Obstructive Sleep ApneaObstructive Sleep Apnea

Babak Saedi .M.D

Imam Khomeini Hospital

What is OSA?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 OSAEpidemiology 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?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 ImpactHealth 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 ImpactHealth 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 ImpactHealth 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 ImpactSocietal Impact

2006 American Academy of Sleep Medicine

Societal ImpactSocietal Impact Increased Traffic Accidents

simulated driving: SDB ~100x more likely to drive off the road Acta Otolaryn 1990; 110: 136ff

7x increased risk of auto accidents Clin Chest Med 1992; 13: 427-34

PATENT Vs COLLAPSED AIRWAYPATENT Vs COLLAPSED AIRWAY

2006 American Academy of Sleep medicine

How’s it Diagnosed?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?Who gets it?

Men who snore and who are overweight

adenotonsillar hypertrophy

nasal obstruction hypothyroidism acromegaly Down syndrome sedative use Alcohol Smoking

micrognathia retrognathia Obesity Neck circumference vocal cord paralysis H&N masses

Risk factors

HistoryHistory Associated Complaints

Weight changes Thyroid/Growth

Hormone abnormalities GERD

Habits sleep schedule EtOH

PMH/Meds Hypertension Sedatives;

Antihistamines

SITUATION CHANCE OF DOZING

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 breakLying down to rest in the afternoon when circumstances permitSitting and talking to someone

Sitting quietly after a lunch without alcoholIn a car, while stopped for a few minutes in traffic

Physical ExamPhysical Exam Height and Weight (BMI)

BMI=[703.1 x weight(pounds)] / [Height (in)2] neck size Face-retrognathia Nose Oral cavity- palate, uvula, tonsils/pillars,

tongue, occlusion

OBESITYOBESITY

Strongest risk factor for OSA

Present in > 60% of patients referred for

a diagnostic sleep evaluation

Wisconsin Sleep Cohort Study A one standard deviation difference in BMI was

associated with a 4-fold increase in disease prevalence

ObesityObesity

Alters upper airway mechanics during sleep1. Increased parapharyngeal fat deposition:

neck circumference: > 17” males

> 16” females

With subsequent:

smaller upper airway

increase the collapsibility of the pharyngeal airway

obesityobesity

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 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 ExaminationPhysical Examination

Evaluation 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 NasopharyngolaryngoscopyFiberoptic 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?How To Treat?

Minimal intervention Drop the Weight!

Continuous Positive Airway Pressure (CPAP)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 EffectsCPAP 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 DesignAppliance 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 TherapyOral 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 OptionsSurgical 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

SurgerySurgery

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?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 Tissue- Uvulopalatopharyngoplasty(UPPP)

Remove Tissue- Uvulopalatopharyngoplasty(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 SurgeriesRemove 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 Space-Other SurgeriesEnlarge the Bony Space-Other 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 AdvancementMaxillomandibular Advancement

Palatal ExpansionPalatal 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?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?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 TreatmentRisks 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

2006 American Academy of Sleep Medicine

Sleep ApneaSleep Apnea

Otherwise snore and this will happen to you….

Otherwise snore and this will happen to you….

Or sleep alone….

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