Lec#5 Sleep Apnea , Internal

8/2/2019 Lec#5 Sleep Apnea , Internal

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Sleep ApneaWe will be talking today about a disease that youll frequently face, and in

many times you will be the 1st persion to detect this disease , and if you

suspect a patient of yours having this problem its an ethical and legals

obligation that you refer him to a specialist to deal with this problem andtreat it , well , we will be talking about sleep apnea syndromes, and Ill let

you know why Im saying that you are very important part in detecting and

treating this disease .

In USA , they created American academy of dental sleep medicine

,because the importance of the dentist in the management with this disease .

You can look for AADSM and find useful information for you as a dentist

A small preview about whats sleep , and abnormalities that can occur in

sleep :

We usually sleep 1/3 of the night , ~ 8 hours , this the time required for an

adult to get a refresh sleep , so that he will not be sleepy or hypoactive or

having some concentration problems in the next day . However, some

people sleep less , some people sleep more .

When we sleep we go into stages, its not a uniform process ( light

superficial sleep and deep sleep ) .

Light sleep: occupies almost 75% - 85% of the sleep time. Collectively, we

call it Non REM sleep . But theres another stage we call it REM sleep, and

this is a distinct sleep stage , because during this stage we have ( in the

normal people ) complete muscle paralysis , but we have intense mental

activity . This is the stage we have dreams in, and this occupies almost of

the night.


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The non REM sleep which occupies the rest of the night, we have stage 1

and stage 2 , the light sleep , the deep sleep or the delta sleep , we used to

call it (stage 3& 4) but now we in the new calcification they call it stage 3

,they added stage 4 to stage 3 because theres no clinical difference between

the two stages .

The function of each these 3 stages is very important :

* The light sleep facilitates you in the transition between sleep and

awakeness .

The deep sleep is the sleep which restore your body activities The REM sleep , is responsible for rearranging your mental files in your

brain , so that you will have good mental activity in the next day .

Usually we need 7-10 mins in sleep , some people need longer ( normally ,

up to half an hour ) , but if you take more than 30 minutes, you usually

have a problem with sleep we call it insomnia , and this may be a

symptom of a sleep disorder , we usually inter the Non REM sleep and

then we go into the REM sleep , the REM periods occur initially for shortperiods in the night , and at the end of the night ( at Down ), we usually

have the longest REM period which can be( 1-1.5) hours, thats why you

notice most of the dreams come at the end of the night , thats why you

may remember some of your dreams , and the REM and Non REM sleep

alternate during the night .


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We call it sleep Histogram or hypnogram , people go from a weight

stage to light stages .

REM sleep , periods initially shorter but starts to be more prolonged by the

end of the night .

To study sleep we have something called sleep study , we do it in

the sleep lab , similar to any graphic study that we do for heart,

muscles and eyes. Its a collective of them , this is very important for

you to know , that the polysomnogram is none all of the night , when

the patient enters sleep lab , we give him 1-2 hours in order to take

the environment after that we

get him to sleep .

we connect 2 or 4 leeds for

EEG in cephalogram ,

occulograms leads for theocculogram to detect the eye

movements , we put also

EMG on the chin for the chin

muscle to detect the muscle

activity .

we usually monitor Pulse

oximetry, cardiac rhythm by

EKG , and this will give us an

idea about the sleep stages .

Every night has different histogram and every person have different

histogram


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But to detect the breathing disorders that occurs during the sleep and

this is the most important thing we need something to detect the

airflow, so we have nasal and oral detectors, to detect the flow of the

air and we have plethysmographs, (something like a band we put iton the chest and abdomen to detect the chest and abdominal

movements.)

Some sleep labs , as the one we have in hospital have more

sophistications , we can have video monitoring for the patient to

detect which monitor he is sleeping in ( sopine , left side or right side)

and we have audio recording for the snoring .

Any patient we make sleep study we shold stop hypnotics at least 2 weeks

because this will affect sleep stages

Sleep Apnea

What we care about is the

upper airway , if its open

or not .

normal subject for normalMRI for his upper airway ,

the opening is wide .

and this is a comic thatcompares between the

blocked airways which is

the main pathology in obstructive sleep apnea .

In the past they used to study obstructive sleep apnea by during MRI during

sleep .


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Apnea: :

cessation breathing of (airflow) lasting greater then ten seconds .

