"The Not So Commonly Recognized Associations of Sleep Disorders" Zubin Bham (04/06/2022)

April 18, 2022

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00:00And reminders. So first Yale Sleep
00:04Seminar is available for CME credit and
00:06to receive credit you need to text the
00:09ID for the lecture to the Yale cloud CME.
00:11The ID does show up on the slide of the talk
00:14as well as in the chat recordings of the
00:16lectures are available within two weeks,
00:18so you can look for that as well,
00:20and then third,
00:21if you have questions during the talk,
00:23use the chat type questions in as
00:25we go and we will address them
00:26at the end and at the end.
00:28We'll also give you permission to unmute
00:30yourself if you'd like to ask your own.
00:31Question a couple of upcoming events
00:33that I just want to mention next week,
00:36April 13th is our joint conference
00:38Sleep Seminar,
00:39so we're going to be hearing
00:40from Doctor Sebert Sebra Abbott.
00:42She's going to discuss the management of
00:44circadian disorders the following week.
00:46April 20th is our visiting professor
00:48for the year Doctor Eileen Rosen.
00:50She will be speaking at Sleep
00:52seminar at 2:00 PM.
00:53It's this usual time slot on
00:55the future of Sleep Medicine.
00:57She is also going to speak at
00:59the PCSM grand rounds.
01:01Immediately after this at 3:00 PM,
01:03and she's going to speak on sleep and sleep.
01:05Deprivation in medicine,
01:06and she will give another presentation
01:08on Thursday at our research conference.
01:11So everyone is invited to those sessions.
01:14And please email Debbie Lovejoy
01:15if you have any questions.
01:17These are hybrid sessions you
01:18will be here in person,
01:19so we would love it if you could attend
01:22in person. If you're able to do so.
01:24So now.
01:25Anyway,
01:25I'm going to turn the session over to Dr.
01:27Ian Weir,
01:27who is program director of the Newark
01:29Hospital Pulmonary Fellowship and the north.
01:32Fellowship and he will introduce Doctor Baum.
01:35Thanks thanks take away Ian.
01:38Thank you doctor Hilbert.
01:39So I have the pleasure of
01:42introducing our speaker today.
01:44For those of you don't know,
01:45Doctor, Bam doctor Zubin Bam,
01:47pulmonary critical care and sleep fellow
01:49four years in the Norwalk and Yale.
01:52System has been through a countless
01:55number of COVID surges from 2020 to
01:59at Yale last year and we really are.
02:02Just a happy to have him as a sleep fellow
02:05and he really has brought a tremendous
02:07amount of energy to our fellowship.
02:09Doctor Bam will be staying in the area,
02:12which were so fantastic to hear
02:14he'll be working within the Yale
02:16system at Bridgeport Hospital in
02:17Milford Hospital as a pulmonary
02:19critical care and sleep physician.
02:21And so I can go on and go on and talk
02:23about all the accolades for Doctor Ben,
02:24but I'll just give you one sentence
02:26that will kind of sum it up.
02:28He won the Norwalk Hospital
02:31Board of directors.
02:32Award last year for the most
02:35outstanding resident or fellow in
02:37in the entire Norwalk Hospital,
02:39so he's well respected and he's going to
02:42be a fantastic asset to the Bridgeport area,
02:45so without a doubt without you know,
02:48more accolades.
02:49I'd like to present that through Bam,
02:52who's going to be talking on not so
02:54commonly recognized disorders of sleep,
02:56associations of sleep disorders,
02:58and, you know we were talking
03:00about what to present here and we,
03:02you know, we sort of said, hey,
03:03listen, you know?
03:03I tell the fellows it's there and the medical
03:06students and all the people that rotate.
03:07There's basically four reasons
03:09why people come to see us.
03:11They're sleepy, they can't sleep.
03:13They have weird stuff happened
03:15to them during their sleep,
03:16or someone told them to see a sleep doctor.
03:19So this is sort of that sociation
03:22of sleep disorders talk,
03:24so I'll take it away, Doctor Bam.
03:27Thank you so much Doctor Weir doctor Hilbert.
03:30Hi guys and Doctor Bam I'm zoomin.
03:31I'm one of the pulmonary sleep train
03:34people at Norwalk bring you for seven
03:36years now so it's been a long long time
03:38here but I'm sad to stay in the area.
03:40I'm originally Canadian like Doctor
03:42Krieger and a lot of other people that
03:45come to Norwalk and so Connecticut
03:47has become my adopted state.
03:49I guess home as well.
03:50So what I wanted to do was kind
03:52of focus on the not so commonly
03:54recognized associations of sleep
03:56disorders like Doctor Weir mentioned.
03:58Those last two reasons that people see
04:00us weird stuff happens when I sleep.
04:02Somebody sent me here and kind
04:04of focusing on that.
04:05I just want to kind of go over
04:08some disorders that are very,
04:09very common,
04:09but we don't normally associate
04:11them with sleep disorders itself.
04:15And so this is the CME slide.
04:19I think this should be in your
04:21chat as well and I can bring it up
04:23after at the end of the talk for
04:24people that need need the code.
04:26And so today we'll go over different organ
04:28systems affected by sleep disorders.
04:29And they suspected pathophysiology.
04:30I was as I was making this talk.
04:32You know, you can take a really deep
04:34dive into sleep disorders and all the
04:36different organ systems they affect.
04:37I kind of wanted to highlight
04:39certain organ systems.
04:40I'll make a brief mention of some
04:42other ones at the end as well.
04:44And then there'll be a lot of
04:45a lot of proposed mechanisms.
04:47A lot of reasons why we think this happens.
04:49Obviously, as we evolve in Sleep
04:51Medicine will know more.
04:53We'll talk about the need to screen
04:54for sleep disorders as a contributing
04:56factor in a lot of different.
04:57Z States and we'll talk about some
05:00unique treatment options in this
05:02in this group of patients that
05:04have colored sleep disorders as
05:06well as other disease states.
05:07So Sleep Medicine itself continues to evolve.
05:11It's still considered to be in its infancy.
05:13Our screening continues to evolve.
05:15Our testing continues to evolve
05:17and then obviously the treatments
05:18continue to evolve as well.
05:20We've we've had so many treatments
05:23over the years.
05:24And and and as this continues
05:26to evolve as a specialty,
05:28we're recognizing that sleep plays a
05:30role in a lot of pathophysiology across
05:33different organ systems over the last decade,
05:36we've had a lot of self specialties
05:38in in within sleep itself emerge,
05:40so we're most of us are pretty
05:42familiar with sleep dentistry,
05:43but the sleep cardiology,
05:44the sleep, ophthalmology, sleep,
05:45psychiatry, and even sleep urology,
05:48and so they all deal with specific disease
05:51states within their own organ system.
05:53How they pertain to sleep?
05:55And then the fact that all these
05:58different sleep branches exist tells
06:00us that there's a lot of interplay
06:02between these organ systems and so
06:03that's what we'll kind of talk about.
06:05So jumping right into it, you know,
06:07cardiovascular manifestations,
06:08sleep disorders.
06:09Most of us are pretty familiar with
06:12the adverse outcomes associated
06:14with untreated sleep apnea,
06:15so we know about hypertension
06:17resistant hypertension,
06:18the increased risk for stroke,
06:20arrhythmias, heart failure,
06:21the data still out back and forth.
06:23It seems to be maybe.
06:24Laser roll and diastolic heart
06:26failure or heart failure preserved.
06:27EF not so much with systolic heart failure,
06:30but we know systolic heart failure
06:32can cause sleep issues and CAD.
06:35What I wanted to focus on was a very
06:38unique topic within cardiovascular
06:40system that we don't really
06:42commonly associate or know about
06:44and these are both real cases that
06:46I've had during my sleep year.
06:48As a fellow.
06:49And so we'll start off with this one.
06:51It's a 26 year old male that came to us.
06:58And you. Umm? So excessive daytime
07:02sleepiness and vivid dreaming,
07:04it was a value for the sleepiness as
07:06a teenager underwent the PSG and MSLT
07:09that showed the diagnosis are confirmed.
