Download Obstructive Sleep Apnea

Obstructive Sleep Apnea
Babak Saedi .M.D
Imam Khomeini Hospital
What is OSA?
Disorder of obstructed breathing occurring
during sleep
 Apnea: cessation of breathing with
respiratory effort lasting greater than 10s
 Hypopnea refers to a greater than 50%
reduction in air flow

Epidemiology of OSA
Prevalence - 2% in women, 4% in men
 In the elderly, estimates range from 28% to
67% in men and 20% to 54% in women
 two thirds are obese

Why is it so Important?

Hypertension
 25%
of hypertensives have OSA (AI>5)
 Sleep Heart Health Study
 6000
patients corrected for bmi, neck, EtOH
• Nieto, et al. JAMA 283 (14): 1829-36, April 2000
 SDB
(including snoring) and Htn correlate
 1700
patients
• Bixler, et al Arch IM 160 (15): 2289-95, 2000
 Sleep
1980; 3: 221-4
 BMJ 1987; 294: 16-19
Health Impact

MI
 REI
>20 independent predictor of MI
 223
German males with angio confirmed CAD
• Schafer, et al. Cardiology 92(2): 79-84, 1999
 Increased
mortality in CAD patients
5
y study (Sweden)-62 patients; 19 with OSA (RDI
17)
• OSA mortality: 37.5%; Non-osa mortality: 9.3%
• Peker, et al. Am J Resp Crit Care 162 (1): 81-6, 7/2000
Health Impact

CVA
 REI
severity is independent predictor of Stroke
 128
patients (UM)- 75 stroke; 53 TIA
 62.5% with AHI >10 with stroke vs 12% controls
• Bassetti, C et al. Sleep 22(2): 217-23, 3/1999
Health Impact

Death
 AI<20,
at 8y follow-up: 4% mortality
 AI>20, at 8y follow-up: 37% mortality
 treatment with trach or CPAP: 0% mortality
 Chest

1988; 94: 9-14
NCSDR 1993
 38000
CV deaths related to OSA per year
Societal Impact
2006 American Academy of Sleep Medicine
Societal Impact

Increased Traffic Accidents
 simulated
driving: SDB ~100x more likely to
drive off the road
 Acta
 7x
Otolaryn 1990; 110: 136ff
increased risk of auto accidents
 Clin
Chest Med 1992; 13: 427-34
PATENT Vs COLLAPSED AIRWAY
2006 American Academy of Sleep medicine
How’s it Diagnosed?
History, Physical Examination, and Sleep
Study
 History

 Disrupted
sleep, restless sleep, awaken with
gasping and choking
 Loud snoring
 Tired, inappropriate falling asleep
 Witnessed apneas
Who gets it?

Men who snore and who are overweight
Risk factors








adenotonsillar
hypertrophy
nasal obstruction
hypothyroidism
acromegaly
Down syndrome
sedative use
Alcohol
Smoking






micrognathia
retrognathia
Obesity
Neck circumference
vocal cord paralysis
H&N masses
History

Associated Complaints
 Weight
changes
 Thyroid/Growth
Hormone abnormalities
 GERD

Habits
 sleep
schedule
 EtOH

PMH/Meds
 Hypertension
 Sedatives;
Antihistamines
SITUATION
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g a theater
or a meeting)
As a passenger in a car for an hour without a
break
Lying down to rest in the afternoon when
circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without
alcohol
In a car, while stopped for a few minutes
in traffic
CHANCE OF
DOZING
Physical Exam

Height and Weight (BMI)
 BMI=[703.1
 neck
x weight(pounds)] / [Height (in)2]
size
 Face-retrognathia
 Nose
 Oral cavity- palate, uvula, tonsils/pillars,
tongue, occlusion
OBESITY

Strongest risk factor for OSA
 Present
in > 60% of patients referred for
a diagnostic sleep evaluation
 Wisconsin
A
Sleep Cohort Study
one standard deviation difference in BMI was
associated with a 4-fold increase in disease
prevalence
Obesity

Alters upper airway mechanics during sleep
1.
Increased parapharyngeal fat deposition:
neck circumference: > 17” males
> 16” females
With subsequent:
 smaller upper airway
 increase the collapsibility of the pharyngeal
airway
obesity
2. Changes in neural compensatory
mechanisms that maintain airway
patency:
 diminished protective reflexes which
otherwise
would increase upper airway dilator
muscle
activity to maintain
airway patency
obesity
3. waist circumference
Fat deposition around the abdomen produces
 reduced lung volumes (functional
residual
capacity) which can lead to
loss of caudal
traction on the upper airway
 low lung volumes are associated with
diminished oxygen stores
Physical Examination
Evaluation

thyroid function tests

Poly somnography is the gold standard
 History
and physical examination
identify only 52% of OSA patients,
with a specificity of 70%

Clinic of North America 1999
Fiberoptic
Nasopharyngolaryngoscopy



Determines level of
obstruction
Provides estimate of degree
of obstruction
Technique
 supine
(i.e., in a sleeping
position)
 at FRC-point of maximal
relaxation
 snore maneuver
 Mueller maneuver- inspire
against a closed airway
UpToDate
How To Treat?
 Minimal
intervention
Drop
the Weight!
Continuous Positive Airway
Pressure (CPAP)

