Is Snoring Bad For You?Is Snoring Bad For You?

Dr. Shanthi ParamothayanDr. Shanthi Paramothayan

BSc MBBS PhD LLM MScMedEd FHEA FCCP FRCPBSc MBBS PhD LLM MScMedEd FHEA FCCP FRCP Consultant Respiratory PhysicianConsultant Respiratory Physician

Honorary Senior LecturerHonorary Senior Lecturer

St. Helier University HospitalSt. Helier University Hospital

88thth September 2012 September 2012

HistoryHistory

Mr. ANMr. AN

35 years35 years Non smokerNon smoker Cab driverCab driver Minimal Minimal

alcoholalcohol

DivorcedDivorced Poor sleepPoor sleep DepressedDepressed FatigueFatigue Snores loudlySnores loudly Un-refreshedUn-refreshed Daytime somnolenceDaytime somnolence

HistoryHistory

New girlfriend reports:New girlfriend reports:

Loud snoringLoud snoring ApnoeasApnoeas Snorts and gruntsSnorts and grunts

ExaminationExamination

Obese :Obese : Wt = 182 kg, Ht = 190 cm, BMI = 50 Wt = 182 kg, Ht = 190 cm, BMI = 50 Collar size = 23 inchesCollar size = 23 inches

BP = 150/95BP = 150/95 Narrow oropharynxNarrow oropharynx Chest clearChest clear Epworth Sleepiness Score: 16Epworth Sleepiness Score: 16

Epworth Sleepiness ScoreEpworth Sleepiness Score

How likely are you to doze off or fall asleep during the following How likely are you to doze off or fall asleep during the following situations, in contrast to just feeling tired?situations, in contrast to just feeling tired?

Score of 0 to 3 where 0= would never dose; 1= slight chance; Score of 0 to 3 where 0= would never dose; 1= slight chance; 2= moderate chance; 3 = high chance.2= moderate chance; 3 = high chance.

SituationSituation ScoreScore

1.1. Sitting and ReadingSitting and Reading

2.2. Watching TVWatching TV

3.3. Sitting inactive in a public placeSitting inactive in a public place

4.4. As a passenger in a car for an hour As a passenger in a car for an hour

Without a breakWithout a break

5.5. Lying down to rest in the afternoonLying down to rest in the afternoon

6.6. Sitting and talking to someoneSitting and talking to someone

7.7. Sitting quietly after lunch (no alcohol)Sitting quietly after lunch (no alcohol)

8.8. In a car while stopped in trafficIn a car while stopped in traffic

Epworth Sleepiness ScoreEpworth Sleepiness Score

Score of < 6: NormalScore of < 6: Normal Score of > 8: Possible sleep disordered Score of > 8: Possible sleep disordered

breathingbreathing Score of > 12: Probability of OSAScore of > 12: Probability of OSA Score of > 16: High probability of OSAScore of > 16: High probability of OSA Score of > 20: Consider narcolepsyScore of > 20: Consider narcolepsy

Maximum score = 24Maximum score = 24

So what is the diagnosis?So what is the diagnosis?

Differential diagnosis of snoring:Differential diagnosis of snoring:

1.1. Simple snoring – consider ENT causes (e.g Simple snoring – consider ENT causes (e.g deviated septum). May be positional and deviated septum). May be positional and exacerbated by alcohol, sedativesexacerbated by alcohol, sedatives

2.2. Upper airways resistance syndrome (UARS)Upper airways resistance syndrome (UARS)

3.3. Obstructive sleep apnoea (OSA)Obstructive sleep apnoea (OSA)

HypersomnolenceHypersomnolence

1.1. UARSUARS

2.2. OSAOSA

3.3. NarcolepsyNarcolepsy

4.4. Obesity-hypoventilation (Pickwickian) Obesity-hypoventilation (Pickwickian) syndromesyndrome

5.5. Insomnia/other sleep related disordersInsomnia/other sleep related disorders

6.6. Restless Leg Syndrome (periodic limb Restless Leg Syndrome (periodic limb movement)movement)

7.7. REM behaviour disorderREM behaviour disorder

8.8. Chronic insufficient sleepChronic insufficient sleep

Obstructive Sleep ApnoeaObstructive Sleep Apnoea

Apnoea Apnoea means “without breath” in Greekmeans “without breath” in Greek

People with OSA stop breathing repeatedly during their sleep, People with OSA stop breathing repeatedly during their sleep, often for a minute or longer, even up to 100 x every nightoften for a minute or longer, even up to 100 x every night

