"Comorbid Insomnia and Sleep Apnea: Where Are We?" Olurotimi Adekolu (04.28.2021)

May 04, 2021

ID6564

To CiteDCA Citation Guide

00:02OK, there we go.
00:29Alright everybody welcome.
00:30We're going to get started.
00:32My name is Lauren Tobias and I'd
00:34like to welcome you to our Yale
00:37Sleep Center this afternoon.
00:38I have a few quick
00:40announcements before we begin.
00:41First, please take a moment to
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01:01If you have any questions
01:02during the presentation,
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01:21And finally,
01:22please feel free to share announcements
01:25about our lecture series to anyone else
01:27who you think might be interested.
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01:31to be added to our email list.
01:34Now a final announcement for today.
01:36I just want to let everybody
01:39know that this Friday,
01:40April 30th is our 6th annual Sleep
01:43and Symposium research slick sleep
01:44and Symptom Research Symposium.
01:46This is Co sponsored by the School
01:49of Nursing in the School of Medicine.
01:52And this is a free event that's
01:54open to everybody that will run
01:56from 10:00 o'clock in the morning
01:58until 2:00 in the afternoon,
01:59so please feel free to join us
02:01for part or all of this event.
02:04I'm going to put the link to
02:06register for this in the chat
02:08and it just takes a moment.
02:10So with that I'll turn this
02:12microphone over to Andres in
02:13check who's going to introduce
02:15Doctor Otukolo for today's talk.
02:22Good afternoon everyone.
02:23Thank you again for joining us and I
02:26have a distinct pleasure of introducing
02:28Doctor Adekola today for today's sleep
02:30grand rounds and I'm excited to do
02:33so because I have worked with Doctor
02:35Adekola and a couple of research
02:37projects and he's been an outstanding
02:40fellow this year and actually program.
02:42But he has received his medical degree
02:45at the Obafemi Awolowo College of
02:47Health Sciences in Nigeria before he
02:49made the journey to the United States and.
02:53Long and short of it,
02:55and he ended up becoming a resident
02:57and intern at the University of
02:59Connecticut and followed that with
03:01being a chief resident at the Yale
03:03Waterbury Eternal Medicine program.
03:05And after that he realized
03:07that clinical care,
03:08his passion,
03:09and so he ended up doing personal
03:11care fellowships at the Beth Israel
03:14Medical Center in New Jersey.
03:16Followed by joining us for Sleep Fellowship.
03:19Before he did that,
03:20he has had a prolific history
03:23of presenting at the American
03:25Thoracic Society at the Chest,
03:27College of Physicians and American Heart
03:30Association and is also published in a
03:33paper in journals like the Blue Journal.
03:36And so I'm excited to introduce
03:39him for today's talk,
03:40and he's going to be focusing on the
03:44overlap between sleep apnea, insomnia,
03:46something that we see clinically.
03:48Quite frequently,
03:49and so just as a little bit
03:51of an advertisement.
03:52In addition,
03:53today's stock Holder is going
03:54to be giving a presentation at
03:56the American Academy of Sleep
03:58Medicine meeting this summer.
03:59He's invited to give a research
04:01talk and also will be giving a talk
04:03at the Sleep Research Symposium or
04:05presenting a poster in Sleep Research
04:07Symposium this coming Friday.
04:08So please stay tuned and without further ado,
04:11olowe the mic is yours.
04:12Let's take it away.
04:15Yeah, thank you for that very kind. Uh.
04:23Presentation are doctors in joke.
04:26You know my talk today?
04:28Mr Gas to comorbid insomnia and sleep apnea.
04:32What I call comet for shorts and
04:36the question is where are we
04:39with this clinical presentation?
04:41I decided to go with this topic
04:45just because it's so common and a
04:49large percentage of our population.
04:52In our sleep clinic,
04:54either presents with sleep
04:55apnea or insomnia or bolts,
04:58so I hope at the end of the stock I
05:01would have shared something interesting.
05:09Alright, I have no conflicts of interest.
05:13And then if you wish to get
05:16to see me for this talk,
05:19just text 21624 to the year CME accounts.
05:23So I would first start up by giving a brief
05:28synopsis of a case I saw in the sleep clinic.
05:33Miss A is a 48 year old woman with
05:37a past medical history of class 3,
05:40obesity, anxiety and depression.
05:42She presented with sleep onset,
05:44insomnia, and frequent awakenings.
05:46She also complained of snoring,
05:48gasping and choking episodes.
05:50I airport sleepiness,
05:52scale and was 12.
05:53Insomnia severity index of 22 and
05:56modified FSQ functional outcome
05:58of sleep Questionnaire was 18.
