OBSTRUCTIVE SLEEP-RELATED BREATHING DISORDERS IN ADULTS

1. OBSTRUCTIVE SLEEP-RELATED BREATHING DISORDERS IN ADULTS DR. MOHSEN PAZOOKI

2. Obstructive sleep-related breathing disorders • Snoring • Upper Airway Resistant Syndrome • Obstructive Sleep Apnea Syndrome

3. Snoring • Incidence • 40% M • 20% F • Often (but not always) accompanies sleep disordered breathing • Not ass. With excessive daytime sleepiness or insomnia

4. Snoring • AHI < 5 without daytime symptoms • PSG is not required for Dx • No ass. With : • Arousals • Desaturations • Airflow limitation • Arrhythmias

5. Upper airway resistant syndrome • Do not meet OSA criteria but experience excessive daytime somnolence and other debilitating somatic complaints

6. Upper airway resistant syndrome • characterized by respiratory effort related arousals (RERAs) • RERA is detected using esophageal pressure manometry, which reveals a pattern of progressively increasing negative esophageal pressure followed by an arousal.

7. Upper airway resistant syndrome • PSG : • Frequent arousals associated with snoring, abnormally negative intrathoracic pressure, or increased diaphragmatic electromyogram activity.

8. OSAS • Incident : • 2% of F & 4% of M > 50y

9. OSAS • five or more respiratory events (apneas, hypopneas, or RERAs) • Ass. with • excessive daytime somnolence, • Waking with gasping, choking, or brearh-holding, or • witnessed reports of apneas, loud snoring, or both

10. OSAS • apnea or hypopnea commonly accompanied by: • Reductions in blood oxygen saturation of at least 3% to 4% • Usually terminated by brief, unconscious arousals

11. OSAS • Snoring: • frequent complaint of bed partners • often the symptom that prompts these patients to seek medical attention • Excessive daytime somnolence : common presenting complaint

12. OSAS • Other complaints : • Automobile accidents • increased cardiovascular morbidity and mortality • morning headache, sore throat • fatigue or a feeling of being unrefreshed regardless of the duration of sleep

13. OSAS • Exacerbation : • ingestion of alcohol • Sedative use • weight gain

14. Sleep disordered breathing symp • Restless sleep • Loud snoring • Observed apnea,choking or gasping episodes • Excessive daytime sleepiness(E DS) • Morning fatigue or irritability • Memory loss • Decreased cognitive function

15. Sleep disordered breathing symp • Depression • Personality or mood changes • Decreased libido and impotence • Morning and nocturnal headaches • Nocturnal sweating • Nocturnal enuresis

16. Pathophysiology • collapse of the pharyngeal airway during sleep due to relaxation of the pharyngeal dilator muscles

17. Obesity • soft tissue hypertrophy • craniofacial characteristics such as retrognathia

18. Major areas of obstruction • Nose • Palate • Hypopharynx • laryngeal obstruction from bilateral laryngeal paralysis, laryngomalacia, and obstructing laryngeal lesions has also been reported.

19. Obesity • major risk factor for OSA • deleterious effects on metabolism, ventilation, and lung volume, resulting in V/Q mismatch • Significantly reduce lung volume, which results in a reduction of functional residual capacity

20. Adenotonsillar hypertrophy : major cause in children • In adults : multiple craniofacial variations

21. Consequences of untreated OSAS • increased mortality • increase in cardiovascular disease: • hypertension, coronary heart disease, congestive heart failure, arrhythmias, sudden death, pulmonary hypertension, and stroke • neurocognitive difficulties • increased risk of motor vehicle accidents by 2.5-fold

22. Consequences of untreated OSAS • independent risk factor for insulin resistance • contribute to the development of diabetes and metabolic syndrome,theterm used to describe the commonly occurring conditions of obesity, insulin resistance, hypertension, and dyslipidemia.

23. Consequences of untreated OSAS • GERD : (Treatment with CPAP decreases the occurrence of GERD) • problems with attention, working memory, and executive function (all of which are improved with CPAP treatment)

24. Diagnosis • most common symptoms : • loud snoring • restless sleep • daytime hypersomnolence

25. Diagnosis • Obesity :70% of adult patients • Screening, including a detailed sleep history and physical examination, is recommended for all obese patients

26. Epworth Sleepiness Scale

27. Epworth Sleepiness Scale • OSA may be suspected in patients with an ESS greater than 10

29. Dx • patients with HTN, CAD, CHF, CVA, and DM, must be carefully screened for the signs and symptoms of OSA • Women : insomnia, heart palpitation, ankle edema

30. P.E. • P.E. strengthens the Dx • BMI , BP , Neck circumference

36. Dx • Fiberoptic Flexible Nasopharyngoscopy (with Muller’s Maneuver) • Drug induced sleep videoendoscopy • Nocturnal PSG : gold standard

37. Sleep related breathing disorders

38. Sleep related breathing disorders

43. Medical Tx. • a stepwise manner begins with conservative medical measures. • 'Weight loss” for all overweight patients • Consultation with a bariatric surgeon in morbidly obese patients • surgically induced weight loss significantly improves obesity-related OSA and parameters of sleep quality as early as 1 month after surgery.

44. Medical Tx. • CPAP : gold standard for moderate to severe OSAS • Reduction in AHI, sleepiness, CVA, motor vehicle accidents & improvement in QOL • Decreased inflammation as measured by a decrease in the inflammatory markers CRP and IL-6, improved endothelial function, and reduced diurnal sympathetic activity.

45. Medical Tx. • BiPAP • APAP • Oral appliances for mild, moderate OSA (greater satisfaction) • Pharmacologic therapy: alternative in CPAP intolerance: Modafinil, Fluticazone, Montelukast, nasal dilator strips, topical decongestants

47. Indications of Surgical Tx.

48. Sx. options

49. Sx. options

50. Sx. options