Wake-up Call FROM THE AMERICAN SLEEP APNEA ASSOCIATION W I N T E R
ASAA A.W.A.K.E. NETWORK NEWS
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ON THE CUTTING EDGE Ideas on Surgery and OSA From Anesthesiologists
As we crossed into the New Year, the A.W.A.K.E. network passed another milestone: With the formation of Ohio’s A.W.A.K.E. in Toledo, the number of groups reached 300…. Southwest Mississippi A.W.A.K.E. in McComb, Miss., held its first meeting in November, and filed an upbeat report about the attendance and the response to its farranging presentation…. Charlevoix Area Hospital A.W.A.K.E., in Charlevoix, Mich., reported that its October session on “Drowsy Driving” was one of its best-ever meetings, thanks to a great panel that included a gun-toting sheriff…. West Metro A.W.A.K.E. of St. Louis Park, Minn., had a December meeting on “Circadian Rhythms and Bright Lights Therapy,” a topic particularly suited to the Minnesota winter…. A.W.A.K.E. on the Bay in Marinette, Wis., had a seasonally appropriate presentation that also took the prize for best rhyme. “Cold Or Flu? What Do I Do?” was the question addressed by nurse Joan Solander…. Runner-up on the rhyme front was Morton Plant Mease A.W.A.K.E., where “What Lack of Sleep Can Do to You” was discussed…. Complex Sleep Apnea, a newly defined syndrome that was the subject of the fall edition of the WAKE-UP CALL, was addressed by several groups, including East Carolina A.W.A.K.E. in Morehead City, N.C., and North San Diego County A.W.A.K.E. in Vista, Calif…. They may not be as far apart as Mars and Venus, but men and women are not the same, not even when it comes to OSA. Physician Sharon Esau discussed “Gender Differences in Sleep Apnea” at the November meeting of University of Virginia A.W.A.K.E. in Charlottesville….
A.W.A.K.E. - Alert, Well, AND Keeping Energetic
e’ve come a long way since the days – not that long ago – when a person undergoing surgery had to rely on a whiff (generally of nitrous oxide) and a prayer. Anesthesia today encompasses a sophisticated array of general and local techniques that are equal to the challenge of providing pain relief during even the most invasive and complex surgical procedures. But when someone has Obstructive Sleep Apnea (OSA), anesthesia poses special challenges, for both medical personnel and patients. How should an anesthesiologist, using agents that suppress or depress breathing, best handle a patient whose breathing is already disturbed? How should a patient, groggy after an operation, deal with an over-worked nursing staff that may never have seen a CPAP machine? “For a long time, we weren’t that attuned to the problem,” says anesthesiologist Jeffrey Gross, of the University of Connecticut School of Medicine in Farmington. “But we’re seeing a lot more sleep apnea than we used to, and we’ve become a lot more aware of it. It’s now a hot topic.” In 2003, Dr. Gross became the chair of an American Society of Anesthesiologists task force charged with developing guidelines for the management of patients with OSA. The resulting “Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea” were approved by the society in 2005, and were published in the May 2006 issue of the journal Anesthesiology. (You can download a copy from www.asahq.org/publicationsAnd Services/sleepapnea103105.pdf.) Starting with the premise that “both pediatric and adult patients with OSA … present special challenges that must be systematically addressed … to improve [their] care and reduce the risk of adverse outcomes,” the task force – which included an otolaryngologist and bariatric surgeon in addition to anesthesiologists and methodologists – made recommendations for preoperative preparation, intraoperative
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Guidelines, continued on p. 3
INSIDE Letter From the Director . . . . . . . . . . p. 2 Young Brains at Risk . . . p. 2
ASAA in Brief . . . . . . . . . p. 3 Sleep Apnea Awareness Day . . . . . . . . p. 4
A LETTER FROM EXECUTIVE DIRECTOR ED GRANDI he Board of Directors of the American Sleep Apnea Association held its annual meeting in November. At that time, we thanked outgoing board member Dale McPherson for his service to the Association and welcomed Nancy Rothstein as an incoming board member. Mrs. Rothstein is not herself an apnea patient, but brings the spouse’s perspective to the problem. In addition to having extensive experience on non-profit boards, she is an author. Scholastic, publisher of children’s literature, recently issued her picture book, entitled “My Daddy Snores.” A companion web site – mydaddysnores.com – provides useful information and links to other websites, including the ASAA’s. Mrs. Rothstein’s first ASAA assignment was to chair the Sleep Apnea Awareness Day (SAAD) 2007 events. (An article on SAAD’s activities appears on page 4.) If you will be in Washington in early March, I hope you will come to the lecture on March 7. If you cannot attend,
