Dr. Benjamin D'Souza discusses the cardiovascular complications of obstructive sleep apnea and how to build a comprehensive screening practice for patients with undiagnosed obstructive sleep apnea.
Buddy, good morning. Uh, thank you for having me. Uh. So again, my name's Ben DeSouza. I'm the director of electrophysiology at the University of Pennsylvania, Penn Presbyterian up here in Philadelphia. It's nice to meet all of you. Virtually and I'm going to be talking for a few minutes about actually a topic that I myself am learning as we go, to be honest, and it's always humbling the new things that we can learn and sort of start to establish, but in particular, sort of the interplay of sleep apnea and in particular electrophysiology. I'm an electrophysiologist and a cardiologist as well, but do. I try to spend a little bit of time wearing multiple hats. Unfortunately, I'm wearing my Philadelphia Eagles hat, they're not, they're not doing too great these days, but um, I'm gonna start by showing a couple of cases and then sort of go through how we developed a program here at Penn to be able to help uh with sort of treating some of the comorbidities of our patients who have uh atrial fibrillation in particular. So let me just make sure you guys can see me dancing disco, all right. So this is actually a case of mine from almost 10 years ago now actually. I was a relatively new attending at that time, and I'm here in Philadelphia. We tend to get a lot of transfers. We're also the trauma center here at Penn Presby, so we get patients sent to us for multiple reasons. So I was on the, the, you know, the EP consult service, and this young woman was transferred to us. So she's a 40 something year old lady who really didn't have any significant medical history. She essentially lost consciousness while driving her car, which was always, you know, relatively terrifying for all of us and tends to be a sort of a difficult console because of the, you know, the. The issues related to, you know, licensing and driving, etc. So she had a very much normal workup at a local hospital in New Jersey and then was sent to us for further management, normal echo, normal stress test, but she did admit to sort of daytime somnolence and felt like she actually probably fell asleep while, you know, driving, which was of course concerning to us and was transferred to us at Penn for further evaluation. So I apologize, this EKG is a little bit hard, it's, it's 10 years old, um, but just showing sinus bradycardia, relatively long QT interval, but really nothing else of concern, but I was, I was worried about her just because of the presentation, um, and again. And the implications for her driving a car again or doing anything and, and so I actually did an EP study on her, which was completely normal, pristinely normal, normal, uh, HP interval. uh, I even did like a sinus node recovery time stuff that we don't really do an EP anymore. um, we gave her meds to increase her heart rate. Her QT sort of narrowed. I was concerned that maybe she had a ventricular arrhythmia and that's why she lost consciousness, but really didn't find anything of concern. So then I ended up putting a loop monitor in her. Now again, this was years ago, in fact, I just got a message from my scheduler today that she didn't realize the loop monitors we can actually pair with your smartphone now and they can transmit in real time, which is a sort of separate issue in terms of interpreting that data quickly. Unfortunately, this um young woman died in her sleep, so, uh, looking back at all of this, I think that she had untreated sleep apnea that was not. You know evaluated, uh, and treated, and you can see here that she actually, uh, it doesn't show the beginning of the strips, but she radied down and then went into VF. We actually have a patient right now in the hospital who had the exact same thing. Luckily he survived, um, and is going to get a defibrillator later today by one of my colleagues. You can also see here that the EKG was suspended after 2 minutes. Um, you can see that that the rhythm just goes into this sort of agonal Brady rhythm and then. This was before these loop monitors transmit in real time. So from the local hospital that was actually following her, the nurse called me and was worried, and I told them they actually had to call the police and broke down her door. She lived alone and she was unfortunately passed away in her bed. So I think this was one of the sort of early moments for me that recognized that untreated sleep apnea is not benign and it can cause some pretty dangerous things and obviously this patient died and so. Moving forward again. More recent consults, so this was actually, and I can say that probably on a regular basis we use Epic as our EMR. Just yesterday I got at least 2 or 3 messages in my inbox from my nurse practitioner with