10. obstructive sleep apnea syndrome
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Transcript of 10. obstructive sleep apnea syndrome
Obstructive Sleep
Apnea
Syndrome (OSAS)
Dr. Krishna Koirala
MBBS, MS (E.N.T. )22/08/2016
• Sleep is a reversible behavioral state of
perceptual disengagement and unresponsiveness
to surrounding
• Normal sleep is essential for normal health
– 2 Stages
•NREM ( 80 % ) - Relaxed Mind, Active body
•REM ( 20 % ) - Alert Mind, Relaxed body
• International Classification Sleep Disorders
– Dyssomnia : excessive sleepiness or difficulty
in initiating or maintaining sleep, affects
quality /duration of sleep. eg. OSAS
– Parasomnia : unacceptable behavior during
sleep
Common Definitions
• Arousal : An abrupt change from a 'deep' stage
of NREM sleep to a 'lighter' stage, or from REM
to awake
• Apnea : Cessation of breathing >10 sec &
arousal
– Obstructive : Chest wall moves
– Central : Chest wall doesn’t move
– Mixed : Chest wall partly moves
• Hypopnea : Decreased airflow (<50% from
baseline ) with > 4% Hb O 2 desaturation &
arousal
• Respiratory Disturbance : Apnea & Hypopnea
• The Apnea–Hypopnea Index (AHI)
– Index used to indicate the severity
of sleep apnea
– Represented by the number
of apnea and hypopnea events per hour
of sleep
• OSAS is defined as AHI > 5
• Grades:
– Mild : 5-14
– Moderate : 15-29
– Severe : >30
Pathophysiology• Incompletely Understood !
• Hypothesis
– During REM sleep : Collapse occurs in
upper airway ‘pharynx’ (due to defect in
pharyngeal dilator muscles activity and
anatomical abnormalities) Hypoxia
arousal Upper airway collapse
improves and patient sleeps
– During sleep, airway again collapses
leading to hypoxia and arousal
• Multiple arousals result in poor quality of
sleep and day - time sleepiness
• Chronic repeated hypoxia causes
hemodynamic complications like
– Pulmonary HTN
– Systemic HTN
– CAD, CVA, CHF
Pharyngeal Dilators
•Medial Pterygoid
• Tensor Veli Palatini
•Genioglossus
•Geniohyoid
•Stylohyoid
Upper Airway Obstruction
Symptoms• Day- time
– Sleepiness
– Morning Fatigue
– Morning headache
– Cognitive
Impairment
– Heartburn
– Depression
– Impotence,
Xerostomia
• Night- time
– Snoring
– Observed
Gasping/ Apnea/
Choking
– Repeated waking
– Nocturnal
sweating
– Nocturnal
enuresis
Typical Syndromic Patient• Old Age
• Male
• Obese - BMI > 30
• Thick / Short Neck >17″
• Hypertension
• Thyromegaly
• Large Bulky tongue
• Tonsils• Nasal Obstruction• Pitting Edema• Disproportionate
Anatomy
Approach to management
• Detailed History
– Involve Bed-partner
– Ask sleep history
•Bed time
•Alcohol /
Sedative use
•Body position
•Snoring
•Arousals
•Apneas
• Assess Day time
sleepiness
– Epworth Sleepiness
Scale
– Stanford Sleepiness
Scale
• Examination:
– B.M.I
– B.P
– E.N.T. Examination
•Anterior Rhinoscopy : DNS, Turbinate
hypertrophy, Polyp , Mass
•Oro-pharynx : Tongue, Tonsils, Uvula,
Pharyngeal walls
•Neck : Circumference (> 17” ),Thyroid
•Flexible Endoscopy : Mueller’s Maneuver,
Assess Airway collapse
– CVS Examination : Complications
Normal Airway Bulky Base of Tongue
Before Mueller’s Maneuver
After Mueller’s Maneuver
Flexible Endoscopy
Investigations
• Polysomnography
– Gold Standard Investigation
– Done in a “SLEEP LAB”
– Measures:
•EEG/EOG/ EMG
•ECG / B.P
•Position of Patient / Movements of Chest
and abdomen
•Airflow /O 2 Saturation
•Esophageal Pressure
• Portable Monitoring
• Cephalometry
– Anatomical Risks for OSA
•X-Ray /CT Scan /MRI /Fluoroscopy
/Acoustic Reflex
• Multiple Sleep Latency Test
– Document daytime sleepiness
– Subject asked to sleep 4-5 times in day every
2 hours.
• TSH
• ECHO
Investigations contd…
Differentials
• Primary Snoring
•Mild upper airway obstruction
•RDI < 5
•No Daytime sleepiness
• Upper Airway Resistance Syndrome
•Moderate upper airway obstruction
•RDI < 5
•Arousal Index > 15•Excessive Negative Intra-thoracic pressure•Daytime sleepiness occurs
Medical Management• Weight Reduction
• Sleep Hygiene
– Elevate head – end of bed
– Avoid alcohol, sedatives
– Avoid lying supine (T-shirt with tennis ball at
back )
• Positive Airway Pressure (PAP) Device
– CPAP (Continuous) / Bi–PAP(Biphasic)
/APAP(Automated)
• Positioning Devices
– Mandibular Advancement Device
– Tongue Retaining Device
•Nasal CPAP is first line treatment
with ~100 % Efficacy (Gold
standard medical R x )
•Compliance is very low ~ 50%
•Pressure must be individually
titrated
•A/E : Noise, Mask discomfort,
Claustrophobia
Surgical Treatment
1. Nasal Surgery
2. Palatal Surgery
3. Tongue Base Surgery
4. Maxillo -facial Surgery
5. Tracheostomy
Nasal Surgeries
• Rarely suffice alone
• Relieve snoring > apnea
1. Office Radio-frequency Turbinate
Ablation
2. Septo-turbinoplasty
3. Polypectomy
4. Nasal Valve Reconstruction
5. Adenoidectomy
6. Nasal mass Excision
Palatal Surgeries
1. UPPP (Uvulo Palato Pharyngo
Plasty) : Most commonly
performed procedure
2. LAUP (Laser assisted Uvulo
Palatoplasty)
3. RFUP (Radio frequency Uvulo
Palatoplasty)
4. Uvulopalatal Flap
5. Lateral Pharyngoplasty
6. Transpalatal Advancement
Pharyngoplasty
UPPP
Complications : Hemorrhage, Stenosis, Velopharyngeal Incompetence
LAUP
RF Palatal Ablation
Lateral Pharyngoplasty
Uvula Flap
Tongue Procedures
1. RFTA Tongue2. Lingual Tonsillectomy3. Linguloplasty4. Tongue Base Suspension5. Hyoid Myotomy &
Advancement
RFTA
Linguloplasty
Tongue Suspension
Maxillofacial Procedures •Genio-glossal advancement & hyoid
myotomy
Maxillofacial Procedures
Maxillo-mandibular osteotomy & Advancement
Tracheostomy
Last Resort in Treatment Failure cases
Complications• Systemic Hypertension• CAD• CHF• Arrhythmias• Pulmonary Hypertension• CVA• Risk Accidents• Marital Discord• Professional Setbacks• Depression• Impotence• Sudden Death