1. The Management of Snoring and Obstructive Sleep ApneaRex Moulton-Barrett, MD Plastic and Reconstructive Surgery Otolaryngology & Head and Head Surgery Alameda Hospital June 2005

2. Spectrum of Sleep Disordered Breathing

4. DefinitionsUpper Airway Resistance Syndrome ( UARS ) • • Daytime somnolence • • No significant apnea or O2 desaturation • • Habitual loud snoring (crescendo) • • they wake from their own noise of snoring • Guillaminault C, Stoohs R, Duncan S. Chest 99:40-48;1991 • Guilleminault C, Stoohs R, Clerk A et al. Chest 104:781-787;1993

5. Definitions • Hypopnoea: ‘ Chicago Criteria’ 1. Fall in average tidal volume by > 50% but < 10 second apnoea or < 50% tidal volume reduction and 2. at least 4% in oxyhemoglobin desaturation 3. EEG evidence of arousal

6. Definitions • Apnea • Cessation of airflow for at least 10 seconds • Obstructive / Central / Mixed • based on presence or absence of respiratory movement

7. Prevalence of Sleep Apnea • AHI = RDI • = apnoea+hyponoea / hour • >5 : 24% Males & 9% Females • 4 - 6 times more common in men • 20 million Americans • Young T, Palta M, Dempsey J. N Engl J Med 328:1230-1235;1993

8. Pathophysiology Scale • RDI / AHI • UARS <5 • Mild 5-20 • Moderate 21-40 • Severe >40

9. A RDI of 15-20 events per hour is close to what adults seem to be able to tolerate with no clinical consequence. Hosselet JJ, Ayappa I, Norman RG et al. Classificatin of sleep-disordered breathing. Am J Respir Crit Care Med 163:398-405;2001 What is Significant RDI?

10. 10x > risk, VAMV UCLA 2000

11. Somnolence Induced MVAs 3 fold increase in motor vehicle accidents if RDI> 5

12. Morbidity and Mortality • Risk factor for cardiovascular disease • Hypertension • MI –polycythemia, platelet aggregation • Stroke • Mortality • AI>20 = 37% mortality over 8 yrs compared with 4% for AI<20 (Chest 94:9-14, 1988)

13. History • Heroic snoring • Cardinal symptom of OSAS • Observed apneas or choking • Excessive sleepiness • Witnessed apnoeas • Change in personality – depression, anxiety • Cognitive dysfunction – memory, concentration • Morning headaches • Decreased libido or impotence • Car or work accidents • History alone is only 60% specific and 60% sensitive • Need objective testing

14. Sleep Apnea Risk Factors • •Obesity • •Increasing age • •Male gender • •Anatomical abnormalities of upper airway • •Family history • •Alcohol or sedative use • •Smoking

15. Diagnosis: Physical Exam • Upper body obesity / thick neck • >17” males • >16” females • Airway abnormality • Nasal • Oropharyngeal • Hypopharyngeal

16. Differential Diagnosis of OSAS • • Narcolepsy • REM sleep within 10 minutes • • Excessive daytime sleepiness associated with psychosocial and psychiatric disorders • • Drug related syndromes • • Restless Legs / Periodic limb movement disorder • • Idiopathic hypersomnolence

17. Evaluation of Upper Airway • No consistent characteristic in OSA • Quantitative measures depend on state • Methods of Evaluation • Cephalometric radiographs

18. Anatomic Factors in Airway Obstruction • •Increased nasal resistance. • •Excessive palatal length. • •Increased tongue size. • •Increased vertical airway length • •Enlarged tonsils. • •Mandibular retrusion.

19. Impact of nose on snoring and OSAS • • Obstruction increases airway resistance • • Anterior rhinomanometric volume has an inverse relationship with RDI p<0.05 • • Nasal obstruction is an important cause of OSA • Virkkula, P et al. Acta Otolaryngol, 2003 • (Finland)

20. Malampatti I-IV: Airway Classification Visualize • I:Soft palate, tonsils, uvula • II:No tonsils seen • III:Soft palate only seen • IV:Hard palate only seen IV

21. Muller Maneuver Maximal inspiratory movement

22. Velopharyngeal Closure Patterns • A. Coronal 71% • B. Circular 19% • C. Circular +Passavant’s Ridge 7% • D. Sagittal 2% • Finkelstein , Talmi , Nachman .Plastic Rec Surg 1992;89:631-639

23. Snoring: “a marker for airway resistance during sleep” Hofffstein V, Mateika S, Nash S. Comparing Perceptions and Measurements of Snoring. Sleep 19:783-789;1996