07:11The diagnosis of narcolepsy at the
07:13time the parents chose to manage the
07:15disease with just schedule maps avoid
07:17any medications which is not uncommon,
07:19especially when you tell them about
07:20ziron zywave and the potential for abuse,
07:22yadda yadda yadda.
07:25He gets older, realizes that you know
07:27he's able to get through high school college,
07:29but now he's finding it really, really hard.
07:31It's hard to take schedule Naps,
07:33where as an adult,
07:34which I'm finding out now with.
07:36With that with the House and the baby.
07:39And it's hard to function during the day,
07:41and so he's unable to have a social
07:42life and so comes back to us and
07:44says I still have this this problem,
07:46you know, and I was diagnosed
07:47with narcolepsy as a teenager.
07:49But in addition to that,
07:50I'm starting to notice,
07:51you know a couple other things.
07:52Light sensitivity, cold intolerance,
07:54some Lightheadedness.
07:55I feel really lightheaded and dizzy when I
07:58stand up too quickly or after working out.
08:01So that's case one.
08:04The next case,
08:05also something that we saw in
08:07in our sleep clinic.
08:0831 year old woman diagnosed with
08:10the history are coming in with the
08:12issue of excessive daytime sleepiness
08:13and multiple fainting spells,
08:15so she came in for an evaluation
08:17and her sleep studies confirmed the
08:19diagnosis or suggested a diagnosis.
08:21Geopathic hypersomnia.
08:23Our biggest complaint or issue
08:26was her daytime sleepiness,
08:27and so she was started on treatment with
08:30Adderall and she had some improvement,
08:32but it wasn't isn't.
08:33It wasn't quite good enough for
08:35her and she was still requiring
08:36a lot of sleep during the night.
08:38On the weekend she would even
08:40take naps during the day and so
08:42ultimately between COVID and the
08:43amount of sleep she's requiring.
08:45She realized that working from home
08:46would be the best solution for her.
08:49We continue to see her in follow up
08:50and in the interim we found out that
08:53she had been tested for idiopathic
08:55gastroparesis and was referred for
08:57autonomic dysfunction testing and
08:59ultimately going down this pathway.
09:02She had tiltable testing perform and
09:04it confirmed the diagnosis of pots or
09:07postural orthostatic tachycardia syndrome.
09:09And so autonomic dysfunction in narcolepsy,
09:11something that is very very well known
09:13as I was doing my research on this has
09:15been known for a couple of years now,
09:17but it's not something that we
09:19routinely look for or screen for,
09:20and this is a couple of the
09:23manifestations of the disease itself.
09:25So Rexin is implicated in
09:27various physiologic functions,
09:29sleep break regulation,
09:30and they actually has orexins
09:32been implicated and actually
09:34controlling autonomic regulation
09:35as we are asleep and narcolepsy,
09:37we have a deficiency of orexin and
09:39so you can see a lot of these.
09:41Patients will have abnormal
09:43sympathetic activation during sleep.
09:44They can have non dipper
09:46blood pressure profile.
09:46They can have heart rate variability.
09:48They can have abnormal pupillary function
09:50leading to some light sensitivity issues.
09:52They can erect all dysfunction,
09:55fainting spells, orthostasis as
09:56well as heat or cold intolerance.
09:59All in all, what this adds to
10:02this complex group of patients is
10:03that even if we treat their sleep
10:06disorders and their sleep complaints,
10:08if we don't really address or recognize the
10:10autonomic dysfunction in these patients.
10:12They can continue to feel pretty
10:14crummy and not feel so great.
10:16And and so we're essentially
10:19partially treating them.
10:20I don't know what those functions
10:21also been known to.
10:22Current idiopathic hypersomnia and more
10:24recognized as pots in these patients,
10:27and so autonomic nervous system dysfunction.
10:29NIH is commonly represents
10:31with resting tachycardia,
10:32orthostatic intolerance,
10:33and so there's been a couple of
10:35studies looking at this autonomic
10:37dysfunction burden in patients with
10:39IH and I'll talk about you scoring
10:41systems that are used commonly,
10:42so composite autonomic symptoms score,
10:45which is the compass 31 and the
10:48scope of the UT, which are two.
10:50How many used screening tools
10:51for I don't know.
10:52Dysfunction have been shown
10:54in both narcolepsy and IH.
10:57To cause autonomic dysfunction.
10:59Typically if you just have a
11:01patient with isolated pots,
11:03they typically will have
11:04complaints of insomnia,
11:05poor sleep efficiency if you study
11:07them on a polysomnography study,
11:08test patients with.
11:10I,
11:11however,
11:11have great sleep efficiency as diagnosed
11:14by their increased sleep drive and
11:18also present very interestingly
11:19and so it's important for us to
11:21recognize that these patients can
11:23have these coronary conditions and
11:25we can take care of the sleep issues
11:27if we don't address the patient.
11:29Completely,
11:29they continue to feel pretty measurable.
11:32When I was doing preparing for this talk,
11:34it also came across as this
11:36interesting fact that 33 patient
11:37of pots had diagnosed with Eller,
11:39Danlos, hypermobility,
11:40subtype,
11:40which we know is a risk factor for feedback,
11:43you know,
11:44and so it's something to keep in the
11:46back of our mind as patients with IH
11:48and POTS can also have sleep apnea,
11:50just increasing the overall
11:52disease burden and complexity
11:53of taking care of these people.
11:55And so like I mentioned,
11:56there's a couple ways to measure
11:58automatic Ness dysfunction.
11:59The scope by UT is a well validated study.
12:02Used in a lot of synucleinopathies most
12:05commonly in Parkinson's to measure the
12:08autonomic burden in these patients.
12:10And it's a 30 question screening
12:12questionnaire that kind of addresses
12:15different domains similar to the Compass 31,
12:18which looks at 6 different
12:19domains including security,
12:20motor, vasomotor pupil, motor GI,
12:23orthostatic, and neurologic function,
12:25and determines the amount of burden
12:27that these patients have when
12:29dealing with the autonomic symptoms.
12:31And so this was an interesting
12:33study out of France.
12:34It looked at the autonomic dysfunction
12:36burden in patients with narcolepsy one.
12:38So what they wanted to do?
12:40Who's looking at a group of
12:42patients that had narcolepsy 1
12:43formally diagnosed and compared
12:44them to control patients that
12:46were otherwise healthy and compared the
12:48amount of autonomic dysfunction in these
12:50patients as measured by the compass 30
12:52scope by UT sorry and then the other
12:54to do is look back at these patients.
12:56Treat them for narcolepsy and see if
12:59the disease, the autonomic symptom.
13:01Dysfunction symptom burden went up or down
13:04when the narcolepsy was actually treated.
13:07And so they actually
13:09looked at these patients.
13:10And they all authority confirmed narcolepsy,
13:13either by PSG MSLT showing a
13:15sleep lensey less than 8 minutes
13:18combined with two Sorin periods,
13:20or CSF orexin level less than 110.
13:22Now keep in mind that this
13:24study was based out of France,
13:26and so the medications used to
13:28treat narcolepsy in the study
13:30were almost 95% stock.
13:31Your stimulus to keep the patient
13:33awake so would affinal methylphenidate
13:35or patellar send sodium.
13:37Oxybate was only about 22%
13:39and then anti cataplectic.
13:40Medications like SSRI SNRI were used
13:43in about 50% of the patients with NT.
13:46One or narcolepsy tech one.
13:49This is the baseline demographic
13:51data for these patients and what
13:52I wanted to point out really,
13:54is that compared to controls,
13:56patients with narcolepsy type 1
13:57tending to be more wise so there
14:00BMI greater than 30 was much more
14:02common in the NT one patients,
14:04and they also happen to have more
14:05disability and compared to the controls,
14:07which is not surprising.
14:09We know that poor sleep leads to.
14:12Increase.
14:14Appetite increase kind of cravings
14:18for carbohydrates.
