Vol. 18 •Issue 7 • Page 24
Welcome to My world
Sleep-Disorder Breathing Issues in Home Care
It has become clear over the past 30 years that sleep-disordered breathing (SDB) has become a major health concern, with obstructive sleep apnea (OSA) the most prevalent. It affects nearly 4 percent of adult men and 2 percent of women.
It is not just OSA by itself that is of concern. One of the contributing factors to OSA—weight—has taken on considerable significance. The worldwide epidemic of obesity affecting the general population has even found its way into the military. Increased weight of military personnel is of major concern, and military officials are referring a significant number of military personnel to physicians who are administering a full battery of tests including polysomnography, ECG, electromylogram, electro-oculogram pulse oximetry, airflow measurement, body movement, and chest and abdominal movement evaluations.
Military men and women who exhibited a disorder were placed on a trial of nasal CPAP. Researchers conducted extensive follow-ups including the Epworth Sleepiness Scale to quantify daytime sleepiness. From the military group referred for evaluation of SDB, researchers found 40 percent were diagnosed with periodic limb movements, 40 percent were found to have SDB and 20 percent were found to have alpha-delta sleep.
Of those referred for insomnia, 60 percent had periodic limb movements, 20 percent had idiopathic hypersomnolence and 20 percent had SDB. Whenever the diagnosis was a sleep-breathing disorder, the prescribed therapy was CPAP or BiPAP®.
The common factors among those needing therapy were obesity and thick necks. In 1998, Lindquist and Bray in Prev Med (2001; 32, 1:57-65) reported that 54 percent of the U.S. military personnel were overweight.
A large body of epidemiological studies has demonstrated the correlation between cerebrovascular accidents (CVA) and SDB, even though these two disorders may have risk factors completely independent of one another. Hemotologic, hemodynamic and metabolic changes occurring during SDB cause a decrease in cerebral perfusion and increased coagulation. OSA is defined as the stopping of airflow or breathing due to airway closure 10 seconds or longer and oxygen saturation reducing more than 3 percent. The severity of apnea is expressed as an apneaÐhypopnea index or ratio. More than five episodes an hour is abnormal. Many patients with SDB also suffer from pulmonary, cardiovascular or cerebrovascular disease (or a combination).
Some Risk Factors
There are several modifiable and non-modifiable risk factors for CVA. Some of the modifiable factors include cigarette smoking, alcohol consumption, diet and sleep. Non-modifiable factors are age, ethnicity, gender and heredity. In addition, circadian rhythm has an influence on CVA. The greatest reduction of cerebral blood flow occurs during nonÐREM sleep; sleep apnea causes an increase in intracranial pressure which is linearly related to the length of the apneic periods.
Patients with OSA have been found to have decreased cerebral vasodilator reserves that inhibit the ability of the cerebral vasculature to adapt to changes in metabolic needs. Pronounced blood flow changes occur during apneic periods; and changes in vessel wall tension lead to chronic strain of the brain blood vessels and enhance platelet aggregation. Positive pressure ventilation helps to normalize cerebral blood flow velocity and decrease plasma fibrinogen.
Short attention span, hyperactivity, impulsiveness, problems in social and academic functioning, hypersomnolence, snoring, restless leg syndrome and disturbed sleep are all symptoms of attention deficit hyperactivity disorder (ADHD). This is a common illness, which can persist into adulthood. Do the symptoms sound familiar? They can also be indicative of OSA.
Many individuals with these symptoms are treated with a stimulant such as methylphenidate to improve the symptoms, and many get relief but must persist with medication therapy. Numerous individuals presenting with these symptoms are referred to sleep labs for evaluation and are quantified with polysomnography, nocturnal pulse oximetry and physical examination. They are evaluated for the size of the nasal turbinates, physical body mass size, condition of the nasal septum, neck and collar size and oropharynx and tongue size.
In home care, we treat people for all of the above as well as a myriad of other problems. We utilize such devices as home ventilators, CPAP and BiPAP, trach care, cool mist generators, in-exsuffalators, IPPB and IPV, apnea monitors and pulse oximeters, oxygen devices and small volume nebulizers among other modalities.
We, of course, follow the written prescription of the licensed physician, but we are expected and requested often to add our professional expertise to the scope and parameters of the prescription.
We are, after all, the professional respiratory end of the prescription and the front line of continuing care for the patient. As home care therapists, we make weekly, monthly, quarterly, semiannual or as-needed visits to the patients’ homes. Often we are called in the middle of the night to solve a crisis. Long hours, indeed grueling at times, are still satisfying. As in any facet of health care, sometimes we are successful and occasionally we are not.
“During the past decade, health care outcomes and evidence-based medicine have had an impact on health care organizations, health care financing and health care policy,” noted Vernon Pertelle, RRT, Apria’s Pacific Region corporate director of respiratory care. “We must always strive for the best care for our patients to ensure a successful outcome.”
Paul Olkin is a supervisor of respiratory care for Apria Healthcare Inc. in California.