Apnoea:Apnoea: complete obstruction of airways for > 10 secs complete obstruction of airways for > 10 secs Hypopnoea:Hypopnoea: Partial obstruction of airways (30 –50 %) for > 10 Partial obstruction of airways (30 –50 %) for > 10

secssecs AHI:AHI: apnoea/hypopnoea index (no / hour, same as RDI) apnoea/hypopnoea index (no / hour, same as RDI)

Mild OSA:Mild OSA: AHI of > 10 / hr AHI of > 10 / hr Moderate OSA:Moderate OSA: AHI of > 20 / hr AHI of > 20 / hr Severe OSA:Severe OSA: AHI of > 30 / hr AHI of > 30 / hr

Obstructive sleep apnoea and upper airways Obstructive sleep apnoea and upper airways resistance syndromeresistance syndrome

UARS:UARS: Snoring with brief, repetitive arousals due to increases in Snoring with brief, repetitive arousals due to increases in

resistance to airflow and increased respiratory effortresistance to airflow and increased respiratory effort Negative intrathoracic pressure Negative intrathoracic pressure autonomic and CV autonomic and CV

changeschanges hypertension. No oxygen desaturations hypertension. No oxygen desaturations Sleep fragmentation results in daytime somnolenceSleep fragmentation results in daytime somnolence

OSA:OSA: Snoring with apnoeas and hypopnoeas and Snoring with apnoeas and hypopnoeas and oxygen oxygen

desaturationsdesaturations ( ( 4% from baseline) 4% from baseline)

The AHI is a continuous variable like BP, so separating normal The AHI is a continuous variable like BP, so separating normal from abnormal is difficult.from abnormal is difficult.

Epidemiology of OSAEpidemiology of OSA

Common: 5 % of women and 10 % of men aged Common: 5 % of women and 10 % of men aged over 35 (USA: Wisconsin cohort study, 9-over 35 (USA: Wisconsin cohort study, 9-2424% in M % in M and 4 –and 4 – 9 9% in F)% in F)

M:F = 2-3 : 1 (M:F = 2-3 : 1 ( in F after menopause) in F after menopause)

Prevalence increases with agePrevalence increases with age

Race: Prevalence > in African-AmericansRace: Prevalence > in African-Americans

Mortality and Morbidity: retrospective data Mortality and Morbidity: retrospective data suggest the greater mortality in patients with AHI suggest the greater mortality in patients with AHI > 20 / hour> 20 / hour

Risk Factors for OSARisk Factors for OSA

Obesity:Obesity: BMI > 25, collar size > 17 inches BMI > 25, collar size > 17 inches Age:Age: loss of muscle mass in airways and neck and loss of muscle mass in airways and neck and

excess fatexcess fat Nasal problems that impede airflowNasal problems that impede airflow Enlarged tonsils and adenoids (children)Enlarged tonsils and adenoids (children) HypothyroidismHypothyroidism AcromegalyAcromegaly Other structural abnormalities: retrognathia, Other structural abnormalities: retrognathia,

micrognathiamicrognathia Amyloidosis, neuromuscular disorders, Marfan’s, Amyloidosis, neuromuscular disorders, Marfan’s,

Down’sDown’s Can be exacerbated by: Can be exacerbated by: supine position, alcohol supine position, alcohol

and sedativesand sedatives

Low threshold for referral in

Overweight patients Snoring or disturbed sleep Unexplained tiredness Unexplained sleepiness Lack of concentration, memory, libido Resistant hypertension (requiring many

antihypertensives Metabolic syndrome: Diabetes, HT,

hypercholesterolaemia Cardiovascular disease (heart failure,

arrhythmias,

So what happens in OSA?So what happens in OSA? Site of obstruction is soft palate, extending to the Site of obstruction is soft palate, extending to the

region at the base of the tongue (no rigid structures region at the base of the tongue (no rigid structures to hold airway open)to hold airway open)

When awake, muscles in the region keep passages When awake, muscles in the region keep passages openopen

When asleep, muscles relax, and there is reduced When asleep, muscles relax, and there is reduced neuromuscular activity, causing airway collapse and neuromuscular activity, causing airway collapse and obstruction of airwayobstruction of airway

This results in an oxygen desaturationThis results in an oxygen desaturation

When breathing stops, the sleeper awakens (arousal) When breathing stops, the sleeper awakens (arousal) for a few seconds and there is a rise in BPfor a few seconds and there is a rise in BP

Repeated arousals cause sleep fragmentation (no Repeated arousals cause sleep fragmentation (no REM sleep) and un-refreshed sleepREM sleep) and un-refreshed sleep

