SOMNOSCOPYSOMNOSCOPY

Cristian Dragos ŞTEFĂNESCU Ph.D.Cristian Dragos ŞTEFĂNESCU Ph.D.

ENT ENT Head & Neck Head & Neck surgeonsurgeon

SomnologystSomnologyst

National Institute of Aeronautical and Space Medicine, Bucharest, RomaniaNational Institute of Aeronautical and Space Medicine, Bucharest, Romania

TOWARD an integrated TOWARD an integrated and and interdisciplinary approach SD approach SD

All tretment options must be complementary

We should offer every patient the chance to choose between the existing therapeutic possibilities

Therapeutic options should be used rationally, alone or in combination, depending on the patient particularities

Surgical indication does not rule out other treatments

SomnoscopySomnoscopy

Fibreoptic examination of the pharynx Fibreoptic examination of the pharynx under drug-induced sleepunder drug-induced sleep..

AA test that helps to detect the areas of test that helps to detect the areas of vibration and collapse in patients with vibration and collapse in patients with sleep-disordered breathing. sleep-disordered breathing.

SomnoscopySomnoscopy

Obstructive sleep apnoea syndrome (OSAS) Obstructive sleep apnoea syndrome (OSAS) affects from 2% to 4% of the adult populationaffects from 2% to 4% of the adult population..

The treatment of choice is nocturnal continuous The treatment of choice is nocturnal continuous positive airway pressurepositive airway pressure..

In cases with low compliance or in those where In cases with low compliance or in those where CPAP is not indicated, surgery CPAP is not indicated, surgery ((or intraoral or intraoral devicesdevices) ) can be appropriate. can be appropriate.

SomnoscopySomnoscopy

TThe latest Cochrane review of the he latest Cochrane review of the literature on sleep apnoea surgeryliterature on sleep apnoea surgery the conclusion the conclusion - - surgery cannot be surgery cannot be

recommended as treatment for nonselected recommended as treatment for nonselected OSAS patients OSAS patients

Somnoscopy Somnoscopy offers the possibility of visualising the UAW of offers the possibility of visualising the UAW of

patients with OSAS and simple snoring patients with OSAS and simple snoring

SomnoscopySomnoscopy - - validityvalidity

we have to respond to the question of we have to respond to the question of whether it represents normal sleep whether it represents normal sleep

bispectral index (BIS), a system of EEG bispectral index (BIS), a system of EEG monitoring that gives us an index of how monitoring that gives us an index of how deep the anaesthesia is. deep the anaesthesia is. tthe levels of BIS at which consciousness is he levels of BIS at which consciousness is

lost vary from one individual to another, lost vary from one individual to another, approximately 50 - 70approximately 50 - 70

Safety of Safety of SomnoscopySomnoscopy tthere are authors who have performed more here are authors who have performed more

than 7000 tests without complications.than 7000 tests without complications.

in cases of childhood OSASin cases of childhood OSAS,, can be performed can be performed safely to ascertain the areas of collapse that safely to ascertain the areas of collapse that cause the apnoeas.cause the apnoeas.

aalthough it is not necessary to carry out the test in the lthough it is not necessary to carry out the test in the operating theatre, the place chosen has to be operating theatre, the place chosen has to be equipped with resuscitation devices and with a equipped with resuscitation devices and with a complete monitoring unit.complete monitoring unit.

iit should be remembered that these patients, some of t should be remembered that these patients, some of them cases of severe OSAS, have a significant risk them cases of severe OSAS, have a significant risk potential and an airway of difficult intubation.potential and an airway of difficult intubation.

Indications Indications for for SSomnoscopyomnoscopy

- Patients with moderate or severe OSAS without morbid Patients with moderate or severe OSAS without morbid obesity, who cannot tolerate CPAP as the diagnostic test obesity, who cannot tolerate CPAP as the diagnostic test before appropriate surgical indication or MAD.before appropriate surgical indication or MAD.

- Patients with mild OSAS or simple snoring with MAD or Patients with mild OSAS or simple snoring with MAD or in which surgical treatment is indicated.in which surgical treatment is indicated.

- Patients with OSAS that have not responded to surgical Patients with OSAS that have not responded to surgical treatment.treatment.

- Children with residual obstructive sleep apnoea after Children with residual obstructive sleep apnoea after adenotonsillectomy.adenotonsillectomy.

