sleep disordered breathing/ obstructive sleep apnea

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SLEEP DISORDERED BREATHING/ OBSTRUCTIVE SLEEP APNEA. JHANSI NALAMATI MD. TYPES. Obstructive Sleep Apnea Central Sleep Apnea Mixed Apnea Upper Airway Resistance Syndrome (UARS). Historical background. Apnea- literally means “without breath” Pickwickian papers fat boy “Joe” - PowerPoint PPT Presentation

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  • SLEEP DISORDERED BREATHING/ OBSTRUCTIVE SLEEP APNEA

    JHANSI NALAMATI MD

  • TYPESObstructive Sleep ApneaCentral Sleep ApneaMixed ApneaUpper Airway Resistance Syndrome (UARS)

  • Historical backgroundApnea- literally means without breathPickwickian papers fat boy JoeOsler and later Burwell applied the name Pickwickian Syndrome to patients with Obesity, Hypersomnolence and signs of Chronic hypoventilation

  • 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.

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

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

  • Prevalence9% of men and 4% of women, in one study of state employees had AHI of 15 events/hr12 million people in the US have OSA

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

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

  • Risk factors for OSAObesityAge- middle aged men and post- menopausal womenOlder age- due to loss of muscle mass and tone? Family Hx of OSA

  • Risk factors (contd.)Anatomic abnormalities- receding chin, ?Nasal congestion, ? DNSEnlarged Tonsils and adenoids esp.in childrenEnlarged and inflammed uvula, worsened by chronic smoking, GERDAcromegaly

  • Risk factors (contd.)Amyloidosis, post- polio syndrome, neuromuscular disordersMarfans syndrome, Downs syndromeUse of alcohol and sedatives that relax the upper airwayIncreased neck circumference > 16 inches in women and 18 inches in men

  • SymptomsMost of the symptoms are from disruption of normal sleep architectureExcessive Daytime Sleepiness (EDS)- falling asleep even in stimulating environment, during a conversation, eating, business meetingH/O Snoring

  • Symptoms (contd.)Non- restorative sleepAutomobile AccidentsPersonality changesDecreased MemoryErectile DysfunctionFrequent Nocturnal Awakening

  • Symptoms(contd.)Drowsy Driver SyndromePolyuriaEarly morning headacheDry mouth

  • SignsLoud SnoringWitnessed apneasObesityHTNMetabolic syndromeIncreased Neck circumferenceAnatomic Abnormalities

  • SHHSSleep 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

  • Screening for OSA2 of the three symptoms- EDS, loud Snoring, Witnessed ApneasHigh Score on ESS(Epworth Sleepiness Score)>12, or Stanford Sleepiness Score

  • Epworth Sleepiness Scale (ESS)Maxiumum score of 24The scale is used to rate the 8 situations below that apply best to each individual0-no chance of dozing1- Slight chance of dozing2- moderate chance of dozing3- high chance of dozing

  • ESS (contd.)Sitting and readingWatching televisionSitting inactive in a public place ( theater, meeting)As a passenger in a car for about an hr. without breakLying down to rest in the afternoon when circumstances permitSitting and talking to someoneSitting quietly after lunchIn a car, while stopped for a few minutes in traffic

  • ESS ( contd.)1-6 : getting enough sleep7-9 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

  • Types of Sleep StudyFull night Polysomnography ( PSG)PSG with CPAP titrationSplit- Night PolysomnographyMultiple Sleep latency test ( MST)Maintainance of wakefulness Test ( MWT)

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

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

  • UARSUpper Airway Resistance SyndromeCannot be diagnosed with PSGRepetitive arousals that probably result from increased Respiratory effort and high resistance in the airwayCan be diagnosed by measuring esophageal pressure (Pes)

  • Medical ComplicationsUncontrolled HTNDiminished quality of life from chronic sleep deprivationIncrease risk for CVAWorsening of CAD and CHF

  • TreatmentBehavioral Tx- weight loss Sleep hygeineAvoiding alcohol too close to bedtimeAvoid sedatives and hypnotics, narcoticsAvoid caffeine

  • Treatment(contd.)Positional Tx- helpful with Primary snoringPositive Airway pressure (CPAP or BiPAP) ENT SurgeryOral appliances

  • Positive airway pressureEffective, Non-invasiveMask fit, air seal, comfort and humidification are importantNasal mask, full face- masks, nasal pillows, Nasal aire prongs

  • Complications of CPAPLocal dermatitisAir leak, nasal congestion,rhinorrheaDry eyesNose bleedAerophagiaRare- tympanic rupture, pneumothoraxCompliance is the biggest issue

  • Surgery Except tracheostomy,helps only mild to moderate cases or only primary snoringNot curative for OSASomnoplasty- office procedure- radiofrequency ablation of the soft palate- only for snoring

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

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

  • Jaw surgeryUseful for retrognathia, involves partial excision of maxilla or mandibleGenioplastyComplicated surgery

  • Bariatric surgeryGastric bypassWeight loss and decrease in adipose tissue of the parapharyngeal region leads to improvement or cure of OSAWeight loss has to be at least 20-30lbs before any change in AHI can be seen

  • Oral appliancesDevices that are worn during sleep that retract the jaw and alleviate upper airway obstructionTongue retaining devices for people with macroglossia

  • Jaw Positioning Devices

  • Alternative Surgeries for Obstructive Sleep Apnea (Osteotomies)

    1) Bi-maxillary advancement 2) Genio-tuberule advancement

  • CPAP Therapy

  • CPAP TherapyPositive impact on subjective sleepiness and depression (in RCTs)Fatigue, generic health related quality of life, vigilance, driving performance are all improved ( prospective trials)These parameters are sensitive to Tx duration and compliance

  • Commercial driving and OSA OSA has to be effectively treated before clearing the patient for workObjective documentation of regular CPAP use and testing by Multiple sleep latency test and/or MWT( Maintainance of Wakefulness Test)

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