sleep disordered breathing - doctorlogic...(eg, prader-willi syndrome, down’s syndrome) •...
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Sleep Disordered Breathing
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SDB Is an Umbrella Term for Many Disorders
SDB
• Characterized by a cyclical
alternating pattern of increased
and decreased periods of
breathing typically followed by
a central apnea.
• A form of another disorder that
is often associated with severe
heart failure patients, those
who have suffered a stroke or
who have experienced brain
injuries.
• A reduced rate and depth of
breathing.
• It occurs due to the loss of
muscle tone during sleep and
especially during REM sleep.
• Often occurs in patients with
chronic obstructive
pulmonary disease (COPD),
neurological impairments,
restrictive diseases (e.g,
scoliosis) or those who are
obese.
• most common type
of sleep apnea
• caused by the
partial or complete
collapse of the
upper airway.
• characterized by
repetitive pauses
in breathing during
sleep despite the
effort to breathe.
• occur for a
minimum of 10
seconds
• The individual may
not be aware of
the problem
• characterized by
a lack of drive to
breathe
• Results n
repetitive
pauses in
breathing with
no effort
• Occurs for a
minimum of 10
seconds
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Terms Used in Diagnosing SDB
• Flow limitation — upper airway narrowing; earliest sign of impending upper
airway closure
• Hypopnea — a >30% reduction in airflow lasting >10 seconds and with at
least a 4% oxygen desaturation from baseline
• Apnea — a cessation of airflow for >10 seconds
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A large, underpenetrated market: 26% of US adults age 30-70 have sleep apnea
(16% mild sleep apnea, 10% moderate to severe sleep apnea)
* Peppard PE et al. Am J Epidemiol 2013
Prevalence of Sleep Apnea*
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Depression
Heart Failure
Coronary
Artery Disease
Drug-Resistant
Hypertension
Obesity
Type 2
Diabetes
A-fib
76%
57%
49%
72%
77%
83%45%
Prevalence
Stroke
63%
References: available upon request
Sleep Apnea Prevalence in Other Diseases
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Main Headline Goes HereObstructive Sleep Apnea (OSA)
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Obstructive Sleep Apnea (OSA)
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• 1 in 4 (26%) US adults has at least mild OSA
• (AHI≥5 apneas per hour)1
• 1 in 10 (10%) US adults have moderate to severe OSA
(AHI≥15 apneas per hour)1
• At least 85% are undiagnosed2
Prevalence of OSA
1 Peppard PE et al. Am J Epidemiol 2013
2 Young T et al. Sleep 1997
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Male vs. Female: What are the Differences?
‘Typical’ OSA Symptoms: snoring, witnessed apneas, EDS
Epworth sleepiness scale - >10
Severe OSA
Obstructive apneas
More body position related (supine)
CVD, type 2 diabetes, stroke
Higher AHI’s than women
Symptoms: Insomnia, fatigue, daytime tiredness, headaches, muscle pain
Epworth sleepiness scale – typically lower score (have higher threshold for sleepiness
Less severe, more mild and UARS
Large amounts of flow limitation/UARS
Sleep stage related (mostly REM)
CVD, Type 2 diabetes, stroke and dementia
Lower AHI’s than men (more episodes of UARS)
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• Obesity
• Adenoids or tonsil hypertrophy
• Craniofacial syndromes
(eg, cleft palate, micrognathia)
• Neurodevelopmental disorders
(eg, Prader-Willi syndrome,
Down’s syndrome)
• Neuromuscular disorders (eg, spinal muscle atrophy, muscular
dystrophies, cerebral palsy)
Pediatrics at Risk for SDB
Mindell JA and Owens JA. Wolters Kluwer 2010
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Signs and Symptoms of Pediatric OSA
Mindell JA and Owens JA. Wolters Kluwer 2010
• Mouth breathing/dry mouth
• Chronic nasal congestion
• Hyponasal speech
• Rhinorrhea
• Morning headaches
• Frequent infections
• Difficulty swallowing
• Poor appetite
• Daytime sleepiness
• Hyperactivity
• Difficulty learning/focusing
• Failure to thrive or obesity
• Mood changes
Day-time Symptoms
• Loud, continuous snoring
• Apneic pauses
• Paradoxical movements
• Restless sleep
• Sweating during sleep
• Abnormal sleeping position
• Mouth breathing
• Enuresis
• Sleep disturbance
Night-time Symptoms
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Risk Factors for OSA
Obesity
IncreasingAge
Endocrineand
metabolic
Male Gender
Anatomic abnormalities of the upper
airway
Family history of
sleep problems
Alcohol or sedative use
Smoking
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Clinical Symptoms of Sleep Apnea
• Excessive daytime sleepiness
• Morning headaches
• Difficulty concentrating
• Loud or frequent snoring
• Irregular breathing during sleep
• Depression
• High blood pressure
• Weight problems
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Consequences of Sleep Apnea: Personal
Untreated OSA can lead to:
• Excessive sleepiness, which may cause problems at work.
