Post on 16-Nov-2015
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Obstructive Sleep ApneaBrent A. Senior, MDAssociate Professor Chief, Rhinology, Allergy, and Sinus SurgeryOtolaryngology/Head and Neck SurgeryUniversity of North Carolina
What is Significant OSA?Uh, I dont knowMost consider significant sleep apnea to be present with an REI > 1515-25: Mild Apnea26-40: Moderate Apnea>40: Severe Apnea
Whos Got It?NCSDR-199340 million Americans with chronic sleep disorder20 million with occasional sleep disorderSDB (REI >5): 24% middle aged males9% middle aged femalesOSA >15/hr: 4% middle aged males2% middle aged femalesNEJM 1993; 328: 1230-35
Why is it so Important?Hypertension25% of hypertensives have OSA (AI>5)Sleep Heart Health Study6000 patients corrected for bmi, neck, EtOH
Nieto, et al. JAMA 283 (14): 1829-36, April 2000SDB (including snoring) and Htn correlate1700 patients
Bixler, et al Arch IM 160 (15): 2289-95, 2000Sleep 1980; 3: 221-4BMJ 1987; 294: 16-19
Health ImpactMIREI >20 independent predictor of MI223 German males with angio confirmed CAD
Schafer, et al. Cardiology 92(2): 79-84, 1999Increased mortality in CAD patients5 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 ImpactCVAREI severity is independent predictor of Stroke128 patients (UM)- 75 stroke; 53 TIA62.5% with AHI >10 with stroke vs 12% controls
Bassetti, C et al. Sleep 22(2): 217-23, 3/1999
Health ImpactDeathAI20, at 8y follow-up: 37% mortalitytreatment with trach or CPAP: 0% mortalityChest 1988; 94: 9-14NCSDR 199338000 CV deaths related to OSA per year
Societal Impact
Societal Impact 75% of 75000 screened will be diagnosed with OSA ($275 million)Fragmentation of sleep occurring with SDBincreased daytime sleepiness, decreased intellect, behavioral and personality changes, enuresis, sexual dysfunctionAm J Resp Crit Care Med 1996; 153: 1328-32
Societal ImpactIncreased Traffic Accidentssimulated driving: SDB ~100x more likely to drive off the roadActa Otolaryn 1990; 110: 136ff7x increased risk of auto accidentsClin Chest Med 1992; 13: 427-34
Societal ImpactReaction times with OSA equivalent to a normal control who was legally intoxicated (ABL >0.8)Powell NB et al. Laryngoscope. 109(10):1648-54, 1999UPPP decreases the number of MVAORL 1991; 53: 106-111Laryngoscope 1995; 105: 657-61
Hows it Diagnosed?History, Physical Examination, and Sleep StudyHistoryDisrupted sleep, restless sleep, awaken with gasping and chokingLoud snoringTired, inappropriate falling asleepWitnessed apneas
HistoryAssociated ComplaintsWeight changesThyroid/Growth Hormone abnormalitiesGERDHabitssleep scheduleEtOHPMH/MedsHypertensionSedatives; Antihistamines
18.psd
Physical ExamHeight and Weight (BMI)BMI=[703.1 x weight(pounds)] / [Height (in)2]neck sizeFace-retrognathiaNoseOral cavity- palate, uvula, tonsils/pillars, tongue, occlusion
Physical Examination
Physical Examination
Fiberoptic NasopharyngolaryngoscopyDetermines level of obstructionProvides estimate of degree of obstructionTechniquesupine (i.e., in a sleeping position)at FRC-point of maximal relaxationsnore maneuverMueller maneuver- inspire against a closed airway
13.psd
Objective Sleep MonitoringRationale: Difficulty predicting OSA by H&P with no EDSLoud snoring and witnessed apneas identify OSA 54-64% of the timeSleep 1988; 11: 430-36H&P predict OSA only 60% of the timeSleep 1993; 16: 118-22
10.psd
How To Treat?Minimal interventionDrop the Weight!Dental AppliancesVariable success rates, though probably more useful for mild apnea?complianceInterventionalCPAPSurgery
CPAPThe Gold Standard in the treatment of OSAWorks the best in the most peoplePositive pressure ventilation functions as a pneumatic splint for the collapsing upper airwayBut... compliance is very poor159/214 (74%); mean 5.6 h/night; 77-89% compliance (!) Krieger. Sleep 15 (6 Suppl) S42-6, 1992
SurgeryTracheotomyAn incision in the tracheaCures OSA nearly 100% of the timePrior to 1980, its all we had; still useful for severe apneics
Remove Tissue-Other SurgeriesLaser Midline GlossectomyPalatal SomnoplastyLAUPRadiofrequency tongue base reductionWoodson, et al, AAO 2000, Washington DC18 patients completed protocol, average 15,696 J
REI decreased from 45.3 to 33.3
35.psd
Enlarge the Bony Space-Other SurgeriesGenioglossus Advancement/ Hyoid RepositioningSuccess ~80% (11-18mm)Less effective with RDI >60Maxillo-mandibular AdvancementParticularly useful in the setting of hypopharyngeal obstruction (Fujita 2 or 3)Best results when performed following Stage 1 surgery
33.psd
Complication AvoidanceAll OSA patients are at risk of Airway Obstruction (even mild)Minimize risk:Expect intubation disasterPharyngeal procedure with nasal procedure increases risk regardless of apnea severityMickelson and Hakim, Oto HNS 119: 352-6, 1998Amount of intraoperative narcotic- worse with greater apnea severityEsclamado, Laryngoscope 99: 11-29, 1989Monitor post-op with continuous oximetry
SummaryOSA is a potentially life-threatening disorder that demands proper evaluationComponents of that proper evaluation include detailed sleep history, PE, and endoscopic evaluationObjective sleep evaluation is required prior to intervention
SummaryTreatments includeConservative non-interventional techniquesWeight loss, dental appliancesCPAPSurgery