please visit the special SAAD 2007 link at www.sleepapnea.org, where, pending the resolution of some technical issues, you will find a webcast that will enable you to hear the lecture. A printed transcript will also be available on the site a few weeks after the lecture is delivered. This year, National Sleep Awareness Week® involves a direct advocacy component. Representatives from the National Sleep Foundation (sponsor of NSAW) and other sleep groups, including the ASAA, will hold a congressional briefing at the Capitol on March 7. The briefing will educate members of Congress, their staffs, and representatives of federal agencies about the importance of recognizing and treating sleep disorders. The briefing also marks the launch of the National Sleep Awareness Roundtable (NSART), of which the ASAA is a founding member. Looking a little further into the year, the ASAA is developing two major initiatives. The first is the grassroots Apnea Advocacy Action Program. It will provide a platform for all people with sleep apnea to speak out on the issues that concern them. Watch for details in
future issues of the WAKE-UP CALL. The second project is in response to the numerous requests we get from people with sleep apnea who lack insurance coverage for treatment of the condition. The ResMed Corporation, one of our corporate sponsors, will donate CPAP machines to distribute through the A.W.A.K.E. Network of support groups. Details of the program are still being worked out and will be available on the ASAA web site in March. If you would like to help subsidize the work of the ASAA, there is something simple you can do. Use www.goodsearch.org as your web search engine, designating the American Sleep Apnea Association as the cause you support. Each time you do a search from the site, the association receives 1 cent. It’s only pennies, but multiplied by the millions of people with sleep apnea and their families and friends, it could turn into something big. This year promises to be an exciting one for the association. Please continue to help us help others. We appreciate your support. ■
YOUNG BRAINS MAY BE AT RISK FROM OSA
performance tests, that the neural changes were linked to neuropsychological deficits. While the study will need to be replicated and expanded before it can be considered definitive, lead author Ann Halbower, M.D., a lung specialist at the Johns Hopkins Children’s Center, hails it as “a wake-up call to both parents and doctors” that undiagnosed or untreated sleep apnea might harm developing brains. Researchers and clinicians have known for years that interrupted breathing and its consequent fragmented sleep and oxygen deprivation can impair children’s school performance. But this is the first time that OSA has been linked to changes in the brain’s chemistry, Dr. Halbower believes. “We saw changes that suggest injury in areas of the brain that house critical cognitive functions, such as attention, learning, and working memory.” Dr. Halbower says. “We cannot say with absolute certainty that sleep apnea caused the injury, but what we found is a very strong association between changes in the
neurons of the hippocampus and the right frontal cortex, and IQ and other cognitive functions in which children with OSA score poorly.” Children with untreated OSA had lower mean IQ test scores (85) than children without OSA (101). Children with OSA also performed worse on tests measuring verbal working memory (8 versus 15) and word fluency (9.7 versus 12). Further study is needed to determine whether these deficits are reversible when the sleep apnea is successfully treated. OSA affects 2 percent of children in the United States, but it is unclear how many of these suffer from a severe form of the syndrome. Dr. Halbower estimates that up to 17 percent of sleep apnea patients seen at the Children Center’s sleep clinic are severe cases. In children, the leading cause of sleep apnea is enlarged tonsils and adenoids, and the first line of treatment is surgical removal. Some children are also candidates for CPAP therapy. ■
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n a small but provocative study, researchers at Johns Hopkins Medical Institutions in Baltimore have found that children with serious, untreated Obstructive Sleep Apnea appear to suffer damage in two brain structures – the hippocampus and the right frontal cortex – that are tied to memory and learning. Writing in the Aug. 22, 2006 issue of the global online journal Public Library of Science Medicine, the Hopkins investigators say they compared 19 children with severe OSA to 12 children who did not have the disorder. Using magnetic resonance spectroscopic imaging, which plots the levels of brain chemicals, the researchers identified changes to the two structures that are indicative of cell injury. The researchers then determined, using IQ and other standardized
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Guidelines, continued from p. 1
ASAA IN BRIEF
management, and postoperative management of people with OSA. (These three together constitute the “perioperative” of the paper’s title.)
