Obstructive Sleep Apnea in the Primary Care Setting: Screening and Beyond

Pri-Med West Wednesday, April 27, 2011 9:30 – 10:45 am

Sponsored by pmiCME

Session 2: Obstructive Sleep Apnea in the Primary Care Setting: Screening and Beyond Learning Objectives 1. 2. 3.

Describe how evidence-based screening and diagnostic guidelines can improve the care of patients with obstructive sleep apnea (OSA) who are at-risk for diabetes and cardiovascular disease. Identify and implement practice-based procedures to screen, diagnose and refer patients with, or suspected of having OSA to sleep specialists. Co-manage patients with OSA and encourage continued monitoring and compliance with CPAP therapy.

Faculty Barbara Phillips, MD, MSPH Professor Pulmonary, Critical Care and Sleep Medicine University of Kentucky College of Medicine

Barbara Phillips, MD, MSPH, received her MD from the University of Kentucky, College of Medicine in 1977 and her master of science in public health from the University of Kentucky in Lexington in 1991. She completed her internal medicine residency and pulmonary fellowship training at the Medical College of Virginia in Richmond. Dr Phillips is currently professor of pulmonary, critical care, and sleep medicine in the Department of Internal Medicine at the University of Kentucky, College of Medicine. Dr Phillips is board-certified in internal medicine, pulmonary medicine, critical care medicine, and sleep medicine. She directs the Sleep Center at the University of Kentucky Good Samaritan Hospital in Lexington. Additionally, Dr Phillips serves on the Board of Regents of the American College of Chest Physicians (ACCP), on the Medical Advisory Board of the Federal Motor Carriers Safety Administration of the Department of Transportation, and as chair of the Steering Committee of the Sleep Institute of the ACCP. She is immediate past-chairman of the National Sleep Foundation, and has served on the boards of the American Lung Association, the American Academy of Sleep Medicine, and the American Board of Sleep Medicine. She has received a Sleep Academic Award from the National Institutes of Health and has served on the advisory board to the National Center on Sleep Disorders Research. Nancy Nadolski, FNP, MSN, MEd, RN Northwest Pulmonary and Sleep Medicine Boise, Idaho

Nancy Nadolski is a family nurse practitioner. She is currently the clinical director of insomnia medicine at Northwest Pulmonary and Sleep Medicine, a multidisciplinary practice that specializes in adult and pediatric pulmonary and sleep disorders. Ms Nadolski has authored sleep-related articles for a variety of nursing audiences and is currently completing her second book, Raising a Family of Good Sleepers, which is due to be published in 2011. An avid conference speaker, Nancy has presented at the 3rd International Nurse Practitioner Conference in Groningen, Netherlands, as well as state and national advanced practice nursing conferences around the country. She has an interest in women’s mental health, including depression, anxiety, and menopausal sleep problems.

Faculty Financial Disclosure Statement The presenting faculty reported the following: Dr Phillips has no relationships to disclose. Nancy Nadolski has no relationships to disclose.

Session 2

Education Partner Financial Disclosure Statements The content collaborators at Athena Education Group, LLC, have reported the following: Wendy Gloffke, PhD, has no relationships to disclose. Nike Gazonas, MS, has no relationships to disclose.

Drug List Generic fluticasone mirtazapine physostigmine

Trade Flonase Remeron Antilirium

Suggested Reading List Alattar M, Harrington JJ, Mitchell CM, Sloane P. Sleep problems in primary care: a North Carolina Family Practice Research Network (NC-FP-RN) study. J Am Board Fam Med. 2007;20:365-374. Gami AS, Pressman G, Caples SM, et al. Association of atrial fibrillation and obstructive sleep apnea. Circulation. 2004;110;364-367. Available at http://circ.ahajournals.org/cgi/content/full/110/4/364. Hiestand DM, Britz P, Goldman M, Phillips B. Prevalence of symptoms and risk of sleep apnea in the US population. Chest. 2006;130:780-786. Netzer NC, Hoegel JJ, Loube D, eat al. Prevalence of symptoms and risk of sleep apnea in primary care. Chest. 2003;124:1406-1414. Punjabi NM, Caffo BS, Goodwin JL, Gottlieb DJ, Newman AB, et al. Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med. 2009;6(8):e1000132. doi:10.1371/journal.pmed.1000132. Shaw JE, Punjabi NM, Wilding JP, et al. Sleep-disordered breathing and type 2 diabetes. A report from the International Diabetes Federation Taskforce on Epidemiology and Prevention. Diabetes Res Clin Practice. 2008;81:2-12. Victor LD. Treatment of obstructive sleep apnea in primary care. Am Fam Physician. 2004;69:561-568,572-574. [Includes a patient information handout] Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea. Am J Respir Crit Care Med. 2002;165:1217-1239.

