Prof. A K JanmejaHead, department of Pulmonary Medicine

&Medical Superintendent,

Govt. Medical College & Hospital, Chandigarh

Obstructive Sleep Apnea Syndrome

Objectives• What is sleep?• Common sleep disorders• Magnitude of sleep disorder problem• Sleep apnea• Prevalence of OSA• Clinical features of OSA• Diagnosis • Treatment options • Prevention / control of disease

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What is Sleep ? • Sleep is NOT the absence of wakefulness • Active• Complex• Highly Regulated• Involves different areas in the brain • Purpose is not understood• Essential to life • We all do it

Sleep Academic Award 4

Sleep Positions

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Sleep States of Human Being (adults)

REM Sleep~20% of night

NREM Sleep~80% of night

Wake2/3 of life

Sleep Stages• Light Sleep. - Stage 1 [N1]

4-5% of total sleep time is considered normalIncreases to 15% by age 70

• Restful Sleep. - Stage 2 [N2]45 - 55% of total time

• Deep Sleep. - Delta or Slow Wave Sleep 3 & 4 [N3]- Range of total sleep: 10 - 20%- % decreases with age- about 40 - 50% in children - to total absence by age 40 - 50- Growth hormone reaches peak levels in Stage 4- usually appears only in the first 1/3 of the sleep episode

• REM. - Rapid Eye Movement sleep - 20 - 25% total time [R]- get body paralysis - atonia- mind very active- very vivid hallucinatory, imagery or dreaming- do problem solving- 5 - 55% of total time

Sleep Architecture

• Each NREM - REM couplet is equal to one cycle• Normally go through a sleep cycle every 90 minutes• Go through about 4 - 5 cycles in a good 7.5 hour sleep• REM cycles get longer & closer as sleep length gets

longer

Sleep Latency in Normal Adult

• Normally it takes 10 - 15 minutes to fall asleep • If you are asleep in < 5 min : excessive sleepiness• Normal REM latency ranges : 70 –120 min [90 min]

Basic Significance of Sleep

• Good sleep: critical for overall physical-mental health• Body compared to a battery;

-needs regular re-charge-or it will get run down / even die!

• The body needs 7 - 8 hrs of quality sleep every night• Overall health pays eventually for constant sleep

deprivation• Best to go to bed at regular time each night and get up

at a regular time every morning – 7 days a week

History of Sleep Medicine• Charles Dickens - The Pickwick Papers• William Osler - Pickwickian Syndrome 1918• Sleep apnea-1965• Guilleminault - OSAS - 1973• Sleep stage scoring by Rechtshaffen & Kales-1968• MSLT by American Narcolepsy Association-1978• Fujita - UPPP - 1981 • Colin Sullivan - CPAP – 1981• Before 1980-Tracheostomy was treatment for OSA• 1980s-Book -Principles & Practice of Sleep Medicine

What is sleep apnea?

• Momentary cessation of breathing / irregular breathing while asleep

• Apnea- complete interruption in respiratory air flow lasting ≥10 S

• Hypopnea- decreased respiratory air flow

Types of sleep apnea?

• OSA- respiratory interruption where no air flow despite respiratory effort due to obstruction in UA

• CSA-respiratory interruption without respiratory effort & without obstruction in upper airways

• Mixed- respiratory interruption that is a combination of obstructive and central sleep apnea

Obstructive Sleep Apnea Syndrome

• Repeated episodes of complete cessation or near complete cessation of airflow through upper airway

• Presence of oxyhemoglobin desaturation• Presence of hypercapnia

Apnoea: – complete or near complete cessation of, airflow lasting at least 10 sec.

Obstructive Sleep Apnea

• Upper airway tissue collapseduring sleep & block’s the airpassage with continuedchest and abdominal effort

• These apnoeic events ↓O2 amount in the blood which eventually leads to gasping for air

Pathophysiologic Cascade in Sleep Apnea

Clinical Features of OSAS

Consequences of 3 major phenomenon in OSA:• Mechanical obstruction/ increase airways

resistance• Arousal from sleep• Oxyhaemoglobin desaturation with hypercapnia

Symptoms of OSA; Mechanical Obstruction [A]

• Snoring• Stop breathing while sleeping - then snort• Witnessed Apnea• Choking/gagging/gasping• Dyspnoea• Restlessness• Diaphoresis• Reflux• Dry mouth upon awakening• Mouth breathing