"Cessation of breathing that lasts less than 10 secs is not apnea, it

might occur in normal individual"

If the amplitude of the tide is going down this is a Hypopnea , but to be

significant , this amplitude has to be decreased by 50%, or if its not

decreased by 50 % , to be associated with a decrease in the oxygen

saturation by about 3% .

Reduction in the amplitude of breathing flow >50% Or < 50% Reduction offlow + 3% Reduction in SpO2 ]

e all can have apneas and hypopnea during their sleep , but the number of

these apneas is the most important factor , if you have less than 5 apnea or

hypopnea per hour , this is normal , and we do not consider any problem.

But if you have more that 5 apneas , then you have sleep apnea syndrome ,

We divide sleep apnea to :

Obstructive and Central

Obstructive apnea ( we dentist deal mostly with this )Cessation of airflow by the nose & mouth despite continuous respiratory

effort.

The problem is in upper airway , the brain is functioning well , thers no

problem , the CNS has no problems , it is ( CNS ) giving signals fro the Chest

and abdominals muscles to move , but the airways are blocked , chest and

abdominals will keep moving and actually this movement may be sometimes

vigorous , if the obstructions prolonged .


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Central apnea ( due to medical disorder as heart faitlure , strokes ,neurological problems)

Cessation of airflow @ the nose & mouth with no respiratory effort .

everything is not working , the abdominal movenet are relaxed , no chest

wall movement , no air flow .

Mixed apnea:

starts as central apnea followed by an obstructive apnea or the opposite

Mallampati Score :

This is something you will face because your life is facing this picture , you

ll keep facing the patients opening their mouth , and theres a score , we call it

mallampati score, they use it in anesthesia ,to know how to incubate patients.

But they found that this mallampati score is also associated with the risk for

obstructive sleep apnea, and since youre the person who tell people to opentheir mouth , so that you will deal with their teeth , you will have the chance

to detect people who may have higher risk for obstructive sleep apnea .


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So in class 1 , mallampati score, the whole tonsils are visible , the soft and hard

palate are seen and you see the tonsils

In class 2 , half of the tonsils are seen

Class 3 , you cannot see the tonsils but you see the hard and soft palate and you

see the uvula

Class 4 , part of the hard palate is seen

And whenever you see class 3 and class 4 , you may ask the patient few

questions and if hes fitting the profile for obstructive apnea , you need to

refer him to a specialist . (( Refer to the picture above ))

A student asked a question : the problem is that we see the hard palate , not

when see the tonsils ??

Answer : No , the thing that , people who obstructive sleep apnea have low

palate , the lower the palate the opening is smaller , so will not be

seeing the tonsils , so if you ask him to open his mouth you can see the

hard palate obstructing the view, so when you open the mouth and you

tell the patient you use a tongue depressor to depress his tongue and you

cannot see the tonsils ( you can see only the hard palate ) , this is a severe

mallampati score .

Those who are going to maxillofacial surgery also this score is very important

to them when they are dealing to there patients .


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Obesity is strongly correlated with obstructive

sleep apnea. However, they found that some

people who are not obese may have

obstructive sleep apnea , about 10-15% of

patients of obstructive sleep apnea are not

obese . However, obesity and other anatomical

abnormalities play an important role if the

patient is predisposed to obstructive sleep

apnea, there are some functional abnormalities

that people with obstructive sleep apnea who die and you do autopsy for the

pharyngeal muscle, you will not have any histological problems. However,

they function in an abnormal way , they collapse quickly , they relax quickly

and they predispose the airway to be closed .

When we sleep , all our

muscles relax , so if you look

at the diameter of the upper

air way , normally , the

dilator pharyngeal muscle

keeps the upper airway

open , will also relax , and

the diameter will be narrow

. However , we dont need

much oxygen during sleep ,

so this diameter as adequate for our activities during sleep . However, people

who have obstructive sleep apnea this excessive relaxation whether its

aggravated by anatomical abnormalities or not , will lead to a critical narrow ,

this will make the patient snore . so patients usually they snore , and with the

proverition of this explosure the air way is completely closed , so the patient

will have apnea , the patient will not suffocate .

There is a strong association

between Mallampati score &

obstructive sleep apnea .. but

this doesn't mean that all

patients who scored 4 in this

system have obstructive sleepapnea ,, they just have higher

risk than patients who scored 1

or 2.


