Fisiopatologia Respiratoria e Disturbi nel Sonno: proposta di rete Antonio Foresi Direttore U.O.C. di Pneumologia e Fisiopatologia Respiratoria Presidio

Fisiopatologia Respiratoria e Disturbi nel Sonno: proposta di

rete

Antonio ForesiDirettore

U.O.C. di Pneumologia e Fisiopatologia RespiratoriaPresidio Ospedaliero di Sesto San Giovanni

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http://www.icp.mi.it/web/guest/

full hub/spoke/satellite service

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Specialità Strutture di degenza Servizi senza posti letto

Bacino Max Min*

Bacino Max Min*

Pneumologia 0,8 0,4 ? ?

* (x milioni di abitanti)

Bozza Decreto su “Definizione degli standard qualitatitivi, strutturali, tecnologici, e quantitativi relativi all’assistenza ospedaliera…” 9 Luglio 2014

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Sleep Medicine is a very prevalent disorders with effective treatments that change patients lives

Sleep Unit with polisomnograpy needs higly specialised personnel and complicated

technology. Sleep technology is a rapidly growing, advancing, and evolving field

Sleep Medicine is chronic care management discipline, not a diagnostic one

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Classification of Sleep Disorders - ICSD-2

Thorpy MJ - Neurotherapeutics (2012) 9:687–701@AForesi 7

Patologie sonno-correlate di maggiore interesse pneumologico

• OSA(S)• BPCO• Overlap syndrome • Apnee centrali• CSR-CSA• S. obesità-ipoventilazione (OHS)• DRS in corso di patologie neuromuscolari o

restrittive toraciche

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Functions and obligations of primary care and sleep units with respect to the handling of patients with OSA, or suspected of having OSA

Martínez-García M.A. – Breathe Review 2010

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Patologie respiratorie nel sonno: modelli organizzativi

• Pre-test evaluation• Screening/Referral

• Diagnosis• Treatment

• Compliance/Adherence• Follow-up

• Long term care• Costs

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risk factors commonly associated with OSA: obesity, gender (more common in men than women), age (more common in older age), hypertension and diabetes.

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Percent of UK hospitals delivering each service

ARTP Working Groups on Standards of Care and Recommendations for Lung Function Departments (2007)

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OSAS: Sonnolenza o fatica?

Su 197 soggetti :•Astenia : 62%•Fatica : 57%

•Stanchezza : 61%•Sonnolenza : 47%

Chervin RD. Sleepiness, fatigue, tiredness, and lack of energy in obstructive sleep apnea. Chest 2000;118:372–9

Cosa fare per inquadrare il paziente

Scala della sonnolenza di Epwort (ESS)Scala di autovalutazione della Fatica (FAS)Questionario SWIFT?

Questionario di valutazione funzionale del sonno

Ann Intern Med. 2014;161:210-220.

Masa JF, et al. Effectiveness of home single-channel nasal pressure for sleep apnea diagnosis. SLEEP 2014

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AUCs from ROC curves for the manual and automatic HNP home single-channel nasal pressure scorings,

based on AHI polysomnographic cutoff points

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Masa JF, et al. Effectiveness of home single-channel nasal pressure for sleep apnea diagnosis. SLEEP 2014

A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care

Chai-Coetzer C.L. - Thorax 2011;66:213-219 @AForesi 19

157 pts aged 25-70 years attending their primary care physician for any reason

patients with < o > AHI 30

performance of the OSA50

screening

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When GPs take an active role in screening and referral pathways then this is beneficial to the patient, the GP and the sleep clinic

BLF 2014






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•Up to 80 per cent of people with OSA have not been diagnosed

BLF 2014

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timely access to diagnostic services

Ann Intern Med. 2014;161:210-220. doi:10.7326/M12-3187

Night-to-night variability of apnea-hypopnea index in individuals having 2 in-laboratory polysomnograms

Respir Care 2010;55(9):1196–1212

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PSG

Respiratory polygraphyin sleep apnoea diagnosis

SWISS MED WKLY 2007;137:97–102 ·@AForesi 26

Phenotypes of patients with mild to moderate OSA as confirmed by cluster analysis