almost the exact same thing. So this is a gentleman who is semi-retired. Um, he works for, I'm sorry, I'm not supposed to say HVACS, so does heating and air conditioning, and was admitted to a local hospital again in New Jersey, um, that's where I see a good amount of our patients in addition to here in Philadelphia. Who had a PE and while he was on telemetry, he was noted to have significant pauses and potentially concern for high degree AV block. Um, here in Philadelphia, we have no shortage of folks who enjoy their cheesesteaks and lots of other unhealthy things while they watch my Eagles play. And so he was diagnosed with untreated sleep apnea and. There was a debate at the local hospital whether he should be transferred to us for a pacemaker. They don't necessarily do that at that hospital, so they called us and we decided to, you know, send him home with a halter. And again you can see here that he's got AV block. His PR interval, you know, doesn't really prolong, and, you know, you can also see at what time this was if you squint, it was at 12:30 in the morning. So, you know, this gentleman. There was a, you know, consideration whether we should put in, you know, a regular pacemaker or a leadless pacemaker, but what we did for him was really just encourage him to get his sleep apnea treated, which clearly these pauses were happening at night. They were not happening during the day. He did not have any history of syncope, but this is again another untreated cause of um, bradyarrrrhythmias. So I've showed you ventricular arrhythmias, bradyarrhythmias as well, and. Um, AFib is one that I spend a lot of time doing. Today I'm gonna do 3 concomitant, um, pulse field ablation and left atrial appendage closure devices Watchman's for patients that need them, and, um, I care about how these patients are gonna do and make sure that they don't have recurrence. So this is also a very common scenario that, uh, we get as well. Again, this is another, uh, loop monitor showing a patient. That at about, you know, right around now, 7 o'clock in the morning, had their first recurrence of AFib after an ablation. This was their only recurrence that happened, and this was while they were sleeping. So, again, there's a very strong interplay between atrial arrhythmias and sleep apnea, untreated sleep apnea, in particular, again, um, OSA, which is what we tend to see the most of in, in our, um, in our communities here, here in Philadelphia, which are probably very similar. And this is actually in the guidelines, so the AHA ACC HRS guidelines, um, uh, there's, you know, a statement that's been out, this is from 2021, but it's not changed, that essentially says that we are required to, you know, screen patients for obstructive sleep apnea, um, and, uh, it is a very much a reversible cause of atrial arrhythmias. And again, I'm part of a registry that um we have been publishing on for the last few years that essentially looks at outcomes data for our Afib ablations, and I think that as we try to move away from just doing more and more procedures and really quality of medicine and looking at these metrics, you know, we're looking at this at a health system-wide level now in terms of our our. Atrial fibrillation ablation outcomes and you can imagine that, you know, Medicare and CMS and private insurances are not going to necessarily pay for the 2nd, the 3rd, the 4th afib ablation. And so we really do need to pay attention to this stuff and I care about this too, so I want to make sure that the procedures I'm doing today on my patients that they do well. And so following that data and making sure that their outcomes are improved is important. And there's also very clear data that shows that atrial fibrillation ablation outcomes are tied to treatment for sleep apnea, and this is regardless of the modality, so whether they get an ablation or or a drug, or even just rate control. That their outcomes actually do better if uh we treat their sleep apnea, so it's very important in our patient population in my patient population to be able to treat these, and again, not benign. I've seen patients unfortunately die from the complications related to untreated sleep apnea. So, you know, we essentially determined this was important and that for our outcome selfishly, I wanna make sure that these patients do well, that I'm convincing them to come up and have a procedure with me today or you know, in the past. So what's the scope of the problem? It's actually pretty significant and so, you know, it can affect, you know, a large amount of patients, certainly, and again our obesity epidemic that continues here in Philadelphia and in the rest of the United States. It it is not a small number of patients, and I can say even today, I'll have our anesthesiologist when we're going to, you know, uh. Put the patient's under general anesthesia, they'll