• Depression, memory problems, difficulty concentrating.
• Less social engagement, lack of physical exercise, trouble with bed partner due to snoring, and even impotence.
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Consequences of Sleep Apnea: Perioperative Risk1
Patients with OSA who are undergoing surgical procedures are at higher risk
for complications than patients who do not have OSA.
Perioperative medications:
May reduce muscle tone,
drive to breathe and ability to
wake up
Upper airway narrowing:
Surgical factors (e.g., swelling
from breathing tube) may
increase airway narrowing
making collapse easier
Supine positioning:
Many patients have OSA that
is worse when lying in a
supine position
1 Kaw R et al. Chest 2012
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Consequences of Sleep Apnea: Traffic Accidents
Untreated sleep apnea can lead to a 15-fold increases in traffic accidents risk1
For every dollar spent on CPAP, $3.49 would be saved in reduced collision costs2
1 Horstmann S et al. Sleep 2000
2 Sassani A et al. Sleep 2004
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Consequences of Sleep Apnea: Occupational Health
60 – 90% of industrial and transportation
accidents occur due to human error
(caused by sleep deprivation, fatigue, boredom, etc.)
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Consequences of Sleep Apnea: Economic
• It is estimated that the total economic cost of sleep disorders in Australia in
2012 was $818 million annually
• Compared to patients without OSA,
patients with OSA had:
o Twice the healthcare costs
o 50% more physician visits
o Longer hospital stays.
National Sleep Foundation:
Sleep in America Poll_2011_Summary_of_Findings
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Consequences of Sleep Apnea: Morbidity and Mortality
Untreated OSA is
significantly
associated with
increased
morbidity and
mortality
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Types of Sleep Apnea
Nocturnal
hypoventilation
Complex
sleep apnea
(CompSA)
Obstructive
sleep apnea
(OSA)
Central
sleep apnea
(CSA)
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Main Headline Goes HereTreatment
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• Positive airway pressure (PAP) is the gold standard treatment
for SDB
• Alternatives:
o Behavioral modifications
o Dental appliances
o Drug therapies
o Surgery (UPPP, LAUP, mandibular advancement)
o Tracheostomy
Methods of Treatment
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Treatment – Behavioral Modifications
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Treatment – Mandibular Repositioning Device (MRD)
• Mandibular repositioning device (MRD) is a custom made, adjustable, oral
appliance available only from a dentist that maintains the lower jaw in a
forward position during sleep.
• This mechanical protrusion widens the space behind the tongue and
reduces the vibration and physical obstruction to breathing and the
tendency to snore.
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Narval CC Features
• The first and only CAD/CAM solution on the market
o Computer-aided design (CAD) enables a high degree of customization to suit
the complex dental anatomy of individual patients
o Computer-aided manufacturing (CAM) through selective laser sintering
guarantees a consistently accurate MRD
o Ensures precise fit and comfort retention
• Narval CC is metal-free, flexible and light weight. It is made of highly
resilient and durable biocompatible polymer material
• Narval CC is easy to reproduce with CAD/CAM
• Narval CC is easy to titrate; highly adjustable
o 16mm protrusive range–1mm increments
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Treatment – Surgery
• Adenotonsillectomy
• Nasal reconstruction
• UPP (uvulopalatopharyngoplasty)
• Jaw repositioning
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Treatment – PAP therapy
Device
Transports air through a filter and provides a set air pressure
Humidifier
Moistens the delivered air to relieve nasal irritation and dryness
Circuit
Two components:• Air tubing: Carries are
from device to mask.• Interface (mask): Delivers
pressure to patient’s airway.
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PAP Therapy