14:19As most of us will know after working
14:21on call shift what we crave mostly
14:23carbohydrate so it's not surprising
14:25but that was kind of the baseline
14:27demographic data for these patients.
14:28Then they got into the actual scope
14:30ET questionnaire and so you can
14:32see that it's it's broken down
14:35by actual different organ systems
14:37and the autonomic dysfunction that
14:39can be precipitated and what I've
14:41highlighted here in blue are the
14:43organisms that were not different.
14:44Between the two groups,
14:46so everything else 15 out of the 25.
14:50We're actually statistically
14:51significant in the narcolepsy group,
14:53so more drooling,
14:54more GI symptoms such as Constipation,
14:57abdominal fullness, fecal incontinence,
14:59urinary symptoms, not to urea,
15:03Lightheadedness,
15:04hyperhidrosis,
15:05oversensitivity to light temperature
15:07and tolerance for all more common
15:10in the narcolepsy type.
15:11One patients compared to
15:13the control patients,
15:14which is pretty significant.
15:15Then they went back and said,
15:17well, let's treat these patients
15:19and see if treating them improves.
15:21Or diminishes the autonomic dysfunction
15:24burden, and so these are the drug
15:26free patients in this group.
15:28And these are the treated
15:29patients and the drugs.
15:30We talked about that we used to treat.
15:32And what's interesting here is regardless
15:34of the treatment that they received.
15:36None of them really had an improvement
15:38in their autonomic dysfunction score,
15:40so the treatment itself didn't really get
15:42rid of the dysautonomia in these patients,
15:44which is important because a lot
15:45of times the question becomes,
15:47well, chicken and the egg, right?
15:48That the narcolepsy or IH led
15:51to the autonomic
15:52dysfunction?
15:53Or did it occur independently of it?
15:56And based on this study you know
15:57it would seem like it occurred
16:00independently just because treating
16:01one didn't get rid of the dysautonomia.
16:04That being said,
16:04a lot of these medications that we use.
16:06To treat autonomic dysfunction in narcolepsy.
16:10Will cause out of dysfunction in some.
16:12The stimulants themselves can
16:14cause some autonomic dysfunction.
16:15The SSRI is the SNRI's so it's hard to say.
16:20Which did what?
16:23And so we kind of went over the study itself.
16:25But you know, most of the patients
16:27in compared to the controls
16:29on 15 items on the scope.
16:30IT had increased symptom burden
16:32in the 59 patients treated
16:35with narcolepsy medications,
16:37there was no difference in the
16:38scope of the UT and what they
16:41found was the increase scope.
16:42UT score was associated with an
16:44older age and longer duration of
16:46the diagnosis of narcolepsy rather
16:48than the erection levels in your
16:51CSF or the severity of narcolepsy.
16:53Suggesting that there's something else
16:55at play here besides just the fact
16:58that you might have bad narcolepsy
17:00or really low CSF orexin levels.
17:02We we know that autonomic
17:04dysfunction in sleep apnea occurs.
17:06This is typically thought to be secondary
17:09to abnormal adrenergic tone in these
17:12patients do intermittent hypoxemia.
17:14And often very, very commonly,
17:16it goes unrecognized,
17:17and so we can take care of their sleep apnea.
17:19The excessive daytime sleepiness.
17:21But they might still continue to feel crummy.
17:24Because the disorder only persists
17:27despite adequate treatment.
17:29And so these are the proposed mechanisms.
17:32So we talked about narcolepsy 1
17:34deficiency and orexin teams seems
17:36to be the biggest issue here
17:38in idiopathic hypersomnia.
17:39Interestingly,
17:39there appears to be an immune dysfunction.
17:41There's something that's just regulating
17:43the amount of sleep that predisposes
17:45them to automate dysfunction in pots.
17:47And subsequently there might be a
17:49role for immune modulators in these
17:51patients to actually treat both
17:53their IH as well as the autonomic
17:55dysfunction and sleep apnea.
17:56It's the intermittent hypoxia
17:57that leads to a polyneuropathy.
17:59Ultimately leading to dysfunction
18:01of the autonomic nervous system.
18:04And so we've kind of talked about this,
18:06right?
18:06People that have another dysfunction and
18:08comorbid sleep disorders will report
18:10a poor quality of life and address
18:12an increase in depressive symptoms.
18:14And so,
18:14as sleep possessions,
18:15we might take care of these sleep disorders.
18:17But if we don't really take care of
18:19their if they're autonomic dysfunction,
18:20they might continue to feel
18:23terrible and inadequately treated.
18:25And then obviously a lot of these
18:27medications that we use to treat
18:29excessively attentiveness can
18:31lead to worsening dysautonomia
18:32and dysregulation of the NSA.
18:34So this is just a quick overview,
18:37you know basic signs, 101,
18:40sympathetic,
18:40parasympathetic and you can see the
18:42amount of control that this autonomic
18:44nervous system has on our body,
18:45and so the the amount of.
18:48Impact that dysregulated sleep will
18:50have on a patient even if we take
18:53care of their sleep complaints.
18:54They can continue to feel terrible
18:57and so talking about management
18:59of this autonomia and hypersomnia.
19:02You know,
19:02treatment with CPAP therapy has been
19:04shown to improve dysautonomia symptoms.
19:06Now these were small case
19:07theory case studies,
19:08mostly in Pediatrics and in Pediatrics,
19:11at least.
19:12Anecdotally,
19:12what we're seeing is the sleep deprivation.
19:15Sleep fragmentation does have an
19:17almost an amplified response to the
19:19dysautonomia that kids will present with,
19:22and so PAP therapy has been shown to
19:25improve the dysautonomia symptoms.
19:27Interestingly, like I mentioned, I, uh,
19:29there seems to be an immune component.
19:32Immune response to these patients,
19:34and so the the case presentation
19:36that I started off with the young
19:38lady that was diagnosed with
19:40idiopathic hypersomnia idiopathic
19:41gastroparesis and diagnosed with pots.
19:43She actually ended up with IVIG to
19:46treat her any about the gastroparesis,
19:48and surprisingly she actually had
19:51improvement in her IH complaint.
19:53She was less sleepy,
19:55required less stimulants,
19:56and so I've actually been shown to
19:58help with the autonomic symptoms,
20:00so that would be a very unique.
20:02Treatment pathology for patients
20:04that have IH with comorbid
20:06autonomic dysfunction and then,
20:08you know,
20:08increase salt and water is recommended
20:10for all patients with pots to keep the
20:13intravascular volume and the tone high.
20:15And so if you do have a patient
20:16with narcolepsy with a lot
20:18of autonomic dysfunction,
20:19this might be the person that might
20:21benefit from desire instead of desire wave,
20:24they actually might benefit from
20:26the increased salt load compared
20:28to the low salt medicine,
20:29even if it doesn't taste as good.
20:34This is a quick little summary.
20:37Let's say you do have a patient that
20:39came to you referred from cardiology
20:41with pots with Steve complaints.
20:43So our job or the cardiologist job might
20:46be to recognize the pots, screen them
20:48for sleep complaints if they have any.
20:50If they don't continue to treat the parts,
20:52they do have sleep complaints,
20:53then our job becomes to do a sleep focused
20:56agent P and really break it down into these
20:59sleep disorders that we might see first.
21:01Insomnia, we can talk about
21:02the standard which would be.
21:03BT melatonin and then recognize that a lot
21:06of these patients might be on beta blockers.
21:09Beta blockers can worsen insomnia
21:11and can worsen restless legs
21:13if it's poor sleep hygiene.
21:15Kind of the same thing.
21:17If you have a delayed sleep phase,
21:18some of these patients that are diagnosed
21:20with pots are on the younger side,
21:21so they are predisposed to
21:23this disorder to begin with.
21:25Considering actigraphy,
21:26consider melatonin and phase shifting them.
21:29Patients that present with
21:31concern for sleep apnea or PLM.
21:33You can study them.
21:35They come in complaining of really
21:37hypersomnia excessive sleep drive
21:39studying with the BSG MSLT they have RLS.