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Patients with obstructive sleep apnea do not dying during sleep , unless they

have some other problems .

A student asked a question ,but unfortunately I didnt hear !

Answer : The problem is not in the bronchi , the problem is in the upper airway

, in the pharynx .

When the apnea happens , God created a mechanism in your brain that causes

something we call it arousal , this arousal is restoration of EEG that you have

during awakening, and your brain will stimulate the muscle to contract againand open the upper airway ,and the apnea will be terminated , but this arousal(

in most people ) will not reach the level of complete awakening , however some

people complain that they have awakening , so the cycle will be repeated , andaccording to the severity of the disorder, this will be repeated according to the

number of times that the patient is having this phenomena .

Now , this is if the patient is not under the effect of anything that suppresses

the brain activity , so its dangerous to

people who are having obstructive

sleep apnea , or suspected to have

obstructive sleep apnea to be under theeffect of alcohol , drugs , narcotics ,

anesthetics and any CNS depressants .

Certain anatomical abnormalities are

associated with obstructive sleep apnea

here are examples of them :

1- Nasal problems like people whohave allergic rhinitis with

hypertrophy of the nasal mucosa

, they can have similar picture ,

presence of nasal polyps ,

deviated nasal septum .


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2- in the children , the most common cause of obstructive sleep apnea istonsilar hypertrophy , and those kids when you do adeonotonsilectomy

most of them you cure them from obstructive sleep apnea .

3- If you have hypertrophy of any structure in the upper airway, nasal softpalate , uvula .

4- facial malformations : as micrognathia .5- the whole anatomy is distorted as acromegaly patiens : they have large

tongue , large structures that may cause narrowing of the airway . also ,

marphans syndrome. Down syndrome also well known to have

obstructive sleep apnea.

Neurological disorders that are associated with obstructive sleep

apnea , Parkinson disease , muscular dystrophy , strokes , motorneuron disease, poliomyelitis, parkinsonism .

6- endocrine abnormalities: Acromegaly, hypothyroidism

This patient is having a massive uvula as

shown in the picture :

When uvula is large it can obstruct the

airway during sleep .

Massive tonsils , we see it in children more

than old people, sometimes due to recurrent

tonsillitis . ( kissing tonsils )

This is taken when the patient is awake

(small space) , you can imagine what space

will be left when he is asleep !

(very small )


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People with acromegaly or other causes of macroglossia , you see the intents of

the teeth over the edges of the

tongue .A patient may come to a doctor

has some specific presentation

like EDS (excessive daytime

sleepiness), snoring and

witnessed apnea , on the other

side, he may came with many

non-specific presentation :1- morning headache2- 2-cannot control his blood

pressure

3- depression4- Anxiety5- tempermental behavior ( )6-

poor job performance

7- impotence(sexual problems )8- mouth breathing .

Sleep deprivation is the most common cause of excessive daytime sleepiness.

This tongue is enlarged & the

irregular surfaches at both

sides represent the teeth

markings

[[Teeth marks on tongue ]]

mean macroglossia ]]


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Some patients have medical disorders that prevent them from sleep as cancer

patients , toothache patients , sleep derivation from any source medical

disorder , neurologic disorder , life style problem they all have EDS .

Many scales to assess the degree of sleepiness (severity ) , the most common

one is Epworth sleepiness scale .

* One of the most important things that are not included in the reports or

the sleeping skills reports or may be Included indirectly is to ask the

patient whom you suspect has excessive sleepiness or obstructive sleep

apnea that if he\she has ever slept while driving and had a car accident.

Maybe they dont check here in Jordan but in the US you are not allowed

to drive if you have obstructive sleep apnea, even if you havent caused

an accident, as well as epileptics until you get well after detected

SSiittuuaattiioonn CChhaannccee OOff DDoozziinngg

-Sitting and reading

-Watching TV

-Sitting inactive in a public place (e.g a theater or a

meeting)

-As a passenger in a car for an hour without a

break

-Lying down to rest in the afternoon when

circumstances permit

-Sitting and talking to someone

-Sitting quietly after a lunch without alcohol

-In a car, while stopped for a few minutes in traffic

0 = no chance of

dozing

1 = slight chance

of dozing

2 = moderate

chance of dozing

3 = high chance

of dozing


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examinations (epileptics 3-5 years), (obstructive sleep apnea maybe 1

month).

