Download Obstructive Sleep Apnea Syndrome

Obstructive Sleep Apnea
Syndrome
Robert H. Stroud, M.D.
Francis B. Quinn, M.D.
February 4, 1998
History
 Charles
Dickens - The Pickwick Papers
 William Osler - Pickwickian Syndrome
1918
 Guilleminault - OSAS - 1973
 Fujita - UPPP - 1981
 Sullivan - CPAP - 1981
Epidemiology
 85%
men
 Prevalence - 2% in women, 4% in men
 two thirds are obese
 elderly
 African-American
Pathophysiology
 Bernoulli
principle and Venturi effect
 snoring
 tissue
laxity and redundant mucosa
 anatomic abnormalities
 decreased muscle tone with REM sleep
 airway collapse
Pathophysiology
 desaturation
 arousal
with restoration of airway
 sleep fragmentation leading to
hypersomnolence
Pathophysiology - complications
 desaturation
with compensatory
polycythemia
 hypercapnia with pulmonary hypertension
 systemic hypertension
 arrythmias
Evaluation
 complete
H&P
 snoring - characteristics
 daytime sleepiness
Evaluation - history
 restless
sleep
 personality change
 impaired cognitive
skills
 weight gain
 morning
headache
 nocturia/enuresis
 sexual dysfunction
 sedative use
Evaluation - history
 adenotonsillar
 micrognathia
hypertrophy
 nasal obstruction
 hypothyroidism
 acromegaly
 Down syndrome

retrognathia
 obesity
 vocal cord paralysis
 H&N masses
Evaluation - physical exam
 retrognathia
 mouth-breathing
 “tired”
appearance
Evaluation - physical exam
 Nasal
obstruction - turbinate hypertrophy,
polyposis, septal deviation
 oral cavity and oropharynx
–
–
–
–
–
redundant mucosa
beefy red
elongated uvula
macroglossia
AT hypertrophy
Evaluation - physical exam
 fiberoptic
examination
 Mueller’s maneuver
 examine in supine position
 usually difficult to localize one site of
obstruction
Evaluation
 Polysomnography
–
–
–
–
–
EEG
EOG
submental EMG
nasal and oral airflow
respiratory muscle
effort
–
–
–
–
oxygen saturation
ECG
anterior tibialis EMG
sleep position
Evaluation - polysomnography
 central,
obstructive, mixed apneas
 apnea - cessation of flow for 10 secs
 hyponea - 50% decrease in flow or EEG
arousal
Evaluation - polysomnography
 respiratory
disturbance index (RDI) apneas + hyponeas per hour
 apnea duration
 degree of desaturation
 sleep disturbance index - arousals per hour
Evaluation - radiography
 lateral
neck film in children
 CT and MRI of limited benefit
 somnofluoroscopy
 cephalometrics
Evaluation - other studies
 thyroid
function tests
 arterial blood gas
 complete blood count
 audio tape
 rhinomanometry
 multi sleep latency test (MSLT)
Treatment
 raise
intra-pharyngeal pressure
 decrease pharyngeal closing pressure
 increase muscular activity
Treatment
 weight
loss
 avoid sedatives
 pharmacotherapy
 orthodontic devices
 continuous positive airway pressure
Treatment - CPAP
 100%
effective
 titrate pressure
 poor compliance - 50-80%
Treatment - surgical
 adenotonsillectomy
- preferred treatment in
children
 tracheostomy - cure for OSAS
– used for failure of more conservative treatment
– life threatening cardiopulmonary complications
– alternative techniques to lessen complications
Treatment - surgical
 Uvulopalatopharyngoplasty
(UPPP)
– excise excess tissue from free margin of soft
palate
– +/- tracheostomy
– variable response - approximately 50%
– +/- nasal surgery
Treatment - surgical
 laser
midline glossectomy
 mandibular advancement
 maxillary advancement - LeFort I
osteotomy
 hyoid suspension and inferior sagittal
mandibular osteotomy
 hyoid expansion
Treatment - complications
 failure
to achieve relief
 difficult airway, anesthetic risk
 decreased respiratory drive
 bleeding, infection, pain
 velopharyngeal incompetence
 nasopharyngeal stenosis
 post-obstructive pulmonary edema
Conclusion
 life
threatening complications
 suboptimal treatment either due to poor
response or limited compliance
 good patient selection and long-term
follow- up