21:42You can screen them with the ferritin
21:45completed if necessary and then
21:47consider medication to treat the
21:49underlying RLS understanding that
21:50patient with pots can present a lot
21:52of times when sleep complaints and
21:54it's our job as sleep physicians to
21:57kind of filter out what's what to get
21:59the patient treated overall rather
22:01than just their sleep disorders.
22:05Switching gears a little
22:07bit from cardiovascular and
22:08dysautonomia to ophthalmologic
22:10manifestation of sleep disorders.
22:12And so this was a disease condition
22:15that I'd never even heard of before
22:17I started working on this and
22:19some of you might recognize it.
22:21But this is floppy eyelid syndrome.
22:23And so I'll get into that exactly
22:25what it is and it's associated with
22:27association with sleep disorders,
22:29mainly sleep apnea.
22:31Again, so this is another case
22:33that we had in in in in our sleep
22:35Center 62 year old female with
22:38the history of hypothyroidism.
22:39She originally presented to
22:40the ER with sudden onset,
22:42painless central vision locks
22:44upon waking up in the morning.
22:46She went to the ER.
22:48They did imaging.
22:49There was no evidence of a stroke.
22:51They did an ophthalmological evaluation
22:54and revealed and Afrin pupillary
22:57defect with optic disc edema.
22:59This was what was reported in the ER.
23:01I'm sure it was done by an ophthalmologist,
23:04certainly as a sleep physician.
23:05I can tell you that I would know
23:07how to do an ophthalmological
23:09evaluation kind of pick this up.
23:11She ultimately did see a neuro
23:13ophthalmologist after these
23:15findings in the ER and.
23:16And was referred to us for
23:18evaluation for sleep disorder,
23:20breathing, and so for those units
23:22that might recognize this,
23:23this is nonarteritic anterior
23:26ischemic optic neuropathy.
23:28So,
23:28and ion is is what she was
23:30referred to us for,
23:32which is the first time for me and I believe
23:34I saw this patient with Doctor Weir,
23:36but it's obviously not the first time
23:37that he seen somebody with this referral,
23:39and so just going down that pathway.
23:41There's a lot of sleep eye conditions that
23:44sleep disorders have been associated with,
23:46so.
23:46Canon is fairly frequently associated with
23:49this and opthamologist neuro ophthalmologist.
23:51You know that this association exists,
23:53and so when they diagnosed with
23:55somebody with this condition,
23:56they're very frequently will refer
23:57them for a sleep study to make sure
23:59that there's no underlying sleep apnea.
24:01Floppy outlets, you know,
24:02is something that I came across.
24:04Doing my research and talk about
24:06that a little bit later glaucoma.
24:08It's a huge spectrum of disease that exist,
24:12but the two that are most often
24:14associated with sleep pathophysiology
24:15is primary open angle glaucoma,
24:18and then normal tension glaucoma
24:20papilledema a lot of different
24:22ideologies behind papilledema,
24:24which ultimately comes down to
24:25increased intracranial pressure,
24:26intraocular pressure,
24:28nocturnal lagophthalmos.
24:29This was interesting.
24:31I knew what this was before
24:32doing this research, is it it's?
24:34The inability to close your eyes at
24:36night or completely close them at night.
24:38Interestingly,
24:38it's seen more commonly in
24:41patients with sleep disorder,
24:42breathing, sleep apnea,
24:44obstructive sleep apnea,
24:45and then obviously we know we deal
24:48with this pretty frequently.
24:49It's actual sleep,
24:50cpap related eye complications.
24:54So getting back to NI on or non underdog
24:57anterior schematic optic neuropathy,
24:59it's characterized by sudden onset,
25:01painless unilateral vision loss that it can
25:03affect the central and peripheral vision.
25:05Typically,
25:06patients will present pretty
25:07quickly when a central vision
25:08because it's very obvious to them once
25:09in a while they might lose peripheral
25:11vision and not present till much later on.
25:13It is the most common cause of
25:15optic neuropathy in patients over 50
25:17years of age in the United States.
25:20And then the visual loss is
25:22actually irreversible.
25:22Unfortunately, and up to 33% of
25:25patients will continue to have
25:27ongoing or evolving vision loss
25:29over the over the coming days or
25:32weeks after the initial insult.
25:34And so this table right here talks about
25:37the prevalence of an ion and sleep apnea,
25:39and so you can see it's as high
25:42as 89% in patients with sleep
25:43apnea with the risk ratio of 4.9.
25:46So five times as compared to
25:48the general population.
25:49Another one says that the prevalence
25:51is about 71% of patients that had
25:54an iron had comorbid sleep apnea.
25:56This is what the imaging this is,
25:58what the FUNDOSCOPY would show
26:00you again as a sleep trained.
26:03Provider having done residency in
26:05medicine and plumbing group care.
26:07I cannot tell you that I will
26:08be able to get this fundoscopic
26:10image and describe it to you,
26:11but essentially what we're looking at
26:14is somebody with a normal eye here and
26:16a right eye with mild disc edema here,
26:19which looks very very subtle to me.
26:21But essentially that's what
26:22we're supposed to be seeing when
26:24somebody gets diagnosed with this.
26:26And so the pathophysiology of Anon is very,
26:28very interesting.
26:29And This is why there's an association
26:31rather than a causation which for a lot
26:33of these conditions will hold true.
26:34So the most common risk factor is
26:36age of our 50 hypertension, diabetes,
26:38atherosclerosis, hyperlipidemia, right?
26:39So when you look at those risk factors.
26:43There's so much overlap here between
26:46here and and a CDCB a patient that you say,
26:51well, isn't this just a subtype of that?
26:53When you look at patient with sleep apnea?
26:55Regardless of all these risk factors,
26:57their risk ratio,
26:58like we talked about,
26:59is 5 times compared to the general
27:01population development,
27:02and so if you meet all these criteria,
27:05if you're over 50,
27:06if you have high blood pressure diabetes,
27:08and you add sleep apnea on top of that,
27:10your risk ratio gets up very,
27:12very quickly for the development of.
27:14And the potential mechanisms of the
27:17proposed mechanisms are variable.
27:18Some of them suggest impaired optic
27:21nerve blood flow autoregulation during
27:23recurrent apneas there's also apnea
27:26induced blood pressure variation.
27:27So as the blood pressure varies
27:29when we have periods of happening
27:31rather than dipping and non dipping,
27:33the autoregulation again is broken
27:35and can lead to this impaired blood
27:37flow and then during periods of
27:40hyperventilation we end up inducing
27:41hypercapnia increase CO2 leads
27:43to an increased.
27:44SCP,
27:44which can further compress the optic nerve,
27:46so there's a lot of studies that show
27:49one of these pathophysiology mechanisms.
27:52None have been proven because
27:53it's hard to know how much each of
27:56these is playing a role in somebody
27:58with underlying sleep apnea.
28:02Unfortunately, despite us knowing the
28:04association between these two conditions,
28:06there's no proven therapy for an ion.
28:09Typically most ophthalmologists.
28:11Neurologists will recommend some type
28:14of antiplatelet therapy to reduce
28:17your risk for recurrent insult.
28:19And despite those known association
28:21between sleep apnea and and the
28:24treatment of sleep apnea with
28:26PAP therapy has not been shown to
28:29reduce the development of nylon.
28:31More often than not,
28:32patients will actually end up
28:34with another episode or another
28:37insult in their contralateral eye.
28:39Even if they've been diagnosed
28:40and are being treated for sleep
28:42apnea with PAP therapy,
28:44and so it's one of those things where there's
28:47an association we don't have causation and,
28:50and even if we treat the sleep apnea,
28:53it still doesn't appear to reduce
28:54the risk of of developing an ion,
28:56and this might go back to the
28:59coronary risk factors age over 50.
29:00Atherosclerosis,
29:02hypertension, diabetes,
29:04so floppy outlet syndrome.
29:05I think it does a great job of
29:07describing what the disease is stated.
29:09Health is essentially it's an easily
29:12everted floppy eyelid and and and so we
29:15associated with the papillary conjunctivitis.