There was a magazine called (AL-Arabi) that had a topic titled laugh

and the world laughs with you which mentioned that for the people

who got obstructive sleep apnea (snore and you sleep alone) :S wereinvolved in many divorce cases due to the snoring .

In children: the prognosis is similar but instead of having hypoactivity and

sleepiness they will be in a state of hyperactive attention, nocturnal

enuresis (bed wetting), they will have nightmares and night terrors etc.

* Obstructive sleep apnea incidence:

- adults > children (>40 years) apart of children have adenotonsillectomy .

- males (4%) > females (2%)

- obese (high risk)

Plysomnogram:We account for the number of apnea per night, so if the patient slept for 6

hours wed take the number of apnea and then divided that

by 6 to get the number of apnea or

hypopnea per hour (Apnea/Hypopnea

Index (AHI) ) or (Respiratory Disturbance

Index (RDI) ) so both AHI or RDI have the

same meaning which is the # of apnea

hypopnea per hour. There are some differences but they arent important.

Some theories suggest thatOSA in elderly should be

diagnosed when Apnea-

hypopnea index is more than 6.


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Apnea Hypopnea Index (AHI):

Normal: less than 5 events per hour Mild: 5-15 events per hour Moderate: 16-30 events per hour Moderately Severe: 31-39 events per hour Severe: over 40 events per hour

The most significant amount for severe cases is between 50s and 60s.

Q/why do we care about the apnea and obstructive sleep apnea and their

numbers when they dont cause death?

A/people with OSA have higher mortality rate (so the severity is directly

proportional to the mortality rate)

-as you can see in the figure above the blue line (squares) represents the

amount of apnea/hypopnea that is lower than 20 which is less morality in

comparison to the red line (triangles) which is higher than 20.


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*the mortality usually occurs due to 2 reasons:

1- road traffic accidents (sleep) but now its decreased.

2- Cardiovascular events (strokes): the patients with obstructive sleep

apnea will get with the apnea hypoxemia, reoxygenation, temporally

hypercapnia, intrathoracic pressure changes because of vigorous breathing

and the arousals of the brain.

All these primary mechanisms will stimulate intermediary mechanisms

(all sympathetic pathways, coagulation, endothelial function, inflammatory

pathways, cytokines and insulin) and all of these will stimulate and will

lead to cardiovascular diseases.

Cardiovascular disease include cardiac arrhythmias, hypertension, heart

failure, coronary artery disease, cardiac ischemia, more myocardial

infarction(MI) or heart attacks , strokes and pulmonary hypertension (not

mentioned in the slide) which will lead to the right side heart failure.

(see slide #33)

If we get a patient with no obstructive sleep apnea and we admit him

into the sleep lab and we recorded snoring and we checked the breathing

flow which was normal and everything else was normal except that he was

only snoring it will be fine, as to no indications of a sleeping problem.

In patients with central sleep apnea:

1-breathing flow is absent 3- the chest not moving2- the abdomen is not moving as well. what we see there is just peristalsis.

In central apnea: no airflow, no chest & abdominal effort

The small waves in this abdominal plethysmograph are artifacts caused


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Q/someone asked about the duration of apnea?

A/ Dr. answered: it should be at least 10secs no less if its less we dont

consider it as an apnea or hypopnea.

In the obstructive sleep apnea there isnt any flow. However there ismovement but its abnormal (the patient tries his best to move the chest and the

abdomen walls but the effort is not consistent).

Treatment of OSA:

Nonsurgical Reaction :Weight Loss: 80-85% are obese , it has been documented in multiple

studies that weight loss will result in decreasing the apnea\hypopnea

index , and we have to targets in treatment of obstructive sleep apnea :

A-Decrease the apnea\hypopnea index , (immediate target).B-Turn the index to normal .

Weight loss has been documented in multiple studies to decrease

apnea\hypopnea index so , Decrease the risk from obstructive sleep apnea.

The aim of Treatment is to reduce Apnea-hypopnea index as mortality &

morbidity of obstructive sleep apnea are associated with high index..

In obstructive sleep apnea: Minimal or very low airflow, chest &

abdominal efforts are present despite being irregular..