06:01She wait again June 27 pounds.
06:05A BMI of 51 and on visual oral
06:09examination and she was a mallampati
06:124 hi on subsequent sleep study was 12
06:16an hour with them in oxygenation of
06:2097% and an idea of 87% a sleep diary.
06:25Also provided objective evidence
06:27of both sleep onset and sleep
06:31and maintenance insomnia.
06:33So, having said that,
06:35this is a common presentation which a lot
06:39of us can identify with in the clinic,
06:42and it brings forward.
06:44The thoughts in terms of what are the
06:48risk factors for patients who present
06:51with comorbid insomnia and sleep apnea?
06:55What impact will this patients
06:57insomnia have on their obstructive
07:00sleep apnea and vice versa?
07:02And what's the optimal timing of
07:05the treatment of this patients
07:07once we determine what the best
07:10approach to treatments will be,
07:13so my learning objectives for today.
07:16Is to dive into why?
07:19Comorbid insomnia and obstructive
07:21sleep apnea is important,
07:23and,
07:23to you know,
07:24talk about the pathophysiology and the
07:27interplay of obstructive sleep apnea
07:29and insomnia in commissa patients.
07:32Review the different clinical faces of
07:35Camisa as well as address technical
07:38challenges in the management of
07:41this patient and I hope that at
07:44the end of the stock would have
07:46covered all of this objectives.
07:49So insomnia in general is defined as a
07:53persistent difficulty with sleep initiation,
07:56duration,
07:56consolidation,
07:57or quality that occurs despite adequate
08:00opportunity and circumstances for
08:02sleep in and thereby resulting in
08:05some form of daytime impairment.
08:07Now they the main diagnostic
08:10manuals in terms of the I see as
08:15the three the DSM four or the ICD
08:1810 all vary in their approach.
08:21With regards to defining insomnia
08:24and based on this definition,
08:26it gives us a range of prevalence
08:30extending from 10 to 4% depending
08:32on how insomnia is defined,
08:35either as a symptom or
08:37as a specific disorder.
08:39Again, you can have different prevalences.
08:43Obstructive sleep order.
08:45A apnea, on the other hand,
08:47is a disorder characterized by upper
08:50airway narrowing or closure during sleep,
08:52while respiratory effort continues.
08:55There is a high disease
08:57body and as we as we know,
08:59associated with have just having
09:01obstructive sleep apnea alone or sleep
09:04apnea seven as an independent risk
09:07factor for cardiovascular disease,
09:08metabolic disease,
09:10and psychiatric disorders.
09:12Doctor sleep apnea has a
09:15prevalence of about 9 to
09:1838%, So what is? Call me Sir.
09:22What is comorbid insomnia and sleep apnea?
09:26The first case of Camisa was actually
09:30destroyed by Glenn Law in 1973
09:33when at that time you wrote a paper
09:36where it describes 2 middle age and
09:40patients who had protracted history
09:43of persistent nighttime arousals
09:45and difficulty maintaining sleep.
09:47Despite use of several are sedatives.
09:51It was an important finding at that time,
09:54'cause a lot of patients will put
09:57would present with chronic insomnia
09:59and would have used a sedatives and
10:02and we know the implications of using
10:05benzodiazepine's in obstructive sleep apnea.
10:08So it concluded that an unknown
10:10percentage of the larger number
10:12of patients complaining of chronic
10:14insomnia do have profound disorders
10:17of respiratory our control.
10:22And then following this paper in 1973,
10:26there was a possibly a lack of research
10:30studies up to about 1999 and then 2001
10:35when Lichstein and Krakow published
10:37papers with regards to Camisa and their
10:42research at that time did bring attention
10:46to the presence of this conditions and
10:50that served as a spring spring board.
10:54For several order publications down
10:56the line up to the present time.
11:00But even then, in the large scope
11:03of data of large scheme of things,
11:07not a lot of work has been done
11:11with regards to commissa research.
11:14So having said that, let's talk about
11:18what the prevalence of camisa ES,
11:21Crackle and his colleagues
11:23looked at about 231 patients.
11:25I'm with sleep disordered breathing and
11:28they found out that half of the pop off
11:33that population had clinically meaningful.
11:35I'm insomnia, Smith and others.
11:37Also prospectively studied
11:39about 105 sleep apnea patients,
11:41of which about 29% met the
11:44criteria for insomnia.
11:46So overall, in in the literature today,
11:49it's about a 30 to 50% comorbidity of
11:53insomnia in obstructive sleep apnea.
11:56How about the risk factors?
11:59Zangon orders?