Session 2

Objectives

Obstructive Sleep Apnea in  the Primary Care Setting:  Screening and Beyond

• Describe how evidence‐based screening and diagnostic  guidelines can improve the care of patients with  obstructive sleep apnea (OSA) who are at‐risk for  diabetes and cardiovascular disease • Identify and implement practice‐based procedures to  screen, diagnose and refer patients with, or suspected of  having OSA to sleep specialists 

Nancy Nadolski, FNP, MSN, MEd, RN  Clinical Director, Insomnia Medicine Northwest Pulmonary and Sleep Boise, ID

• Co‐manage patients with OSA and encourage continued  monitoring and compliance with CPAP therapy 

Barbara Phillips, MD Professor of Pulmonary, Critical Care and Sleep Medicine University of Kentucky School of Medicine Lexington, KY

Why Obstruction Occurs During Sleep

What is Obstructive Sleep Apnea (OSA)?

• Supine position • Control of breathing during normal non‐rapid eye movement  sleep • Lack of “wakefulness” drive – Minute volume decreases about 16% – PaCO2 increases 4‐6 mmHg  – SaO2 decreases as much as 2% • Decreased tone of pharyngeal muscles • Depressed reflexes, including pharyngeal dilator • Depressed response to hypoxia in men • REM sleep decreases tone of intercostal and accessory  muscles, less effect on diaphragm; depression of minute  volume, increase in CO2 not as great, depression of response  to hypoxia greater

• Recurrent episodes of upper airway  obstruction  during sleep • Apnea: ≥ 10 sec between breaths • Hypopnea: Shallow breathing; low respiratory rate • Characterized by recurrent arousals and episodic  oxyhemoglobin desaturations during sleep 

1. Patil SP, et al. Chest. 2007;132(1):325-337.

Pre-test ARS

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Pre-test ARS

How likely are you to screen for OSA in a  patient with diabetes and normal BMI? 1. 2. 3. 4. 5. 6. 7.

How likely are you to screen for OSA in a  patient with refractory hypertension?

Very likely  ‐ ‐ ‐ ‐ ‐ Not very likely

1. 2. 3. 4. 5. 6. 7.

1

Very likely  ‐ ‐ ‐ ‐ ‐ Not very likely

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Pre-test ARS

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Pre-test ARS

How likely are you to screen for OSA in a  patient who reports daytime sleepiness? 1. 2. 3. 4. 5. 6. 7.

1. Screen high‐risk patients (e.g., obese, large  neck circumference)  2. Screen AND evaluate patients using validated  tools 3. Screen, evaluate AND refer patients to sleep  specialists 4. Screen, evaluate, refer AND co‐manage  patients with OSA 5. I don’t perform any of these activities

Very likely  ‐ ‐ ‐ ‐ ‐ Not very likely

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ARS

Clinical Practice Recommendation

Mrs. Pancheli’s physical exam and history increase her  risk for  obstructive sleep apnea (OSA). A large neck is  also a risk factor. Which of the following neck  circumferences is the lower threshold associated with  an increased risk of OSA in women? 1. 2. 3. 4.

• Practice Recommendation:  The risk for obstructive sleep apnea correlates on a  continuum with obesity,  large neck circumference, and  hypertension. Combinations of these factors increase the  risk for OSAHS in a non‐linear manner. 

10 inches 12 inches 14 inches 16 inches

ARS

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Which of the following do you perform in your  practice?

• Evidence‐Based Source:  Institute for Clinical Systems Improvement  • Web Site of Supporting Evidence: http://www.icsi.org/sleep_apnea/sleep_apnea__diagnosis_ and_treatment_of_obstructive_.html

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Risk Factors for OSA

Compared with men with obstructive sleep apnea (OSA), women with OSA are less likely to:

• • • • • •

1. Be obese 2. Complain of insomnia and nightmares 3. Have had their bed partner report snoring or  witness apneas 4. Be over 60 years of age

Obesity1,2 Male gender (until about age 50 years) Postmenopausal state3 Upper airway anatomic obstruction African‐American, Asian, or Hispanic ethnicity1,3,4,5  Being a football player6 or truck driver7

1. Kripke DF, et al. Sleep. 1997;20(1):65-76. 2. Tsai WH, et al. Am J Respir Crit Care Med. 2003;167(10):1427-1432. 3. Young T, et al. Sleep. 2003 Sep;26(6):667-672. 4. Stepanski E, et al. J Sleep Res. 1999;8(1):65-70. 5. Li KK, et al. Laryngoscope. 1999;109:137-140. 6. George CF, et al. Sleep Med. 2003;4(4):317-325. 7. Gami AS, et al. N Engl J Med. 2005;352(12):1206-1214.

