sleep disordered breathing/ obstructive sleep apnea
DESCRIPTION
SLEEP DISORDERED BREATHING/ OBSTRUCTIVE SLEEP APNEA. JHANSI NALAMATI MD. TYPES. Obstructive Sleep Apnea Central Sleep Apnea Mixed Apnea Upper Airway Resistance Syndrome (UARS). Historical background. Apnea- literally means “without breath” Pickwickian papers fat boy “Joe” - PowerPoint PPT PresentationTRANSCRIPT
SLEEP DISORDERED BREATHING/ OBSTRUCTIVE SLEEP APNEA
JHANSI NALAMATI MD
TYPES
Obstructive Sleep Apnea
Central Sleep Apnea
Mixed Apnea
Upper Airway Resistance Syndrome (UARS)
Historical background
Apnea- literally means “without breath”
Pickwickian papers fat boy “Joe”
Osler and later Burwell applied the name “Pickwickian Syndrome” to patients with Obesity, Hypersomnolence and signs of Chronic hypoventilation
Historical (contd.)
Sleep apnea -Rediscovered by Gestaut and co- workers in 1965 by simultaneously recording sleep and breathing in a “Pickwickian” patient and described all 3 types of apnea.
Postulated that sleepiness is due to repetitive arousals associated with resumption of breathing that terminated the apneic events.
Historical(contd.)
First description of successful Tx of OSA by tracheostomy followed in 1969.
First Tx with CPAP – in 1980’s soon after NIPPV was described by Charles Collins of Australia
Definition of Apnea
Apnea-Cessation of breathing(air flow) for 10 seconds
Hypopnea- decreased in the airflow by 30-50%, and associated with an arousal and a drop in oxygen desaturation by 3-4%
Prevalence
9% of men and 4% of women, in one study of state employees had AHI of 15 events/hr
12 million people in the US have OSA
Pathophysiology
Pharynx is abnormal in size or collapsibility.
As an organ for speech and deglutition it must be able to change shape and close
As a conduit for airflow it must resist collapse
Pathophysiology(contd.)
Exact mechanism is not knownDuring the day muscles in the region keep the airway openDuring sleep muscles relax to a point where the airway collapses to an extent that it gets obstructedOnce breathing stops, individual awakens to breathe and arousal can last few seconds to a minute
Risk factors for OSA
Obesity
Age- middle aged men and post- menopausal women
Older age- due to loss of muscle mass and tone
? Family Hx of OSA
Risk factors (contd.)
Anatomic abnormalities- receding chin, ?Nasal congestion, ? DNS
Enlarged Tonsils and adenoids esp.in children
Enlarged and inflammed uvula, worsened by chronic smoking, GERD
Acromegaly
Risk factors (contd.)
Amyloidosis, post- polio syndrome, neuromuscular disorders
Marfan’s syndrome, Down’s syndrome
Use of alcohol and sedatives that relax the upper airway
Increased neck circumference > 16 inches in women and 18 inches in men
Symptoms
Most of the symptoms are from disruption of normal sleep architecture
Excessive Daytime Sleepiness (EDS)- falling asleep even in stimulating environment, during a conversation, eating, business meeting
H/O Snoring
Symptoms (contd.)
Non- restorative sleep
Automobile Accidents
Personality changes
Decreased Memory
Erectile Dysfunction
Frequent Nocturnal Awakening
Symptoms(contd.)
Drowsy Driver Syndrome
Polyuria
Early morning headache
Dry mouth
Signs
Loud Snoring
Witnessed apneas
Obesity
HTN
Metabolic syndrome
Increased Neck circumference
Anatomic Abnormalities
SHHS
Sleep heart health study- initiated by NIH in 1996 and initial data shows that treatment of SBD improved outcomes in control of HTN, CHF atherogenesis, glycemic control
Screening for OSA
2 of the three symptoms- EDS, loud Snoring, Witnessed Apneas
High Score on ESS(Epworth Sleepiness Score)>12, or Stanford Sleepiness Score
Epworth Sleepiness Scale (ESS)
Maxiumum score of 24The scale is used to rate the 8 situations below that apply best to each individual0-no chance of dozing1- Slight chance of dozing2- moderate chance of dozing3- high chance of dozing
ESS (contd.)