say this patient has, you know, untreated sleep apnea. They're obstructing right now as we're inducing, and I'll look back and say I didn't recognize that. No one's even diagnosed this. And so, again, in uh our patient populations, we tend to see more obstructive than central sleep apnea, though we do see a small subset that have uh central sleep apnea as well, but again, this airway obstruction leads to desaturations and again, I may diagnose some patients just today with the same thing. And the prevalence is quite high actually in our patients that I'm talking about that we're going to be putting pacemakers in today. We're doing ablations for their atrial fibrillation, which can be upwards of, you know, 50 to 60% of the patients, and I'm not even referring to, and again, I'm, I'm sort of covering patients that are EP. Related, but there's a very close inner tie with heart failure. And so, you know, mentioned I do a lot of work with CCM and cardiac contractility modulation. We started the carotid variim program here at Penn as well, and I partner with our colleagues in vascular surgery. So just, you know, we're we're trying to be sort of more. Holistic as we treat these patients, that's sort of one of the messages that instead of just being an ablationist, I, you know, I need to be an electrophysiologist, a cardiologist, and a physician and make sure that we treat all of these things. I think that's uh something that is very much a pivot in the way that we've tried to approach this in terms of trying to be a center of excellence for heart failure and for atrial fibrillation. So again, very high patient population. And again, as, as I sort of alluded earlier, it's actually these patients who have severe untreated sleep apnea that do the worst. Those are the ones that, you know, die suddenly of either Brady or tachyarrhythmias, and if you can get them to a lower risk, ideally no obstructive sleep apnea, but even to a mild level, you can see the data that their Kaplan-Miyer curves are better in terms of their cumulative risk of morbidity and mortality, so. Taking those patients that have, you know, high AHI, you know, indexes, apnea, hypopnea indexes, and sort of drive them down, truth be told, prior to a couple of years ago, I didn't, didn't even really know what AHI was to, to a level where I would, you know, recognize it and deal with it. But I think we recognized this was a problem, we had patients that were being untreated and needed to try to build a pathway and a program for us to be able to get these patients in with sleep medicine and with pulmonary and treat them however they felt appropriate to treat them, again, uh, as I sort of showed earlier, very high, um. Relationship between atrial fibrillation and obstructive sleep apnea, and a good percentage of them have at least moderate to severe obstructive sleep apnea that is untreated, uh, and so in our patient population, it's not a small number, it's a very high percentage, so we know it's a problem, we know that patients need to have it addressed. So what do we do about it? And again, as I had mentioned, not even, uh, again, I showed earlier some ablation, I think I we'll show some slides on this as well, data, but even patients who come in cardioverted, so we have probably maybe 4 or 5 patients today that are going to get the uh a cardioversion for new diagnosis of. Atrial fibrillation that was diagnosed by our cardiology colleagues or by internal medicine, etc. and we're gonna cardiovert them and then get them follow up with us uh in EP clinic after and that the risk of recurrence of AFib just from a cardioversion is almost twice as high if uh patients have untreated sleep apnea, so. Again, it's a problem, it's an issue in terms of being able to improve outcomes for patients who have atrial fibrillation, which, you know, is the number one arrhythmia that we certainly see in our patient population. And again, this is post ablation. This is older data, again, this, this is not with sort of the newest uh versions of pulse field ablation though, you know, we still have this debate that pulse field ablation, while we do believe it to be safer and has been widely adopted at Penn and I ran the clinical trials to get it FDA approved for the current iterations of uh PFA, it's not been a higher success rate, uh, that we've seen in the data as well. In fact, I have a text chain of all my friends that were all, you know, graduated from Pendent. Together that we're seeing recurrences, you know, a year out from the ablations we did last year. So it's not, you know, the holy grail in terms of treatment. The safety is obviously improved, but again, anything I can do to improve my outcomes for my patients is important to me, and it's important to all of us, I think. And so this is again older data that shows that the risk of recurrence of atrial fibrillation