The Sleep Specialist’s Role in Airway Evaluation
Transcript of The Sleep Specialist’s Role in Airway Evaluation
The Sleep Specialist’s
Role in Airway Evaluation
Karel Calero, MD Assistant Professor
Pulmonary Critical Care and Sleep Medicine University of South Florida Morsani College of Medicine
Objectives
Physical exam findings complicating
obstructive sleep apnea
Airway changes in specific conditions
Imaging modalities to assess sites of
obstruction in the upper airway
Drug Induced Sleep Endoscopy
Airway Obstruction
General Examination
Respiration. 2012;83(6):559-66. doi: 10.1159/000335839. Epub 2012 Mar 1.
Down’s Syndrome
Narrowed midface/throat
Adenoid & tonsillar
hypertrophy
Macroglossia
Decreased muscle tone
Central apnea
Obesity
Nasal Examination
Nasal Obstruction
Kryger, M.H. Atlas of Clinical Sleep Medicine. ISBN 978-1-4160-4711-7. Pub. 2010.
Nasal Valve Collapse
Nasal Strips
Oropharynx Examination
Airway Classification
Mallampati Friedman
Tonsillar Hypertrophy
UPPP Outcomes
Kryger, M.H. Atlas of Clinical Sleep Medicine. ISBN 978-1-4160-4711-7. Pub. 2010.
Mandibular & Dental Assessment
Kryger, M.H. Atlas of Clinical Sleep Medicine. ISBN 978-1-4160-4711-7. Pub. 2010.
Dental Device Assessment
Kryger, M.H. Atlas of Clinical Sleep Medicine. ISBN 978-1-4160-4711-7. Pub. 2010.
Other Factors Affecting OSA Severity
Sleep position preferences
Neck size
Katz SL, et al. Does neck-to-waist ratio predict obstructive sleep apnea in children?
J Clin Sleep Med. 2014 Dec 15;10(12):1303-8. doi: 10.5664/jcsm.4284.
Condition Specific Airway Changes
Obesity
QJM. 2014 Dec;107(12):949-54. doi: 10.1093/qjmed/hcu029. Epub 2014 Feb 6.
Retropalatal Fat Deposits
Fat
deposit
Weight loss decreases size of fat deposits and increases airway size
Retropalatal
airspace
Horner RL. Respiratory control of the upper airway. In: SRS Basics of Sleep Guide.
Opp MR, et al. Westchester, IL: Sleep Research Society. pp. 91-97, 2005
Head & Neck Cancer
3.5 cm x 3.8 cm x 4 cm mass arising from the tongue base
Barnes, et al. Sleep Med. 2004 Nov;5(6):605-7
Pregnancy
Reduced FRC
Increased Mallampati IV score by 34%
Larger neck circumference
Decreased nasal patency
Lin, et al. Gender differences in obstructive sleep apnea and treatment implications.
Sleep Med Review 2008 Dec;12(6):481-96. doi: 10.1016/j.smrv.2007.11.003. Epub 2008 Oct 31.
Aging
Variation in bony pharynx
Increased soft palate length
Increased pharyngeal fat pads
Decreased genioglossus response
Lin, et al. Gender differences in obstructive sleep apnea and treatment implications.
Sleep Med Review 2008 Dec;12(6):481-96. doi: 10.1016/j.smrv.2007.11.003. Epub 2008 Oct 31.
Gender Specifics
Men
Inferior hyoid
Anterior lower facial
height
Women
Anterior hyoid
Posterior facial height
Rama, et al. Sites of Obstruction in OSA. CHEST 122 (4): 1139-47 Oct 2002
Where is the Obstruction?
Techniques to Assess Sites of
Upper Airway Obstruction
Method Advantages Disadvantages
Endoscopy Direct visualization
+/- PSG
Stenting by scope
Anesthesia
Fluoroscopy Real time imaging
See outside pharyngeal
airway
+/- PSG
Radiation
Two-Dimensional
+/-Sedation
Catheters Full night data
+/- PSG
Stenting by catheter
Precise localization
CT scan Scan entire upper airway
+/-PSG
No anesthesia
Radiation
MRI Real time imaging
Non-invasive
No simultaneous PSG
Need sedation
Who Needs Further Assessment?