12:00Did a meta analysis on 37 studies
12:04of camisa patients and what they
12:07found that was that the predominant
12:10insomnia presentation was difficulty
12:14maintaining sleep at 42%.
12:17There was also difficulty falling
12:20asleep at 18% and early morning
12:24awakening at 21% female patients.
12:26Pasculli were more likely to
12:29have difficulty falling asleep
12:31and early morning awakenings,
12:34and there was a correlation between
12:37having a higher BMI and having insomnia.
12:44How about the pathophysiology of cammisa?
12:47It's interesting because insomnia,
12:50perpetrates, obstructive sleep apnea,
12:52and obstructive sleep
12:54apnea perpetrates insomnia,
12:56so it is just a a vicious cycle.
13:02Sleep onset Eegs of patients with Camisa
13:06did show elevated cortical arousal,
13:09especially during entry to
13:11sleep when compared to controls.
13:13Also, we do have studies shown that chronic
13:17insomniacs suffer from hyperarousal,
13:20evidenced by increased 24 our metabolic rate.
13:24Basically, this state of Hyperarousal
13:26keeps them in a lighter stage of sleep,
13:30which increases their vulnerability.
13:33To have Nick episodes also when they have
13:37ventilatory overshoots during arouse,
13:39our customers increase our CO2 clearance,
13:42which leads to a decrease in upper
13:46airway muscle tone and increases the
13:49tendency for them to have apnic episodes.
13:53How about the other way around?
13:56Obstructive sleep apnea?
13:57Perpetrate in insomnia?
13:59We do know that they can serve
14:02as a precipitant.
14:04For both our difficulty initiating
14:07and difficulty maintaining and sleep,
14:09and the idea is that when there is
14:13repeated struction of light sleep,
14:16it can subsequently lead to a perception
14:20of continued wakefulness for the patients.
14:23Now,
14:23this perceived sleep onset of sleep
14:26maintenance difficulty can subsequently
14:28lead to sleep related anxiety,
14:31thereby triggering the simplenet
14:33sympathetic nervous system.
14:35As well as the hypothalamic pituitary
14:38adrenal axis and which if this occurs
14:42repeatedly overtime it becomes a cue
14:45that then leads to conditioned insomnia
14:49or psychophysiological insomnia.
14:54They thought mechanism I wanted to
14:58highlight was the mechanism of sleep depths.
15:02We do know that patients with camisa they
15:07have excessive wake time and basically we
15:11know that in patients with sleep apnea,
15:15one of the pathophysiological Pheno
15:18type is low arousal threshold.
15:21However, we studies have shown that.
15:25Arousal threshold varies across
15:27patients with obstructive sleep apnea,
15:30and we know that our results treshold
15:34reflex the patients sleep debts.
15:37Now, Unisan colleagues came up with a good
15:41way to measure a patients and slipped EPS
15:46by a concept called the odds ratio products,
15:51which you know basically is calculated from.
15:55The EEG and it ranges from zero,
15:59which means deep sleep to 2.5,
16:02which means wakefulness and studies
16:05have shown that the sum of arouser
16:09of arousals and during sleep there
16:13is ability index has a strong,
16:16almost perfect correlation with
16:18the odds and wish your products.
16:21Also, the odds ratio products
16:24correlates with the AHI.
16:26So patients with obstructive sleep apnea
16:29have a setting degree of sleep depth,
16:32which we think is probably a traits cause.
16:36Different patients with sleep
16:38apnea have different sleep debts,
16:41and even when we control for the patients
16:45age high by treating them with C Pap,
16:49you know,
16:50see PAP would improve the patients hi
16:53and improve the Arousal Awakening index.
16:56But really doesn't have any effects
16:59on the odds and wish your products,
17:02also confirming that patients
17:04have this intrinsic slip depth,
17:06which in turn determines how aroused,
17:09able and they have all their
17:12tendency to arouse when there is an
17:15external or internal disturbance.
17:17The odds ratio products nine year
17:20is just a better or a simple.
17:23I would say simpler way to
17:25measure the odds ratio.
17:27Products and it's,
17:29you know,
17:30the measurements of the orchestration
17:32products in the 1st 9 seconds after,
17:36and arousal events.
17:37So putting all this together,
17:40insomnia in itself will cause hyper
17:43arousability and increase the propensity
17:46of the patient of a patient with
17:49commissa to wake up on the other and
17:53obstructive sleep apnea increases
17:55apnic episodes and in the presence of.
17:58No,
17:59arousal threshold increases their
18:01propensity to have excessive
18:03wait time through the night,
18:05and when we combine that with
18:08an already low sleep depth as
18:11measured by the odds ratio products,
18:15all of that comes together to determine
18:18the mechanism for excessive wait time.