29:18It's been linked to a variety
29:19of systemic disorders you have.
29:20Obesity, hypertension,
29:22diabetes, CD phrases,
29:24so you can see it as a theme building here.
29:26There's a lot of overlap between
29:27a lot of these conditions,
29:29sleep disorders and disease States
29:30and that's why so far we haven't
29:32been able to get a strong associate a
29:34causation for a lot of these conditions.
29:37There remains just an association.
29:40However,
29:40with floppy eyelid the strongest as
29:42though she does remain a sleep apnea,
29:44and so in some present studies
29:46the the incident of sleep apnea
29:49patients were floppy eyelid syndrome
29:51ranges from 96 to 100%,
29:53which is which is pretty pretty significant.
29:56The mechanisms behind floppy
29:58outlet syndrome and sleep apnea,
30:01so you can have mechanical stress
30:02from from rubbing and stretching the
30:04eyelid during sleep against pillow.
30:06This is seen to occur more frequently in
30:08people that have fragmented or disrupted.
30:09Deep there's a scheming reperfusion
30:11injury that results from tissue
30:13that results in tissue inflammation
30:15during periods of hypoxia.
30:17Pathologies actually shown loss of
30:19elastin fibers in the tarsal plates of
30:22some of these patients with floppy eyelids,
30:25and then there's elevated leptin
30:27and MMP matrix metalloproteinases
30:28in these patients with sleep apnea.
30:30That's also been associated with
30:32a floppy eyelid syndrome.
30:33And so we we have all these
30:36proposed mechanisms.
30:37There's no way to link the two again because.
30:40A lot of systemic disorders overlap
30:43between these two conditions.
30:45And so let's say we do get some.
30:46We referred to us for floppy eyelid.
30:48Or we have somebody that comes in
30:50has sleep apnea has been diagnosed
30:53with and is being treated with CPAP
30:55and they complain if I issues such
30:57as something that suggests floppy
30:59eyelids or pathway conjunctivitis.
31:01I think we should recognize
31:03this condition and send them to
31:04optomology for a full evaluation.
31:08Usually the treatment is pretty conservative.
31:10We talk about weight loss since it
31:12is associated with obesity as well.
31:13So sleep apnea, eye Shields,
31:15protecting the cornea lubrication if needed.
31:18Ophthalmic steroids and
31:19antibiotics if ultimately needed.
31:21Which is why I referred to
31:23ophthalmology would be very important.
31:25There's also evidence that treating
31:27these people with PAC therapies so
31:29CPAP does reduce the disease burden
31:31itself and so makes them less likely
31:34to have the Calgary conjunctivitis.
31:36Which is the biggest issue,
31:38at least irritation.
31:41Glaucoma.
31:42It's another group of ophthalmic
31:44condition that's been associated
31:46with with sleep fragmentation and
31:48so essentially characterized by
31:50progressive optic neuropathy with a slow
31:53degeneration of the retinal ganglion
31:54that results in visual field loss.
31:56A lot of patients that will have glaucoma
31:59actually present very late in the disease.
32:01The reason being usually glaucoma
32:03presents with peripheral vision loss
32:06and so all the time they have vision
32:08loss affecting the central vision.
32:10They will.
32:11They will be pretty far into their disease.
32:15It is the second most common cause of
32:17blindness and 2nd and the most common
32:20cause of irreversible blindness and
32:22the most competent type of glaucoma
32:24is primary open angle glaucoma,
32:26POG.
32:26There is studies showing that the
32:28province of sleep apnea in patients with
32:30either one of these types of glaucoma
32:33can be highest 27% compared to 2%
32:35prevalence in the general population,
32:37so you know it's nine times as
32:39high in some of these studies.
32:41Link glaucoma to sleep apnea.
32:45These are some of these prevalence studies,
32:48so people diagnosed with primary open
32:50angle alcoma 20% had sleep apnea.
32:54Normal tension 44%.
32:55You can see some of these are
32:57just very small case studies,
32:59the biggest one being about 600 patients.
33:03But there's a lot of overlap
33:05between these two conditions,
33:06so again, it's an association.
33:07It's something that we,
33:09as sleep physicians sleep
33:11specially should be aware of.
33:13And and and and know to recognize
33:15and the suspected pathophysiology
33:16is not so different from the other
33:19two that we talked about already.
33:21General risk factors being about
33:23the same increased age genetics,
33:25a thin cornea and elevated intraocular
33:27pressure are the most commonly cited
33:29risk factors for this condition.
33:31However, the proposed mechanism
33:33linking glaucoma and sleep apnea
33:34include direct hypoxic injury to the
33:36optic nerve during periods of apnea.
33:38We can also have disrupted auto
33:40regulation like we did in patients
33:42with N ion that leads to optimistic.
33:44Uptake,
33:44nerve injury and then reperfusion
33:47and then you can also have increased
33:49IOP during fall periods of apnea
33:51like we talked about so you can see
33:52there's a lot of overlap between
33:54the proposed mechanisms for a lot
33:56of these conditions because they
33:58hold true to a lot of sleep apnea.
34:01So what do we do for these patients that
34:02have chronic sleep apnea and glaucoma?
34:04You know,
34:05if we get somebody that's been.
34:08Valued for glaucoma and coming to
34:09us for a sleep study,
34:11we should obviously study them
34:12and recognize that a lot of these
34:14patients might not screen very
34:15highly with their traditional stop,
34:17bang,
34:17Epworth and so a home sleep study might
34:19not be the right test for these people,
34:22and PSC would probably be the study to
34:24to perform in these patients because
34:27of the low pretest probability,
34:28they have high pretest,
34:30probability and glaucoma.
34:31You know, I think the right step
34:32is a home sleep apnea study,
34:33but just to be aware of that,
34:35a home sleep apnea test is
34:37not effectively without.
34:38Uh, sleep disorder.
34:39Breathing in these patients.
34:42We should also recognize that a lot
34:44of ophthalmologists will refer to us
34:46to do a sleep study when they have
34:48a patient with these conditions,
34:50but us as sleep physicians and a
34:52patient complaining to us of visual defects,
34:54visual loss,
34:55peripheral vision problems,
34:57they have other risk factors such as
34:59advanced age or or atherosclerosis
35:02risk factors.
35:03We should refer them to optimize be like,
35:05hey,
35:06have you had your eyes examined recently?
35:09Because a lot of these times if we
35:10catch the glaucoma early enough,
35:12we can minimize.
35:13Visual field loss going into the
35:15future because it's usually irreversible.
35:18Typically we manage glaucoma
35:19using topical drugs to lower
35:21the intraocular pressure,
35:22and sometimes surgeries required and again
35:25small case series that should benefit of
35:28PAP therapy and improving normal tension.
35:30Glaucoma,
35:31not primary angle,
35:32open angle glaucoma,
35:34and actually improving the visual
35:35field deficit in these patients.
35:37So I think as we continue to evolve
35:39and recognize these associations,
35:41ultimately leading to a causation theory.
35:43Will be able to kind of propose
35:45pack therapy and treat underlying
35:47sleep disorder breathing for these
35:49patients and and minimize the
35:52morbidity associated with them.
35:57Moving on a little bit further,
35:58so there is also lots of lots of data out
36:01there and it keeps coming out in the last
36:04five years about the gastrointestinal
36:06or GI manifestations of sleep disorders.
36:09There's been lots of studies showing
36:12a strong association between sleep
36:13disorders and GI diseases, and it appears
36:16to be back and forth between the two.
36:19So I think sleep fragmentation sleep
36:21disruption leads to a lot of symptoms.
36:24Daytime GI symptoms, on the other hand,
36:28nocturnal GI symptoms and diseases
36:30such as IBS, IBD, leads to poor sleep,
36:33insomnia, sleep fragmentation,
36:34which can be a perpetual cycle between the
36:38two, and so I'll talk about a few here.
36:40We'll talk about gastroesophageal
36:42reflux disease or GERD.
