10. obstructive sleep apnea syndrome

Obstructive Sleep

Apnea

Syndrome (OSAS)

Dr. Krishna Koirala

MBBS, MS (E.N.T. )22/08/2016

• Sleep is a reversible behavioral state of

perceptual disengagement and unresponsiveness

to surrounding

• Normal sleep is essential for normal health

– 2 Stages

•NREM ( 80 % ) - Relaxed Mind, Active body

•REM ( 20 % ) - Alert Mind, Relaxed body

• International Classification Sleep Disorders

– Dyssomnia : excessive sleepiness or difficulty

in initiating or maintaining sleep, affects

quality /duration of sleep. eg. OSAS

– Parasomnia : unacceptable behavior during

sleep

Common Definitions

• Arousal : An abrupt change from a 'deep' stage

of NREM sleep to a 'lighter' stage, or from REM

to awake

• Apnea : Cessation of breathing >10 sec &

arousal

– Obstructive : Chest wall moves

– Central : Chest wall doesn’t move

– Mixed : Chest wall partly moves

• Hypopnea : Decreased airflow (<50% from

baseline ) with > 4% Hb O 2 desaturation &

arousal

• Respiratory Disturbance : Apnea & Hypopnea

• The Apnea–Hypopnea Index  (AHI)

– Index used to indicate the severity

of sleep apnea

– Represented by the number

of apnea and hypopnea events per hour

of sleep

• OSAS is defined as AHI > 5

• Grades:

– Mild : 5-14

– Moderate : 15-29

– Severe : >30

Pathophysiology• Incompletely Understood !

• Hypothesis

– During REM sleep : Collapse occurs in

upper airway ‘pharynx’ (due to defect in

pharyngeal dilator muscles activity and

anatomical abnormalities) Hypoxia

arousal Upper airway collapse

improves and patient sleeps

– During sleep, airway again collapses

leading to hypoxia and arousal

• Multiple arousals result in poor quality of

sleep and day - time sleepiness

• Chronic repeated hypoxia causes

hemodynamic complications like

– Pulmonary HTN

– Systemic HTN

– CAD, CVA, CHF

Pharyngeal Dilators

•Medial Pterygoid

• Tensor Veli Palatini

•Genioglossus

•Geniohyoid

•Stylohyoid

Upper Airway Obstruction

Symptoms• Day- time

– Sleepiness

– Morning Fatigue

– Morning headache

– Cognitive

Impairment

– Heartburn

– Depression

– Impotence,

Xerostomia

• Night- time

– Snoring

– Observed

Gasping/ Apnea/

Choking

– Repeated waking

– Nocturnal

sweating

– Nocturnal

enuresis

Typical Syndromic Patient• Old Age

• Male

• Obese - BMI > 30

• Thick / Short Neck >17″

• Hypertension

• Thyromegaly

• Large Bulky tongue

• Tonsils• Nasal Obstruction• Pitting Edema• Disproportionate

Anatomy

Approach to management

• Detailed History

– Involve Bed-partner

– Ask sleep history

•Bed time

•Alcohol /

Sedative use

•Body position

•Snoring

•Arousals

•Apneas

• Assess Day time

sleepiness

– Epworth Sleepiness

Scale

– Stanford Sleepiness

Scale

• Examination:

– B.M.I

– B.P

– E.N.T. Examination

•Anterior Rhinoscopy : DNS, Turbinate

hypertrophy, Polyp , Mass

•Oro-pharynx : Tongue, Tonsils, Uvula,

Pharyngeal walls

•Neck : Circumference (> 17” ),Thyroid

•Flexible Endoscopy : Mueller’s Maneuver,

Assess Airway collapse

– CVS Examination : Complications

Normal Airway Bulky Base of Tongue

Before Mueller’s Maneuver

After Mueller’s Maneuver

Flexible Endoscopy

Investigations

• Polysomnography

– Gold Standard Investigation

– Done in a “SLEEP LAB”

– Measures:

•EEG/EOG/ EMG

•ECG / B.P

•Position of Patient / Movements of Chest

and abdomen

•Airflow /O 2 Saturation

•Esophageal Pressure

• Portable Monitoring

• Cephalometry

– Anatomical Risks for OSA

•X-Ray /CT Scan /MRI /Fluoroscopy

/Acoustic Reflex

• Multiple Sleep Latency Test

– Document daytime sleepiness

– Subject asked to sleep 4-5 times in day every

2 hours.

• TSH

• ECHO

Investigations contd…

Differentials

• Primary Snoring

•Mild upper airway obstruction

•RDI < 5

•No Daytime sleepiness

• Upper Airway Resistance Syndrome

•Moderate upper airway obstruction

•RDI < 5

•Arousal Index > 15•Excessive Negative Intra-thoracic pressure•Daytime sleepiness occurs

Medical Management• Weight Reduction

• Sleep Hygiene

– Elevate head – end of bed

– Avoid alcohol, sedatives

– Avoid lying supine (T-shirt with tennis ball at

back )

• Positive Airway Pressure (PAP) Device

– CPAP (Continuous) / Bi–PAP(Biphasic)

/APAP(Automated)

• Positioning Devices

– Mandibular Advancement Device

– Tongue Retaining Device

•Nasal CPAP is first line treatment

with ~100 % Efficacy (Gold

standard medical R x )

•Compliance is very low ~ 50%

•Pressure must be individually

titrated

•A/E : Noise, Mask discomfort,

Claustrophobia

Surgical Treatment

1. Nasal Surgery

2. Palatal Surgery

3. Tongue Base Surgery

4. Maxillo -facial Surgery

5. Tracheostomy

Nasal Surgeries

• Rarely suffice alone

• Relieve snoring > apnea

1. Office Radio-frequency Turbinate

Ablation

2. Septo-turbinoplasty

3. Polypectomy

4. Nasal Valve Reconstruction

5. Adenoidectomy

6. Nasal mass Excision

Palatal Surgeries

1. UPPP (Uvulo Palato Pharyngo

Plasty) : Most commonly

performed procedure

2. LAUP (Laser assisted Uvulo

Palatoplasty)

3. RFUP (Radio frequency Uvulo

Palatoplasty)

4. Uvulopalatal Flap

5. Lateral Pharyngoplasty

6. Transpalatal Advancement

Pharyngoplasty

UPPP

Complications : Hemorrhage, Stenosis, Velopharyngeal Incompetence

LAUP

RF Palatal Ablation

Lateral Pharyngoplasty

Uvula Flap

Tongue Procedures

1. RFTA Tongue2. Lingual Tonsillectomy3. Linguloplasty4. Tongue Base Suspension5. Hyoid Myotomy &

Advancement

RFTA

Linguloplasty

Tongue Suspension

Maxillofacial Procedures •Genio-glossal advancement & hyoid

myotomy

Maxillofacial Procedures

Maxillo-mandibular osteotomy & Advancement

Tracheostomy

Last Resort in Treatment Failure cases

Complications• Systemic Hypertension• CAD• CHF• Arrhythmias• Pulmonary Hypertension• CVA• Risk Accidents• Marital Discord• Professional Setbacks• Depression• Impotence• Sudden Death