18:21In Camisa there is still a lot of
18:25variance that is still not explained.
18:29So you know,
18:30we still need further research
18:32for better understanding of this.
18:35Patients haven't talked about the risk
18:38factors as well as the mechanism of camisa.
18:42Let's delve a little bit into what
18:46their clinical characteristics might
18:48be Hans Dot C and his colleagues.
18:51They examine the Icelandic sleep
18:54apnea co-ops, pretty large cohort,
18:56and basically they were, you know.
19:00Looking for the prevalence of
19:02insomnia symptoms in this patient
19:05sandwich sleep apnea.
19:07They had two groups of patients,
19:10those untreated with sleep apnea.
19:13Sample size of 824,
19:15and a control group of sample
19:19size of 760. At two they obtained a
19:23symptoms or defined insomnia based on
19:26the basic Nordic slip question here,
19:29which basically looks at two major questions.
19:33Have you had difficulties falling asleep
19:36in the past three months that basically
19:39defines difficulty initiating sleep,
19:42or how often have you awakened at
19:45night and during the past three
19:49months to finding difficulty?
19:51Maintaining sleep and this questions
19:54were rated on five points and if
19:58you have four or more points,
20:01you are defined as having insomnia
20:05in that respective category.
20:07And of course they use excessive
20:10sleep at the airport,
20:12sleepiness and score to
20:14determine excessive sleepiness.
20:16So basically what they found.
20:19What's that difficulty?
20:21Maintaining sleep just as observed earlier,
20:24and was the overall most common,
20:27presenting insomnia complaints
20:29in sleep apnea patients when
20:32compared to the general population,
20:35they also found that woman with
20:38obstructive sleep apnea who
20:40tend to have both initiating and
20:43maintaining sleep insomnia when
20:45they present on patients who also
20:49had difficulty maintaining sleep,
20:51tend to have.
20:53A higher F was sleeping at a scale
20:57compared to those who presented
21:00with difficulty initiating sleep.
21:07So among the patients who had
21:10obstructive sleep apnea and insomnia,
21:13female gender and smoking were independent
21:16risk factors for difficulty initiating sleep
21:19while age and RLS were independent risk
21:23factors for difficulty maintaining sleep.
21:26So I realized his restless leg syndrome also
21:30lower mental and physical qualities of life.
21:35We also see that with both difficult in the
21:38shading and difficulty maintaining sleep both
21:41amongst the controls as well as patients,
21:44we are sleep apnea.
21:48So a study by Wallace and colleagues
21:52arm followed up with this.
21:55An initial study an in Wallace study is
21:59aim was to identify sleep apnea patients
22:04based on their insomnia presentation.
22:07So he was to determine their their
22:11category based on the ISI profiles,
22:15Insomnia Severity Index profiles.
22:18And basically what it did was that
22:22he also wanted to determine what the
22:25predictors of these profiles where,
22:29and as we can see,
22:31a large percentage of this patients
22:35actually up to some the 774% of
22:39this patients actually had insomnia.
22:41The caveat, though,
22:43is that this study was done among
22:47VA veteran patients.
22:49Who we know have a higher level of
22:53insomnia than the general population
22:56which regards to predict us.
22:59He found out that mood disorder,
23:03chronic pain,
23:04and PTSD were predictors for
23:07having severe insomnia,
23:09whereas age was more of a predictor
23:13for having less of insomnia
23:16and having more of daytime.
23:19Symptoms and actually a one year
23:22age increment was associated with an
23:25approximately 4% lower likelihood of
23:28belonging to the severe insomnia category.
23:35So now that we know what the clinical
23:39characteristics of this patients is,
23:42what I had consequences.
23:44Why is camisa important and why
23:47should we know about this condition?
23:50Well, the study by Cyrus Ranta and
23:54colleagues really delved into that
23:57he was a cluster analysis and it
24:00was a large quarts of patients.
24:04The patients were actually got
24:06in from the European sleep apnea
24:09database and she looked at almost
24:117000 patients with obstructive sleep
24:14apnea in this database and what
24:16you know she found out was she.
24:20She came up with four categories,
24:22those with insomnia,
24:24those with excessive daytime sleepiness,
24:26those with both insomnia and
24:28excessive daytime sleepiness,
24:30as well as those who had none of.
24:34This symptoms and again as we can
24:38see a large population more than
24:4150% had some form of insomnia and
24:45the other thing she found out was
24:48there was a higher comma mobility
24:51of cardiovascular pulmonary
24:53psychiatric disorders with respect
24:56to the insomnia category,
24:59and they also had a trend towards lower CPK.
