Screening Obstructive Sleep Apnea - Part II
Risk factors for obstructive sleep apnea (OSA) include obesity and high blood pressure; having diabetes increases that risk by 40-50%. Considering that half of all Americans have a one or more of these conditions, it is likely that many of your patients have undiagnosed OSA, due either to a lack of awareness, focus on the treatment of other diseases, or an attribution of OSA symptoms to the disease or reaction to treatment.
When screening for OSA in your patients, here are a few more things to consider:
Coverage
CMS will cover treatment if results show AHI or RDI greater than or equal to 15. Treatment will be covered with as few as 5 events/hour, however you have to make the case for your patients. Make it known that they have comorbid issues such as hypertension, sleepiness, ischemic heart disease, insomnia, or mood disorders that exacerbate the disorder and its consequences.
For continued coverage and clinical benefit of CPAP, a patient must use it for a minimum of four hours each night.
Am I going to die?
If a patient asks you whether they are going to die in their sleep, you can comfortably tell them “No.” Even though that has happened, sleep apnea is not a rapid killer. It slowly increases the risk of death over a period of years because it increases the risk of so many other deadly factors.
However, if a patient has severe hypoxemia (60-70), then you should tell them that they are at risk of dying and should move to treat the disorder immediately. However, typically this is a long term issue.
You’re treating the disease…finally!
What are the most effective treatments for severe OSA?
Continuous Positive Airway Pressure
Managing patients with OSA with CPAP requires TLC. They are completely changing their sleeping habits, which for most patients takes quite a bit of time. To smooth the process, suggest some behavioral therapy at the outset.
1) Have the patient avoid alcohol and nicotine, as well as sleep medications (both alcohol and sleep medication can induce respiratory suppression).
2) Suggest weight loss when applicable
So what can you do to help an uncomfortable patient?Education, education, education.
Stress that CPAP takes time (sometimes as long as 6 months) to get used to. Tell your patients that their face will learn to get used to wearing the mask during sleep. Suggest that they wear it while awake to get used to it, but don’t let them quit.
Add heated humidity for improved airflow. If that doesn’t work, change the mask. Use bilevel pressure after other remedies have failed. Other remedies are cheap and fast and bilevel pressure requires the patient to undergo another sleep study.
Highlight the effectiveness of CPAP for them. If they know the benefits (decreased sleepiness, improved executive function, lower risk of car accidents, a decrease in healthcare costs and hospitalizations, improved glucose control blood pressure, reverses ED) they will be more likely to commit to treatment. Patients will be easier to work with in terms of compliance.
Physical and mechanical treatments
If your patient can’t come to terms with CPAP (and some never do) move on to oral appliances like a mandibular advancement device. However, be aware that the patient will need a follow-up sleep study to understand whether the device is working.
Surgery is indicated in very rare cases, but the evidence does not support it as a general treatment. No medication is indicated for the treatment of OSA.
The presenters did express their desire for more data on treatment efficacy, hoping that it would shed light on which patients do better with particular treatments.