after catheter ablation, again, this was with radiofrequency ablation, which we still do certainly here at Penn for multiple arrhythmias, including ventricular. Was higher uh if the, and again, this is older data, so the outcomes I think are not indicative. The registry that I showed earlier from real AF we published at least in PAF of, you know, high 80s percentage for paroxysmal atrial fibrillation, but no matter what, anything that I can do to improve those outcomes is, is important for all of us. And so, and as I mentioned, the severity of atrial fibrillation is what is associated. So the severe sleep apnea patients are the ones that do worse regardless of what we do, whether we give them antiarrhythmic drugs, ablation, or even just a simple cardioversion, so. And again there are um a couple of risk factors that sort of add to this, and again I'm an electrophysiologist, not a sleep medicine physician, so I won't belabor the point, but uh a lot of these patients we see, and we do believe that this is largely related to structural modeling of the atrium, right? When we do, when I'm doing my ablations today. I'll make an electroanatomic map. We'll look at scarring. I, I try to look at what percentage of scarring occurs in the left atrium. Uh, we think that it's likely a helpful prognostic factor to be able to see if the patients are gonna recur, the mantra that Afib begets Afib and it damages, um, the atrium. But there are different um reasons for this. Obviously the hypoxia, the, the changes in intrathoracic pressure that occur leads to atrial dilatation, increases atrial arrhythmias, PACs in EP we have sort of two main, um, factions, so to speak. The trigger um idea which is uh one that we believe in a pen, meaning that a PAC gets into the circuit around the pulmonary veins and initiates atrial fibrillation. There's also a concept of rotors, debate within the EP community regardless, we, we don't really know for sure what is the etiology of atrial fibrillation per se, but conceptually it makes sense, um, and then hypercapnia increases, it actually changes conduction, uh, velocities of the atrium, uh, and. Contributes to atrial fibrillation and then over time this damage that occurs leads to further dilatation. I mentioned uh atrial fibrosis, um, and then decreases our ability to treat these patients effectively we largely know that as atrial fibrillation progresses, success rates of ablation and really anything that we do go down, so we try to intervene earlier in the disease process and sleep apnea contributes to this. And again, sort of uh just reiterating that concept of hypoxia or hypoxemia of the atrial tissue leading to that uh and then sort of pushing the disease mechanism and again, I'm only referring to and uh talking about atrial fibrillation. This obviously has wider implications in the cardiovascular space, whether it be hypertension, I mentioned heart failure, um, heart failure with preserved ejection fraction. I had a gentleman yesterday, I did his Afib ablation. He did not carry a diagnosis of really anything but Afib, and I checked his left atrial pressure, and it was 24, and he in sinus, so he has undiagnosed heart failure and preserved ejection fraction, and I'm gonna start to work through the process of screening him for obstructive sleep apnea, and he sort of has that body habitus for it as well, so I think that we have more and more recognized that this is. An issue and one that has widespread implications again for not just atrial arrhythmias, heart failure, coronary artery disease, stroke, pulmonary hypertension, he path, etc. um, and I have lots of interest in this patient population as well because it's sort of the number one thing that we see now, again, I am not um an ENT. I'm not a doctor that um. You know, places inspired devices. I'm not a sleep medicine physician, but I recognize that many times when I have now added to my, you know, sort of spiel of talking to patients, ask them about obstructive sleep apnea, um, their, their sleep, I'm gonna go through a little bit more of our process as well. And I can't tell you how many times I talked to a patient and nurse, they say, yeah, they told me to wear this mask thing, but I, I don't really like it. I, you know, it doesn't, I, I, I don't wear it and I'm not compliant with it. And so I think we've largely seen this and I kind of just rub my shoulders and continue to move on with talking to them about atrial fibrillation and ablation and stroke prevention, etc. I think we largely recognize that this is a problem even in patients who are diagnosed. I'm largely referring to patients who have not even diag diagnosed with um either OSA or CSA. So, great, we know that this is a problem, we know that this is a modifiable uh risk factor for atrial fibrillation and heart failure, so let's start screening our patients. Well, it's