1184 consecutive patients AHI of 5-30/h, collected over 24 months

• REM predominant OSA, 44.6%• non-REM predominant OSA, 18.9%• supine predominant OSA, 61.9%• intermittent OSA, 12.4%

Joosten SA, et al. Respirology. 2012 Jan;17(1):99-107

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http://www.ncbi.nlm.nih.gov/pubmed?term=Joosten%20SA%5BAuthor%5D&cauthor=true&cauthor_uid=21848707


Comparison of supine-only and REM-only OSA

Gillman A et al. Sleep Medicine 13 (2012) 875–878

prevalence of supine-OSA varied from 23% (strict

definition) to 63% (lenient definition);

prevalence of REM-related OSA was 10%

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Sleep Med Clin 6;309–333;2011 @AForesi 30

PSG






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A Clinical Decision Rule to Prioritize PSG in Patients with Suspected Sleep Apnea

Rodsutti J; SLEEP 2004;27(4):694-9.

Reduction of AHI after automatic titration andmanual titration in 491 patients

Gao W et al. Sleep Breath (2012) 16:329–340

The CPAP after automatic titration and manual titration pressuredetermined by two titration methods involving

808 patients

Gao W et al. Sleep Breath (2012) 16:329–340

Residual sleepiness in obstructive sleepapnoea: phenotype and related symptoms

Vernet C. et al. Eur Respir J 2011; 38: 98–105@AForesi 37

CompSA has been reported to occur in 6% to 15% of

CPAP-treated OSAS patients

Can Respir J Vol 18 No 1 January/February 2011






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Aderenza alla terapia con CPAP

Aderenza alla terapia insufficiente se uso della CPAP inferiore a 4 ore/notte per il 70% (o meno) delle notti del periodo considerato

A livello mondiale tra il 5 e 25% dei pazienti con OSAS rifiuta l’opzione del trattamento con CPAP o ne abbandona l’uso entro la prima settimana di trattamento

Si stima che tra il l 12- 25% dei pazienti restanti abbandoni il trattamento entro i 3 anni dall’inizio .

L’aderenza del paziente al trattamento con la CPAP è il principale fattore che determina l’efficienza del trattamento stesso

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BLF 2014

An Official American Thoracic Society Statement: Continuous Positive Airway Pressure Adherence Tracking Systems. The Optimal Monitoring Strategies and Outcome Measures in Adults.

Clinical algorithm for using continuous positive airway pressure adherence tracking systems.

Published in: Richard J. Schwab; Safwan M. Badr; Lawrence J. Epstein; Peter C. Gay; David Gozal; Malcolm Kohler; Patrick Lévy; Atul Malhotra; Barbara A. Phillips; Ilene M. Rosen; Kingman P. Strohl; Patrick J. Strollo; Edward M. Weaver; Terri E. Weaver; Am J Respir Crit Care Med 188, 613-620.

CPAP Adherence Factors

RussellT. - Semin Respir Crit Care Med 2014;35:604–612.

• subjective adherence was 85.1% and objective adherence was 64.5%.

Respir Care 2013;58(9):1467–1473






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• In the United States, the Center for Medicare and Medicaid Services (CMS) requires at least one face-to-face contact between the 31st and 91st days of therapy with visual inspection of adherence data verifying use > 4 hours per night 70% of the time.






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BLF 2014

“coping with the CPAP mountain”

Prima

Oggi

Configurazione del moduloe abbinamento fra

paziente e S/N

Raccolta del consenso del paziente

Chiamata del tecnico allasede per attivare

la telesorveglianza

La soluzione tecnologica a domicilio

Schema di monitoraggio paziente OSAS






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Full-night PSG for diagnosis and CPAP treatment of OSA are highly cost-effective are robust within the ranges of input

parameter uncertainty. Diagnosis and treatment of OSA contributes to significant

increases in patient quality of life and substantial reductions in the risk of motor vehicle collisions, heart attacks, and strokes.

Pietzsch JB et al. SLEEP 2011;34(6):695-709.