Consequence of Arousal-Sleep [B]

Fragmentation

• Excessive Daytime Sleepiness• Fatigue• impaired memory• Poor concentration• Intellectual deterioration• Personality changes• Depression• Anxiety• Impotence• Visual - motor in coordination• Nocturia

Consequences of Nocturnal Hypoxia / Hypercapnia [C]

• Pulmonary HTN• Corpulmonale• Cardiac dysarrhythmias• Nocturnal angina• Systemic HTN• Chronic Hypercapnia• Morning and nocturnal headache• Polycythemia

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Loss of vigilance;Car Accidents in SAHS

ACCIDENTS single/5yr multiple/5yr

POPULATION

SNORERS RDI>15

ODDS 3.4 7.3Young T. SLEEP 1997;20(8):608-13

n=913

Diagnosis

• History• Establishing the risk

factors • Physical examination• ENT examination• Genetics and

Craniofacial Dysmorphism in Family Studies of OSA

• Laboratory and x-ray

• Polysomonographymeasures brain waves, heart rate, body movements and breathing in an overnight sleep study

• MSLT (Multiple Sleep Latency Test) measures daytime sleepiness

Differential Diagnosis

RISK FACTORS for OSA

• Obesity• Alcohol• Drugs• Smoking• Large neck

circumference• Polyps in upper

airway• Enlarged tonsils

• M > F• Hypertension• Hypothyroidism• Family History

Physical Examination

• Obesity • Nasal obstruction• Vocal cord paralysis• Adeno-tonsillar hypertrophy• Micro-gnathia• Retro-gnathia• Acromegaly• Hypothyroidism

Patient with OSA; Neck size & BMI

• A neck sizeover 16 inchesand [20”]

• Body massindex (BMI)over 25 putsan individualat risk forsleep apnea.

Oral Examination•Note very elongated soft palate

•Massive tonsils could obstruct airway

•Massive tongue; patient severe OSA

Seeking medical help at a sleep center

Polygraphic Monitoring

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Polysomnography

– EEG– EOG– Submental EMG– ECG– Nasal and oral airflow– Respiratory muscle

effort [thoracic]– Abdominal movement

– Oxygen saturation

– Anterior tibialisEMG

– Sleep position – Video recording

Obstructive Sleep Apnoea

Apnea Hypopnea Index (AHI);Severity

• Normal: less than 5 events per hour• Mild: 5 - 15 events per hour• Moderate: 16 - 30 events per hour• Moderately severe: 31 - 39 events per hour• Severe: over 40 events per hour

Treatment

• Lifestyle Modifications-weight loss-avoid sedatives/alcohol-lateral body position during sleep

• Continuous positive airway pressure [CPAP]• Surgery• Orthodontic devices

Continuous Positive Airway Pressure (CPAP)

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95% effective – usually first line treatment for severe disease

CPAP: Positive Airway Pressure Devices

• Most efficacious• CPAP (commonly

used)• Auto-PAP• BIPAP

CPAP

• Minimum of five nights a week, 3 - 4h/night for effective treatment

• 90% obtained benefit from treatment

CPAP Complaints; solutions

Complaint Management

•Claustrophobia Nasal Prongs•Air Pressure Ramping Mechanism•Air Leaks Chin Straps, mask refit•Loss of Intimacy Partner communication•Irritating to Airways Humidification, heat•Noisy Check for leaks•Obtrusive Mask Different mask, nasal prongs

Oral Appliances• For patients with no response to lifestyle

modification• Alternative: who cannot tolerate PAP devices

Dental orthotic or mandibular repositioning devices: surprisingly effective in many cases

Surgical Procedures

• Adeno-tonsillectomy - preferred treatment in children

• Turbinoplasty • Septoplasty• Pillar Procedure• Nasal Polypectomy• Uvulopalatopharyngoplasty (UPPP)• Tracheostomy

41Uvulopalatopharyngoplasty

Prevention & Progression of Disease

• Early detection & Treatment of SA;Weight reduction & control;Eliminate factors causing of nasal congestion

• Considering risk groups in primary care• Good initial treatment and motivating the patient• Preventing the aggravation of SA• Good treatment of concomitant illnesses

Conclusion

• Sleep disorders are common

• Sleep disorders are serious

• Sleep disorders are treatable

• Sleep disorders are underdiagnosedUntreated OSA : ↑morbidity & mortality through

- heart, circulatory diseases - accidents

THANK YOU