easier said than done, right? We only have so much time in the day. Um, I was just, we get our, um, patients fill out surveys on, on their, uh, office visits and, and, and largely mine were pretty good, but the one that I read from over this weekend, one of them said Doctor DeSouza was just really rushing to go through everything, and the problem is that I don't have enough time to cover everything, even in an office visit, and I'm an electrophysiologist who gets to just concentrate largely on one thing, meaning atrial fibrillation, but, um, but it's important, and we recognize that it was important, so. How do we screen our patients? What's the best way to do it? What do we do to be able to figure that out? How do we partner with our colleagues in sleep medicine and pulmonary to be able to get our patients in? And then when we diagnose them with OSA and we recognize that you know a nasal appliance or CPAP or BiPAP is not working for them, how do we get them in with ENT, right? So all of these were significant barriers to us to be able to build a program. And to be honest, what I used to say for years was you should probably follow up with your primary care doctor and um you know, be screened for sleep apnea, and most of my patients would tell me they didn't even have a primary care doctor or they couldn't get in with them for, you know, a significant amount of time or even when they were able to get in with them, they were not able to get in with sleep medicine as I sort of mentioned earlier, a large percent of my patients actually I see in New Jersey, I see patients almost 100 miles from from where I am right now doing my procedures and. They really didn't want to come up to Philadelphia to have a sleep study and and go sleep there as well, and they really didn't want to come up here for anything except for the ablation. So, um, you know, I always joke that in academic medicine, you know, we have a lot of people that help us to do these things and then I take all the credit for it, which I'm doing right now, but I do want to give uh a large amount of credit to my wonderful nurse practitioner Mary, so. Uh, Mary was doing her, uh, DNP project and said, you know, we're seeing all these patients, and usually the way it works is I see the patients first, I'll do their ablation today, and then they'll largely follow up with one of my nurse practitioners in clinic and follow up, so as. We're seeing them post ablation. Mary's talking to them about, you know, the medications, potentially coming off of anticoagulation, you know, appropriate monitoring for them post ablation, etc. but also trying to figure out how do we screen these patients for sleep apnea. And so what she did was, uh, again, this is a sleepiness scale, so you know MedCalp does all these things that we can calculate Chad's vas and has bled, etc. and more and more as insurance companies are denying the Watchman's that I'm going to be trying to do today, we really have to be careful about our documentation and and AI can help us with that. But um what she did very simply is basically put the, you know, this questionnaire. There are two main ones that are used in sleep. Again, we learned all of this kind of from scratch like there was really a process in place for us, so we built the stop bang questionnaire into our epic smart you know phrase so that we basically screened every patient for it that was coming in post AFib ablation or post treatment for their AFib and use this to help us sort of move forward and we sort of found that. Again, there's sort of two main ones. The Epworth sleep scale seemed to be a little bit more subjective and stop bang seemed to be a little bit more objective. So we ended up going with using the stop bang sleep score, and it's very straightforward to be able to utilize it. You could even potentially give the patients that, you know, we have them fill out some questionnaires prior to. We usually just ask them in the office when we're talking to them. Usually this happens. Again, not by me when I see them for the initial consultation, but usually in follow-up, but it can be done, uh, certainly at either, and then what we found was, all right, we can screen these patients relatively easily in follow-up, but. Our colleagues in sleep medicine were not, and I'm not trying to be mean about this, but particularly helpful in getting them in. So we had multiple meetings with our folks in sleep medicine, and you know, I would say that 6 months was a generous amount of time that they would be able to get them in. It typically it was close to a year, and patients give up at that point. They say, you know, I'm not waiting this long to be able to be evaluated. And so to get them in for an in-office, meaning in lab sleep study was, you know, again. 