2

Obesity and OSA Risk: Recent Studies • Excess weight increases both risk and  consequences of OSA1 – Increases severity of oxygen desaturation during/after apneas and hypopneas

• Prevalence of undiagnosed OSA is high among  obese patients with type 2 diabetes (86.6%)2

1. Peppard PE, et al. Am J Respir Crit Care Med. 2009;DOI: 10.1164/rccm.200905-0773OC. 2. Foster GD, et al. Diabetes Care. 2009;32(6):1017-1019.

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ARS

Screening for OSA in the Primary Care  Setting1‐3

Mrs. Pancheli’s tests are negative for anemia,  hypothyroidism, and other causes of fatigue.   In your practice, which of the following do you do next to  assess Mrs. Pancheli’s fatigue? 1. 2. 3. 4.

– Epworth Sleepiness Scale1 – University of Texas, School of Nursing, Family Nurse  Practitioner Program2

Epworth Sleepiness Scale (ESS) Multiple Sleep Latency Test (MSLT) Functional Outcomes of Sleep Questionnaire (FOSQ) Maintenance of Wakefulness Test (MWT)

• Strength of Recommendation: A; Quality of Evidence: Good

1. Johns MW. Sleep.1991;14(6):540-545. 2. Available at http://www.guideline.gov/summary/summary.aspx?ss=15&doc_id=9436&nbr=5057#s23. 3. Elliott AC. J Am Acad Nurse Pract. 2001;13(9):409-417.

Epworth Sleepiness Scale (ESS)1 • How likely are you to doze off or  fall asleep in the following  situations, in contrast to just  feeling tired? This refers to your  usual way of life in recent times.  Even if you have not done some  of these things recently, try to  work out how they would have  affected you. 

• Sitting and reading

• Use the following scale to chose  the most appropriate number for  each situation: – 0 = would never doze – 1 = slight chance of dozing – 2 = moderate chance of  dozing – 3 = high chance of dozing

• Lying down in the afternoon

Typical ESS Scores1 Subject

• Watching TV

Normal controls Primary snorers OSA Narcolepsy Idiopathic hypersomnia Insomnia

• Sitting, inactive, in a public  place • As a passenger in a car for an  hour • Sitting and talking to someone • Sitting quietly after a lunch  without alcohol • In a car, while stopped for a  few minutes in traffic

1. Johns MW. Sleep. 1991;14(6):540-545.

Mean ESS 5.9 6.5 11.7 17.5 17.9 2.2

1. Johns MW. Sleep. 1991;14(6):540-545.

3

OSA and Chronic Primary Care Conditions Condition 

OSA Prevalence

Morbid obesity  Hypertension Drug‐resistant hypertension  Congestive heart failure  Coronary artery disease  Angina  Atrial fibrillation  Diabetes 

>75%1,2 35%‐45%3 >80%4 30‐50%5‐7 30%8 30%9,10 49%11 40%‐50%12,13

Whom to Screen in Primary Care?1 • Patients with hypertension and a BMI over 27  kg/m2 should be questioned about: – Snoring – Witnessed apnea – Irregular breathing during sleep – Restless sleeping – Chronic morning fatigue

1. Somers VK, et al. Circulation. 2008;118(10:1080-1111. 2. Somers VK, et al. J Am Coll Cardiol. 2008;52(8):686-717. 3. Sjöström C, et al. Thorax. 2002;57(7):602-607. 4. Ruttanaumpawan P, et al. J Hypertens. 2009;27(7):1439-1445. 5. Le Jemtel TH, et al. J Am Coll Cardiol. 2007;49(15):1632-1633. 6. Sin DD, et al. Am J Respir Crit Care Med. 1999;160(4):1101-1106. 7. Ferrier K, et al. Chest. 2005;128(4):21162122. 8. Schäfer H, et al. Cardiology. 1999;92(2):79-84. 9. Philips BG, Somers VK. Curr Opin Pulm Med. 2002;8(6):516-520. 10. Sanner BM, et al. Clin Cardiol. 2001;24(2):146-150. 11. Gami AS, et al. Circulation. 2004;110(4):364-367. 12. Shaw JE, et al. Diabetes Res Clin Pract. 2008;81(1):2-12. 13. Einhorn D, et al. Endocr Pract. 2007;13(4):355-362.

