Sleep Apnea Syndromes - الصفحة الرئيسية...Sleep disorders • Directcosts of sleep...

Sleep Apnea SyndromesTreatment of Obstructive Sleep Apnea Syndrome

Laugh and the world laughs with you,

Snore, snore, snoreand you sleep alone

Ali Ali TawfikTawfikAbdelAbdel wahabwahab MouhamedMouhamed

Elsharawy KamalHazem Emam

Waleed RadwanAhmed Mosad

Mansoura ,Egypt

PoliticalPolitical economic signification economic signification of of Sleep disordersSleep disorders

• Direct costs of sleep disorders 15,9 Mill US $

• Hospitalization costs of non-treated

patients with Sleep-Apnoe-syndrome 42 Mill US $

• Traffic and industrial accidents in cause

of tiredness 50 Mill US $

• 38.000 cardivascular cases of death due to Sleep Apnoea Syndrome in the USA

• Prevalence of 87% in a study on 159 american truck-drivers

Sleep Apnea Syndromes

Sleep PhysiologySleep PhysiologyFive phases of sleep: stages 1, 2, 3, 4, (NREM) and REM (rapid eye movement).

These stages progress in a cycle from stage 1 to REM sleep.

Then the cycle starts over again with stage 1 . We spend almost :-• 50 % of our total sleep time in stage 2 sleep. • 20 % in REM sleep. • 30 % in the remaining the other stages. Infants, by contrast, spend about half of their sleep time in REM sleep.

•NonREM sleep

§ superficial sleep (phase I and II)

- sleeper can be easy waked up by little influences

§ deep sleep (phase III and IV)

§REM sleep (dream sleep)

- brain waves similar to those when you`re awaken, rapid eye-movement, raised muscle-tension

Sleep PhysiologySleep PhysiologySleep Apnea Syndromes

SnoringDefinition:• Sounds generated by the loose

redundant soft tissue of the upper airway in the during sleeping .

Social effects of snoring:• Snoring may be disruptive to

the family life.

Incidence of Snoring • 53% of the adult male population snore

intermittently • 31% snore regularly.• 38% of adult female snore

intermittently .• 19% snore regularly.

• Different grading scales for snoring have been developed.

• An easy grading system was developed by Pelausa and Trashis (1989).

o Grade I No snoring.o Grade 11 Occasional snoringo Grade III Persistent snoring.o Grade IV Persistent loud snoring.

SnoringSnoring

• Camilleri et al (1995), have adopted this technique

and proposed a simplified grading for patients with

simple snoring :

• Grade 1: Palatal snoring.

• Grade 2: Mixed snoring.

• Grade 3: Non-palatal (tongue base) snoring.

SnoringSnoringSleep Apnea Syndromes

Should everyone who snores undergo a sleep study?

q When the snoring is accompanied by symptoms of OSA, such as morning headache, and restless sleep……..

q When snoring is socially disruptive but not accompanied by symptoms of sleep apnea, the picture is not so clear.

q Unfortunately, even "apneas" witnessed by bed-partners are not predictive of OSA.

q The only reasonably accurate method of detecting OSA remains the sleep study.

q Therefore, current recommendations suggest obtaining a sleep study before to any surgery for sleep apnea or snoring.

What questions should you ask for a patient with suspected SAS?q Does your snoring ever awaken you from sleep?q Do you ever awaken suddenly, gasping for air?q Do family members complain about your snoring?q Does your spouse notice periods in which breathing

temporarily stops?q Do you feel rested (sleepy) after a night's sleep?q Do you feel drowsy at work.q Do you fall asleep at inappropriate times (such as at work,

while driving, or while on the telephone)?q Do you have morning headaches?

Are there special tests to evaluate for SAS?q Epworth Sleepiness Scale is a sensitive screening tool for OSA. q It is a series of questions about daytime somnolence. q A numerical score is assigned that correlates well to the

eventual diagnosis of OSA.q Polysomnography is the most sensitive and specific test in the

evaluation of SAS:-q The patient needs to spend a night in sleep lab.

q Gives an apnea index (AI), respiratory disturbance index (RDI), and oxygen desaturations

q differentiate between pure OSA, and central sleep apnea and can characterize the severity of the apnea.

Are there special tests to evaluate for SAS?q Home sleep studies have recently been implemented in an effort to reduce

cost. q These studies range from simple continuous pulse oximetry recordings to

multi-channel recordings using devices similar to those used in a sleep laboratory.

q Although these tests are gaining popularity, none is as sensitive or specific as a sleep laboratory study.

q The multiple sleep latency test is also performed in a sleep laboratory, but it is done during the day.

q The subject is given the chance to take naps, and this test assesses the time it takes for the subject to fall asleep.

q An average sleep onset of < 5 minutes is generally considered pathologic and suggests excessive daytime sleepiness.

