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Sleep Apnea Syndromes

Suleiman M. Momany, MD, FCCPSchool of Medicine / J ordan University of Science & Technology

&King Abdullah University Hospital

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Normal Sleep Fraction

How Much Sleep?

Normal sleep fraction(Average Adult) ~33 % of the day

About 8 hours of sleep per 24 days:

Some People Less Than 4 hrs

Others More Than 10 hrs

1/3

SLEEP

2/3

WAKE

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Refreshing RestorativeSleep

(Adequate)

Adequate Time

Adequate Depth

Adequate Continuity

Consolidated(Non-Fragmented)

Sleep

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Animals do sleep

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Sleep Staging

Non-REM Sleep

= 75 - 85%

Light Sleep

Stage1 = 1- 2.5%

Stage2 = 45 -55%

Deep Sleep (Sleep)

Stage3 = 3 -8%

Stage4 = 10 -15%

REM Sleep

= 20 - 25% Stage5 : Occurring in 4

to 6 Discrete Periods

Stage Zero (W)

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N1

N2

N3

RRR R R

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The Sleep SwitchThe transition between sleep and wakefulness is fast and smooth

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Sleep Studies

All-night polysomnogram

8 hours of sleep to score 1 record

(3 hours @ least)

Epochs: each = 30 sec

2 lead electroencephalography

2 lead electrooculography Submental EMG

EKG

Oral and nasal airflow (thermistors) Chest & abdominal respiratory effort

(impedance plethysmography) Bilateral anterior tibialis EMG

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Apnea- Hypopnea

Apnea:cessation breathing of (airflow)

lasting greater then tenseconds

HypopneaReduction in the amplitude of

breathing flow >50%

Or

< 50% Reduction of flow + 3%Reduction in SpO2

Sleep apnea syndromeMore then 5 apneas- hypopneas /hour during sleep

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Sleep Apneas

Obstructive apneaCessation of airflow @ the nose &mouth despite continuous

respiratory effort

Central apneaCessation of airflow @ the nose &

mouth with no respiratory effort

Mixed apneaInitial central component followed

by an obstructive apnea event

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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

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Pathogenesis

FunctionalAbnormalities Pharyngeal dilator muscle

dysregulation

Intrinsically unstable ventilatorycontrol( High Loop Gain)

Other mechanisms Increased lung volumes: longitudinal

tethering of pharyngeal muscles

Upper airway sensory impairment

Anatomic

Abnormalitiescompromising pharyngeallumen dimensions

Obesity

Soft Tissues

Craniofacial Structures

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Presentation: Symptoms of OSA in Adults

EDS

Snoring

Witnessed apneas

Non-specific

Other Non-specificsymptoms

Restless sleep

High blood pressure Morning headache Dry mouth upon awakening

Depression Severe Anxiety Short term memory loss Intellectual deterioration Temperamental behavior

Poor job performance Impotence

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Neck size and BMI

A neck size over 16 inches and / or a body mass

index (BMI) over 25 puts an individual at riskfor sleep apnea.

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Body Mass Index

Normal = 18.5 to 24.9

Overweight = 25.0

29.9 Obese = 30.0 39.9

Extremely obese = >40

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Mortality in the Obstructive Sleep

Apnea syndrome

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Treatment Modalities For

OSA Nonsurgical

Weight Loss nCPAP

Positional changes

Orthodontic appliances

Equalizer

Tongue retaining

Pharmacologic Protriptyline

Progesterone

Oxygen

Nicotine

doxapram

Surgical Uvulopalatopharygoplasty

(UPPP)

Tracheotomy

Mandibular Advancement

Hyoid bone suspension

Tonsillectomy &adenoidectomy

Thyroidectomy

Nasal septal deviation repair

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Apnea + Hypopnea index

0

20

40

60

80

100

120

140

pre wt loss post wt loss

DBE/hrT

ST

Weight Loss

Treatment of morbidly obese patients with obstructive

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Treatment of morbidly obese patients with obstructive

sleep apnea with gastric bypass surgery

A. Vazir, R, Goldenkranz,J. Nahmias, M. Karetzky

Newark Beth Israel Medical Center & UMDNJ Newark, NJ

The mean body mass index decreased from 50.3 + 3.5 to 38.6 + 3.4 (p

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Treatment Modalities For

OSA

Nonsurgical

Weight Loss

nCPAP Positional changes

Orthodontic appliances

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Picture of CPAP

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Treatment Modalities For

OSA

Nonsurgical

Weight Loss

nCPAP

Nasopharyngeal Tube

Positional changes Orthodontic appliances

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Treatment Modalities For

OSA

Nonsurgical

Weight Loss

nCPAP

Nasopharyngeal Tube

Positional changes

Orthodontic appliances EqualizerTongue retaining

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OSA Treatment Modalities (cont.)

Surgical

Uvulopalatopharygoplasty (UPPP)

Tracheotomy

Mandibular Advancement

Hyoid bone suspension

Tonsillectomy & adenoidectomy

Thyroidectomy

Nasal septal deviation repair

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UPPP

50% effective in curing OSA.

Greater than 90% effective in alleviating snoring

Patient selection criteria to improve

effectiveness Cephalometrics

Mueller maneuver

CT scan of Neck Complications: nasopharyngeal regurg., nasal

quality of voice

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UPPP and Tonsillectomy

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Genio-Glossus Advancement

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H oid Sus ension

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Avoid Alcohol or any other CNS depressants

within 4 to 6 hours of sleep.

Pre Surgical Warning

http://rds.yahoo.com/_ylt=A0WTb_6bndJMwXYAytKJzbkF;_ylu=X3oDMTBpc2ozM2gzBHBvcwM0BHNlYwNzcgR2dGlkAw--/SIG=1kh0j3osg/EXP=1288957723/**http%3a//images.search.yahoo.com/images/view%3fback=http%253A%252F%252Fimages.search.yahoo.com%252Fsearch%252Fimages%253Fp%253Dwarning%2526ei%253DUTF-8%2526vm%253Dr%2526fr%253Dyfp-t-892%26w=600%26h=500%26imgurl=cyberbrethren.com%252Fwp-content%252Fuploads%252F2009%252F11%252F600px-Warning.svg_.png%26rurl=http%253A%252F%252Fcyberbrethren.com%252F2009%252F11%252F21%252Fwarning-signs-that-a-lutheran-pastor-or-layperson-is-headed-toward-rome%252F%26size=54KB%26name=Several%2bwarning%2b...%26p=warning%26oid=db06aa21a7eecbadcf2217fe71618b09%26fr2=%26no=4%26tt=5550000%26sigr=13cesb6n9%26sigi=123ast7tf%26sigb=12h1iej68%26.crumb=wrdN2T/qspa

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Quiz

1. The most accurate determination of

severity for obstructive sleep apnea is

made by :

.....................