CPAP intolerant patients
Pressure out of proportion to airway
anatomy
Choosing modalities other than CPAP and
predicting response to treatment
– Mandibular Advancement Device
Functional Imaging Predicts MAD
Success
PSG
Low radiation dose CT
scan with/without MAD
Change in UA volume/
resistance
De Backer, et al. Functional imaging using computational fluid dynamics to predict treatment success of mandibular
advancement devices in sleep-disordered breathing. J. Biomech 2007;40(16):3708-14. Epub 2007 Jul 30.
Drug Induced Sleep Endoscopy
https://inspiresleep.wistia.com/medias/2m04a
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Drug Induced Sedation Endoscopy
Flexible nasal endoscopy under moderate sedation in the supine position
Total sedation time: 10-15 mins; Evaluation stage: 10 mins; Recovery quick
Performed for decades and safe, >7500 procedures without side effects or
emergency situations1
1.Hohenhorst et al Oper Tech Otolaryngol 2012; 2. Kezirian et al Eur Arch Otorhinolaryngol 2011
* Airway Level
Direction
Anterior-
Posterior
Lateral Concentric
Velopharynx (Soft Palate)
Oropharynx
Tongue Base
Epiglottis
Degree: None – (no to little obstruction, 0-25%)
Partial – (vibration, 25-75%)
Complete - (collapsed, >75%)
VOTE Method1,2 – Level, Degree, Direction
DISE
Concentric Collapse
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AP Collapse
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Incidence of Severe Airway Collapse
DISE vs Clinical Examination
Zerpa et al. Drug-induced sedation endoscopy versus clinical exploration for the diagnosis of severe
upper airway obstruction in OSAHS patients. Sleep Breath. 2015 Dec;19(4):1367-72. doi:
10.1007/s11325-015-1266-z. Epub 2015 Oct 8.
Propofol Induced Sleep Endoscopy
PSG with and without DISE
Rabelo, et al. Polysomnographic evaluation of propofol-induced sleep in patients with respiratory sleep
disorders and controls. Laryngoscope. 2013 Sep;123(9):2300-5. doi: 10.1002/lary.23664. Epub 2013 Jun 25.
N3 sleep observed. REM sleep was absent.
Surgical Planning
Identify areas of obstruction
Predict surgical failure:
– severe lateral oropharyngeal wall collapse
(73.3% vs. 36.8%, P = .037)
– severe supraglottic collapse (93.3% vs. 63.2%,
P = .046)
Soares et al. Lateral oropharyngeal wall and supraglottic airway collapse associated with failure in sleep apnea
surgery. Laryngoscope. 2012 Feb;122(2):473-9. doi: 10.1002/lary.22474. Epub 2012 Jan 17.
Eichler et al. Does drug-induced sleep endoscopy change the treatment concept of patients with snoring and
obstructive sleep apnea? Sleep Breath. 2013 Mar;17(1):63-8. doi: 10.1007/s11325-012-0647-9. Epub 2012 Jan 22.
Mandibular Advancement Device Evaluation
Prediction of treatment response – Not good for treatment failure prediction
Sites of treatment failure
Vroeqop et al. Sleep endoscopy with simulation bite for
prediction of oral appliance treatment outcome. J Sleep Res.
2013 Jun;22(3):348-55. doi: 10.1111/jsr.12008. Epub 2012
Dec 4.
Kent et al. Drug-Induced Sedation Endoscopy in the Evaluation of
OSA Patients with Incomplete Oral Appliance Therapy Response.
Otolaryngol Head Neck Surg. 2015 Aug;153(2):302-7.
doi: 10.1177/0194599815586978. Epub 2015 Jun 4.
Hypoglossal Nerve Stimulator
Stimulator Off
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Stimulator On
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https://inspiresleep.wistia.co
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Future Directions
Longitudinal evaluation of DISE in the
bronchoscopy room
Evaluation of multiple sedation modalities
during DISE
Conclusions
Airway structure and function changes
during sleep
Identification of the site of airway
obstruction may improve treatment
outcomes