ContraiContraindications ndications for for SSomnoscopyomnoscopy

- Allergy to the components of propofol (especially Allergy to the components of propofol (especially soy or eggs) or of midazolam.soy or eggs) or of midazolam.

- High surgical risk (American Society of High surgical risk (American Society of Anesthesiologist risk score>3).Anesthesiologist risk score>3).

Patients who need to be treated with CPAP, weight loss or Patients who need to be treated with CPAP, weight loss or positional therapy do not need to have DISE, given that knowing the positional therapy do not need to have DISE, given that knowing the areas of obstruction is not important in these methods of treatment.areas of obstruction is not important in these methods of treatment.

Usefulness of SUsefulness of Somnoscopyomnoscopy and and ClassificationsClassifications

aat the moment there are at least six classifications t the moment there are at least six classifications published published

that collapse is multilevel in the majority of the that collapse is multilevel in the majority of the patients patients

there are patients with slight OSAS and multiple there are patients with slight OSAS and multiple areas of collapse,areas of collapse, butbut generally the more serious the apnoea, the more generally the more serious the apnoea, the more

areas of collapse. areas of collapse.

it is also true that there are patients with severe it is also true that there are patients with severe OSAS and a single area of collapse.OSAS and a single area of collapse.

Single-Area Single-Area / / Multi-Level Collapse Multi-Level Collapse in Various Studies Published.in Various Studies Published.

No.: number of patients included in the study;OSAS: obstructive sleep No.: number of patients included in the study;OSAS: obstructive sleep apnoea syndrome; SDB: sleep-disordered breathing; SS: simple apnoea syndrome; SDB: sleep-disordered breathing; SS: simple snorers.snorers.

ClassificationClassification

ClassificationClassification

ClassificationClassification

ClassificationClassification

ClassificationClassification

Conditions to extend the validity of Conditions to extend the validity of flying licencesflying licences

Applicants suffering from sleep apnoea may be assessed as FIT subject to the extent of the symptoms, satisfactory treatment (CPAP, Surgical Methods, Behavioral changes, Dental appliances) and functional evaluation in the working environment.

Pilot / ATC EDUCATION and COMPLIANCE with medical instruction are essential components of the fitness assessment, and shall be confirmed by the appropriate specialist.

NEW PROJECT - 2014NEW PROJECT - 2014 The manner to approach safety proposed in the project The manner to approach safety proposed in the project

adds the medical perspective of somnology to the adds the medical perspective of somnology to the elements of organizational culture. elements of organizational culture.

Somnology (sleep medicine) is however a recent Somnology (sleep medicine) is however a recent interdisciplinary specialty (in USA and Germany since interdisciplinary specialty (in USA and Germany since 2005; in Romania since 2011). 2005; in Romania since 2011).

The main objective of this project is to establish the The main objective of this project is to establish the protocol of expertiseprotocol of expertise (screening, diagnosis, treatment, (screening, diagnosis, treatment, establishment of the conditions to maintain medical establishment of the conditions to maintain medical aptitudes, monitoring of evolution) with regard to the aptitudes, monitoring of evolution) with regard to the aviatorsaviators who suffer from who suffer from sleep disorderssleep disorders (NOT ONLY (NOT ONLY SLEEP APNOEA). SLEEP APNOEA).

The potential of significantly The potential of significantly influence the scientific field by influence the scientific field by

new approachnew approach

The approach to fatigue in aviation from the perspective of sleep The approach to fatigue in aviation from the perspective of sleep medicine, the interdisciplinarity (medicine, psychology, medicine, the interdisciplinarity (medicine, psychology, organizational risk management) and the elaboration of protocols of organizational risk management) and the elaboration of protocols of diagnosis and treatment in main sleep disorders (sleep apnea, diagnosis and treatment in main sleep disorders (sleep apnea, insomnia, circadian rhythm disorders) adapted to the professional insomnia, circadian rhythm disorders) adapted to the professional particularities of pilots / traffic controllers particularities of pilots / traffic controllers can significantly influence can significantly influence the field of flight safety.the field of flight safety.

The results obtained can also be adapted and The results obtained can also be adapted and applied to other applied to other categories of personnelcategories of personnel occupying positions in the field of transport occupying positions in the field of transport safety (technicians, air navigation protection, and communications). safety (technicians, air navigation protection, and communications).

New themes of researchNew themes of research can be opened on the basis of the can be opened on the basis of the conclusions of this research.conclusions of this research.