6 months at minimum and they had to travel. So I see patients all the way down in Cape May, New Jersey. They, you know, they say, Doc, I'll come up for the procedure for the ablation, but otherwise I'm not driving all the way to Philadelphia, um, you know, this is even before the pandemic and then after even more so they didn't want to come up and have this done and so. We really hit barriers sort of every way, every part along the road, so we tried to, and we started partnering with Watchpad, which is a Zole product, but there are multiple ones out there to do home sleep studies. It's actually, again, Mary did the bulk of this work and essentially. After she did the stop bang questionnaire, she would be able to use that to submit it to, you know, insurance to be able to get a home sleep study and again, without really knowing any of this stuff, we sort of built this program and it's gone, you know, quite well in terms of being able to screen these patients. I had never ordered sleep studies before. I would say, you know, I'm, I'm, I'm not great about ordering tests, to be honest. I typically wanna do procedures all the time, which I'm gonna be doing all day today. Uh, but we recognized that this was a problem and it was, you know, again tied to quality metrics in terms of how, uh, these patients do post ablation, so we, we did this, we started doing a home screening study, again, not to beat up on my sleep medicine colleagues too much, but they really didn't like that we were doing this. They felt the gold. Standard was an in-off, uh, in lab sleep study and really didn't want us to do this. They fought us on this, to be honest, but we felt that doing nothing and just sitting with the current process of waiting a year for these patients was not acceptable to us. So we started to do it. So what was our data? We basically screened about 200 patients. And about 75% of them were able to complete the home sleep study. Now, some of them were denied by insurance, but we actually were able to get a good percentage of them by, you know, including this, uh, questionnaire in our, uh, progress notes in our letters when we submitted it to insurance. And again we had sort of a team of people, MA's, uh, nurses, and our nurse practitioners that helped with this. We actually diagnosed almost 70% of our patients, and these are all post-Afib ablation patients that were seen by. Either an internist or or a primary care doctor, a cardiologist, so almost every patient who was sent to me is usually seen by a cardiologist first and me, and they went under general anesthesia and had a procedure done mostly and then uh followed up after. I will say I'm I'm pretty embarrassed that there was a really high percentage of these patients that we diagnosed. We were actually able to get them the sleep study within 2 weeks and then we partnered with one of my colleagues in sleep medicine, giving them this data and you can see sort of at the bottom it was largely split, you know, 25%, 25% in terms of what we diagnosed them with in terms of the severity, so uh. The helpful part was that we now had objective data that said this patient's AHI is 30 based on this home sleep study. Well, just like I can't ignore the epic inbox message that shows high degree AV block or ventricular arrhythmias, our sleep medicine colleagues couldn't ignore this data either, so they were able to get at least the patients that had severe sleep apnea and triage them appropriately. It also helped that we had sort of a personal, uh, you know, meeting with. Some of our sleep medicine colleagues have said, look, we really need to improve this process and we're able to identify um some colleagues that were able to help us with this and so we essentially built this pathway that we, we did the screening, we didn't defer to internal medicine, primary care or even cardiology we in EP did it. And begrudgingly did it, but I really did need to recognize that it was important. We developed it through Epic to be able to order this, get the patients home sleep studies, and then get them in with sleep medicine, and then from there it would be up to them as to what uh we determined would be the appropriate treatment. Obviously, um, you know, uh, CPAP and BiPAP is the mainstay of therapy and so for those patients that tolerated it and needed it. If it was nasal appliance or if it was referrals to our colleagues in ENT, we were able to establish some, some folks both on the Jersey side and the Philly side that had interest in implanting this device. Some of our ENT colleagues were comfortable with using the home sleep study to move forward with treatment. We largely have utilized sleep medicine and pulmonary. To to be the sort of decision tree for for that part, but at least address the problem and we're able to sort of get them in with that as well. So um I'll stop there, but again, I really haven't, there were no slides about Inspire or about the the the device, which