NormalNormal

Sleep apnoea-hypopnoea syndromeSleep apnoea-hypopnoea syndrome

Upper airway resistance increases during sleep in normal subjects

Typical presentation of OSATypical presentation of OSA

Symptoms are insidious and often present for Symptoms are insidious and often present for yearsyears

Snoring, loud and habitual and bothersome to Snoring, loud and habitual and bothersome to othersothers

Witnessed apnoeas that end with a loud snortWitnessed apnoeas that end with a loud snort Gasping and choking sensations Gasping and choking sensations Restless sleep, frequent arousals, nocturiaRestless sleep, frequent arousals, nocturia Feeling un-refreshed, morning headachesFeeling un-refreshed, morning headaches Excessive sleepiness during dayExcessive sleepiness during day Poor: concentration, memory, libidoPoor: concentration, memory, libido Problems with family and workProblems with family and work Road traffic accidents (RTA)Road traffic accidents (RTA)

Approach to a patient with possible OSAApproach to a patient with possible OSA

Get clear history and talk to witnesses (partner)Get clear history and talk to witnesses (partner) Driving history and occupation (truck drivers, train Driving history and occupation (truck drivers, train

drivers)drivers) Assess daytime sleepiness (ESS) and other Assess daytime sleepiness (ESS) and other

symptomssymptoms Weight, height and calculate BMIWeight, height and calculate BMI Collar sizeCollar size Oropharynx (tonsils)Oropharynx (tonsils) Nasal airflowNasal airflow Blood pressureBlood pressure Cardiovascular and respiratory examinationCardiovascular and respiratory examination

Investigating patients with possible OSAInvestigating patients with possible OSA

Bloods: FBC, U+E’s , glucose, thyroid Bloods: FBC, U+E’s , glucose, thyroid functionfunction

Epworth sleepiness scoreEpworth sleepiness score

(Multiple sleep latency test)(Multiple sleep latency test)

If necessary: ECG, CXRIf necessary: ECG, CXR

ENT referralENT referral

Investigating patients with possible OSAInvestigating patients with possible OSA

Overnight Overnight pulse oximetrypulse oximetry

Overnight Overnight limited sleep studylimited sleep study: oximetry, : oximetry, thoracic and abdominal wall movement, thoracic and abdominal wall movement, oronasal airflow, snore volume, BPoronasal airflow, snore volume, BP

Full Full polysomnography:polysomnography: as above plus as above plus

Leg movements (anterior tibialis EMG) and Leg movements (anterior tibialis EMG) and video, video,

Sleep stages (EEG, EMG, EOG)Sleep stages (EEG, EMG, EOG)

ECG and blood pressureECG and blood pressure

Consequences of OSAConsequences of OSA

Untreated OSA is related to a Untreated OSA is related to a significant mortality risk, 3Xsignificant mortality risk, 3X (Sleep, (Sleep, American Heart Association, American College of cardiology,American Heart Association, American College of cardiology,

OSA is a risk factor for developing OSA is a risk factor for developing nocturnal hypertensionnocturnal hypertension (independent of other factors ((independent of other factors (Davies, Thorax 1998Davies, Thorax 1998))

Recent evidence that OSA causes hypertension and treatment with Recent evidence that OSA causes hypertension and treatment with CPAP improves BP (CPAP improves BP (Becker et al, Circulation 2003, 107:68-73, Nieto Becker et al, Circulation 2003, 107:68-73, Nieto et al, JAMA 2000, 283:1829-1836, Peppard P, N Engl J Med 2000, et al, JAMA 2000, 283:1829-1836, Peppard P, N Engl J Med 2000, 342: 1378-1384342: 1378-1384))

OSA increases risk of stroke, heart block and MI OSA increases risk of stroke, heart block and MI

Risk of OSA is increased in patients with pulmonary hypertensionRisk of OSA is increased in patients with pulmonary hypertension

Link between OSA and heart failure (also with central sleep Link between OSA and heart failure (also with central sleep apnoea)apnoea)

Increased risk of RTAIncreased risk of RTA

Evidence of link between OSA and CV disease

Animal models Epidemiology Association long suspected ? Confounding

factors?