24. Balance of forces affecting airway Kuna ST, Sant’Ambrogio G. JAMA 266:1384-88;1991

25. Pathophysiology of OSAS • • Collapse of pharyngeal airway • • Increased upper airway resistance • • Diaphragm movement increases negative airway pressure • • Increased airway collapse • • Hypopnea and apnea – increase vagal tone • • Hypoxia, Hypercarbia – catacholamine rise • • Increased ventilatory effort • • Sleep fragmentation and arousal

26. Who to order a Sleep Study On ?

29. Epworth v. RDI • RDIEPWORTH • 0 8.0+/-3.5 • Mild 12.1 11.0+/-4.2 • Mod 34.8 13.0+/-4.7 • Severe 56.6 16.2+/-3.3 T. Woodson - Monograph

30. Why Get a Sleep Study ? • Documentation • Quantification • Determine Therapy

31. Polysomnography • • Establish diagnosis of sleep apnea • • Assess disease severity • • Rule out other disorders of sleep • • CPAP titration • • Components: • EEG • EOG • EMG • EKG • Chest wall and abdominal wall impedance • Intercostal EMG • Body position • Pulse Oximetry

32. In-Laboratory Polysomnography • Pros • “Full” set of variables recorded • Technician for patient & equipment problems • Able to determine success of C-Pap • Cons • Cost • Accessibility • Patient sleeps away from home • Fails to localize site of obstruction

33. “The Polysomnographic Age …. has ended” • Unattended ambulatory monitoring is “biologically plausible and technologically feasible” • Strohl KP. When, Where and How to Test for Sleep apnea. Sleep 2000;23:S99-S101

34. SNAP Testing • • PSG: polysomnograpghy “considered gold standard” • inherant variability, • problems of reproducibility • • SNAP testing: out-patient, localizes site of obstruction, inexpensive • • Direct and solid correlation between both for measurement of RDI • • For RDI >= 5 : 95% positive predictive value, • 96% specificity • 75% sensitivity • Allan, P, Chaney, J, Mair, E. Otolaryngol HNSurg, 2004

35. SNAPTestingAcoustic Analysis ofOro-Nasal Respiration • • Sound & Airflow Detection • • Pulse Oximetry & Pulse rate • • Apnea & Hypopnea Indices • • Snoring Analysis • • 6 hours+ continuous recording

37. SNAP Data Collection Cannula

38. Effort & Movement Transducer

39. Why SNAP ? • Patient Selection • OSA detection • Snoring Localization & Quantification • Outcome Monitoring

40. SNAP - Apnea

41. SNAP - Oximetry

42. SNAP - Snoring

44. OSA in Children • History • Shyness • Developmental Delay • Aggressive Behavior • Symptoms of ADD • Witnessed apneas: positive predictive value of 86% • T&A are usual source of obstruction • Several studies show improvement in behavior and school performance after T+A

45. Treatment for OSA • Medical • Reduction of Risk factors • CPAP - Most common treatment • Drugs • Airway appliances • Surgical

46. Reduction of Risk Factors • Obesity • Sleep hygiene • Nasal obstruction • Body position • Sedative and alcohol use

47. Drugs • Oxygen - most widely used • Protriptyline • Theophyline • Progesterone • Nicotine • Serotonin antagonists • Modafinil (Provigil)

48. Pharmacologic Treatment Modafinil in obstructive sleep apnea-hypopnea syndrome: a pilot study in 6 patientsby Arnulf I, Homeyer P, Garma L, Whitelaw WA, Derenne JP.Service de Pneumologie et Laboratoire du Sommeil,Hopital Pitie-Salpetriere, Paris, France. Respiration 1997; 64(2):159-61 ABSTRACT We studied the effects of modafinil, a vigilance-enhancing drug, on excessive daytime sleepiness, memory, night sleep and respiration in 6 patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) using a double-blind random cross-over design with 24-hour polysomnography, verbal memory test and a 5-week sleep-wake diary kept by the patients. There were two 2-week treatment periods in which either modafinil or placebo was used; they were separated by a 1-week wash-out period. Our results show that modafinil reduces daytime sleep duration, lengthens the duration of subjective daytime vigilance and improves long-term memory in patients with OSAHS without modifying night sleep and respiration events.

49. CPAP Splints the Upper Airway Collapsing forces • Tissue pressure and mass • Constrictor muscle tone • Negative inspiratory pressure Dilating forces • Dilating muscle tone • Tissue pressures that stabilize the airway • CPAP augments dilating forces

50. CPAP Has Poor Compliance • CPAP is effective • Not a cure • Pattern of use established early • Drop out rate > 25% • 50% effective use