I think is a really cool device. I've had patients that received it and have done well with it, but again. For me, the focus was how do we diagnose these patients? How do we get them in relatively quickly to be able to do this, and then from there, treatment options are the treatment options. I think it's been very rewarding. I'm not usually, I'm the one who gets patients referred to them, not referring out to other practitioners, but I think it's, I've learned a lot from this process over time and it's been a very rewarding sort of partnership with our colleagues in. Sleep medicine, the patients are happy and obviously that's the main focus of all of this. And again, we're publishing a lot of this data and uh we try to build these sort of quality initiatives to do better for our patients and and um and we're going to continue to learn through this process, but again, um I'll stop there and I'll I'll turn it over to Anthony to talk a little bit more about um the program that you guys have locally and happy to answer any and all questions as well. There we go, uh, can everybody hear me and see my slides? We can. Yeah, we sure can. OK, great. Uh, thanks. Most of you know me. For those that don't know me, I'm AJ Carranta with Centerra Pulmonary critical Care and Sleep Medicine. Little known fact is I did my internship and residency at a little known place, unknown place, Presbyterian Medical Center, 39th and Market Street, Ben, um, and uh walked the halls in the late 80s and early 90s with some of the leaders in your field and thought it was all kind of wacky. Uh, to say the least, uh, changed. I would be in the CICU and get these patients back from an 8 hour, 10 hour ablation from Marshalinsky and Gottlieb and Horowitz and all those leaders and thought this was just insane, and here I am talking to you guys, uh, 30 years, 40 years later about obstructive sleep apnea and, uh, and atrial fibrillation. So it's just a small world. Uh, my disclosure slide, I have nothing really to disclose, and as we all know, uh, OSA is a global health problem here in the states. It affects about 33% of adults aged 20 and older and. You know, putting it into number wise, it's over 80 million patients that have obstructive sleep apnea, that some of which aren't diagnosed, as you, as you know. And it leads to a lot of serious uh uh uh health uh concerns, uh, and, and organ disease, of which, uh, the cardiovascular are, uh, most important, um. The, uh, nat uh the uh um uh NSF survey which came out earlier this year, most of us believe, most Americans believe that it is a serious medical condition, OSA, uh, about 88%, and, and most of those, uh, surveyed think that it's worthy of treatment, right? It's it's a bad enough disease that you should be on some therapy, but. The majority of those surveyed aren't aware of all the treatment options available for uh obstructive sleep apnea. And this data was provided by Definitive Healthcare, which is a third party survey system, and looks at the ICD codes involved for the top diagnosis with Center Healthcare. And believe it or not, paroxysmal afib and OSA land in the in the top rung of the ICD 10 code. So it's, we are not immune to this. It's, it's here. These patients are here and it's a serious issue, and Uh, you've just heard about AHI, the apneaapopnea index, um, but this new term called hypoxic burden, which then sort of briefly went over, is probably the driver to everything downstream, right? So it's the, uh, it's the, uh, hypoxic burden is the duration of the desaturation, desaturating event, uh, the degree of desaturation and the number of events that puts stress on the cardiovascular system by. Interfering with baroreceptor and chemoreceptor reflexes. Um, And unchecked, as you heard, it causes a lot of uh cardiovascular problems, especially uh Afib, and it's these patients that we're really trying to find um uh uh that, that aren't treated, right? It's the patients that are on CPAP therapy or some other therapy that. Are taken care of, but patients that show up in your office, uh, and, uh, those that are showing up in the EP lab, uh, that are that aren't treated are the ones that we wanna, uh, hone in on. You know, in looking at patients over the course of 20+ years that I've been doing this, uh, you know, there's 3 major buckets of treatments, right? And oral appliances work. They work good for patients with mild sleep apnea, but not the patients that are going for Afib, afib ablations or patients that have untreated or hard to treat hypertensive disease. It's simply just not a device that's. acceptable for or works for patients with a huge hypoxic burden. Um, so you can kind of really just sort of throw that one out. Uh, so you're left with, uh, CPAP therapy, which is a pneumatic stent, right? So it's just the positive pressure opens up the airway, and then the third option