Are there special tests to evaluate for SAS?q Muller's maneuver is performed as part of an extensive physical

examination and involves passing the flexible fiberoptic scope into the hypopharynx to obtain a view of the entire hypopharynx and larynx.

q The examiner then pinches the nostrils closed, and the patient closes his or her lips while attempting to inhale.

q If the hypopharynx and/or larynx collapse, then the test is positive.q A positive test means that the site of upper airway obstruction is very

likely below the level of the soft palate, and the patient will probably not benefit from a uvulopalatopharyngoplasty alone.

q Tongue base procedures may be necessary

Are there special tests to evaluate for SAS?

q Sleep flexible fiberoptic endoscopy is occasionally perfored for apnea.

q A flexible fiberoptic endoscope is passed into the hypopharynx to watch the patient breathe while under a light general anesthetic.

q This can help to evaluate the site of obstruction and may encourage the physician to do some type of tongue base procedure.

Sleep Apnea

Obstructive

Central

Hypopnea

Obesity- hypoventlation

(Pick wickian syndr.)

Upper-airway Resistance syndr.

Narcolepsy

Insomnia

Periodic leg movement(PLM)

(Restless legs)

Bruxism,

Sleep walking,

Hypersomnia,

Sleep terrors

Neurological

Sleep Apnea SyndromeDefinition:• Apnea:-

Cessation of airflow from the mouth and nose during sleeping period for 10 seconds or more, for 5 times or more per hour.

• Apnea Index (AI):The total number of apneas per hour of sleep.

• Hypopnea:50% or more reduction in the amplitude of a validated measure of breathing or a less than 50% amplitude reduction that is associated with either an arousal or more than 3% drop in oxygen saturation

• Apnea Hypopnea Index (AHl):Summation of apneas and hypopneas per hour sleep.

Sleep Apnea Syndrome• Desaturation:

Drop of oxygen saturation of at least 4% or more from baseline and maintained for at least 10 seconds .Desaturation Index:

The number of desaturation events per hour, averaged over all hours of sleep

• Arousal Index: The number of times per hour a patient is aroused from sleep.

Types of SAS• Obstructive Sleep Apnea• Central Sleep Apnea• Mixed Sleep Apnea• Upper-airway Resistance syndr.

• Obstructive apnea – Cessation of airflow for at least 10 seconds with

respiratory effort• Central apnea

– Cessation of airflow and without respiratory effort for at least 10 seconds

• Mixed apnea– Characteristics of both for at least 10 seconds

• Hypopnea – Hypoventilation secondary to partial obstruction

Types of SASSleep Apnea Syndromes

Evaluation of SleepPolysomnography– EMG– Airflow– EEG – EOG– Oxygen Saturation– Cardiac Rhythm– Leg Movements– Chest & abdominal motion

• Obstructive Sleep Apnea• Central Sleep Apnea• Mixed Sleep Apnea

• Upper-airway Resistance syndr.

Types of SAS

PolysomnogramPolysomnography– EMG– Airflow– EEG – EOG– Oxygen Saturation– Cardiac Rhythm– Leg Movements– Chest & abdominal motion

1. Inpatient (sleep lab)2. Patients home 3. Split night study

Sleep Apnea Syndromes•Polysomnography

What are the polysomnographic characteristics of OSA?•• Apnea:Apnea:-- TTemporary cessation of air exchange due to emporary cessation of air exchange due to

obstruction of the upper airway while normal or extraordinary obstruction of the upper airway while normal or extraordinary respiratory efforts are being made.respiratory efforts are being made.

• Hypopnea a reduction of air exchange associated with oxygen desaturation. It can be obstructive or central.

q Mixed sleep apnea Exhibits components of both central and obstructive apnea but is considered a variant of OSA. Treatment is similar to treatment for OSA.

q Apnea Index (AI) number of apnea events per hour.q Respiratory Disturbance Index (RDI) number of apnea

events plus number of hypopnea events per hour.q "Pickwickian“ Charles Dickens, in The Posthumous Papers

of the Pickwickian Club (1837), described the obese and somnolent Joe ." Pickwickian syndrome is characterized by obesity and hypoventilation who "goes on errands fast asleep and snores .

Polysomnogram• Obstructive apnea

– Cessation of airflow for at least 10 seconds with respiratory effort

• Central apnea– Cessation of both airflow and

respiratory effort for at least 10 seconds

• Mixed apnea– Characteristics of both for at

least 10 seconds

• Hypopnea – Hypoventilation secondary to

partial obstruction

Polysomnogram• Apnea index• Apnea-Hypopnea index = respiratory

disturbance index• Arousal index

Grading of Sleep Apneas

• Mild 5-20 *AI (per hour)• Moderate 20-40 AI (per hour)• Severe >40 AI (per hour)

**(American Sleep Association)

*AI =Apnea Index

Upper airway resistance syndrome (UARS)

• This is considered as a mild variant of OSA, Patients present with complaints of excessive daytime sleepiness and snoring, but not have apneas or hypopneas when evaluated by polysomnography.

• Esophageal pressure manometry demonstrates progressive negative pressure followed by frequent arousals .

• It is diagnosed by esophageal pressure measurement using an esophageal catheter.

Types of SAS

• Obstructive Sleep Apnea• Central Sleep Apnea• Mixed Sleep Apnea

Central Sleep ApneaCentral Sleep ApneaSleep Apnea Syndromes

Central Sleep ApneaCentral Sleep Apnea

• CSA is much less common than OSA and must be distinguished from it.