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very year, the American Sleep Apnea Association is an exhibitor at numerous medical conferences throughout the country. Setting up and staffing a booth at these far-flung events is one of the ways the ASAA helps educate physicians and other healthcare providers about sleep apnea. It is an opportunity to interact with these care-givers and provide a perspective they might otherwise not hear. As patient members of the ASAA, you have insights that are valuable to those involved in the treatment of sleep apnea, and we would like to invite you to help staff our booths at the conferences listed to the right.
We are looking for two or three volunteers per conference. If you can spare a couple of hours on the meeting dates, please contact Ed Grandi at egrandi@sleepapnea.org or (202) 293-3650. Training and lunch will be provided. And as a side benefit to volunteering, you will have access to the whole exhibit hall, and will see the latest gear the CPAP manufacturers have to offer. American Thoracic Society May 20-22, San Francisco, Calif. Associated Professional Sleep Societies June 11-13, Minneapolis, Minn. American College of Chest Physicians Oct. 21-23, Chicago, Ill.
Patients should remain in a semi-upright position if possible, and CPAP should be continued. Those patients on CPAP should be able to bring their own equipment to the hospital. OSA patients should not be sent to an unmonitored setting until they are no longer at risk for postoperative respiratory depression. This may require a longer than usual stay.
hospital stay. Sleep-deprived and suffering, Ms. Thon was unable to figure out where to turn for help. Upon her discharge, she wrote a strongly worded letter to the hospital, and received an apology and the promise that the hospital had changed its policy to allow patients to use their own equipment. But it’s obviously better not to be in a situation where an apology is later required. How to accomplish that? Find out everything you can about hospital procedure, and who is going to be in charge of the different aspects of your care, and make as many people as possible aware of your condition and needs. In these days of (mis)managed care, you may not be able to talk with your anesthesiologist ahead of time, but you can probably arrange a consult with a nurse on the anesthesiology team. Still, no matter how much you communicate before your procedure, problems may arise afterward. Be aware that having done time on the operating table, you may not be your own best advocate. Have a friend or family member – someone familiar with your medical situation – standing by to intervene on your behalf. Many hospitals these days have someone on staff who is designated as the “patient representative” or “patient advocate.” Get that person’s name and phone number, and don’t hesitate to call if you need an intermediary. ■
PREOPERATIVE According to the guidelines, a surgical candidate’s OSA status needs to be established early on, by means of medical histories, family interviews about snoring and arousals, and physical examinations that take into account such risk factors as large neck circumference, and airway and palate anomalies. For someone who has not already been formally diagnosed with OSA, but manifests the clinical signs, surgery may need to be delayed to allow for sleep studies and, possibly, the initiation of CPAP therapy. (A delay in an elective procedure also gives an obese patient a chance to improve his or her OSA status by losing weight.) In the period leading up to the operation, anesthesiologists should work with surgeons to develop a management plan, which would include a determination as to whether the procedure can be safely done on an outpatient basis, or will require inpatient monitoring. INTRAOPERATIVE Given that patients with OSA have airways that are especially susceptible to the effects of inhaled anesthetics, sedatives and opioids, the task force recommends that general anesthesia be avoided in peripheral (that is, arms and legs) procedures and that sedation be minimized. Instead, where possible, local anesthesia or what is called general conduction anesthesia (spinals or epidurals) should be employed. If sedation is required, ventilation should be continuously monitored, and CPAP should be used by patients who have been previously treated with this modality. If possible, recovery should be carried out in a semi-upright or lateral position. POSTOPERATIVE Regional analgesic techniques, such as nonsteroidal anti-inflammatory agents, ice, and transcutaneous electrical nerve stimulation, should be used to reduce or eliminate the need for systemic opioids. Supplemental oxygen should be administered until patients can maintain their baseline oxygen saturation while breathing room air, and continuous pulse oximetry monitoring should be employed.
