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Evaluating a Case of Sleep Apnoea Dr J.M. Joshi Professor and Head Department of Pulmonary Medicine T.N. Medical College B.Y.L. Nair Hospital Mumbai

Evaluating a Case of Sleep Apnoea

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Evaluating a Case of Sleep Apnoea. Dr J.M. Joshi Professor and Head Department of Pulmonary Medicine T.N. Medical College B.Y.L. Nair Hospital Mumbai. SAS. Sleep apnoea syndromes (SAS) represent a group of conditions with abnormal respiration during sleep - PowerPoint PPT Presentation

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Page 1: Evaluating a Case of Sleep Apnoea

Evaluating a Case of Sleep Apnoea

Dr J.M. JoshiProfessor and HeadDepartment of Pulmonary MedicineT.N. Medical CollegeB.Y.L. Nair HospitalMumbai

Page 2: Evaluating a Case of Sleep Apnoea

SAS

• Sleep apnoea syndromes (SAS) represent a group of conditions with abnormal respiration during sleep

• 3 forms of sleep apnea: OSA, CompSAS and CSA constitute 84% 15% and 0.4%, of cases respectively

• Obstructive sleep apnea syndrome-OSAS (objective sleeping respiratory disturbance with daytime sleepiness)

• Nasal continuous positive airway pressure (CPAP) is the most effective treatment for patients with moderate to severe OSAS

Page 3: Evaluating a Case of Sleep Apnoea

Obstructive Apnoea• Obstructive Apnoea when complete

closure of the upper airway

• The respiratory efforts continue

airflow chest abdomen

Page 4: Evaluating a Case of Sleep Apnoea

Central Apnoea

• Central Apnoea complete cessation of effort to breathe

• Airway still open but no respiratory drive, hence no respiratory muscle activity

airflow chest abdomen

Page 5: Evaluating a Case of Sleep Apnoea

CLINICAL FEATURES

Snoring is the cardinal symptom, cyclical with periods of loud snoring exceeding 100 decibels or snoring alternating with quieter intervals of apnoeas

Page 6: Evaluating a Case of Sleep Apnoea

Diagnosis of OSA

A) EDS

B) 2 of the following • Snoring • Witnessed apnoeas• Unrefreshing sleep• Daytime fatigue• Poor concentrationAnd

c) Sleep Study showing AHI > 5

Ref: PSG Task Force, ASDA. Sleep 1997;20:406-22.

Page 7: Evaluating a Case of Sleep Apnoea

Polysomnography (PSG)Neurological• EEG • EOG• EMGCardio-Respiratory• Snoring • Thoraco-abdominal

movements • Airflow• Oximetry

Type 3

Type 4

Ref: Clinical guidelines for unattended PM in the diagnosis of OSA in adult patients. J Clin Sleep Med 2007; 3:737–747

Type 1,2

Page 8: Evaluating a Case of Sleep Apnoea

PSG Before and After CPAP

Page 9: Evaluating a Case of Sleep Apnoea

Severity Grading of OSAS

•Mild: 5–15 events/hour of sleep

•Moderate: 15–30 events/hour of sleep and

•Severe: more than 30 events/hour of sleep

Page 10: Evaluating a Case of Sleep Apnoea

Conventional Diagnostic Therapeutic Approach

• Full polysomnography (PSG) is currently the “gold standard’’ for the diagnosis of OSAS and titration of effective continuous positive airway pressure (CPAP)

• Technicians should titrate CPAP pressures overnight until most of the apnoeas and arousals are abolished, as monitored by PSG

Page 11: Evaluating a Case of Sleep Apnoea

Alternative Ambulatory Diagnostic Therapeutic

Approach• Urgent need to evaluate approaches to

management that did not unduly rely on sleep laboratory–based PSG studies led to

• Diagnostic-therapeutic approach using home

based limited PSG (cardio-respiratory variables only) or oximetry with ambulatory CPAP titration

Page 12: Evaluating a Case of Sleep Apnoea

Clinical Probability of OSAS• Ambulatory diagnostic-therapeutic approach

requires accurate identification of probable cases of OSAS

• Sleepy snorer by Epworth Sleepiness Score

• Sleep Apnea Clinical Score (SACS) based on snoring, witnessed episodes of apnea, neck circumference, and systemic hypertension

Page 13: Evaluating a Case of Sleep Apnoea

Epworth Sleepiness Score

Page 14: Evaluating a Case of Sleep Apnoea

Clinical Probability of OSAS• “Sleepy Snorer” by Epworth Sleepiness Score• Sleep Apnea Clinical Score (SACS)

Ref: Likelihood ratios for a sleep apnea clinical

prediction rule. AJRCCM 1994;150:1279-85.

Page 15: Evaluating a Case of Sleep Apnoea

Summary

• Magnitude of OSA and paucity of sleep labs needs simplified approaches for physicians

• Enough evidence now exists that simple ambulatory diagnostic–therapeutic strategies have equivalent clinical outcome in cases with high pretest probability

• Patients who have a low probability, have co-morbidities or have difficulties during ambulatory management should be referred to a sleep centre for detailed evaluation/in-laboratory attended full PSG and further management