• CSA occurs when the neural drive to the respiratory muscles is temporarily abolished, resulting in an absence of respiratory effort (Chest & abdominal motion).

• CSA is much less common than OSA and must be distinguished from it.

• CSA occurs when the neural drive to the respiratory muscles is temporarily abolished, resulting in an absence of respiratory effort (Chest & abdominal motion).

During sleep respiration is controlled by:-– Automatic feedback system.

Sensory signals from multiple receptors are relayed to the brain stem , where they are integrated, and the brain stem sends signals, which stimulate the muscles of respiration and lungs.

Any condition affecting this feedback system may cause CSA.

During sleep respiration is controlled by:-– Automatic feedback system.

Sensory signals from multiple receptors are relayed to the brain stem , where they are integrated, and the brain stem sends signals, which stimulate the muscles of respiration and lungs.

Any condition affecting this feedback system may cause CSA.

Central Sleep ApneaCentral Sleep ApneaSleep Apnea Syndromes

Respiration During SleepRespiration During Sleepby

Automatic feed back system by

Automatic feed back system

Any causes affect this automatic feed back systemAny causes affect this automatic feed back system

Receptors in respiratory muscles and lungsReceptors in respiratory muscles and lungs

Brain stemBrain stem

Sensory SignalsSensory Signals Stimulatory SignalsStimulatory Signals

Causes of CSA:-Any condition affect this automatic feed back systemCauses of CSA:-

Any condition affect this automatic feed back system

• Congenital central alveolar hypoventilation, which results from a very low sensitivity to increased PCO2.

• Chronic neuropathies may also impair the sensory component.

• Bilateral brainstem lesions:-• vascular conditions .• Infections , and degenerative and metabolic diseases

affect integrative function.

• Neuromuscular disease, such as:-

• Polio, amyotrophic lateral sclerosis, and muscular dystrophies ,impair motor function.

• Chronic obstructive pulmonary disease and congestive heart failure.

• Congenital central alveolar hypoventilation, which results from a very low sensitivity to increased PCO2.

• Chronic neuropathies may also impair the sensory component.

• Bilateral brainstem lesions:-• vascular conditions .• Infections , and degenerative and metabolic diseases

affect integrative function.

• Neuromuscular disease, such as:-

• Polio, amyotrophic lateral sclerosis, and muscular dystrophies ,impair motor function.

• Chronic obstructive pulmonary disease and congestive heart failure.

• CSA can be diagnosed and its degree of severity and can be determined .

• CSA can also be confirmed by measuring :-

–Esophageal pressure. –Respiratory efforts during sleep.

• CSA can be diagnosed and its degree of severity and can be determined .

• CSA can also be confirmed by measuring :-

–Esophageal pressure. –Respiratory efforts during sleep.

With polysomnography (Sleep Lab.):-

The primary treatment for CSA:• Nasal mask ventilation using CPAP, intermittent

positive pressure ventilation.• Medication to stimulate respiration and to increase

the tone of the genioglossus and geniohyoidmuscles have had limited success.

• In the most severe cases tracheostomy .

The primary treatment for CSA:• Nasal mask ventilation using CPAP, intermittent

positive pressure ventilation.• Medication to stimulate respiration and to increase

the tone of the genioglossus and geniohyoidmuscles have had limited success.

• In the most severe cases tracheostomy .

Obstruction Sleep Apnea Syndrome(OSAS)

Pathophysiology of OSA

• Sites of Obstruction• Obstruction tends to

propagate

Pathophysiology of OSA• Sites of Obstruction:

Fujita,et al, 1981

• Pharyngeal collapse• Decreased airway patency• Increase in negative pressure• Becomes a vicious cycle

Sleep Apnea SyndromesPathophysiology of OSA

What is the pathophysiology of OSA?q OSA can be caused by an obstruction at any level of the upper

airway (i.e., above the true vocal cords or glottis).q Respiratory physiology dictates that during inspiration, there

is a negative pressure within the upper airway.q Sleep physiology reveals that during the deeper stages of sleep

(NREM:-_ stages III, IV, and REM), there is muscle relaxation of the entire body, including the muscles of the upper airway.

qMost patients with OSA have redundant tissue or an abnormally small air passage.

What is the pathophysiology of OSA?q In the presence of these anatomic variants, these two

physiologic events combine to result in collapse of the upper airway, with resulting obstruction to airflow.

q Oxyhemoglobin desaturation eventually leads to an arousal to a lighter level of sleep, and the airway is re-established with the characteristic loud snorting respiration.

q Any factor that adds to upper airway obstruction can cause or exacerbate OSA, including:-q Bulky soft palate or uvula, q Fullness in the base of the tongue, q Adenotonsillar hypertrophy, q Low lying hyoid boneq Obstructive laryngeal masses,q Nasal obstruction????????.

