Criteria For Diagnosis Of Obstructive Sleep Apnea

Living With and Managing Sleep Apnea

JIM: I had this problem throughout my life. Driving was always a problem, and I tried to make sure that no place I ever had to go was very far away because I knew I'd fall asleep. Carol Lynn was complaining about snoring and, more specifically, snoring and then long periods of nothing,

and then a gasp when I would, you know, start breathing again. Obviously, I wanted to enjoy my life with my children more than I felt that I was enjoying it. It's Saturday morning, and the kids are at your bed ready to do something, and I'm just like, quot;I gotta sleep, guys. I'm sorry. I can't play with you. I can't do this.quot; And I look back and I'm like, quot;This just can't be right.quot;

I had been talking to my about possibly having depression symptoms. I remember the other thing that I said to the when I went was that I no longer had any dreams. If you're not getting into REM sleep, you have no dreams. And so she's the one who then said, quot;Okay, we're gonna send you for a sleep study.quot; I spent the night there.

The amount of times that I was technically waking, and as low as my blood oxygen levels were, it was extreme. I was diagnosed with severe obstructive sleep apnea. Surgery, as it turned out, really wasn't a good option for me. The next step was that my did prescribe a CPAP machine. CPAP stands for continuous positive airway pressure.

The idea is they have to get the air pressure to your nose or your mouth or both in order to keep your airway open while you sleep. Because it wasn't comfortable for me to use, I was not using it as well as I should have been, in some cases not at all for weeks at a time. And things got worse, other symptoms appeared. I felt confused and out of it and just not right.

And I realized that I really needed to figure out a way to learn to live with this contraption. Now I'm at the point where I am consistently using it and have been for a long period of time. I definitely feel better. I'm looking forward to feeling better yet. Certainly, I have more energy to do activities with the children than I did before, and we do more.

InHome versus InLab Sleep Disorder Studies

Typically everyone used to be evaluated inthe al setting versus at home. But as things are evolving with insurance companies,fewer companies are actually paying for the in lab studies. So I would say the majorityof our practice has become using the inhome sleep studies. If we're just looking for primarysleep disorders such as obstructive sleep apnea that in home study is very effective.If we are concerned about some other type of parasomnia, movement disorders, those typesof things, those would need to be done in lab where we have more extensive monitoring.Also things like narcolepsy we would send somebody to the lab. If we decide to do aninhome sleep study we would set you up for

an appointment to come back to meet with ourrespiratory therapist and she would help you determine where to put all of the little electrodesthat we use. You have some that go on your chest and some that go under your nose. Soshe would teach you how to set that up for yourself when you get home as well as a littleflow sheet on what to do. You can bring a family member as well to help you remember.Then you take the the equipment home that night with you and basically just do whatshe told you to do as far as hooking everything up and then you go to sleep in your own bedand sleep normally how you would normally do and then the next morning you would getup, take everything off and return the equipment

to us. We would download the information thatwe were able to obtain from that and determine whether you met criteria to diagnose you withsleep apnea or another sleep disorder. The main things that we measure for a home sleepstudy is we measure your oxygen levels and we also measure if we have decreased in yourflow of your breathing or if your breathing actually stops altogether.

2015 Atrial Fibrillation Patient Conference Managing AF Risk Factors Panel

Wilber: Well thank you. This is really,I think, a topic that I look forward to talking to people about and I think more and moreit's assuming increasing importance in how we take care of patients. We're going to tryto do a broad overview. We're going to focus specifically on diabetes, sleep apnea andexercise as 00:00:30 potential risk factors and how they can be modified in our care ofpatients with atrial fibrillation, but we'll try to give your broad overview of some ofthe other topics as well. So although I'm going to mostly talk about obesity today andatrial fibrillation, we'll talk about a couple of other things as well.

There are a variety of risk factors for atrialfibrillation and this was initially, I think, mostly of interest to epidemiologists, peoplewho study how disease, what the prevalence of it is, and how it comes to pass. I thinknow we've really begun to understand that central role, not only in sort of understandingthe disease but really in treating it, and if we don't consider these as we treat patientsthen I think our outcomes are not nearly as good as they might be otherwise. This is the traditional list and I think thereare probably even a few more. I've starred a few of them where I think that the evidencenow is becoming very clear that these are

potentially modifiable and that's really whatI want you to take home today. These aren't static risk factors that cause something andthen there's nothing you can do about it but treat the consequences, but in fact by intervening,both early and late, you have a chance to modify the disease and improve outcomes. What that means for you as patients is thatyou have to participate in your care and that's really something I want to emphasize; andif you're not invited to do so, then you must insist on doing it. Because I think your outcomesfor atrial fibrillation really depend on how you address each of these risk factors asthey apply to you individually.

Just to briefly talk about hypertension; wewon't spend a lot of time. It's certainly important; it's one of the most common riskfactors associated with atrial fibrillation. Somewhere between 60% and 80% of patientswho have atrial fibrillation in large populations studies have at least hypertension as a riskfactor, and by itself may account for the 20% to 25% of the overall risk of new onsetatrial fibrillation. There's some evidence that systolic bloodpressure probably plays a more important role than diastolic blood pressure, but there'sno clear threshold value. When you look in large population studies, each increment insystolic blood pressure is associated with

the increasing risk of atrial fibrillation.There's no sort of magic number necessarily that if you get below, your risk of atrialfibrillation goes away. It's probably reasonable and what I like to use as a therapeutic targetis somewhere around below 13080. What that means is that that's even below the sort oftraditional guidelines for treatment of hypertension, but it's very clear that even mild elevationsof blood pressure within the range of what we would call normal can still confer afibrisk. There's no clear superiority of one drug overanother although the control of atrial fibrillation certainly can improve the symptoms and thefrequency with which you have atrial fibrillation.

It's not clear that any single drug is absolutelybetter. There's some evidence that ACE inhibitors and ARBs, which are drugs that many of youmay be on to treat your hypertension, may be particularly beneficial, particularly whenyou have relatively advanced hypertension with end organ involvement like thickeningof the heart muscle, the left ventricular hypertrophy, as we call it. But there's also evidence that uncontrolledhypertension as you start antiarrhythmic drug treatment and after catheter ablation, ifyou enter into that with poorly controlled blood pressure, in fact, you have much pooreroutcomes than if your blood pressure is controlled.

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