1. National Heart, Lung, and Blood Institute. Available at http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_WhatIs.html.

From JNC 7…

Caution: Women with Sleep Apnea Are  Different from Men Women with OSA are more likely to – Present with insomnia1,2 – Be depressed1,2 – Have thyroid disease1 – Report nightmares, palpitation, and hallucinations2 – Have comorbid Restless Legs Syndrome2 And are less likely to have snoring and witnessed apneas1

1. Valipour A, et al. Sleep. 2007;30(3):312-319. 2. Shepertycky M R, et al. Sleep. 2005;28(3):309-314.

JNC 7=The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

ARS

Gender and BMI Effects Change with Age

Mrs. Pancheli’s ESS score is 16. In addition, she  reports that she has been told that she stops  breathing during sleep. Which of the following tests  do you order to CONFIRM the diagnosis of OSA?

• After age 50 years,  GENDER becomes an  unimportant variable1

1. 2. 3. 4.

• After age 60 years,   BMI becomes an  unimportant variable

1. Tishler P V, et al. JAMA. 20037;289(17):2230-2237.

4

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Actigraphy Multiple Sleep Latency Test (MSLT) Functional Outcomes of Sleep Questionnaire (FOSQ) Polysomnography (PSG)

Consequences of Sleep Deprivation and OSA Obstructive Sleep Apnea in  the Primary Care Setting:  Screening and Beyond

Brain: Headaches, memory and  concentration problems; fatigue,  sleepiness, mood disorders; Strokes with sleep apnea

Sleep deprivation, sleep apnea  worsens neuromuscular disorders 

Heart: Increased risk for cardiac disease, death from cardiac disease and hypertension with sleep apnea

Carotid stenosis with sleep apnea

Lungs: Pulmonary hypertension with sleep apnea

Sleep apnea and gastric reflux

Barbara Phillips, MD

Endocrine: DM II; Low growth  hormone

Professor of Pulmonary, Critical Care and Sleep Medicine University of Kentucky School of Medicine Lexington, KY

Reproductive: Male – Low  testosterone;  Female – Poor fetal outcomes with sleep apnea

Restless Legs Syndrome – sleep disturbance

Increased mortality with sleep apnea

Clinical Practice Recommendation

Normal Adult Sleep Architecture

• Practice Recommendation: Polysomnography is the accepted standard test for the  diagnosis of obstructive sleep apnea syndrome. The  benefit of using attended polysomnography for  diagnosis is the ability to establish a diagnosis and  ascertain an effective CPAP treatment pressure. 

Wake REM Stage 1 Stage 2  Stage 3‐ 4

• Evidence‐Based Source: Institute for Clinical Systems Improvement  • Web Site of Supporting Evidence:  http://www.icsi.org/sleep_apnea/sleep_apnea__diagno sis_and_treatment_of_obstructive_.html

Polysomnography EEG Leads EOG Leads

Polysomnography (PSG)

Nasal Respiration Submental EMG EKG Chest Belts Abdominal Belts

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Polysomnographic Characteristics

Limb Movements

• • • •

May have evidence of central events on  baseline PSG1,2 Events more common in nREM sleep3 Elevated arousal index3 Decreased central events on follow‐up1,4

1. Dernaika. Chest. 2007; 81-87 2. Lehman. Journal of Clinical Sleep Medicine. 2007; 462 -466. 3. Morgenhaler.Sleep. 2006; 203 -1209. 4. Javaheri. JCSM. 2009; 5.

Epoch (30 seconds) of a Polysomnogram Epoch (30 seconds) of a Polysomnogram

EEG ECG BP Abd Chest Vt (air flow) 100 75 Pulse Oxygen Saturation

20 sec

Time (minutes)

REM‐Related Apneas/ Hypopneas/  Desaturations

Polysomnography Parameters • AHI   =   Apneas + Hypopneas Total sleep time, in hours • RDI   = AHI, more or less* • ODI  = Number of 4% desats/hr • SDB  = Sleep‐disordered breathing**

* May include RERAs. ** What you say when you are not sure what you AHI= Apnea + Hypopnea Index; RDI= Respiratory Disturbance Index; are including. May include snoring, RERAs and oxygen desaturation. ODI= Oxygen Desaturation Index; RERA= Respiratory Effort Related Arousal.