Pathophysiology - complications

• Desaturation with compensatory polycythemia

• Hypercapnia with pulmonary hypertension• Systemic hypertension• Arrythmias

Polysomnogram• Apnea index• Apnea-Hypopnea index = respiratory

disturbance index• Arousal index

DIAGNOSIS• History• Examination• Investigations

Sleep Apnea SyndromesObstruction Sleep Apnea

• Symptoms of OSA– Snoring (most commonly noted complaint)– Cessation of breathing during the sleep– Daytime Sleepiness– Hypertension and Cardiovascular Disease

are Associated– Pulmonary Disease

• Findings in Obstruction:– Nasal Obstruction ?????– Long, thick soft palate– Narrowed oropharynx– Redundant pharyngeal tissues– Large lingual tonsil– Large tongue– Retrodisplaced Mandible– Retro-displaced hyoid complex– Large or floppy Epiglottis ???

SYMPTOMS and SIGNS OF OSAØ SnoringØ Pauses in breathingØ Gasping or chokingØ Restless sleepØ Excessive sleepiness

or fatigue during the day

Ø Poor judgment or concentration

Ø IrritabilityØ Memory loss

Ø High blood pressureØ DepressionØ ObesityØ Large neck size (>17"

in men; >16" in women)

Ø Crowded airwayØ Morning headacheØ Sexual dysfunctionØ Frequent urination at

Evaluation - history• restless sleep• personality change• impaired cognitive

skills• weight gain

• morning headache• nocturia/enuresis• sexual dysfunction• sedative use

What should you look for on the physical examination of a patient with suspected OSA?

qRetrognathia and/or macroglossia can also contribute to OSA. Full, thick necks may also predispose patients to OSA, especially in the setting of an overall "pickwickian" patient.qLaryngeal examination should be

performed to rule out any obstructing lesion.

Oral cavity and oropharynx• Careful examination of the oral cavity and oropharynx is

of principal importance. • Because many of the surgical procedures performed to

improve OSA are performed on this area. • The examination should take special notes of the

potentially correctable anatomy or deformities . • The oropharynx can be assessed using the modified

Mallampati’s technique :-– The patient is evaluated with the mouth open and without

protrusion of the tongue.– The patient is asked to open the mouth widely with the tongue left

in place and oropharyngeal crowding is graded as follows .

The modified Mallampati technique is highly predictive of the severity of obstractivc sleep apnea

MallampatiMallampati grades grades A.A.GradeGrade I I The tonsils, pillars, and soft palate are clearly visibleThe tonsils, pillars, and soft palate are clearly visibleB. B. Grade Grade IIII The uvula, pillars and upper pole are visible.The uvula, pillars and upper pole are visible.C. C. Grade Grade IIIIII Only part of the soft palate is visible; the tonsils, pillars, Only part of the soft palate is visible; the tonsils, pillars, mid base of the mid base of the uvula cannot be seen.uvula cannot be seen.D. D. Grade Grade IVIV Only the hard palate is visible.Only the hard palate is visible. (Friedman Metal, 1999)(Friedman Metal, 1999)

The The oropharynxoropharynx can be assessed using the modified can be assessed using the modified MallampatiMallampati’’ss technique ):technique ):--The patient is evaluated with the mouth open and without protrusThe patient is evaluated with the mouth open and without protrusion of the ion of the tongue.tongue.The patientThe patient isis asked to open the mouth widely with the tongue left in place andasked to open the mouth widely with the tongue left in place andoropharyngealoropharyngeal crowding is graded as follows`crowding is graded as follows`

The Tonsils can be graded as follows

o Grade 0 : The patient had a tonsillectomy.o Grade I : Tonsils are in tonsillar fossa, barely seen behind the anterior pillars.o Grade II: The Tonsils are visible behind the anterior pillars.o Grade III :The Tonsils are extending three quarters oft he

way to the midline.o Grade IV : The Tonsils are completely obstructing the airway, also known as

kissing tonsils

The tonsil grading was found to be both predictive of the presence of OSA and significantly related to the severity of OSA

Friedman et al, 1999Friedman et al, 1999

Normal nose and pharynx on one side. Abnormalities associated with snoring on the other side: long soft palate and uvula, large tongue and lingual tonsil, large palatine tonsil and deviated nasal septum.

0 I II III IV

Pathophysiology of OSA• Tests to

determine site of obstruction:– Muller’s

Maneuver– Sleep

nasoendoscopy– Fluoroscopy– Manometry– Cephalometrics– Dynamic CT

scanning and MRI scanning

Sleep nasendoscopy. (a) The palatal closure is viewed, (b) The tongue base and larynx are viewed.

Muller’s Maneuver

Sleep nasendoscopy. (a) The palatal closure is viewed, (b) The tongue base and larynx are viewed.

Flexible fiberoptic view of the retropalatal region at rest and with Muller Maneuver A 90 % collapse of the retropalatal region is noted here . (Courtesy of Richard J. Schwab,MDPhiladelphia, PA.)

Fibro – optic nasoendoscopy

DIAGNOSIS

• History

• Examination

• Investigations

OximeteryOximeteryIn Sleep ApneaIn Sleep Apnea

OximeteryOximetery

OximeteryOximetery In Sleep ApneaIn Sleep Apnea

DIAGNOSISSleep Apnea Syndromes

DIAGNOSIS

DIAGNOSISSleep Apnea Syndromes

Complications of OSAS• Related to excessive daytime sleepiness….• Related to cardiovascular system

• Systemic Hypertension

• Pulmonary Hypertension

• Arrhythmia

• Right Heart Failure

• Myocardial Infarction

• Complete Heart Block

Causes of Death in OSAS• Cardiovascular

– Heart Failure– Myocardial Infarction– Complete Heart Block

• Motor Car Accidents

• Findings in Obstruction:– Nasal Obstruction ?????– Long, thick soft palate– Narrowed oropharynx– Redundant pharyngeal tissues– Large lingual tonsil– Large tongue– Retrodisplaced Mandible– Retro-displaced hyoid complex– Large or floppy Epiglottis ???

