Fisiopatologia Respiratoria e
Disturbi nel Sonno: proposta di
rete
Antonio Foresi
Direttore
U.O.C. di Pneumologia e Fisiopatologia Respiratoria
Presidio Ospedaliero di Sesto San Giovanni
@AForesi 1
full hub/spoke/satellite service
@AForesi 2
@AForesi 3
Bozza Decreto su “Definizione degli standard
qualitatitivi, strutturali, tecnologici, e quantitativi
relativi all’assistenza ospedaliera…” 9 Luglio 2014
Specialità
Strutture di degenza
Servizi senza posti letto
Bacino
Pneumologia
Bacino
Max
Min*
0,8
0,4
Max
?
Min*
?
* (x milioni di abitanti)
@AForesi 4
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
@AForesi 5
@AForesi 6
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
@AForesi 8
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
@AForesi 9
Patologie respiratorie nel sonno: modelli
organizzativi
• Pre-test evaluation
• Screening/Referral
• Diagnosis
• Treatment
• Compliance/Adherence
• Follow-up
• Long term care
• Costs
@AForesi 10
risk factors commonly
associated with OSA:
obesity, gender (more
common in men than
women), age (more
common in older
age), hypertension
and diabetes.
@AForesi 11
Percent of UK hospitals delivering each service
ARTP Working Groups on Standards of Care and
Recommendations for Lung Function Departments (2007)
@AForesi 12
Patologie respiratorie nel sonno: modelli
organizzativi
• Pre-test evaluation
• Screening/Referral
• Diagnosis
• Treatment
• Compliance/Adherence
• Follow-up
• Long term care
• Costs
@AForesi 13
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
@AForesi 17
AUCs from ROC curves for the manual and automatic
HNP home single-channel nasal pressure scorings,
based on AHI polysomnographic cutoff points
Masa JF, et al. Effectiveness of home single-channel nasal pressure for
sleep apnea diagnosis. SLEEP 2014
@AForesi 18
A simplified model of screening questionnaire and home
monitoring for obstructive sleep apnoea in primary care
157 pts aged 25-70 years attending their primary care physician for any reason
performance
of the OSA50
screening
patients with < o > AHI 30
Chai-Coetzer C.L. - Thorax 2011;66:213-219
@AForesi 19
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
@AForesi 20
Patologie respiratorie nel sonno: modelli
organizzativi
• Pre-test evaluation
• Screening/Referral
• Diagnosis
• Treatment
• Compliance/Adherence
• Follow-up
• Long term care
• Costs
@AForesi 21
•Up to 80 per cent of
people with OSA
have not been
diagnosed
BLF 2014
timely access to
diagnostic services
BLF 2014
@AForesi 23
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
PSG
Respir Care 2010;55(9):1196–1212
@AForesi 25
Respiratory polygraphy
in 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
@AForesi 28
Comparison of supine-only and REM-only OSA
prevalence of REM-related
OSA was 10%
prevalence of supine-OSA
varied from 23% (strict
definition) to 63% (lenient
definition);
Gillman A et al. Sleep Medicine 13 (2012) 875–878
@AForesi 29
Sleep Med Clin 6;309–333;2011
@AForesi 30
PSG
Patologie respiratorie nel sonno: modelli
organizzativi
• Pre-test evaluation
• Screening/Referral
• Diagnosis
• Treatment
• Compliance/Adherence
• Follow-up
• Long term care
• Costs
@AForesi 32
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 and
manual 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 sleep
apnoea: 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
Patologie respiratorie nel sonno: modelli
organizzativi
• Pre-test evaluation
• Screening/Referral
• Diagnosis
• Treatment
• Compliance/Adherence
• Follow-up
• Long term care
• Costs
@AForesi 39
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
BLF 2014
@AForesi 41
An Official American Thoracic Society Statement: Continuous Positive Airway Pressure
Adherence Tracking Systems. The Optimal Monitoring Strategies and Outcome Measures in
Adults.
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.
Clinical algorithm for using continuous positive airway pressure adherence tracking systems.
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
Patologie respiratorie nel sonno: modelli
organizzativi
• Pre-test evaluation
• Screening/Referral
• Diagnosis
• Treatment
• Compliance/Adherence
• Follow-up
• Long term care
• Costs
@AForesi 46
• 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.
Patologie respiratorie nel sonno: modelli
organizzativi
• Pre-test evaluation
• Screening/Referral
• Diagnosis
• Treatment
• Compliance/Adherence
• Follow-up
• Long term care
• Costs
@AForesi 48
“coping with the CPAP mountain”
BLF 2014
@AForesi 49
La soluzione tecnologica a domicilio
Oggi
Configurazione del modulo
e abbinamento fra
paziente e S/N
Prima
Raccolta del consenso
del paziente
Chiamata del tecnico alla
sede per attivare
la telesorveglianza
Schema di monitoraggio paziente OSAS
Patologie respiratorie nel sonno: modelli
organizzativi
• Pre-test evaluation
• Screening/Referral
• Diagnosis
• Treatment
• Compliance/Adherence
• Follow-up
• Long term care
• Costs
@AForesi 53
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
@AForesi 57
Building a new model of Sleep-Lab
• Provide for diagnosis and treatment for all
sleep disorders
• Balanced capability for in-laboratory and inhome sleep studies
• Define set of outcomes (OSA) sleep apnea
symptoms, ESS, FOSQ, Fatigue, PAP compliance,
blood pressure, HbA1C (for diabetics), and
medication use
@AForesi 58
Barriers to treatment include:
• 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
BLF 2014
@AForesi 59
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
• UK
• Italy
500,000
330,000
120,000-140,000
Sleep Medicine is chronic
care management
discipline, not a
diagnostic one
@AForesi 63
Fisiopatologia Respiratoria e
Disturbi nel Sonno: proposta di
rete
Antonio Foresi
Direttore
U.O.C. di Pneumologia e Fisiopatologia Respiratoria
Presidio Ospedaliero di Sesto San Giovanni
@AForesi 64
Fisiopatologia Respiratoria e
Disturbi nel Sonno: proposta di
rete
Antonio Foresi
Direttore
U.O.C. di Pneumologia e Fisiopatologia Respiratoria
Presidio Ospedaliero di Sesto San Giovanni
@AForesi 65
Hanes et al. / Research in Social and Administrative Pharmacy j (2014) 1–16
@AForesi 66
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
@AForesi 67
1. Referral standards
2. Diagnostic and treatment standards
3. Patient review standards
5. Driving issues
Hanes et al. / Research in Social and Administrative Pharmacy j (2014) 1–16
@AForesi 68
• 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 apnoea
syndrome: 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 expected
to 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 49year-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
Key potential care gaps
Can Respir J Vol 20 No 4 July/August 2013
• ASA / NATA web page :
http://www.sleep.org.au/membersarea/accre
ditation
• (last accessed 24-6-13)