6

CMS’s Definition of OSA

Severity Criteria Based on PSG From the  American Academy of Sleep Medicine1

CPAP will be covered for adults with sleep‐disordered  breathing if: – AHI or RDI > 15             OR – AHI or RDI > 5 with  (“mild, symptomatic”) • Hypertension • Stroke • Sleepiness • Ischemic heart disease • Insomnia • Mood disorders

• “Mild” sleep apnea = 5 ‐ 2 (Sleep Heart Health Study)4 • 5 (Wisconsin Sleep Study; severe AHI)3 Stroke • 1.54 • 22 Atrial fibrillation • 45 Incident HT • 1.5‐3 (Wisconsin Sleep Study; mild‐severe AHI)6 All‐cause mortality 

1‐1.5 (mild‐severe AHI)1

1. Punjabi NM, et al. PLoS Med 6(8):e1000132. 2. Yaggi, HK, et al. New Engl J Med. 2006;354(10):1086-1089. 3. Young T, et al. Sleep.2008;31():1071-1078. 4. Shahar E, et al. Am J Respir Crit Care Med. 2001;163(1):19-25. 5. Mehra R, et al. Am J Respir Crit Care Med. 2006;173(8):910-916. 6. Peppard PE, et al. N Engl J Med. 2000;342(19):1378-1384.

Redline S, et al. Am J Respir Crit Care Med. 2010;182(2):269-77. Epub 2010, Mar 25.

Sleep Heart Health Study: Main Takeaway

OSA and Stroke Risk  •Even mild to moderate sleep disordered   breathing significantly raised levels of  prothrombotic markers

"The importance of diagnosing and treating OSA  requires greater emphasis in general clinical practice, considering it is still under‐recognized by PCPs." 

– For every 5‐point rise in AHI (up to AHI=15) • Plasminogen‐activator inhibitor‐1 (PAI‐1) increased  10% (p 3 antihypertensive  drugs (p = 0.022) 

56%

31%

Average systolic BP  (p=0.059)

147 ± 21 mm  Hg

139 ± 18 mmHg

Heart attack/stroke

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Which of the following is the most effective  treatment for Mrs. Pancheli’s condition?  1. 2. 3. 4.

2 times the risk without OSA

Continuous positive airway pressure (CPAP) Uvulopalatopharyngoplasty Use of an oral appliance Behavioral change, including weight loss             and reduced alcohol consumption

Clinical Journal of the American Society Nephrology. doi: 10.2215/CJN.04030609. Epub ahead of print. November 19, 2009.

Impact of Treating Sleep Apnea • Evidence supports the conclusion that CPAP  treatment improves

CPAP Improves Outcomes and  Clinical Parameters

– CV outcomes – Hypertension – HbA1c

Polysomnogram Results

Baseline Polysomnogram Baseline Polysomnogram

• • • •

Apnea index = 21.3 Apnea + hypopnea index = 43.1 Total sleep time = 4.8 hours O2 saturation nadir = 84%

Trial of Automatic CPAP • Night to night variance in selected pressure 6 ‐15 cm H2O

9

CPAP Titration – CPAP Titration – Development of Central  Events

CPAP Titration Study

Cardiovascular Outcomes With & Without  CPAP n=1,751 Controlling for:  • • • • • • • •

Smoking Alcohol Weight Pre‐existing heart disease Age Hypertension Lipid‐lowering agents Diabetes

1. Marin JM, et al. Lancet.. 2005;365(9464):1046-1053.

Effect of CPAP on Blood Pressure in  Hypertensive Patients1

Survival of Stroke Patients With & Without  OSA + CPAP1 Controlling for: • Age • Gender • Barthel Index • Previous stroke • Ischemic heart disease • Atrial fibrillation • Hypertension • Diabetes • Cholesterol • Fibrinogen • Smoking • Carotid artery stenosis

