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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 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…. 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