36:44We'll talk about little bowel syndrome,
36:45IBS inflammatory bowel disease,
36:48IBD, colorectal cancer,
36:49and non alcoholic fatty liver disease.
36:54So gastroesophageal reflux disease is
36:57is very, very common in sleep apnea.
36:59Nearly 80% of patients with GERD complain
37:02of nocturnal symptoms and ultimately
37:04complain of poor sleep as a result of this,
37:07and GERD symptoms are found to be
37:09three times as more likely in patients
37:12with insomnia compared to patients
37:13with no sleep complaints at all.
37:15So I know when we evaluate patients for
37:18insomnia, we're kind of trying to figure
37:20out what's the underlying ideology.
37:21Do they need a sleep study?
37:22What else are they doing?
37:24Girl is not one of the things that
37:26we frequently ask about that could
37:28be contributing to their insomnia.
37:30Often we'll ask about sleep
37:32fragmentation or less medications,
37:35sleep, hygiene, sleep restriction,
37:36but we might be surprised
37:38that you know they're like,
37:39Oh my heartburn keeps me like a lot of times.
37:43There's also seem very commonly
37:45in patients with sleep apnea,
37:47and it's been associated with high
37:49grade esophagitis and subsequent
37:51development and Barretts esophagus.
37:52So it's some.
37:53It's a it's a culinary condition that
37:56we need to be definitely aware of.
37:58Why do we think this such an
38:00overlap between these two?
38:01One of the proposed mechanisms is that
38:03sleep apnea itself causes intrathoracic
38:05pressure swings that can reduce
38:07the tone of the lower esophageal
38:09sphincter and then promote reflux.
38:11Subsequently,
38:12the other studies that have gone back
38:14to look at this using esophageal
38:15probes and during periods of apnea
38:17it did not show this intrathoracic
38:19pressure swing that reduced the
38:21lower self vaginal tone,
38:22so it's hard to prove whether or not
38:25that's an actual contributing factor.
38:28This is normal,
38:29but during sleep there's
38:30decreased swallowing reflex.
38:31There's decreased salivary secretion
38:33and prolonged esophageal clearance time,
38:36so you can see when we're
38:37not eating and drinking,
38:38as as we do at night and everything kind
38:41of slows down and esophagus is less,
38:44having less prosthesis.
38:45You can have increase in symptoms
38:47of heartburn and reflux as night
38:49obesity also appears to worsen.
38:51Symptoms of sleep apnea angered
38:52and you can see this is a common
38:54factor between the two.
38:58There's very, very good quality
38:59evidence out there actually,
39:01that nasal CPAP reduces your frequency,
39:04and so it's something that we should
39:05encourage a lot of our patients to use,
39:07especially if GERD is one of the
39:09reasons that they're awake at night.
39:11Even more importantly,
39:12and this we've run into a couple of times,
39:14his patients that have GERD with
39:16primarily nocturnal symptoms will
39:18actually use their CPAP less and and
39:20comply less with their CPAP because
39:22in nocturnal symptoms from GERD,
39:24actually inhibiting them from
39:25wearing the CPAP and so.
39:27It's very important for us to recognize this,
39:29saying that if they do
39:30have heartburn symptoms,
39:30we need to make sure they're adequately
39:33treated and referred to GI if if,
39:35if appropriate,
39:35because it will help them actually
39:37keep their CPAP on and night and
39:40not have untreated sleep apnea.
39:44IBS has also been associated
39:46with a lot of sleep conditions.
39:48Patients with IBS report poor sleep and
39:51they have increased arousal thresholds.
39:53There's also evidence of decreased
39:55nighttime melatonin and tryptophan
39:56levels in these patients,
39:57so you can see these patients have
40:00are predisposed to fragmented,
40:01poor quality sleep at night to begin with.
40:04On top of that,
40:05they might have RLS and and this can
40:08contribute to their poor sleep as well.
40:10This was a very interesting
40:12study I came across,
40:13so there was 205 resident.
40:15Positions working in a hospital
40:17that were screened and evaluated
40:20for IBS and 20% of them,
40:22nearly 20% of them met criteria as per
40:25the Rome 3 guidelines for IBS and when
40:28they broke this down even further,
40:30they realized in those residents that
40:32met criteria for IBS for every one hour
40:35less asleep that they got while on call,
40:37there was a 33% increase
40:39in their IBS symptoms,
40:41and so to all the trainees out there,
40:44future trainees.
40:45You know next time they ask
40:46you to take overnight call,
40:47you can just blame this study and say,
40:50well I can't take anymore call
40:51because my IBS is going to flare.
40:54There's good evidence for it out there.
40:57And interestingly,
40:57recognizing that there's a big overlap
41:00between these patients is decreased
41:02melatonin levels in these patients.
41:04There's been a couple of RCT's that
41:06have looked at treatment of IBS poor
41:09sleep in patients with melatonin,
41:12and it showed that patients that were
41:14given melatonin 3 melodramas there was
41:16improvement in their abdominal symptoms,
41:18but there was no difference in
41:20their PSG or Sleep Questionnaire,
41:21so it's not like they were like,
41:22oh, I got better sleep on my sleep.
41:24Efficiency improved based on the PSE,
41:26but they had less.
41:28Donald symptoms,
41:29treatment of RLS with ferritin
41:31and dopamine agonist,
41:33are the two main study medications
41:35also improve sleep efficiency in these
41:38these patients with IBS or small bowel,
41:40intestinal overgrowth,
41:41and so you can see there is
41:43something unique treatment options
41:45modalities in these patients that
41:47have comorbid sleep and IBS that
41:49we don't normally think of that we
41:52very important for us to recognize.
41:55Uh, we know pretty well shift work.
41:57Sleep disorders associated with
41:58increased risk of solid organ cancers,
42:01but there's more and more evidence
42:03coming out that sleep duration actually
42:05changes your risk considerably,
42:07regardless of whether or not you have
42:09shift work disorder or sleep apnea.
42:12So in this study by Thompson and
42:14colleagues showed that there was a 50%
42:17increase in the risk of colorectal
42:19adenomas and patients who slept less
42:21than six hours on the other spectrum.
42:24Other side of that spectrum.
42:25Zang and colleagues showed that
42:27sleeping more than 9 hours was
42:29also associated with increased
42:30risk of colorectal cancer compared
42:32to those that only slept 7 hours.
42:34So you can see that.
42:36Decrease sleep which can be centered
42:38insomnia when these other cornbread
42:40sleep conditions increases the
42:41risk of colorectal cancer.
42:43Conversely, sleeping a lot,
42:44which might be seen in our
42:45patient with hypersomnia,
42:47also increases your risk of
42:49colorectal cancer. Interestingly,
42:51this risk was doubled if the patient was
42:53also noted to be obese and or snored,
42:55and this was a colorectal surgery paper,
42:58and so they use snoring as
43:00a marker for sleep apnea.
43:02They weren't actually tested for sleep apnea.
43:05And why do we think this exists?
43:08We know that lack of sleep is
43:10pretty blown and pro inflammatory.
43:13A lot of people would sleep
43:15deprivation for after a couple of days.
43:16We'll end up with, you know,
43:18overwhelming sepsis.
43:18That kind of storm and so in these
43:20patients they actually looked at the ones
43:22that were sleeping less than six hours,
43:24and they were noted to have increased
43:26Interleukin 6 and CRP levels.
43:28There's also an increase in TNF levels
43:30for every hour under 7 1/2 hours of sleep,
43:33which promotes new tumor growth
43:34and then the instrument.
43:35Epoxy itself is considered to promote
43:38carcinogenesis in these patients,
43:39so you can see somebody who
43:41sleeps less than six hours and
43:43has come up with sleep apnea.
43:45Their risk for development
43:46of some type of cancer,
43:47particularly colorectal cancer,
43:48is significantly elevated.
43:52Lastly, just to round things out,
43:54liver disease has also been
43:56associated with sleep disorders,
43:57and so as an icy dock very commonly
43:59we'll see patients that have cirrhosis,
44:02end stage liver disease of any other
44:05ideology have very, very poor sleep.