Treatment of OSASTreatment of OSASSleep Apnea Syndromes

Treatment of OSASTreatment of OSAS

• Surgical Treatment

• Nonsurgical Treatment

Treatment of SAS

Treatment of OSASTreatment of OSAS

• Surgical Treatment

1. Weight loss2. Drug review( Sedative, Hypnotics)3. Nasal medication4. Nasal Dilators5. Positional advice6. Oral device

a. Mandibular positioning deviceb. Tongue retaining device

7. Continuous Positive Airway Pressure (CPAP)8. Drug treatment (e.g. protriptyline)

Treatment of OSAS• Nonsurgical Treatment

a) Mandibular positioning deviceb) Tongue retaining device

7. Continuous Positive Airway Pressure (CPAP)

8. Drug treatment (e.g. protriptyline)

Treatment of OSASNonsurgical Treatment

Treatment of OSAS

– Weight lossShould be recommended for OSASDecrease the severity of OSASUnfortunately, is difficult to achieve and to

maintain for these patients of OSAS .

Nonsurgical Treatment

•Weight loss–Get below “trigger weight”

–Diet, exercise, bariatric surgery, medications

•Sleep hygiene–Avoidance of sedatives

–Positional changes

Treatment of OSAS

• Drug reviewAvoidance of Sedatives, hypnotics and alcohol because they increase the severity of OSAS.

Treatment of OSASMedical Treatment

Nasal medication

Nasal Dilators

Treatment of OSAS

• Positional advice:-• Mild and Moderate OSAS may be

improved by sleeping in the lateral position by using night shirt with tennis balls in the back

Positional advice

Treatment of OSASOral device

Advances the mandibleRetains the tongue anteriorly

• Nonsurgical TreatmentSleep Apnea Syndromes

Continuous Positive Airway Pressure( CPAP)• 1981• Very effective• Can be modified and

used on a trial basis

• Nonsurgical TreatmentSleep Apnea Syndromes

•During inspiration air will be sucked in: low pressure

•Patients with sleep apnea have a high collapsibility of the upper airways: it comes to a collapse or to a complette occlusion

•The CPAP device opens the upper airwayswith a possitive pressure

Function of theFunction of the CPAPCPAP--therapytherapy

Continuous Positive Airway Pressure( CPAP)• Nonsurgical Treatment

Continuous Positive Airway Pressure( CPAP)• Nonsurgical TreatmentTreatment of OSAS

• Nonsurgical TreatmentContinuous Positive Airway Pressure( CPAP)

Act as a pneumatic splint of the collapsed pharynx

•Titrated to limit all respiratory events•50-90% acceptance – better if daytime

symptoms improved•Side effects in 40-50%

Continuous Positive Airway Pressure( CPAP)

q Nasal continuous positive airway pressure (CPAP) is the most effective nonsurgical treatment of OSA.

q An airtight mask is held over the nose by a strap wrapped aroundthe patient's head.

q CPAP is maintained by a machine that is similar to a ventilator.q Although nasal CPAP is nearly 100% effective in relieving OSA,

compliance is a problem. q The masks and positive pressure are uncomfortable for many

people.q Longterm compliance is 50% to 75%, depending on the level of

support the patients are given by the medical staff.q Bilevel positive airway pressure (BiPAP) is often tolerated better

by decreasing the expiratory pressure.

Continuous Positive Airway Pressure( CPAP)

Treatment of OSASMedical Treatment

Drug treatment (e.g. protriptyline)

Treatment of OSAS

Medical Treatment

Surgical Treatment Philosophy

1. Treatment to cure

2. Site-specific surgical therapy

3. Staged surgical management (if necessary)

4. Full patient disclosure of options and risks

5. Follow-up all treatment

Surgical Treatment of OSASSleep Apnea Syndromes

Surgical Indications for Treatment1. Apnea-hypopnea index of >15

2. Oxyhemoglobin desaturation of <90%

3. Excessive daytime sleepiness

4. Upper airway resistance syndrome, preferably with objective improvement

of neurocognitive dysfunction using medical therapy

5. Significant cardiac arrhythmias associated with obstructions

6. Unsuccessful or refused medical therapy and desire for surgery

7. Medically stable enough to undergo the recommended procedure (s)

Surgical Treatment of OSAS• The success depends on proper diagnosis.• After failure of medical treatment.• Presence of specific surgically correctable abnormality.

• The aim is widening the upper airway by:-• Reduction of the soft tissues of the oroph.• Advancement of the tongue or jaws

• Types of Surgery depend on :-– The site of obst. – Grade of obst.– Cause of obstruction.