25:04Usage which has been
25:06improving in the literature.
25:12So there are other studies that have
25:15looked at the other possible consequences
25:18and what we know is that there is
25:22greater use of sedative and psychotropic
25:25medications in commissa patients.
25:27They do have greater daytime impairments.
25:30They have poorer physical and mental
25:33quality of life an they have higher
25:36likelihood of cerebrovascular disease
25:38as observed by Gupta and colleagues.
25:44So having said that,
25:46we can see that the healthcare burden
25:49of camisa he is quite astronomical.
25:53Not only that, we can see that to
25:57some extent as conditions we we
26:00under diagnose patients with camisa
26:02as opposed to just obstructive
26:06sleep apnea or standalone insomnia.
26:09So let's talk about diagnosis and treatment.
26:13What are the clinical challenges and that
26:16we face taking care of those patients?
26:20So my finger here illustrates what the
26:23conventional approach is and to the
26:26clinical management of commissa patients.
26:29Usually they come to us without presenting
26:32complaints or a reason for referral,
26:35and that serves as a basis
26:38for a provisional diagnosis,
26:40which then leads us to two parallel.
26:44Clinical pathways if we're
26:46thinking more towards insomnia,
26:47would probably get a sleep diary,
26:50actigraphy some question yes,
26:52and go down the Lane of
26:55treating their insomnia.
26:57With CBT, I or sometimes hypnotics,
27:00and on the other hand,
27:02if we're thinking of more
27:05of obstructive sleep apnea,
27:07we go down that route, assess them,
27:10sat them on either CPAP therapy oral.
27:14Appliance or power airway
27:16stimulation and less likely surgery.
27:18That's usually the conventional
27:21approach and and the problem with
27:24this approach is a lot of times,
27:27like I alluded to earlier on,
27:30you know, commissa patients.
27:32They come combined with with the symptoms,
27:35and if we focus on one more than the order,
27:40we may lose diagnosis of the order parameter.
27:45I'm while I'm going,
27:46you know, through the process.
27:49But having said that,
27:51I think you know one of the more
27:54interesting things to us today is
27:56how do we manage this patients?
27:59Is there an advantage of CBT?
28:01I I'm in addition to see Pap
28:03in in commissa patients and if
28:06there is an advantage,
28:08what would be the best signing
28:10for CDT I should we have CBT?
28:13I proud to see Pap or concurrently
28:16with CPAP or is there any role for.
28:19Hypnotics we see perhaps in the
28:22treatment of commissa patients.
28:24So to answer those questions,
28:26I would go back as far back as 2004.
28:30Crack how Anne and colleagues
28:32and he was the first to look at.
28:36It.
28:36Looked at 17 patients with chronic
28:39insomnia and he placed it.
28:41Did a prospective observational
28:43study place this patients on CBT I
28:47and after four weeks of CBT I he.
28:50Dan sent them for a sleep study
28:52and have them evaluated for
28:54sleep disordered breathing,
28:56and patients who had sleep disordered
28:59breathing were then placed on
29:02some form of therapy, either CPAP,
29:04an oral appliance or surgery.
29:06His outcome measures where changes
29:09in the severity of insomnia and the
29:12quality of sleep as measured by the
29:15highest I and the functional outcome
29:18of sleep questionnaire or the PSQI.
29:20And you wanted to also know how
29:24they did with regards to CPAP use.
29:27And as we can see in this graph of
29:31amine insomnia severity index against
29:34time when this patients initially got CBT,
29:38I there was a pretty significant
29:41drop in their insomnia
29:43and severity. And then when they
29:46were followed with treatment for
29:48their sleep disordered breathing.
29:51There was a further decrease in their
29:55insomnia symptom just to give the
29:58specific numbers for the 7% of the
30:01patients did show a clinical improvement
30:04in the first phase after CBT I but
30:08after the second phase we had 88%
30:12improvement in their insomnia symptom.
30:14I mean we can argue that it's a small.
30:18It's a small study.
30:21You know there were no control group.
30:25But then Sweetman and colleagues Butte
30:28Appan there and crack house study,
30:31and indeed more of a randomized
30:34controlled trial.
30:35Looking at CBT I prior to CPAP
30:38versus treatment as usual,
30:41which is which which was just tap therapy.
30:45And he looked at 145 patients with
30:48Camisa is primary outcome was objective,
30:51average CPAP adherence as well
30:54as changes in sleep.
30:56Efficiency at six months.