Future of sleep medicine

• Budgetary constraints on the health care system make it unlikely that we will see any significant expansion of facility-based PSG resources

• Regional Networks to organise services and management strategies at a regional level

• Shifting from a focus on diagnostic testing to chronic disease management

• Focus on quality outcomes of care moving towards a patient-centered and outcomes-based delivery model

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Building a new model of Sleep-Lab

• Provide for diagnosis and treatment for all sleep disorders

• Balanced capability for in-laboratory and in-home sleep studies

• Define set of outcomes (OSA) sleep apnea symptoms, ESS, FOSQ, Fatigue, PAP compliance, blood pressure, HbA1C (for diabetics), and medication use

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• Lack of awareness of OSA amongst the general population • Lack of undergraduate training for medical and dentistry students • Lack of recognition of the key symptoms by general practitioners • Lack of widespread screening based on the key symptoms • Possible referral bias towards middle-aged overweight men amongst general practitioners • Lack of standardised, accredited training for sleep medicine health care professionals • Lack of standardised, specified service provision • People not coming forward: not thinking there is a problem; embarrassment; fear of losing driving licence; not knowing there is treatment

Barriers to treatment include:

BLF 2014

Brooks R, Trimble M. The future of sleep technology:report from an American Association of Sleep Technologists summit meeting. J Clin Sleep Med 2014;10(5):589-593.

CPAP

• France 500,000• UK 330,000• Italy 120,000-140,000

Sleep Medicine is chronic care management

discipline, not a diagnostic one

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Hanes et al. / Research in Social and Administrative Pharmacy j (2014) 1–16 @AForesi 66

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treating 500 patients for five years prevents one fatal accident, 75 injury accidents, and 224 property damage accidents, and that £5.3 million would be saved, with an estimated treatment cost of £0.4 million (12.3 times return on investment).

BLF 2014

Hanes et al. / Research in Social and Administrative Pharmacy j (2014) 1–16 @AForesi 68

1. Referral standards 2. Diagnostic and treatment standards 3. Patient review standards

5. Driving issues

• 1. There is a rise in demand for services • 2. There is variation in service provision

between and within nations in the UK • 3. There is a growing “follow up mountain” of

people on treatment • 4. There is a need to develop ways to

influence and support the commissioning / planning process

BLF 2014

BLF 2014

Alonderis A, Barbe F, Bonsignore M, Calverley P, De BW, Diefenbach K, et al. Medico-legal implications of sleep apnoeasyndrome: driving license regulations in Europe. Sleep Med 2008;9(4):362-75.

• The Canadian Medical Association recommends that if a physician believes their patient has a sleep disorder, and the patient refuses a sleep study or refuses to comply with treatment, the patient should not drive any type of motor vehicle

Canadian Medical Association. Determining medical fitness to operate motor vehicles: CMA driver's guide. 7th ed. Ottawa: Canadian Medical

Association; 2006.

The Canadian Sleep Society is finalizing a position paper on level III sleep studies. This is expectedto be published in the Canadian Respiratory Journal but the date of publication is not yet known[Personal communication, Dr. Helen Driver, Canadian Sleep Society, June 21, 2010].

Summary of cost analysis studies

PSG

• focus in sleep medicine is shifting from procedures to outcomes.

• This will require that the sleep center team integrate with other

• medical professionals, including primary care physicians,

• otolaryngologists, behavioral specialists, and dentists

• Sleepdisordered• breathing is a common public health problem• that affects an estimated 10% of 30- to 49-

year-old men;• 17% of 50- to 70-year-old men; 3% of 30- to

49-year-old• women; and 9% of 50- to 70-year-old women

Can Respir J Vol 20 No 4 July/August 2013

Key potential care gaps

• ASA / NATA web page : http://www.sleep.org.au/membersarea/accreditation

• (last accessed 24-6-13)

Documents

Fisiopatologia Respiratoria e Disturbi nel Sonno: proposta di rete Antonio Foresi Direttore U.O.C. di Pneumologia e Fisiopatologia Respiratoria Presidio