• Mild 5-20 AI (per hour)• Moderate 20-40 AI (per hour)• Severe >40 AI (per

hour)**(American Sleep Association)

Surgical Treatment of OSAS

– Two phasesPhase I

* Nasal, UPPP, mandibular advancement and GAHM

Phase II* Bimaxillary advancement.* Base of the Tongue Surgery.

(Powell et al.,) 1998

Surgical Treatment of OSAS• Nasal Surgery• Laser-assisted uvulopalatoplasty (LAUP)**• Electrocautery-assisted uvulopalatoplasty (EAUP)**• Radioferquency assisted uvulopalatoplasty (RAUP)**• Adeno-tonsillectomy in children• Uvulo-palato-pharyngoplasty (UPPP)• Genio-glossus advancement with hyoid myotomy (GAHM)• Linguoplasty• Mandibular advancement• Maxillo-mandibular advancement• Tracheostomy

• Nasal Surgery– Limited efficacy when used alone– Verse et al 2002 showed 15.8% success rate

when used alone in patients with OSA and day-time nasal congestion with snoring (RDI<20 and 50% reduction)

• Adenoidectomy

Surgical Treatment of OSAS• Nasal Surgery• Laser-assisted uvulo-palatoplasty (LAUP)**• Electrocautery-assisted uvulopalatoplasty (EAUP)**• Radioferquency assisted uvulopalatoplasty (RAUP)**• Adeno-tonsillectomy in children• Uvulo-palato-pharyngoplasty (UPPP)• Genio-glossus advancement with hyoid myotomy

(GAHM)• Linguoplasty• Mandibular advancement• Maxillo-mandibular advancement• Tracheostomy

Laser-assisted uvulo-palatoplasty (LAUP)**

Electrocautery-assisted uvulopalatoplasty (EAUP)**Radioferquency assisted uvulopalatoplasty (RAUP)**

• Recommended for snorers without OSA.

What are the surgical treatments of snoring and OSA?

Palateq Palate reduction can be achieved by laser-assisted

uvulopalatoplasty (LAUP), submucosalradiofrequency device, electrocautery (termed Bovie-assisted uvulopalatoplasty or BAUP), or uvulopalatopharyngoplasty .

q For snoring, LAUP, BAUP, and the radiofrequency procedures are usually performed. For each of these procedures, as healing occurs the soft palate elevates, shortens, and stiffens, reducing the tendency to vibrate.

q Electrocautery is less expensive and more widely available.

What are the surgical treatments of snoring and OSA?

Palateq These procedures are performed in a doctor's office or in

an outpatient setting under local anesthesia.q They often require two to four stages, each separated by

about 1 month, titrating the procedures to resolve the snoring without causing velopharyngeal insufficiency.

q Radiofrequency procedures usually help about 80% of the patients achieve significant improvement in their snoring.

q It is only minimally uncomfortable for the patients. LAUP, BAUP, and UPPP improve snoring in 90% of patients but cause severe pain for 10-14 days.

q LAUP and radiofrequency palate procedures for the treatment of true OSA have not been widely accepted, although they appear to have some positive effect in mild to moderate OSA.

• Laser Assisted Uvulopalatoplasty– High initial success rate for snoring– Rates decrease, as for UP at twelve

months– Performed awake

Kamami Technihue 1997

Radioferquency assisted uvulopalatoplasty (RAUP)*Surgical Treatment of OSAS

Radiosurgically-Assisted Uvulopalaplasty (RAUP)Surgical Treatment of OSAS

The steps of Radiosurgically-Assisted Uvulopalatoplasty (RAUP). (a) Before the operation (A) Pa/ata/incision on the right side (c) Bilateral palatal incisions (d) The final view after partial uvulectomy.

• Where the snoring is controlled but undiagnosed life threatening OSA may persist .

• Must be considered .

Laser-assisted uvulo-palatoplasty (LAUP)**Electrocautery-assisted uvulopalatoplasty (EAUP)**Radioferquency assisted uvulopalatoplasty (RAUP)**

Silent apneics

Surgical Treatment of OSAS• Nasal Surgery• Laser-assisted uvulopalatoplasty (LAUP)**• Adeno-tonsillectomy in children• Uvulo-palato-pharyngoplasty (UPPP)• Genio-glossus advancement with hyoid

myotomy (GAHM)• Linguoplasty• Mandibular advancement• Maxillo-mandibular advancement• Tracheostomy

• Adeno-tonsillectomy in children

myotomy (GAHM)• Linguoplasty• Mandibular advancement (MA)• Maxillo-mandibular advancement (MMA)• Tracheostomy

Pathophysiology of OSA• Sites of Obstruction:

Fujita,et al, 1981

Riley-Powell-Stanford ProtocolSurgical Treatment of OSAS

Riley-Powell,1998

Fujita,et al, 1981

• Two phasesPhase I

* Nasal, UPPP, mandibular advancement and GAHM

Phase II* Bimaxillary advancement.* Base of the Tongue Surgery.

(Powell et al.,) 1998

Indications of UPPP

• Socially disruptive snoring.• OSAS at the velopharyngeal or upper

oropharyngeal level.