30:57Secondary outcomes were rates of him
31:00idiotsitter acceptance or rejection.
31:02Changes in sleep parameters,
31:04insomnia and severity and daytime impairment.
31:07And this was what is flow chart looks
31:11like two groups CBT I with 72 patients.
31:15Treatment as usual with 73 patients
31:18and then six weeks post randomization
31:21and they were tightening.
31:23They got C pap titration and
31:26they were set up on.
31:28On C PAP and then followed up three
31:31months and then six months and with
31:34basic questionnaire sleep diary,
31:36home polysomnogram as well as assessments
31:39of their see PAP at the parents.
31:43This is a result of the study.
31:47This is a graph of diary measured
31:50sleep efficiency during treatments.
31:52I'm sleep efficiency against time.
31:55The blue line represents and the CBT group,
31:59and the orange dashed line
32:01represents treatment as usual group.
32:03And as we can see there was this
32:07initial improvement in sleep
32:10efficiency going all the way from 60s.
32:13Up to about 84% and they kind of
32:16coasted and maintain that over
32:19the course of their treatment.
32:22Also with regards to Insomnia severity index.
32:25Again,
32:26the insomnia severity against
32:28time we can see in the CBT I group
32:33and that there was a decrease.
32:35You know in, in, in insomnia.
32:38And they also maintain that over
32:41time as compared to the treatment.
32:44As usual group and it was.
32:48It was clinically significant
32:50which regards to CPAP adherence.
32:53There was improved average nightly
32:55at the parents by 61 minutes.
32:59Pretty significant.
33:00There was also lower initial
33:03PAP and rejection.
33:05In fact there was an 87% reduction
33:09in immediate CPAP rejection among
33:12participants in the CBT I group.
33:16He followed the initial study
33:18with a second report looking at
33:21sleepiness the week following CBT.
33:23I mean that that the city I component
33:27of sleep restriction and there was
33:30a 15% increase in in sleepiness.
33:33But then that went back down to the
33:37pre treatment levels over time.
33:40Now he followed that by a third report,
33:44which was quite interesting,
33:46and I thought I should share
33:49that information.
33:51Yes,
33:51this this is a graph of change
33:55in AHI against control and CBT.
33:58I looking at different parameters
34:01in different stages of sleep
34:04and basically the green bars.
34:06Yeah, the darker green bars and that's.
34:10In the summer time position
34:12and the lights are green bars.
34:15That's in the non supine position
34:18and basically just told report was
34:21evaluating the effects of CBT I
34:24on tap on the hi they were looking
34:27at the hi to see if there was
34:30any effect on on the hi and as we
34:34can see there was a significant
34:37effect on the Ahi in this patient.
34:40There was.
34:41Is 7 and a half events an hour greater?
34:45Hi difference across all sleep stages
34:48and postures so when we controlled
34:51for sleep stage and controlled for
34:54body position and when compared to
34:57control there was a 7.5 event per
35:00hour reduction in HI which I thought
35:03was pretty significant that that
35:06was the first study that actually
35:09showed that now hung and colleagues.
35:12Did follow up an with a study of their
35:16own after the Sweet Man study and
35:21basically what they did was to compare CBT.
35:25I prior to Peter ARTPOP therapy versus CBT.
35:30I concurrent with pap therapy versus
35:33just pop therapy only and so they
35:37had three hands of the study and
35:40basically followed them over 90.
35:43Days and the outcome measure was pretty
35:47much the same with the Sweet Man study.
35:51Primary outcome sipopa
35:53Darren secondary outcome.
35:55Influence on insomnia and sleep symptoms.
35:58And as you can see there was a reduction
36:03in the Insomnia Severity Index.
36:07In this draft, the blue line here is the CBT.
36:12I prior to CPAP, the red line is CBT,
36:16I concurrent with C pap and the
36:19green line is part as usual.
36:22So yes, there was a reduction in insomnia.
36:25He was clinically significant between
36:28the CBT groups and the pub groups.
36:31However,
36:31when you measure the difference
36:34between CBT before Pap versus
36:36City I concurrent with pop.
36:39There was no difference at the 90
36:42day and time points or end points.
36:48Yeah, they also looked at specific
36:52clinical endpoints which they define as
36:55good sleepers, remission or response.
36:59So basically a good sleeper was
37:03defined as someone who had a large AA
37:07five point difference less than five
37:11difference in their PSQI remission.
37:14Clinically, was defined as an ISI score.
37:19Of less than eight at study end points
37:22and the response was basically defined
37:25as a reduction in the ISI score by
37:28more than seven points, so you know.
37:31Again, Green is CBT before pop Blue is CBT.
