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OBSTRUCTIVE SLEEP APNOEA
Professor Dato’ Dr Abdullah Sani Mohamed Dept of ORL HNS Faculty of Medicine Universiti Kebangsaan Malaysia
Introduction
Sleep apnoea is disruption of breathing during sleep
This results in fragmented sleep
The commonest form is Obstructive sleep apnoea
The rarest form is Central sleep apnoea
There is also a combined Central and Obstructive form
Introduction
Patients with sleep apnoea characteristically exhibit the following Snoring Daytime sleepiness Frequent waking up / fragmented sleep Uncharacteristic irritability Morning headache Lack of concentration, disorientation,
forgetfulness Inability to perform
Obstructive sleep apnoea
The main patho physiology is upper airway obstruction during sleep
When obstruction is complete, the oxygen deprived brain “wakes up” the patient, making him breath voluntarily
This disruptive cycle of obstruction, waking up to breath, falling back to sleep results in fragmented sleep
Pathophysiology
In the morning patients will complain
Does not have a good night sleep
Has a headache (due to CO2 retention)
Wakes up several times to pass urine
Does not understand why he has the above
Snoring
“Thou dost snore distinctly…… there is meaning in thy snores” William Shakespeare in The Tempest
Simple snoring is rhythmic
In Sleep Apnoea, snoring is non rhythmic, loud and causes distress to the sleeping partner
Daytime somnolence
Patients are sleepy in the morning (1130), afternoon in fact anytime, in the severe cases, all the time!
When not doing physical work, during meetings, conferences, watching TV…… listening to my lecture…..
Daytime somnolence
Of particular concern, during driving and handling of heavy machinery
Or driving a bus….
Other symptoms
They get upset easily, no “energy” easily get tired
All symptoms are attributable to the nocturnal struggle for breath
Sleep is a struggle of Life and Death
They do not “die peacefully in their sleep”
The Signs
Most patients are obese
It’s the fat deposited in the neck
A receding chin (micrognathia)
Swollen uvula
Enlarged tongue
Enlarged tonsils
Sites of obstruction
How is it diagnosed?
History, physical exam, polysomnography
Polysomnography : to document, to see how severe and how urgent to treat
Hospital based or ambulatory (home based)
Polysomnogram
Full attended hospital PSG
Multiple leads, multiple data
Most reliable, expensive
Unattended hospital PSG
Fairly reliable, has first night effect
Unattended home PSG
Fairly reliable, more “at home”
PAT Respiratory
Events
Oxygen
Saturation
Pulse Rate
Body Position
Snoring
Wake /Sleep
state
REM/ Non
REM sleep
stages
Report including Snoring & Body Position
Definitions
Apnoea : cessation (stoppage) of air flow > 10 sec.
Breathing efforts continue
Hypopnoea : reduction of airflow by 50% or more lasting > 10 sec.
Apnoea : Hypopnoea index (AHI) is apnoea AND hypopnea per hour
PSG results
AHI
0-5 normal
6-15 mild
16-30 moderate
>30 severe
Lowest O2 saturation
DISE (drug induced sleep endoscopy)
OT, anaesthetist and ORL surgeon
Propofol infusion to induce sleep
Monitoring of sleep (sedation)
Flexible scope
Evaluation of level and severity of obstruction
04/08/2018 OSA symposium, ISRNP, Putrajaya 27
04/08/2018 OSA symposium, ISRNP, Putrajaya 28
Muller’s manouver
Muller’s Manouver with obstruction at soft palate
Muller’s manouver after surgery
Treatment
The first line of treatment is to ask the patient to lose weight
Try sleeping on the side, raise the head end of the bed
Most patients cannot lose weight
treatment
For mild to moderate OSA we can try Mandibular advancement device
The idea is to protrude the lower jaw forwards
This brings the tongue forward and improves the airway
Treatment
Continuous positive airway pressure device (CPAP) : control rate of >90%
This is the Gold standard treatment
This is the first choice
Everyone deserves a trial
Treatment
If the patient refuse CPAP
Or if the tonsils are enlarged, if there is a deviated nasal septum and enlarged turbinates
We can do surgery to the nose and palate
Historically: UPPP
Uvulopalatopharyngo
plasty (UPPP)
CAPSO
In Malaysia we have stopped doing UPPP
We now do Modified Cautery assisted palatal stiffening operation
No complication of nasopharyngeal stenosis and incompetence
Easier to teach and learn
How does CPAP compare to CAPSO? CPAP is more “powerful” provided the patient
is compliant
Provided there is no nasal obstruction
CAPSO is more popular amongst the younger patients
CAPSO is very2 useful if the tonsils are enlarged
How severe is this OSA problem? Young et al (1993) found 24% of middle aged
males and 9% of females in the US
It is severe because it affects the most productive sector of the population
It is severe because it is complicated by cardiovascular, cerebral events and diabetes if left untreated
The UKM Study
From November 2000 till October 2002 we did a clinic based study of sleep apnoea
We found 76 patients
61 males, 15 females
51 Malays, 13 Chinese and 12 Indians
The UKM study
94.7% were either overweight or obese
53% had severe sleep apnoea
40% had hypertension
Collar size and loudness of snoring showed significant correlation to severity of disease
Age, sex, race, waist size, weight did not correlate with severity of disease
UKM study
Collar size of more than 17 inches is associated with 90% chance of OSA
The louder the snoring the higher the chance of OSA
The UKM Study
Normally blood pressure levels fall during sleep
Blood pressure levels of patients with sleep apnoea remain high during sleep
This correlates with the severity of the disease
2011 UKM – MIROS study on bus drivers We studied 289 bus drivers
We found 44% have OSA!
Many drivers denied increased risk of MVA
We found on record no significant association to MVA
Future Plans and Strategy
All health care workers must be made aware of this condition
Sleep apnoea is now incorporated in the syllabus of all medical schools in Malaysia
Public talks, seminars, TV Talk shows publicize this syndrome
Vendors of CPAP source funds and assistance for patients
Future Plans and Strategy
Study obesity in schoolchildren
Study the incidence of sleep apnoea amongst obese children
Study the effect of sleep apnoea on academic performances
Take home message
Family medicine can diagnose OSA
Snoring and day time somnolence are the major symptoms
Look at their oral cavity
Large tonsils and edematous uvula
Request for sleep study
Many companies are willing to do home sleep tests (RM350)
Refer with sleep study results, its saves time
Conclusion
There is a real need to increase awareness of everyone on the dangers od OSA
Sleep apnoea syndrome is a serious health problem
If left untreated patients develop hypertension, diabetes, stroke, Ischemic heart disease
A sleepy person is a dangerous driver
conclusion
OSA needs to be diagnosed
It can be treated
It needs the cooperation of the patients to control weight and to be compliant to CPAP
Need to control the obesity epidemic
You can do the sleep study and refer with the results ready
The obesity epidemic
Confidential 60
Thank you for your kind attention
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