Obstrutive Sleep Apnea. 07

8/7/2019 Obstrutive Sleep Apnea. 07

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OBSTRUCTIVE SLEEP APNEAOBSTRUCTIVE SLEEP APNEA

PahelPahel M.M. SoibamSoibam

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Obstructive Sleep ApneaObstructive Sleep Apnea

O bstructive Sleep Apnea is a sleepO bstructive Sleep Apnea is a sleep- -related disorderrelated disorderdefined as Apneadefined as Apnea- -HypopneaHypopnea Index (AHI) of 5 orIndex (AHI) of 5 ormore.more.

AHI: number of obstructive apnea/AHI: number of obstructive apnea/hypopneahypopnea perperhour of sleephour of sleep

AHI<5 NormalAHI<5 NormalAHI 5AHI 5--15 Mild O SA15 Mild O SAAHI 15AHI 15--30 Moderate O SA30 Moderate O SAAHI >30 Severe O SAAHI >30 Severe O SA





Th e ProblemTh e Problem

O SA is only one end of a spectrum of SDB (sleepO SA is only one end of a spectrum of SDB (sleep- -disordered breathing) that includes snoring, upperdisordered breathing) that includes snoring, upperairway resistance syndrome and O SA.airway resistance syndrome and O SA.MostlyMostly underdiagnosedunderdiagnosed. .

Indian prevalence (Indian prevalence (UdwadiaUdwadia et al):et al):SDB 19.5%SDB 19.5%O

SAHS 7.5%O

SAHS 7.5%Prevalence becomes higher with age:Prevalence becomes higher with age:55--15% 4015% 40- -65 years65 years2 4%2 4% 65 years65 years

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M ec h anism of OSASM ec h anism of OSAS

T he upper airway dilating muscles, like all striatedT he upper airway dilating muscles, like all striatedmusclesmuscles--normally relax during sleep.normally relax during sleep.

In O SAS, the dilating muscles can no longerIn O SAS, the dilating muscles can no longersuccessfully oppose negative pressure in the airwaysuccessfully oppose negative pressure in the airwayduring inspiration.during inspiration.

Apneas andApneas and hypopneashypopneas are caused by the airwayare caused by the airwaybeing sucked and closed on inspiration duringbeing sucked and closed on inspiration duringsleep.sleep.



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Upper airway anatomySites of obstructionduring sleep apnea

Laryngopharynx

Hard Palate

Soft Palate

Nasopharynx

Hyoid bone

Larynx

Epiglottis Oropharynx

Tongue

Tongue



Pat h op hy siolog yPat h op hy siolog y: OSA & CVDs: OSA & CVDs

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OSA & Cardiovascular DiseasesOSA & Cardiovascular Diseases

Prevalence of O SAPrevalence of O SA

HT N 50%HT N 50%

Acute Stroke 50%Acute Stroke 50%AF requiring version 50%AF requiring version 50%Lone AF 33%Lone AF 33%CAD 33%CAD 33%

HF with SD 30HF with SD 30--40%40%



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Ot h ersOt h ers

DM:DM: Patients from the sleep clinic with AHI>10 are muchPatients from the sleep clinic with AHI>10 are muchmore likely to have impaired glucose tolerance andmore likely to have impaired glucose tolerance anddiabetes (diabetes (MeslierMeslier et alet al EurEur RespirRespir J 2003)J 2003)@ O SAHS can aggravate DM, and treatment of O SAHS@ O SAHS can aggravate DM, and treatment of O SAHS

decreases insulin requirement (HPIM).decreases insulin requirement (HPIM).

NAFLDNAFLD: Increased: Increased steatosissteatosis and fibrosis independent of and fibrosis independent of body weight body weight

AnaetheticAnaethetic Risks:Risks: IncreasedIncreased



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SymptomsSymptoms

Night timeNight time

SnoringSnoring

WitnessedWitnessed apnoeaapnoeaWaking up choking orWaking up choking orgasping for airgasping for airNocturiaNocturiaUnrefresheningUnrefreshening sleepsleep

Dry mouthDry mouthDecreased libidoDecreased libido

DaytimeDaytime

Early morning headachesEarly morning headaches

FatigueFatigueDaytime sleepinessDaytime sleepinessPoor memory,Poor memory,

concentration or motivationconcentration or motivationUnproductive at workUnproductive at work

Falling asleep during drivingFalling asleep during drivingDepressionDepression



Signs of Obstructive Sleep ApneaSigns of Obstructive Sleep Apnea

BradycardiaBradycardia duringduring apneicapneic event event T achycardia after airflow restoredT achycardia after airflow restored

