatric surgery.

“Upper airway stimulation is also a new, fully implantable treatment for patients with OSA,” Waters said. “The system consists of an implanted pulse generator (IPG). Stimulation through the IPG is delivered to key airway muscles, which are controlled by the hypoglossal nerve, primarily the genioglossus muscle responsible for tongue protrusion. The device can be turned on and off with a handheld sleep remote.”

Additionally, oral appliance therapy (OAT) – whether they’re custom-made or pre-fabricated – helps to keep the jaw forward and stabilize it to maintain a more controlled airway during sleep. While custom-made OATs are preferred, all OATs should be prescribed by a qualified dentist.

“Nasal EPAP therapy is a new treatment that consists of a mechanical valve worn in each nostril at night,” Waters explained. “The valves have a low inspiratory resistance and a high expiratory resistance thus increased pressure occurs at exhalation.”

Learn more from Dr. Waters, here: http://bit.ly/Alt_Interventions