Having done time on the operating table, you may not be your own best advocate. These represent the best practices. But until they become the standard of care, OSA patients facing surgery can anticipate some hurdles to getting the care they require. One of the American Sleep Apnea Association’s patient board members, Vicki Thon, recently discovered how high those hurdles can be. An educated and proactive apneic, Ms. Thon thought she had covered all the bases before her foot surgery. But a respiratory therapist’s insistence that she use a leaky hospitalprovided mask, rather than the one she’d brought from home, led to an unnecessarily prolonged and difficult
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SLEEP APNEA AWARENESS DAY he American Sleep Apnea Association is springing into action early with Sleep Apnea Awareness Day, held this year on Thursday, March 8. The date change is courtesy of the Energy Policy Act, signed into law by President Bush in 2005. The act mandated that Daylight Saving Time begin on the second Sunday in March and end the first Sunday in November. As a result, National Sleep Awareness Week®, scheduled to coincide with the moving forward of the clock, has been moved forward (or back, depending upon your perspective). This year, NSAW runs from March 5 to March 11, and focuses on women and sleep. And what we at the Association like to think of as the centerpiece of the week – Sleep Apnea Awareness Day – takes place on the third day of this annual effort to bring attention to the prevalence and consequences of lost sleep.
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In recognition of Sleep Apnea Awareness Day, we are unveiling a new and improved Snore Score card, for people to distribute to help raise awareness of sleep apnea. Contact the office for a supply to hand out to friends, family, co-workers, and others. There are two events planned to mark Sleep Apnea Awareness Day 2007, both in our headquarters city of Washington, D.C. The first is the annual lecture, which takes place on March 7. Our speaker is Dr. Terri Weaver, Associate Professor of Nursing at the University of Pennsylvania. Her topic is “Snoring and Sleep Apnea: The Effect on the Family.” In addition, Ashley Keenan will tell her story of living with sleep apnea. Following the lecture, we are participating in a congressional briefing on Capitol Hill. The briefing is a presentation to members of Congress, their staffs, and
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representatives from federal agencies. After the briefing there will be time for visits to congressional offices. If you are interested in participating in the briefing and/or visits, let Edward Grandi know as soon as possible. The second event takes place on Thursday, March 8, when we visit an innercity elementary school for a reading of the new children’s book “My Daddy Snores,” written by ASAA Board member Nancy Rothstein. We will post additional details on these events, as well as activities sponsored by A.W.A.K.E. groups around the country, on our website. We encourage ASAA members to speak up and speak out during Sleep Apnea Awareness Day. We all need to raise our voices to raise awareness of this very serious – but very treatable – medical condition.. ■
WAKE-UP CALL From The American Sleep Apnea Association
WINTER 2007 Published by The American Sleep Apnea Association BOARD OF DIRECTORS Dave Hargett, Chair Rochelle Goldberg, MD, President and Chief Medical Officer Kathe Henke, PhD, Secretary George Selby, Treasurer Ann L. Pickett Douglas B. Brown, Esq. Robert J. Popoff Michael P. Coppola, MD David Rapoport, MD Steve Feinsilver, MD Nancy Rothstein Joanne Murphy Kingman Strohl, MD Judith A. Owens, MD MPH Vicki Thon, PhD Edward Grandi, Executive Director Deborah Papier, Newsletter Editor
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ASAA INDUSTRY ROUNDTABLE Respironics; ResMed; Sunrise Medical/DeVilbiss Restore Medical; Fisher & Paykel; Invacare Nellcor Puritan Bennett FOUNDING SPONSORS CNS, Inc.; DeVilbiss Healthcare (now Sunrise Medical) Healthdyne Technologies; Medtronic, Inc. Nellcor Puritan Bennett (now Mallinckrodt, Inc.) Respironics, Inc. This newsletter provides general medical information about sleep apnea. Individuals with personal health concerns about sleep apnea, or other sleep disorders, should seek advice from a doctor who concentrates in sleep medicine. Wake-Up Call is copyrighted and cannot be reproduced without written permission from the ASAA. Send all materials, including Letters to the Editor and Ask the Doctor, to the ASAA. AMERICAN SLEEP APNEA ASSOCIATION 1424 K. St., NW Suite 302, Washington, DC 20005 202.293.3650 • FAX 202.293.3656 www.sleepapnea.org • asaa@sleepapnea.org