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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/qspa7/29/2019 OSA Dental 2013
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Quiz
1. The most accurate determination of
severity for obstructive sleep apnea is
made by :
.....................