44:07Now this has been chalked up to
44:09the poor clearance of ammonia,
44:11which can disrupt the sleep wake cycle,
44:14poor production of melatonin,
44:16and and its subsequent consequences in
44:19maintaining a proper sleeping cycle.
44:22But sleep disorders has also been
44:24associated with liver disease and so
44:26non alcoholic fatty liver disease.
44:27NAFLD affects one in four people,
44:30has become a real epidemic ever
44:32since obesity has taken off,
44:34and so both obesity.
44:36Obesity itself has driven the navel and
44:39sleep apnea epidemic together hand in hand.
44:42Interestingly, however,
44:43NAFLD and OSE appeared to.
44:46Occur a lot more frequently than
44:49we previously thought.
44:50NAFLD itself is associated with
44:52increased cardiovascular risk.
44:53It can lead to cirrhosis,
44:54liver failure and battle cellular carcinoma.
44:58And so why do we think these
45:00tend to kind of coexist?
45:01Sleep apnea causes intermittent hypoxia,
45:03leads to oxidative stress,
45:05tissue inflammation,
45:06and overactivation of the
45:08sympathetic nervous system.
45:09This has been shown to
45:11cause pancreatic apoptosis,
45:12which ultimately results
45:14in insulin dysregulation.
45:15And then we can't metabolize fat fatty acids,
45:19and we'll end up with fatty liver disease.
45:22Intermittent hypoxia also directly
45:23leads to hepatic steatosis and
45:25fibrosis due to mitochondrial
45:27injury directly from the.
45:28From anoxia or hypoxia and patients
45:32with non-alcoholic fatty liver disease,
45:35up to a third 3/4 of them,
45:3875% of them might have sleep apnea,
45:40so it's a huge proportion of
45:42these patients that will have
45:44comorbid NAFLD and sleep apnea.
45:46The jury still out whether or not PAP
45:49therapy appears to improve snaffled.
45:52Once you have fatty liver disease
45:54as diagnosed by biopsy on Histology.
45:57If you have sleep apnea,
45:58PAP therapy does not appear to
46:00reverse the fatty liver disease.
46:02They're still trying to figure
46:03out whether or not it slows down.
46:04The progression of this disease.
46:07In this study,
46:08there was also a patient that
46:10randomized auto CPAP versus fixed CPAP,
46:12and there was no difference in
46:13their fiber or last physical,
46:14which is a score that measures
46:16their fibrosis of the liver itself.
46:19There's also screening for patients
46:21with fatty liver disease for
46:23sleep apnea that currently is
46:25recommended by the hepatology.
46:27Association I'm going to speak to him
46:31up a little bit so rheumatology is
46:32also been associated with sleep disorders.
46:34It's been associated with a
46:36bunch of these conditions.
46:37A lot of these patients will already
46:39have sleep disturbances related to sleep,
46:40fragmentation,
46:41insomnia,
46:42and so Ari appears to be the
46:46biggest kind of association.
46:48And so this was a huge study
46:50of 105 patients from Taiwan,
46:52and they looked at 423 patients
46:54with sleep apnea and without sleep
46:56apnea and the risk of development
46:58of autoimmune conditions.
46:59And this is what they saw.
47:00Patients with sleep apnea had
47:02a huge increase compared to
47:04the overall control group of
47:07developing autoimmune disease.
47:08It was higher for rheumatoid arthritis.
47:10It was increased risk for show grinds and
47:13increased risk for base shots as well.
47:16Umm? Going the other way,
47:18they looked at patients that had
47:20rheumatoid arthritis and then they were.
47:22They wanted to see how many of
47:24them ended up developing sleep
47:25apnea and so looking at this.
47:27Conversely, these are all patients
47:29with rheumatoid arthritis and you
47:31can see their risk of developing
47:33sleep apnea appears to be much
47:34higher at the 12 year mark compared
47:36to people that did not have sleep
47:38rooted arthritis to begin with,
47:40so it appears to be a two way
47:41connection between these two diseases.
47:43Autoimmune conditions quickly
47:46going through this.
47:48Rheumatoid conditions arthritis
47:49itself predisposes us to sleep apnea
47:51because if many people pathology
47:53cervical spine instability or
47:55through destruction of the TMJ's,
47:57there's also interleukins that appear
47:59to play a huge role in this that
48:01lead to ultimately fragmentation.
48:03Further inflammation promoting
48:05both sleep dysregulation and
48:07precipitating autoimmune flares.
48:11One thing I wanted to talk about
48:12is anti TNF medications that have
48:14been used to treat rheumatologic
48:17conditions actually improve
48:18sleep latency and increase sleep
48:20efficiency while decreasing a child,
48:22which is very interesting.
48:23So something we used to treat
48:25rheumatologic conditions can actually
48:27overall improve our sleep sleep study,
48:29scores of sleep,
48:30latency and HIV and then treatment
48:32with path therapy for people
48:34with common with sleep apnea also
48:37reproduces inflammatory markers
48:38and has been associated with
48:40decrease in rheumatoid flares.
48:42Hematologic manifestations we
48:43can kind of quickly just go over,
48:45so we know that Paul's have theme
48:47is pretty common in sleep apnea.
48:48Severe sleep apnea patients but
48:50increased RDW and as well as MPV,
48:53which are markers of increased
48:55platelet aggregation and activity,
48:57has also been associated with
48:58people with severe feedback.
49:00Yeah,
49:00so it's one of those things that we
49:02can look for in patients that severe
49:03sleep apnea and and recommend PAP
49:05therapy more aggressively or treatment
49:07of their sleep apnea more aggressively.
49:09If we see one of these indices.
49:11Elevated? You have some other organ
49:14systems linked to sleep disorders.
49:16We know pulmonary.
49:17This increases flags as asthma exacerbation,
49:19and vice versa.
49:21In the OB, we know sleep patterns
49:23associated with preeclampsia,
49:24gestational diabetes,
49:25low birth weight,
49:27neurologic 20 to 80% of patients.
49:29Upsy will have sleep disorder breathing
49:31and actually treating the sleep apnea
49:33with pathway reduces the risk of seizures,
49:35and we know patients with expense
49:37rises will have poor sleep.
49:38But treating their psoriasis and eczema
49:41will actually improve the underlying.
49:43Sleep quality and so this is just a quick
49:46summary because I'm running out of time,
49:48but I want people to ask
49:49questions that they have,
49:50but a lot of these conditions appear
49:52to have a two way communication,
49:54right?
49:54So sleep apnea has been associated
49:55with a lot of these conditions that we
49:57talked about and so our job really.
49:59And the whole point of this
50:00talk is for us
50:01to recognize that these associations
50:03exist and that we should not only be
50:06evaluating patients that have been
50:08referred to us for sleep studies,
50:10but also recommend on the
50:11other side sending them to GI,
50:13sending them to ophthalmology.
50:15Rheumatology, if we see that there
50:17are risk for these common reconditions
50:18or have presenting symptoms for
50:20these commemorative conditions.
50:23Also, recognize that some of these
50:25conditions can be treated very uniquely.
50:27Melatonin IVIG TNF inhibitors can help
50:29you improve the sleep condition as well
50:32as the underlying Coleman mid condition,
50:34and so it's important for
50:36us to recognize that.
50:37Besides, PAP and oral appliances,
50:39there's other things out there
50:40that can be used to treat these
50:43overlapping conditions,
50:43and that's all I got.
50:46Happy to take questions.
50:53So thank you very much.
50:55Doctor Bam for that whirlwind tour
50:59of associated sleep disorders,
51:01but I do think it's really important.
51:03I think you've highlighted,
51:04you know the effects of
51:06association versus causation.
51:07That's really helpful.
51:08And also, you know,
51:10in the world of Sleep Medicine,
51:12we're trying to be more.
51:14Sort of, you know, rather than just
51:15focusing on the sleep disorder.
51:17And that's it. Really.
51:19Looking at multi dimensional
51:20multi interdisciplinary.
51:21And, uh,
51:22how how the sleep disorder may
51:24impact other disease systems
51:25and other disease systems may
51:27affect the person's sleep.