Continuous Positive Airway
Pressure pneumatically splints
open the patient’s airway
during sleep by delivering
pressurized air into the throat

Effective at eliminating apneas
and hypopneas

Considered the gold standard
in the treatment of OSA
CPAP Side Effects


Despite its high efficacy, patients frequently cannot
tolerate its usage every night for life and thus long-term
acceptance has been found to be low (~50%)
Side effects:






Oronasal dryness
Conjuctivitis from air leak
Noise
Claustrophobia
Mask discomfort
Skin abrasions/rash
Appliance Design

Patients find appliances that
encroach the tongue space and
open the bite uncomfortable

No differences in efficacy
between greater or lesser
mandibular opening in
reducing AHI

No difference in treatment
success between 1-piece and
2-piece appliances
Oral Appliance Therapy



There are no strict guidelines in
the design of oral appliances for
OSA management and there is a
plethora of them in use
There are 1-piece or 2-piece
appliances made from soft
elastomeric material or hard
acrylic
2-piece appliances have the
advantage of allowing for
titratable mandibular
advancement
Surgical Treatment Options


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Septoplasty
Turbinoplasty
Partial turbinectomy
Polypectomy
Excision of nasal tumours
Adenoid tonsils excision
Uvulopalatopharyngoplasty
Tonsillectomy
Uvulectomy







Partial glossectomy/tongue
base reduction
Genioglossal advancement
Lingual tonsils excision
Hyoid
advancement/suspension
Maxillomandibular
advancement
Excision of laryngeal
tumours
Tracheotomy
Surgery

Tracheotomy
 An
incision in the trachea
 Cures OSA nearly 100% of the time
 Prior to 1980, it’s all we had; still useful for
severe apneics
Which Surgical Treatment Option?



When an obvious anatomical
abnormality is detected, the
appropriate surgical procedure is
performed accordingly
Unfortunately, even with sound
imaging modalities, it is still
difficult to ascertain the
pathophysiology of OSA
It is often a combination of
multiple sites affecting the upper
airway that contribute to OSA
 Nasal

Reconstruction ?
The Journal of Craniofacial Surgery & Volume 21, Number 6, November 2010
Remove TissueUvulopalatopharyngoplasty
(UPPP)

First successful alternative
to tracheotomy
 12
individuals
preop AI 54 +/- 28
 postop AI 28 +/- 28
 8/12 with post-op AI<20

• Fujita et al. Otolaryngol
HNS 1981; 89:923-34
Remove Tissue-Other Surgeries




Laser Midline
Glossectomy
Palatal Somnoplasty
LAUP
Radiofrequency tongue
base reduction
 Woodson,
et al, AAO
2000, Washington DC

18 patients completed
protocol, average 15,696 J
• REI decreased from 45.3
to 33.3
 UPPP
has been considered to be
effective only in approximately
50% of patients with OSA
Enlarge the Bony SpaceOther Surgeries

Genioglossus Advancement/
Hyoid Repositioning
 Success
~80% (11-18mm)
 Less effective with RDI >60

Maxillo-mandibular
Advancement
 Particularly
useful in the
setting of hypopharyngeal
obstruction (Fujita 2 or 3)
 Best results when performed
following “Stage 1” surgery
Maxillomandibular Advancement
Palatal Expansion



RPE treatment widens the
maxillary bone via distraction
osteogenesis at the midpalatal
suture
Increases the volumetric space
of the nasal cavity, which
helps reduce nasal resistance
Promotes spontaneous
repositioning of the tongue to
a normal position
Which Surgical Treatment Option?

Retropalatal and retroglossal openings are common areas that are
obstructed in the upper airway

Maxillomandibular advancement has been shown to be very
successful at treating OSA with retropalatal and retroglossal
obstructions

However, some believe that maxillomandibular advancement is too
invasive and should only be performed following a poor response to a
procedure involving uvulopalatopharygoplasty, genioglossal
advancement, and hyoid suspension

These clinicians argue that it would be overly aggressive to submit a
patient who would have responded to a less invasive surgery to the
risks/complications from maxillomandibular advancement
What is Successful Treatment?



In surgical studies, the definition of success
is mainly based on objective measures
Common objective parameters are the
apnea-hypopnea index and lowest oxygen
saturation
Current accepted definition for surgical
cure:



AHI less than 20 with a reduction greater
than 50%
Few desaturations less than 90%
Reason for setting the success less than 20
is that several studies have found that an
index >20 translates to increased morbidity
and mortality
Risks of Surgical Treatment

Surgery in the upper airway results in postoperative edema,
which has acute adverse effects on breathing

Several medications used during surgery are respiratory
depressants and can remain in the body in low amounts for
hours/days

OSA can be dangerously aggravated by these drugs thus these
patients need prolonged monitoring following surgery

There is also a concern with postoperative analgesics that are
respiratory depressants

Other complications: nerve damage, excessive bleeding
Sleep Apnea
2006 American Academy of Sleep Medicine
Otherwise snore
and this will
happen to you….
Or sleep alone….
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