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As u can see in the graph below, by losing weight some pts have resolved

completely & other pts improved & got a lower Apnea hypopnea index.

Gastric bypass surgery for Patients who failed to lose weight by diet

resulted in significant decrease in body mass index and Apnea-hypopnea

index, so they advice anybody who is extremely obese and failing weight

reduction by diet to having obstructive sleep apnea .

nCPAP (nasal Continuous Positive AirwayPressure)

very beneficial for those who can't lose weight.

by dietary measures & are not candidates forgastric bypass surgery.

CPAP works as a pneumatic splint & keeps

the airway open during sleep .

0

20

40

60

80

100

120

140

pre wt loss post wt loss

DBE/hrTST


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Components:

PAP machine (provides the airflow) & is

connected by a hose to the interfaceThe Interface: nasal or full face mask (oro-nasal)

or nasal pillows, provides the connection to the

user's airway..

Side Effects

You have to know that this mask is not without side effects, it

may cause severe problems as fracture in nasal bridge or simulitis inthe face , acne in the face . However , The most common problem is

difficulty in tolerating forced air.

nCPAP gives continuous pressure of the same level during

inspiration & expiration; When the patient inspires air that would be

in the same direction of CPAP pressure, but when he expires air it

would be against the machine pressure .

To overcome this problem:

Ramp feature was added to the machine. This feature allows

patients to start with low air pressure, followed by an automatic,

gradual increase in the pressure to the patients' prescribed setting as

they fall asleep.

The pressure is detected by a sleep study , we make polysomnogram

with CPAP treatment to know what pressure needed to eliminate the

apnea , CPAP titration study , we make it after diagnosis .


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Some patients suffer from obesity , sever snoring ,witness apnea and

hypertension , you should not make polysomnogram at one night ,

and the sleep titration study at another night . you should make Split

night study .In the 1st third of the night you polysomnogram (

without CPAP ) , then I wake him up , put the CPAP .

Positional changes:Some patients cant tolerate CPAP, we can advice them

positional changes if the sleep study suggest that most of the apneas

occur in the sopine position , theses patients have to sleep at the right

or left side , HOW ??

The tennis ball trick: by attaching a tennis ball to the back of apajama top, patient can sew a sock to the back of the pajama top,

&put a tennis ball in it. The tennis ball is uncomfortable when patient

lies on his back, and he will respond by turning on his side

In most patients sleep apnea increases in supine position,, that's

why some patients benefit from sleeping on their sides

Orthodontic appliances: (Patients fail in nasal CPAP , or cannot

tolerate CPAP)

Tongue equalizer & Tongue retaining devices , (performed by

dentists) , mandibular repositioning devices .

but they are only effective in mild & moderate cases..

Nasopharyngeal Tube


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Surgical Rx: ( from slides )1) Uvulopalatopharyngoplasty (UPPP)2) Tracheostomy ( final option ) we should not use it unless we

were in the emergency ( breathlessness ) because it has many

complications .3) Mandibular Advancement4) Hyoid bone suspension5) Tonsillectomy & adenoidectomy6) Thyroidectomy7) Nasal septal deviation repair8) Genio-Glossus Advancement9) Somnoplasty

Pre Surgical Warning:

OSA pts shouldn't undergo operations that

needs general anesthesia but if they have to like

if a pt. has appendicitis & has to do

appendectomy urgently.. he must tell his dr. that

he has OSA.. why? The critical period here is

the post-operative period because the patient is

still under the effect of anesthesia that's why

the endotracheal tube shouldn't be removed

after operation or it should be replaced by nasal

CPAP until hes fully awake .

We prefer not to remove the tube .

For more information visit arabicmedical.net & read the essay

of "sleep Apnea" by Dr. Sulaiman Almomany.

Done by : Majd M. Hidmi & Mohammed Al-Esayi

Forgot us for any mistake , Good luck

WARNING

OSA pts must Avoid

Alcohol or any other CNS

depressants (valium ,

diazepam , lorazepam,

hypnotics, anxiolytics,

etc..) within 4 to 6 hours

of sleep.

because these drugs

abolish the protective

arousals leading to

persistent hypoxia which

insults the brain in a way

similar to multi-infarctdementia , strokes , brain

ischemia .

Documents

Lec#5 Sleep Apnea , Internal