Surgical Treatment of OSASUvulo-palato-pharyngoplasty (UPPP)

• The Aim is to enlarge the retropalatal airway by:-1- Excision of the tonsils if

present.2- Excise uvula and posterior

portion of the soft palate.3- Trim or reorient the

anterior and posterior pillars

Uvulo-palato-pharyngoplasty (UPPP)

General anaesthesia1-Very difficult intubation.2- Ready to use an alternative technique of intubation.3- No preop. Sedation.4- Ready for emergency tracheostomy.5- Extubated when fully awake.6- Post operative CPAP.7- IV steroid during and post op.8- No post op. sedative or Hypnotics.9- Post op. ICU especially for cardiac patients

Judging the amount of soft palate to be resected.

Uvulo-palato-pharyngoplasty (UPPP)Surgical Treatment of OSAS

Uvulo-palato-pharyngoplasty (UPPP)

Ikematsu, 1964Fujita,et al, 1981 Simmons et al 1983 Many modifications

A box-like resection. Reconstruction. Deep sutures pulling the posterior pillar forwards.

Fujita et al 1987

Surgical Treatment of OSASUvulo-palato-pharyngoplasty (UPPP)

• Uvulopalatopharyngoplasty– The most commonly performed surgery for OSA– Severity of disease is poor outcome predictor– Levin and Becker (1994) successed up to 80%

initial success, but decreased to 46% success rate at 12 months

– Friedman et al (1999 ) showed a success rate of 80% at 6 months in carefully selected patients

Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 2002; 127: 13–21.

Results of UPPP• Curing snoring 85-90%• Reduce apnea index 77%• Improving excessive daytime sleepiness

and performance

Side Effects of UPPP• Extremely painful op.• Postop. Bleeding up to 3%• Nasal regurgitation• Dry throat• Disturbance of the taste• Hypernasal speech• Velopharyngeal stenosis

UPPP• Still not fully defined, although may

eliminate snoring but it has been not shown to improve long-term mortality.

• This reinforces the importance of patient selection and late postoperative reassessment. (Charles & Michael 1997)

• UPPS Complications– Minor

• Transient VPI• Hemorrhage<1%

– Major• NP stenosis• VPI• Death• Emergent Tracheotomy

( A), Preoperative palate anatomy. (B), Uvula is grasped with a forceps and reflected back toward the soft-hard palate junction; note the muscular crease.( C), The mucosa of the oral aspect of the uvula and soft palate in a diamond shape is removed with cold knife dissection; the uvular tip is amputated and the uvular muscle thinned, if necessary. (D), Trimmed and sutured flap, with the shaded area indicating the location of the tissue before it is repositioned. E, Postoperative appearance, with closure up on the soft palate

The reversible uvulopalatal flap

( Powell ,1996.)

Hypopharyngeal and Base-of-Tongue ProceduresIn the early 1980s, Fujita and colleagues recognized that many patients

with OSA have obstruction at multiple levels of the pharynx. • Riley and colleagues (1985 ) assessed UPPP failures with

cephalometric analysis and concluded that the base of the tongue was the cause of the persistent obstruction.

• Schwab, Gefter, and Hoffman (1995) examined the upper airways of patients with OSA using magnetic resonance imaging and determined that collapse of the lateral pharyngeal wall was a significant component of sleep-related airway obstruction.

• Addressing hypopharyngeal obstruction has substantially improved surgical success rates and motivated the search for surgical procedures to improve reconstruction in this anatomic area.

Genio-glossus advancement with hyoid myotomy(GAHM)

The aim is to widen the hypopharynx by advancing the tongue base.

•Usually is combined with UPPP.

• Rarely performed alone .• Increases rate of efficacy of

other procedures .

Genioglossus Advancement

Usually is combined with UPPP

– Advances hyoid bone anteriorly and inferiorly.

– Advances epiglottis and base of tongue.

– Performed in conjunction with other procedures.

– Dysphagia may result.

Hyoid Myotomy and Suspension

Linguoplasty

1- Failed UPPP.2- Hypopharyngeal collapse.3- Major retro-glossal narrowing.4- By surgery or laser.

• Tongue Base Procedures– Lingual Tonsillectomy

• may be useful in patients with hypertrophy, but usually in conjunction with other procedures

– Lingualplasty• Chabolle, et al success rate of 77%

(RDI<20, 50% reduction) in 22 patients in conjunction with UPPP

• Complication rate of 25% - bleeding, altered taste, odynophagia, edema

• Can be combined with epiglottectomy

Lingual Suspension:

Tongue Base Procedures

Mandibular advancementSurgical Treatment of OSAS

Mandibular advancement

Maxillo-mandibular advancement

RESERVED FOR PATIENTS WITH SEVERE OSAS

Maxillo-mandibular advancementSurgical Treatment of OSAS

What are the surgical treatments of snoring and OSA

Tongue baseq Radiofrequency tongue base reduction, lag screw and suture

suspension of the tongue and hyoid, advancement genioplasty combined with a hyoid suspension, distraction osteogenesis, partial midline glossectomy, and maxillomandibular advancement are used to reduce obstruction at the tongue base.

q Radiofrequency tongue base reduction can obtain a 17% reduction in tongue base volume and has been shown to decrease RDI from 40 to 8, but it can require four to eight staged procedures, with a month between each one.

q Patients should be in a monitored setting for the night after the procedure.