1. Becker HF, et al. Circulation. 2003;107(1):68-73.

1. Martinez-Garcia MA, et al. Am J Respir Crit Care Med. 2009;180(1):36-41.

10

Change in HbA1c with CPAP1

Managing Patients with OSA

1. Babu AR, et al. Arch Intern Med.. 2005;165(4):447-452.

Treatment of Sleep Apnea

Medications for OSA

• Behavioral therapy

“CONCLUSIONS: There is insufficient evidence to recommend  the use of drug therapy in the treatment of OSA. Small studies  have reported positive effects of certain agents on short‐term  outcome. Certain agents have been shown to reduce the AHI  in largely unselected populations with OSA by between 24  and 45%. For fluticasone, mirtazapine, physostigmine and  nasal lubricant, studies of longer duration are required to  establish whether this has an impact on daytime symptoms.  Individual patients had more complete responses to  particular drugs. It is likely that better matching of drugs to  patients according to the dominant mechanism of their OSA  will lead to better results and this also needs further study.”1

– Avoid alcohol, nicotine and sleep  medications – Lose weight if overweight

• Physical /mechanical treatment – CPAP (Continuous Positive Airway  Pressure) is treatment of choice – Bilevel PAP  – Oral appliances – Positional therapy

• Surgery in very rare cases 1. Smith I, et al. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003002.

CPAP/Bilevel Positive Airway Pressure

Effectiveness of Nasal CPAP • Decreases sleepiness • Improves glucose  control • Improves quality of life • Improves cognitive  • Lowers blood pressure function • Reduces cardiac risk • Decreases  • Reduces mortality rate hospitalizations                                                 • Reverses impotence and health care costs • Decreases car accidents

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CPAP Improves Clinical Outcomes

CPAP Treatment Reduces Crash Risk1

Outcomes Cardiovascular  outcomes1,2

Stroke survival3 Blood pressure4 Glucose  parameters5

1. Buchner NJ, et al. Am J Respir Crit Care Med. 2007;176(12):1274-1280. 2. Marin JM, et al. Lancet. 2005;365(9464):1046-1053. 3. Martinez-Garcia MA, et al. Am J Respir Crit Care Med. 2009;180(1):36-41. 4. Becker HF, et al. Circulation. 2003;107(1):68-73. 5. Babu AR, et al. Arch Intern Med. 2005;165(4):447-452.

1. Federal Motor Carrier Safety Administration (FMCSA), 2007.

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ARS

Coverage for PAP (CMS 2008) • Adherence to therapy is defined as use of PAP = 4  hours per night on 70% of nights during a  consecutive 30 day period anytime during the first  3 months of initial usage

What is the minimum average number of hours    of nightly use of CPAP required for continued  insurance coverage and clinical benefit? 1. 2. 3. 4.

CPAP Effect • 64% reduction in CV risk independent of age and  preexisting CV comorbidities1 • Significantly reduced fatal/nonfatal CV events compared  to untreated patients (0.55/0.89 vs 1.06/2.13 per 100    person years; p=0.02/ 30 c/w n=338 with RDI < 5) OR  Adjusted for Age, Sex, BMI, CHD

NSVT

3.4 (1.03‐11.2)

CVE

1.74 (1.11‐2.74)

Atrial Fibrillation

4.02 (1.03‐15.74)

NSVT, nonsustained ventricular tachycardia CVE, complex ventricular ectopy

1. Mehra R, et al. Am J Respir Crit Care Med. 2006;173(8):910-916.

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2010 Updates: OSA Treatments •Sleep Apnea With COPD Boosts Mortalitywith chronic obstructive pulmonary disease  (COPD), obstructive sleep apnea increases the risk of hospitalization and death ‐ but  not if they use ...News, Reuters Health Information, April 2010 •Treatment Reverses Brain Changes in Patients With Obstructive Sleep Apnea...June  17, 2010  (San Antonio, Texas) — In patients with obstructive sleep apnea (OSA),  changes in white matter and gray...News, Medscape Medical News, June 2010 •CPAP Effective Even If Apneic Patients Aren't Sleepy...May 21, 2010 (New Orleans,  Louisiana) — In people with obstructive sleep apnea (OSA) who do not experience  daytime sleepiness...News, Medscape Medical News, May 2010 •Heated Humidification May Reduce Nasal Mucosal Inflammation Caused by  CPAP...July 9, 2010  Heated humidification may reduce the nasal mucosal...pressure (CPAP) treatment in  patients with obstructive sleep apnea (OSA), according ...News, Medscape Medical  News, July 2010

1. Peppard PE, et al. N Engl J Med. 2000;342(19):1378-1384.

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