51:28So I think it's really helpful to
51:30think to think broadly so we can
51:33open it up for comments questions.
51:37I will look at the oh the the chat,
51:40but also feel free to unmute
51:42yourself and ask a question so
51:45I have something from the chat.
51:47Awesome jobs you've been.
51:48Can you go over how to identify floppy?
51:52Eye again,
51:53since it's so common
51:55four, I can't say personally
51:57I've ever picked this up,
51:59but maybe it's I've already come across
52:02it and never really looked for it,
52:04and so really it's an ever to floppy,
52:06eyelid and paper conjunctivitis.
52:07So if I go back to this image So
52:11what are you really looking for?
52:12Is a patient.
52:13Look down and then use their eyelid
52:15and look up so it's one of those things
52:17you should do as a kid where you
52:19should flip your eyelid inside out.
52:20If that happens very easily and they have
52:24an associated with the redness underneath it,
52:27it might suggest floppy eyelids.
52:30So essentially you're looking for something
52:31that says that comes in complaining,
52:33saying my, you know,
52:34my outlet seems a little bit more LAX,
52:35a little bit more floppy, so to speak.
52:38You can do this quick.
52:40Evaluation for EVERSION,
52:41but again, not an ophthalmologist.
52:43It is a sleep condition and
52:46an associated eye condition.
52:47I would send them to the appropriate.
52:50Specialty specialist,
52:52yeah, can
52:53I just say a word about that?
52:55So one of the ways you can get
52:56a hint is that when the patient
52:59comes in that the eyelids are
53:01practically at the level of the pupil,
53:04like when they're looking at you.
53:06It's like you start to wonder how
53:08can this person see because the
53:10islands are like really low and and
53:12that's that's a clue that they're
53:14going to have floppy eyelids.
53:16So if you see here, I think what doctor
53:18Cruz mentioned is like you can see,
53:19this looks like almost like.
53:20Closest where the island is have.
53:23Shielding some of some of the actual.
53:26Pupil iris and so yeah that would
53:28that would be a clue as well.
53:32Yeah, the the interesting with the getting
53:34on the eye thing that would glaucoma.
53:36This glaucoma is such a common,
53:39you know sleep disorder and I disorder
53:42like you mentioned and it can lead to
53:44blindness and and so I guess you know
53:46when you have a patient who you diagnosed
53:49with severe obstructive sleep apnea.
53:51We spend a lot of time,
53:52you know talking about CPAP and treatment.
53:56I wonder if there is some role to say hey,
53:58these are the conditions that have
54:00been associated with this and.
54:01Maybe you know, did you have your eye exam?
54:04How is your thyroid?
54:05Have you been screened for
54:07hypothyroidism and some other other
54:09things we didn't touch on the the
54:11metabolic effects of for thyroid.
54:13That's a whole separate talk on itself,
54:16but I think it does offer an
54:18opportunity to just make sure that
54:19they're up to date with all their age
54:22appropriate screening and so forth.
54:24Yeah, I. I definitely think
54:26there's a role for for that.
54:27You know, I think, as we found out,
54:29you're supposed to have two.
54:31By exams in your 20s,
54:32one in your 30s and then one typically
54:34at least one ophthalmologic evaluation.
54:37By the time you're 40 and so
54:38you can just be like, hey,
54:39have you ever seen enough theologist?
54:41Have you ever had an eye exam and keeping
54:43up with that certainly makes sense.
54:47So have a nice comment,
54:48terrific talk and I'm going to be
54:51a couple of the other questions.
54:53So can pulmonary disease or
54:57extra pulmonary results to OSA.
55:00I was trying to read it to make
55:01sure I understand the person
55:02could unmute themselves that they
55:04want to clarify the question.
55:05Sorry, extra pulmonary disease.
55:10Sorry, I'm I I'm not understanding
55:12the question is this.
55:13Yeah, I'm sorry there's a
55:15question by Ying Cat CAII.
55:17Just I'm sorry I don't.
55:18I don't understand the exact
55:19question if they wanna ask him,
55:21maybe they could unmute themselves.
55:25And one other question,
55:27while we're waiting for that is for
55:29patients with narcolepsy or idiopathic
55:32hypersomnia and autonomic symptoms,
55:34would you treat yourself or do you
55:37inform the PCP of what's going on?
55:41So typically if I do have a
55:43patient with narcolepsy and IH,
55:44we actually have one with formally
55:46diagnosed pots so pots is
55:49typically diagnosed with biologist,
55:51tiltable testing, Valsalva yada, yada yada.
55:54And so if we're trying to treat
55:56the this autonomia depending
55:57on what they're presenting,
55:58symptom is I might refer them back
56:01to cardiology who made the diagnosis.
56:04If it's disappointed to kind of.
56:07Presenting otherwise,
56:07let me feel comfortable just
56:10giving them the salt, water,
56:12increased salt and water intake.
56:14Now if we're talking about something
56:16like IVIG for somebody with idiopathic
56:19hypersomnia and they do have this
56:21whole host of immune presentation would
56:24have idiopathic gastroparesis pots.
56:26I would probably send them to immunology.
56:29Who who might do further recommendations?
56:32Do IG subclass testing and then
56:34actually recommend IVIG or not.
56:36So that was just a 1 * 1 case series
56:40that showed improvement in sleep
56:42parameters after IVIG infusions.
56:44For this autonomia,
56:45I don't know if it's proven.
56:48Therapy with a track record.
56:50But if it's simple enough,
56:53I feel comfortable dealing with
56:54it in terms of dysautonomia,
56:56but when you're getting into other
56:58manifestations of disease at
56:59probably leave it to the specialist
57:01so cardiologists are pretty good
57:03resource neurologist manage a lot of
57:05dysautonomia and patients with Parkinson's,
57:07and so you might might send them to a
57:09neurologist if you diagnose these again,
57:11sleep urology is is is a thing as well,
57:15so if they have your logic manifestations,
57:17it's definitely possible.
57:20Yeah,
57:20and I think there are specific
57:22centers that manage pots,
57:24so pots was a specific diagnosis.
57:26Cardiology would make the diagnosis.
57:29There may or may not initiate treatment,
57:31but there are some centers that
57:34specialize in pots as well and then
57:36we have another question about this.
57:37Tonami and narcolepsy.
57:38Do you think that Zyra would have
57:41enough salt to be effective and and
57:44would wonder if this type of symptom
57:47would worsen when you switch from?
57:48My ziram to zywave.
57:51Yeah, so I think typically
57:52ziron is thought to have
57:562000% of the daily salt intake,
57:58which you know it's a lot of salt.
58:01When we, when we usually give
58:02me to the pediatric population,
58:03we don't think about it so much
58:05and a lot of them will actually
58:06feel really really good on it.
58:08Anecdotally, I haven't had anybody
58:11feel worse switching desire wave.
58:13I've had people just say,
58:14like you know what I like Zara
58:16better than Zywave in case anyways,
58:17because some people will say zywave
58:19taste like cleaning solution to them.
58:22That being said, that being said,
58:24Ziram does have a lot of salt to begin with,
58:28and so some people struggle
58:30consuming enough water and salt,
58:32and so if you can just get away with cyrum,
58:33it's definitely one of those things where.
58:36I would stick with Xyrem rather
58:39than suggesting Zywave because of
58:41that increased salt load in that
58:43medication we have given our pediatric
58:46patients salt tabs on top of the
58:48ziram because they did have pots and
58:51they continue to feel terrible, but.
58:54Maybe one of those times where
58:56the exam is probably better.
58:58If you do have this autonomia
59:00orthostasis syncope, or near syncope.
59:04OK, well we're past the hour.
59:07I know we have a great speaker for a
59:09state chest at over in the pulmonary
59:12side so I wanna thank you everyone
59:14for joining and also some great
59:16comments that you did a great job
59:18zoom in on the comments section and I
59:20appreciate it and have a great week.
59:23Thanks everyone.
59:25Thanks so much. See you next week.