Obstructive Sleep ApneaBrent A. Senior, MDAssociate Professor Chief, Rhinology, Allergy, and Sinus SurgeryOtolaryngology/Head and Neck SurgeryUniversity of North Carolina

What is OSA?Disorder of obstructed breathing occurring during sleepApnea: cessation of breathing with respiratory effort lasting greater than 10sHypopnea: decreased airflow of >70% Any decreased airflow with desaturation

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

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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

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EvaluationKey Features of the History and ExamHistory (105 patients)apnea reported by bed partner (p

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

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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- Uvulopalatopharyngoplasty(UPPP)First successful alternative to tracheotomy12 individualspreop AI 54 +/- 28postop AI 28 +/- 288/12 with post-op AI

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

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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

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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