diagnosis of sleep disordered breathing by dr. aditya agrawal

SLEEP APNEADr Aditya Agrawal

Consultant Chest PhysicianAllergy, Critical Care and Sleep Medicine Specialist

Bhatia HospitalApollo Spectra I Cumballa I Motinben Dalvi I St Elizabeth I Masina

Tel No: 9022163859

What is Apnea?

• Apnea: a Greek word - “want of breath”

• Obstructive

• Central

• Mixed

Barriers to Diagnosis & Treatment

What are the screening tools?Berlin questionnaire (primary care setting)

10 itemsSnoring severity, significance of daytime sleepiness, witnessed apnea,

obesity, hypertension

STOP-BANG screening test (preoperative setting) 8 items STOP: Snoring, Tired, Observed apnea, high blood Pressure historyBANG: elevated BMI, Age > 50, increased Neck circumference, Gender male

Neither tool precludes formal sleep testing

Berlin questionnaire

Snoring severity,

significance of daytime sleepiness,

witnessed apnea,

obesity,

hypertension

STOP-BANG screening testSTOP:

Snoring,

Tired,

Observed apnea,

High blood Pressure history

BANG:

elevated BMI,

Age > 50,

increased Neck circumference,

Gender male

Screening and Prevention Ask all adults about sleep problems or daytime sleepiness

If response is positive: perform OSA screening

Take further clinical history

Use validated questionnaire

Screen is also warranted for all patients with:

Significant obesity

CVD

History of drowsiness while driving

What symptoms should prompt consideration of OSA?

Witnessed episodes of apnea

Loud, frequent, bothersome snoring

Choking/gasping during sleep

Excessive daytime sleepiness

Drowsy driving

Unrefreshing sleep, sleep fragmentation

Insomnia

Nocturia

Morning headaches

Decreased concentration, memory loss

Decreased libido

Nocturnal presentation

• Apnea

• Dyspnea

• Snoring

• Mouth breathing

• Restless sleep

In the absence of symptoms, what other diseases should prompt evaluation?

Morbid obesity

If patient scheduled for bariatric surgery

Hypertension

If refractory to medical therapy

What other conditions should be considered?

Chronic sleep deprivation disorder (shift-work

disorder)

Circadian rhythm disorder

Depression and anxiety

Hypothyroidism

Obesity hypoventilation syndrome

Central sleep apnea syndrome

Congestive heart failure (Cheyne-Stokes respiration)

Opiate-induced central sleep apnea

Physical Examinat ion

• Respiratory,

• Cardiovascular and

• Neurologic systems

• Presence of and degree of obesity

• Signs of upper airway narrowing

• Neck >16” women, >17” men

• Mallampati score of 3 or 4

• Macroglossia, tonsillar hypertrophy

• Enlarged or elongated uvula, high/arched

palate

• Nasal obstruction

• Retrognathia

Sources of Cost for Undiagnosed OSA

Comorbidities & Mental Health

HypertensionHeart Disease

DiabetesAsthma/Breathing Disorders

InsomniaDepression/Anxiety/Mental Health

Includes cost of healthcare services, medication, and

quality of life.

Motor Vehicle Accidents

Commercial

Non-Commercial

Includes medical costs, emergency services, property damage, lost productivity, and monetized quality adjusted life

years (QALYs) incurred by company, insurer, victims, government and others.

FatalNon-Fatal

Fatal

Non-Fatal

$6.9 B

Includes fatal and non-fatal accidents. Includes medical costs and lost productivity.Workplace Accidents

Lost ProductivityProductivity

Absenteeism

TREATMENT

Initial ManagementCounsel overweight patients about weight loss

Treat any nasal congestion

Advise alcohol avoidance close to bedtime

Offer trial of therapy (CPAP) if patient has

Daytime sleepiness or frequent nocturnal awakenings

Recent accident or near-miss attributable to sleepiness

Controversial: whether to treat asymptomatic patients with mild or moderate OSA

Alternative Treatment ModalitiesUvulopharyngopalatoplasty (UPPP):

in CP pt and hypotonic upper airway muscles; it has not been studied in the uncomplicated pediatric patients

Oral appliances have not been reported in children (it may adversely affect the facial configuration

of the growing child) In children, CPAP is usually used when T&A is unsuccessful or contraindicated

rather than as a primary treatment Young infants Medical conditions