Systemic hypertensionSystemic hypertensionPulmonary hypertensionPulmonary hypertensionPolycythemiaPolycythemiaCorCor pulmonalepulmonaleT ypically no respiratory abnormality while awakeT ypically no respiratory abnormality while awakeArterial blood gasses while awake may showArterial blood gasses while awake may showmetabolic alkalosismetabolic alkalosis



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DiagnosisDiagnosis

A good sleep historyA good sleep historyAssessment of obesity, oral cavityAssessment of obesity, oral cavityAssessment of possible predisposing causes: H T N,Assessment of possible predisposing causes: H T N,

hypothyroidism,hypothyroidism, acromegalyacromegaly andandPolysomnographyPolysomnography: gold standard tool: gold standard tool



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Th e Epwort h Sleepiness ScoreTh e Epwort h Sleepiness Score



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Th e Epwort h Sleepiness ScoreTh e Epwort h Sleepiness Score

Patients with total Score >11 or those for whomPatients with total Score >11 or those for whom

sleepiness during work or driving poses problemssleepiness during work or driving poses problemsneed to be referred to a sleep specialist.need to be referred to a sleep specialist.



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Pol ysomnograp hyPol ysomnograp hy

EO GEO G -- E lectrooculogramE lectrooculogramEE GEE G -- E lectroencephalogramE lectroencephalogram

EMGEMG -- E lectromyogramE lectromyogramEK GEK G -- E lectrocardiogramE lectrocardiogramT racheal noiseT racheal noiseNasal and oral airflowNasal and oral airflowT horacic and abdominal respiratory effort T horacic and abdominal respiratory effort PulsePulse oximetryoximetry



Current Treatment for OSACurrent Treatment for OSA

A.GeneralA.General

Wt loss.Wt loss. Avoid alcohols, sedativesAvoid alcohols, sedatives Raise HeadRaise Head- -End of bedEnd of bed Sleep in lateral positionSleep in lateral position

C. SURGICALC. SURGICALT racheostomyT racheostomy

UPPPUPPP GlossectomyGlossectomy HyoidHyoid

advancement advancement MandibularMandibularadvancement advancement

B.C PAP



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CPAP Th erap yCPAP Th erap y

Works as a pneumatic splint Works as a pneumatic splint 11st st choice in moderate to severe O SAHSchoice in moderate to severe O SAHSIndication:Indication:

AHI 15 orAHI 15 orAHI 5 with symptoms ( EDS, Impaired cognition,AHI 5 with symptoms ( EDS, Impaired cognition,

mood disorders), H T N, CAD or CVA.mood disorders), H T N, CAD or CVA.Success rate 95Success rate 95- -100%100%Long term compliance 60Long term compliance 60- -70%70%



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CPAP Th erap yCPAP Th erap y-- Side EffectsSide Effects

Nasal congestionNasal congestionRhinorrhoeaRhinorrhoea

O ronasalO ronasal drynessdrynessSkin abrasions/ rashSkin abrasions/ rashConjunctivitis fromConjunctivitis fromair leakair leak

Chest discomfort Chest discomfort ClaustrophobiaClaustrophobia



2 02 0

Oral AppliancesOral Appliances

MandibularMandibular & tongue retaining devices& tongue retaining devices

Appropriate first Appropriate first- -line treatment for Mild O SA, primaryline treatment for Mild O SA, primarysnoring, upper airway resistance syndrome ( UARS )snoring, upper airway resistance syndrome ( UARS )

Not as effective as CPAPNot as effective as CPAP

Young, nonYoung, non- -obeseobese

Patient s choicePatient s choice -- Not tolerating / refuse to use CPAP,Not tolerating / refuse to use CPAP,or are not surgical candidatesor are not surgical candidates

M AD

TRD



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Surger ySurger y

BariatricBariatric SxSx

Tonsillectomy

Tonsillectomy

RetrolingualRetrolingual pharynx:pharynx: mandibularmandibular advancement, lingualadvancement, lingual plastyplasty andandresection,resection, mandibularmandibular osteotomyosteotomy, , genioglossusgenioglossus advancement with hyoidadvancement with hyoidmyotomymyotomy & suspension, and maxillary && suspension, and maxillary & mandibularmandibular advancement advancement osteotomyosteotomy(MM O )(MMO )

UPPPUPPPT racheostomyT racheostomy: Severe cases: Severe cases



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ConclusionConclusion

Screening patients with obesity, H T N, CAD, DM,Screening patients with obesity, H T N, CAD, DM,CVA, dementia, NAFLD, G ER D for sleep apnea isCVA, dementia, NAFLD, G ER D for sleep apnea isworthwhile.worthwhile.

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Obstrutive Sleep Apnea. 07