diagnosis of sleep disordered breathing by dr. aditya agrawal
TRANSCRIPT
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