What are the surgical treatments of snoring and OSA?Tongue baseq Lag screw and suture suspension of the tongue and hyoid are

procedures that pull the tongue forward.q Lag screws with preloaded sutures are driven into the inner cortex of

the anterior mandible below the level of the teeth.q A floor of mouth incision is made for the tongue suture.q Submental incisions are made for the hyoid suspension. Sutures are

then passed around the hyoid and through the tongue base to pullthe tongue forward.

q The best data presented showed a 60% average decrease in RDI from 74 to about 30.

q Although this is a painful procedure, it is less morbid than some of the other options.

What are the surgical treatments of snoring and OSATongue baseq Partial midline glossectomy, using either a laser or

electrocautery, can be performed.q It requires a tracheotomy because significant bleeding

and swelling can occur. q It is highly effective, with average decreases in RDI

from 59 to 8. Because of the tracheotomy this procedure has not gained wide acceptance.

q Maxillo-mandibular advancement is highly effective in a select group of relatively young, healthy, thin patients with retrusive midfaces and retrognathicmandibles.

q Success in this select group of patients is essentially 100%.

q This is a much larger operation than the UPPP, but it does successfully alter the anatomic anomalies that cause OSA.

q Maxillo mandibular advancement is achieved using bilateral sagittal split osteotomies in the mandible and LeFort I osteotomies in the midface.

•The risks of UPPP include postoperative ;-•Bleeding (196-5%). •Infection (2%). •Transient nasal reflux (12%-15%).•Nasopharyngeal stenosis (<1%). •Altered speech (rare).

•The complications associated with the genioglossus advancement and hyoid suspension include:-•Infection (2%-5%). •Need for root canal therapy (4%). •Permanent anesthesia (6%). •Seroma (2%).•There are also small risks of mandibular frac-ture, aspiration, and death.

Surgical complications

Edelman RR et al, 1990.

Surgical ResultsThree to four months after upper airway

reconstruction, patients should undergo a postoperative polysomnogram to determine the response to surgical therapy.

The success of surgical intervention has

been defined in a number of ways.

•50% reduction in the AHI or a 50% reduction in the AI •Polysomnographic improvement.• Patients should experience relief from their snoring and improved sleep hygiene. •The elimination. •Excessive daytime somnolence. •Better-quality sleep. •Improved ability to concentrate. •Elimination of the necessity of naps. •Improved work performance. •If neurocognitive dysfunction exists—even with mild obstructive objective sleep parameters—additional treatment should be considered.

Defining Surgical SuccessSurgical Treatment of OSAS

Tracheostomy• Bypasses all areas of obstruction• Virtually 100% effectiveTwo indications

1- Temporary procedure during airway reconstruction.

2- Severe OSA when CPAP refused, ineffective, or not tolerated or if other conditions exacerbated by the apneas.

3- OSA associated with serious complications as cardiac arrhythmias or cor-pulmonale

• Line the tract with skin flaps• Lack of social acceptance

•Tracheostomy

Tracheostomy for treatment of OSAS

• Cures 100% of OSAS• Indications• Severe OSAS• Failure of medical and surgical treatment• Associated complications• Life-saving for serious cardiac arrhythmias• A Tracheostomy will allow many

patients to return to a near normal lifestyle

•Tracheostomy

q Tracheotomy remains the gold standard in the treatment of OSA.q It bypasses the upper airway entirely and is effective in almost all

patients, including those with severe disease. q In patients with very severe disease, those who are markedly

obese, or those who are debilitated, it is probably the initial procedure of choice.

q Effectiveness in this group of patients is in the high 90% range. q The other methods that have been described realistically have

little chance of benefit. q However, the patient must live with and care for the tracheotomy

on a daily basis, which is undesirable to most patients. q For children with craniofacial abnormalities, such as Pierre

Robin syndrome, a tracheotomy is a good intervention until the child grows enough to undergo mandibular advancement procedures.

TracheostomySurgical Treatment of OSAS

Conclusions• SAS is extremely common medical disorder

in the past 30 years.• 4 to 5% of the population complain of SAS.• 2 to 4% of the population complain of OSAS.• SAS plays a large part of the road traffic and

industrial accidents due to sleepiness.

Sleep Apnea SyndromesSleep Apnea Syndromes

Conclusions (Cont.)

• Proper diagnosis and treatment needs • Team work consists of :- Chest physicians, ENT

surgeons, Cardiologists, Neurologists and Anaesthetists.

• Sleep lab.• Searching for a simple, safe, cheap, objective and

reliable methods for diagnosis and treatment of OSAS.

What does the future hold for OSA?

q Improvement in weight control may be available in the near future with advances in behavioral, pharmacologic, nutritional, and possibly genetic treatments.

q Continued improvement of CPAP and BiPAP machines .q Surgical advances, such as radiofrequency reduction of

parapharyngeal fat pads, are being investigated.q Phrenic nerve to hypoglossal nerve has been studied in

animal models.q When a breath is taken, the phrenic nerve would stimulate

the hypoglossal nerve to move the tongue forward.

Thank YouThank YouThank YouLaugh and the world laughs

with you,Snore, snore, snore and you

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