is, uh, somewhat newer, right? It's been around since early 2000s and didn't get FDA approval until 2014 with the START trial. So it's really, uh, uh, you know, has been around for maybe about 10+ years, and it's a hypoglossal nerve stimulator. So, you know, a lot of patients that I will see when they come in with their wife or spouse or girlfriend, um, you know, simply refuse or say there's just no way I'm gonna put anything on my face to go to sleep with, so, you know, 50% of those patients, they'll say. You know, you can test me, but I'm not gonna wear a CPAP machine, so you're sort of left with a decision, well, what do I do, right? You know, do you, do you want me to help you or not want me to help you, right? And then there's this arbitrary rule, uh, of this 4 hours, 70% compliance to be compliant with your CPAP therapy. It's. really hasn't been well vetted. It's an arbitrary rule that the CMS looked at, and a lot of people lose their CPAPs because they simply don't, they don't qualify under, under the guidelines for keeping their CPAP. And then over time those that are using CPAP will wane in using their CPAP, right? So over, over a year or two years you lose about 50% of those patients and they never come back to us, right? They'll never come back. They put it in the closet, they send it back, they sell it on eBay or whatever, and they're lost to follow up until they show up in your office. So those are the patients that um we, we struggle with. We know that CPAP therapy is the gold standard um uh but what do you do with these patients that are refusing CPAP therapy? So, like I said, uh the newer device now is uh that is in our bag of tricks is the hypoglossal nerve stimulator and inspires taking the lead on this, and I, I, uh, consider it our pacemaker. Um, but it is, um, now, um, a simpler device. It has an accelerometer built into the generator, uh, that measures inspiratory, uh, an expiratory breath sensation, uh, and it has a lead, a lead with a cuff that is wrapped around, uh, the distal end of the hypoglossal nerve, and. Going back to physiology 101, your hypoglossal nerves, your cranial nerve 12. It is a uh motor nerve, not sensory nerve that in the distal branches innervate the genioglossal muscle, which allows the tongue to move in an anterior position. Hopefully, um. This is going to work. It's working on my computer. I don't know if you see it, but, uh, the sensing lead is now inside the device. Um, it senses both inspiration expiration. It delivers the pulse during inspiration, and hopefully you can see, uh, the tongue movement. It's an anterior movement of the tongue during stimulation and it relaxes, uh, during expiration. Uh, and again, let's get this to work hopefully. Oops. I'm sorry, let's see if I can do this. So, um, on the left side is a patient who doesn't, who has obstructive sleep apnea, and on the right side is the patient with uh a hypoglossal nerve stimulator, and you can see the difference. It's not, again, it's not as good as CPAP therapy. But it does reduce the burden uh of the AHI and left unchecked, we already heard from Doctor DeSouza the, the complications, the end organ complications of cardiovascular system. So this is now a tool that we can use for patients who simply refuse to wear a CPAP, uh, who, um, uh, uh, fail therapy after a number of years and can't get, can't get used to the CPAP pressure or. They, they lost to the DME for for getting supplies replaced or they simply can't afford the supplies and they lost their insurance. So there are some checks and balances on who can, who's an acceptable candidate for the inspired device. It's not only AHI, but it's their BMI as well, and they have to go through a stepwise process and see if they're a candidate. They need to have the anterior collapse as opposed to the circumferential collapse. So in summary, just real quick. Uh, you know, think about obstructive sleep apnea, as Doctor DeSouza said, and patients that you're seeing in the office who have poorly controlled hypertension or come in with arrhythmias, um, you know, go through the screening questionnaire to stop bang is the best thing we have. The higher the score, the more likelihood of the, uh, of cardio end organ cardiovascular problems and the higher the sensitivity, and please check with them that they're compliant with their therapy, um, and again, you know, we don't have a mechanism like. Uh, pen does, but, uh, um, you can call me, text me, um, refer to Centera Pulmonary Critical Care Medicine, or go on the Inspire website if they tell you that they're simply not going to wear CPAP, at least you can, uh, refer them to an Inspire physician, uh, for evaluation of, uh, hypoglossal nerve stimulator. So that was my 10 minute spiel. Um, if you have any questions, be happy to answer them as well.
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