37:35I whip up an Gray is pop only,
37:39so there was a significant difference.
37:41When we look at CBT with pop versus pop only.
37:46But when we look at the timing
37:48of CBT I before pop versus.
37:51We pop, there was no clinically
37:54significant and difference,
37:56and that was quite interesting that,
37:59you know, we have two randomized,
38:03well done and randomized control trials,
38:06but giving us different results with
38:09regards to economics and and see Pap,
38:13we already know that benzodiazapines
38:16don't help and they increase
38:19at Nick episodes and increase.
38:22The Noddy oxygen disseration during sleep.
38:25However non benzodiazepine's might you
38:29know show some efficacy year literary
38:33and colleagues and did look at a couple
38:37of patients and and they showed that.
38:41And on benzodiazapines pasquali eggs
38:44or peak lawn and can improve tolerance
38:48of C pap titration and can also improve
38:52adherence to CPAP when used in in
38:56the initial days of a C pap therapy.
39:01So in summary with regards to therapy,
39:05CBT plus pop is better than pop alone.
39:09For insomnia symptoms the effects
39:11on pop adherence,
39:13well,
39:13we have two very well done studies
39:16that show different results,
39:18so that's still unclear the with
39:21regards to sequential versus
39:23concurrent CTI wypad again two
39:26different results that still unclear.
39:28We need for the studies too.
39:31Before the clarify what should be
39:34done we are seeing from the Sweet
39:37Man study that CBT I can potentially
39:40decrease the severity of obstructive
39:43sleep apnea and zopiclone improves
39:46CPAP titration and adherence.
39:48So having said all of that,
39:51I think you know one of the most
39:55important things I'm in taking care of
39:59Camisa patients is a patient centered.
40:02Yeah,
40:03and that's you know,
40:05developing a treatment plan that puts.
40:09In the forefront,
40:11what is personally relevant to
40:13the patient as our previously
40:16presented different patients do
40:18have different risk factors and
40:21today presents in different ways.
40:23And understanding of this risk
40:26factors would help us to better
40:29take care of these patients.
40:31I think one thing is important and
40:35essential that taking care of commissa
40:38patients is multi disciplinary.
40:41It involves a sleep specialist
40:43on the primary.
40:45Care specialists are behavioral specialists.
40:47We you know we have to have all of
40:51of this on board and also frequent
40:55followups is a senchal to keep
40:59tabs with the patient and see
41:02if what we're actually doing is
41:05making a difference in their lives.
41:08Future directions.
41:09I think we need implementation.
41:12So these are in camisa to provide
41:15guidance for what
41:16the optimal therapy as well as
41:20combinations and sequence should
41:22be we do need guidance for other
41:25treatment combinations beyond just
41:27see DTI and tap terapy and I think
41:31it's interesting to study what the
41:34interplay would be between sleep debt,
41:37objective wakefulness,
41:38obstructive sleep apnea.
41:40During CBT I and C pap.
41:43Impatience with Camisa just to
41:46further elucidate what the potential
41:48mechanisms and like I said,
41:50there's still a lot of variance and
41:53that is unexplained with regards to
41:56excessive wakefulness in this patient.
41:59So in conclusion,
42:00comorbid insomnia in obstructive
42:02sleep apnea is a highly prevalent,
42:05but under recognized and
42:07condition commits to patients.
42:09They do have higher psychiatric,
42:11cardiovascular,
42:12and cerebral cerebral vascular comorbidities.
42:14When compared to patients with
42:17some obstructive sleep apnea alone,
42:19the Insomnia severity Index,
42:21sleep diary and other measures of
42:24daytime impairment there paramounts
42:26in evaluating this patients CBT I +
42:30C PAP is better than CPAP alone and
42:32multi disciplinary approach is key.
42:34So having said that,
42:36I want to say a big thank you to my
42:40program director and Doctor King for support.
42:44Doctor crager. Four is awesome.
42:47Support doctors in troop.
42:49Thank you. You're always there.
42:51Always there to give a helping
42:53hand and to you know,
42:55direct me in in in the right direction.
42:58So thank you so much for being
43:01such a great mentor.
43:03And of course Dr Schneeberg,
43:05we send you a ton of patients with insomnia.
43:09I want to say thank you for you
43:12know keeping tabs on this patient
43:15and taking care of them.
43:17Having said that,
43:18I am going to close my talk for today.
43:29Thank you second call.
43:31That was really a great overview.
43:33I want to open it up for questions.
43:36I will start off.
43:38I, you know, having read all of
43:41this literature and seeing what
43:43the data is for using concurrent
43:45CBT and C PAP initiation or
43:48CBT prior to C PAP initiation,
43:50how will this change your practice?
