SLEEP DISORDERED BREATHING/ OBSTRUCTIVE SLEEP APNEA

1. SLEEP DISORDERED BREATHING/ OBSTRUCTIVE SLEEP APNEA JHANSI NALAMATI MD

2. TYPES • Obstructive Sleep Apnea • Central Sleep Apnea • Mixed Apnea • Upper Airway Resistance Syndrome (UARS)

6. Historical background • Apnea- literally means “without breath” • Pickwickian papers fat boy “Joe” • Osler and later Burwell applied the name “Pickwickian Syndrome” to patients with Obesity, Hypersomnolence and signs of Chronic hypoventilation

7. Historical (contd.) • Sleep apnea -Rediscovered by Gestaut and co- workers in 1965 by simultaneously recording sleep and breathing in a “Pickwickian” patient and described all 3 types of apnea. • Postulated that sleepiness is due to repetitive arousals associated with resumption of breathing that terminated the apneic events.

8. Historical(contd.) • First description of successful Tx of OSA by tracheostomy followed in 1969. • First Tx with CPAP – in 1980’s soon after NIPPV was described by Charles Collins of Australia

9. Definition of Apnea • Apnea-Cessation of breathing(air flow) for 10 seconds • Hypopnea- decreased in the airflow by 30-50%, and associated with an arousal and a drop in oxygen desaturation by 3-4%

10. Prevalence • 9% of men and 4% of women, in one study of state employees had AHI of 15 events/hr • 12 million people in the US have OSA

11. Pathophysiology • Pharynx is abnormal in size or collapsibility. • As an organ for speech and deglutition it must be able to change shape and close • As a conduit for airflow it must resist collapse

12. Pathophysiology(contd.) • Exact mechanism is not known • During the day muscles in the region keep the airway open • During sleep muscles relax to a point where the airway collapses to an extent that it gets obstructed • Once breathing stops, individual awakens to breathe and arousal can last few seconds to a minute

15. Risk factors for OSA • Obesity • Age- middle aged men and post- menopausal women • Older age- due to loss of muscle mass and tone • ? Family Hx of OSA

16. Risk factors (contd.) • Anatomic abnormalities- receding chin, ?Nasal congestion, ? DNS • Enlarged Tonsils and adenoids esp.in children • Enlarged and inflammed uvula, worsened by chronic smoking, GERD • Acromegaly

17. Risk factors (contd.) • Amyloidosis, post- polio syndrome, neuromuscular disorders • Marfan’s syndrome, Down’s syndrome • Use of alcohol and sedatives that relax the upper airway • Increased neck circumference > 16 inches in women and 18 inches in men

22. Symptoms • Most of the symptoms are from disruption of normal sleep architecture • Excessive Daytime Sleepiness (EDS)- falling asleep even in stimulating environment, during a conversation, eating, business meeting • H/O Snoring

23. Symptoms (contd.) • Non- restorative sleep • Automobile Accidents • Personality changes • Decreased Memory • Erectile Dysfunction • Frequent Nocturnal Awakening

24. Symptoms(contd.) • Drowsy Driver Syndrome • Polyuria • Early morning headache • Dry mouth

25. Signs • Loud Snoring • Witnessed apneas • Obesity • HTN • Metabolic syndrome • Increased Neck circumference • Anatomic Abnormalities

26. SHHS • Sleep heart health study- initiated by NIH in 1996 and initial data shows that treatment of SBD improved outcomes in control of HTN, CHF atherogenesis, glycemic control

27. Screening for OSA • 2 of the three symptoms- EDS, loud Snoring, Witnessed Apneas • High Score on ESS(Epworth Sleepiness Score)>12, or Stanford Sleepiness Score

28. Epworth Sleepiness Scale (ESS) • Maxiumum score of 24 • The scale is used to rate the 8 situations below that apply best to each individual • 0-no chance of dozing • 1- Slight chance of dozing • 2- moderate chance of dozing • 3- high chance of dozing

29. ESS (contd.) • Sitting and reading • Watching television • Sitting inactive in a public place ( theater, meeting) • As a passenger in a car for about an hr. without break • Lying down to rest in the afternoon when circumstances permit • Sitting and talking to someone • Sitting quietly after lunch • In a car, while stopped for a few minutes in traffic

30. ESS ( contd.) • 1-6 : getting enough sleep • 7-9 about average and probably not suffering from Excessive daytime Sleepiness (EDS) • 10 or greater- need further evaluation to determine the cause of EDS or if you have underlying sleep disorder

31. Types of Sleep Study • Full night Polysomnography ( PSG) • PSG with CPAP titration • Split- Night Polysomnography • Multiple Sleep latency test ( MST) • Maintainance of wakefulness Test ( MWT)

32. Diagnosis • Nocturnal Polysomnography-in lab study, where EEG, EMG, HR, body position, leg movements, Oximetry, Snoring, abdominal and chest wall movements are recorded • Home studies are limited as EEG is not recorded, or in some limited studies only Nocturnal Pulse oximetry is done

35. Definition of OSA • Normal- AHI < 5 • Mild OSA- AHI 5-20 • Moderate OSA- AHI 20-40 • Severe OSA- AHI 40-60 • RDI( respiratory disturbance Index)- AHI+ RERA( Respiratory Effort Related Arousals)

36. UARS • Upper Airway Resistance Syndrome • Cannot be diagnosed with PSG • Repetitive arousals that probably result from increased Respiratory effort and high resistance in the airway • Can be diagnosed by measuring esophageal pressure (Pes)

37. Medical Complications • Uncontrolled HTN • Diminished quality of life from chronic sleep deprivation • Increase risk for CVA • Worsening of CAD and CHF

38. Treatment • Behavioral Tx- weight loss • Sleep hygeine • Avoiding alcohol too close to bedtime • Avoid sedatives and hypnotics, narcotics • Avoid caffeine

39. Treatment(contd.) • Positional Tx- helpful with Primary snoring • Positive Airway pressure (CPAP or BiPAP) • ENT Surgery • Oral appliances

40. Positive airway pressure • Effective, Non-invasive • Mask fit, air seal, comfort and humidification are important • Nasal mask, full face- masks, nasal pillows, Nasal aire prongs

41. Complications of CPAP • Local dermatitis • Air leak, nasal congestion,rhinorrhea • Dry eyes • Nose bleed • Aerophagia • Rare- tympanic rupture, pneumothorax • Compliance is the biggest issue

42. Surgery • Except tracheostomy,helps only mild to moderate cases or only primary snoring • Not curative for OSA • Somnoplasty- office procedure- radiofrequency ablation of the soft palate- only for snoring

43. Surgery( contd.) • LAUP- laser assisted uvuloplasty, only for snoring, office procedure • UPPP (UP3)- (Uvulo-palato-pharyngo-plasty) • Complicated surgery • Patients have to observed in the hospital overnight

44. UPPP(contd.) • Decreases AHI by only 50% • Complications include- nasal regurgitation of fluids, pharyngeal stensosis • In children- tonsillectomy and adenoidectomy alone is curative

45. Jaw surgery • Useful for retrognathia, involves partial excision of maxilla or mandible • Genioplasty • Complicated surgery

46. Bariatric surgery • Gastric bypass • Weight loss and decrease in adipose tissue of the parapharyngeal region leads to improvement or cure of OSA • Weight loss has to be at least 20-30lbs before any change in AHI can be seen

47. Oral appliances • Devices that are worn during sleep that retract the jaw and alleviate upper airway obstruction • Tongue retaining devices for people with macroglossia