Sitting and readingWatching televisionSitting inactive in a public place ( theater, meeting)As a passenger in a car for about an hr. without breakLying down to rest in the afternoon when circumstances permitSitting and talking to someoneSitting quietly after lunchIn a car, while stopped for a few minutes in traffic
ESS ( contd.)
1-6 : getting enough sleep
7-9 about average and probably not suffering from Excessive daytime Sleepiness (EDS)
10 or greater- need further evaluation to determine the cause of EDS or if you have underlying sleep disorder
Types of Sleep Study
Full night Polysomnography ( PSG)
PSG with CPAP titration
Split- Night Polysomnography
Multiple Sleep latency test ( MST)
Maintainance of wakefulness Test ( MWT)
Diagnosis
Nocturnal Polysomnography-in lab study, where EEG, EMG, HR, body position, leg movements, Oximetry, Snoring, abdominal and chest wall movements are recorded
Home studies are limited as EEG is not recorded, or in some limited studies only Nocturnal Pulse oximetry is done
Definition of OSA
Normal- AHI < 5
Mild OSA- AHI 5-20
Moderate OSA- AHI 20-40
Severe OSA- AHI 40-60
RDI( respiratory disturbance Index)- AHI+ RERA( Respiratory Effort Related Arousals)
UARS
Upper Airway Resistance Syndrome
Cannot be diagnosed with PSG
Repetitive arousals that probably result from increased Respiratory effort and high resistance in the airway
Can be diagnosed by measuring esophageal pressure (Pes)
Medical Complications
Uncontrolled HTN
Diminished quality of life from chronic sleep deprivation
Increase risk for CVA
Worsening of CAD and CHF
Treatment
Behavioral Tx- weight loss
Sleep hygeine
Avoiding alcohol too close to bedtime
Avoid sedatives and hypnotics, narcotics
Avoid caffeine
Treatment(contd.)
Positional Tx- helpful with Primary snoring
Positive Airway pressure (CPAP or BiPAP)
ENT Surgery
Oral appliances
Positive airway pressure
Effective, Non-invasive
Mask fit, air seal, comfort and humidification are important
Nasal mask, full face- masks, nasal pillows, Nasal aire prongs
Complications of CPAP
Local dermatitis
Air leak, nasal congestion,rhinorrhea
Dry eyes
Nose bleed
Aerophagia
Rare- tympanic rupture, pneumothorax
Compliance is the biggest issue
Surgery
Except tracheostomy,helps only mild to moderate cases or only primary snoring
Not curative for OSA
Somnoplasty- office procedure- radiofrequency ablation of the soft palate- only for snoring
Surgery( contd.)
LAUP- laser assisted uvuloplasty, only for snoring, office procedure
UPPP (UP3)- (Uvulo-palato-pharyngo-plasty)
Complicated surgery
Patients have to observed in the hospital overnight
UPPP(contd.)
Decreases AHI by only 50%
Complications include- nasal regurgitation of fluids, pharyngeal stensosis
In children- tonsillectomy and adenoidectomy alone is curative
Jaw surgery
Useful for retrognathia, involves partial excision of maxilla or mandible
Genioplasty
Complicated surgery
Bariatric surgery
Gastric bypass
Weight loss and decrease in adipose tissue of the parapharyngeal region leads to improvement or cure of OSA
Weight loss has to be at least 20-30lbs before any change in AHI can be seen
Oral appliances
Devices that are worn during sleep that retract the jaw and alleviate upper airway obstruction
Tongue retaining devices for people with macroglossia
Jaw Positioning Devices
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Alternative Surgeries for Obstructive Sleep Apnea (Osteotomies)
1) Bi-maxillary advancement 2) Genio-tuberule advancement
CPAP Therapy
CPAP Therapy
Positive impact on subjective sleepiness and depression (in RCTs)
Fatigue, generic health related quality of life, vigilance, driving performance are all improved ( prospective trials)
These parameters are sensitive to Tx duration and compliance
Commercial driving and OSA
OSA has to be effectively treated before clearing the patient for work
Objective documentation of regular CPAP use and testing by Multiple sleep latency test and/or MWT( Maintainance of Wakefulness Test)