43:53Everything you've learned
43:54in preparing for this?
43:58So I I think.
44:02You know, going through sleep fellowship,
44:05you know at the beginning there's a there
44:07was a lot of partial knowledge and you
44:10know we put all that knowledge together.
44:14But as I come to the end
44:16of my my sleep fellowship,
44:18you know a lot of the knowledge has
44:21been consolidated and with my practice,
44:24absolutely this patients say they need CBT.
44:26I we have to, you know, put them on.
44:30CBT I you know we know.
44:32It's going to improve your CPAP,
44:35had errands is gonna help them cope better.
44:37So CBT I proud to see Pap would
44:40be the way to go for me.
44:43I know you would have further been
44:46research into this to see what you know
44:48should be done but I would do CBT.
44:51I proud to see Bob.
44:57Great thanks.
44:58Yeah, I think you know logistically.
45:00Sometimes we run into challenges
45:02of making that happen,
45:03and it's interesting.
45:04The questions that that sort of
45:06that your presentation raises.
45:08I think about some of the current
45:10insurance rules about when we see someone,
45:13and then when their sleep study
45:15has to be completed and when
45:17they have to receive C pap.
45:19And if in fact one of the routes for
45:22care is that they should actually
45:24get CBT 1st and get plugged in with
45:27that before they get their machine.
45:30That kind of changes our thinking about
45:32how we should arrange this workflow,
45:35but thank you.
45:36It was a really excellent overview
45:38of everything question anyone else.
45:43Although I have a quick question,
45:46do you think that all
45:48sleep apnea patients should receive CBT I?
45:51Prior to being started on treatment.
45:55So I I I do not think all
45:59sleep apnea patients shoot,
46:02you know, they all have this.
46:06Multiple clinical phenotypes of
46:08how you know they they present.
46:11Certainly the patients with insomnia,
46:14you know, should,
46:16especially those who have you know,
46:19difficulty initiating sleep and and
46:22have this iPod arousal state is usually
46:27very difficult for them to cope with.
46:30You know, using using C pap,
46:34so definitely those patients I would.
46:37You know, put on CBC I bought,
46:39but not not everyone, not everyone.
46:47I would love to hear.
46:48I know there is some.
46:49Oh God, is there a question?
46:54I was going to say I would love to hear
46:57from many of the psychologist I know.
47:00We have at least a couple I think
47:03behavioral psychologists on the call today.
47:05If people want to chime in and sort of share,
47:09you know their experience about managing
47:11patients who are concurrently dealing
47:13with both insomnia and CPAP acclimation.
47:16I know that those can be challenging
47:19things to deal with simultaneously.
47:22But it's it's heartening to see that we
47:25can potentially have favorable impact on
47:27each disease with treatment of the other.
47:43I have a quick question to ask her.
47:47This is the stupid man from California
47:50in patients who have strictly sleep
47:54maintenance insomnia with zero
47:56sleep onset insomnia I have seen.
48:00Usually very good result.
48:02When you can control the sleep apnea.
48:06The sleep maintenance insomnia
48:09improves is that a special group
48:13that would tend not to need CPI CPI?
48:20So yeah, so absolutely there is.
48:24You know that group of patients who have,
48:30you know, just you know, sleep,
48:34maintenance, insomnia that is
48:37particularly majorly driven by.
48:40The Apnic episodes they get so we
48:43do have those group of patients
48:46that you place them on C pap
48:49and they will improve our ever.
48:52The problem is we also have a group of
48:55patients that would also present the same
48:58way but would not necessarily improve.
49:02You know with C pap and that's
49:05where the issue of sleep depth as
49:08a trait comes into play 'cause.
49:11Different people have different
49:13sleep debts and have different
49:16tendencies to arouse from sleep.
49:18When there's a disturbance.
49:20So I would say again when it comes to that,
49:25the individual patient and an you know,
49:29like I mentioned in the presentation,
49:32that I would follow up this
49:35patients frequently 'cause you know
49:37sometimes you just have to tailor
49:40things to the individual patient.
49:55Alright, well if there's numerous
49:57questions and I think I'll let everybody
49:59know about our talk next week.
50:02So we're going to have our another
50:04sleep fellow, Doctor Glenda Bowen,
50:06who's going to be speaking about
50:09narcolepsy and provide a review
50:11in an update on treatment.
50:13And in the meantime,
50:14if anyone is interested in joining us
50:17for the Sleep Symposium this Friday,
50:19please feel free to sign up and thank
50:22you again only for a great presentation.
50:26Thank you.