Wisconsin Sleep Cohort study– 18 year follow up of 1522 (30-60 yrs) with mild,

moderate, or severe OSA or no OSA– Mortality was 19% with severe OSA v 4% with no OSA

Sleep study (Australia)– 14 year study of 380 – Moderate-to-severe sleep OSA was an independent risk

factor for dying (33% in severe OSA v 7.7% in no OSA)

Mechanism of increased cardiovascular morbidity in Mechanism of increased cardiovascular morbidity in OSAOSA

OSA associated with increased CV morbidityOSA associated with increased CV morbidity

Intermittent hypoxia increases formation of reactive Intermittent hypoxia increases formation of reactive oxygen species and oxidative stressoxygen species and oxidative stress

Reactive oxygen species cause rupture of unstable Reactive oxygen species cause rupture of unstable atherosclerotic plaquesatherosclerotic plaques

Inflammatory pathways activatedInflammatory pathways activated

Inflammatory cytokines and adhesion molecules: Inflammatory cytokines and adhesion molecules: cell/leukocyte/platelet interactioncell/leukocyte/platelet interaction

Endothelial dysfunctionEndothelial dysfunction

Syndrome ZSyndrome Z

HypertensionHypertension Central ObesityCentral Obesity Syndrome XSyndrome X Insulin resistanceInsulin resistance HyperlipidaemiaHyperlipidaemia

OSAOSA Syndrome ZSyndrome Z

So suspect OSA in patients with above risk So suspect OSA in patients with above risk factorsfactors

Management of patients with OSAManagement of patients with OSA

Depends on severity of OSA and symptomsDepends on severity of OSA and symptoms

General:General:

Weight reductionWeight reduction (dietician, medication) (dietician, medication) Advice on sleep position (tennis ball !)Advice on sleep position (tennis ball !) Avoidance of alcohol and sedativesAvoidance of alcohol and sedatives Treat nasal congestionTreat nasal congestion Try devices to stop snoring (e.g snorban)Try devices to stop snoring (e.g snorban) Information, telephone numbers and websitesInformation, telephone numbers and websites

Information about DrivingInformation about Driving : : Patient must inform Patient must inform DVLA if they are being investigated for OSA DVLA if they are being investigated for OSA

Management of patients with OSAManagement of patients with OSA

Oral appliancesOral appliances

CPAPCPAP

Medication: Modafinil (Provigil)=stimulant. For Medication: Modafinil (Provigil)=stimulant. For patients still symptomatic despite CPAPpatients still symptomatic despite CPAP

Surgery: uvulopalatopharyngoplasty (UPPP), Surgery: uvulopalatopharyngoplasty (UPPP), craniofacial reconstruction, tracheostomycraniofacial reconstruction, tracheostomy

Oral AppliancesOral Appliances

Oral appliances move tongue or mandible Oral appliances move tongue or mandible forwardforward

Suitable as 1Suitable as 1stst line therapy for mild OSA if line therapy for mild OSA if patient doesn’t tolerate CPAP patient doesn’t tolerate CPAP

Not as effective as CPAP (Engleman, 2002)Not as effective as CPAP (Engleman, 2002) Mandibular advance devicesMandibular advance devices move lower jaw move lower jaw

forwardforward Tongue-retaining devicesTongue-retaining devices pull tongue forward pull tongue forward Should be fitted by specialist Should be fitted by specialist

dentist/maxillofacial surgeondentist/maxillofacial surgeon Side effects: TMJ pain, excessive salivationSide effects: TMJ pain, excessive salivation

CPAP (Continuous Positive Airways Pressure)CPAP (Continuous Positive Airways Pressure)

Treatment of choice in moderate and severe OSATreatment of choice in moderate and severe OSA CPAP improves snoring, sleep quality, daytime CPAP improves snoring, sleep quality, daytime

sleepiness, mood, cognitive function, QOL (Becker, sleepiness, mood, cognitive function, QOL (Becker, 2003)2003)

CPAP decreases BP and has other cardiovascular CPAP decreases BP and has other cardiovascular benefits in patients with OSA (RCT evidence)benefits in patients with OSA (RCT evidence)

Compliance is a major problem: 50 – 70 % use it Compliance is a major problem: 50 – 70 % use it regularly and significantlyregularly and significantly

Common side effects: rhinorrhoea, dry mouth, dry Common side effects: rhinorrhoea, dry mouth, dry eyes, nose bleeds, claustrophobia, aerophagiaeyes, nose bleeds, claustrophobia, aerophagia

Need regular assessment, advice, help with mask Need regular assessment, advice, help with mask fitting, humidifier etc – so need competent technical fitting, humidifier etc – so need competent technical staffstaff

Patients with OSA can drive once established Patients with OSA can drive once established effectively on CPAPeffectively on CPAP

So what happened to my cab driver?So what happened to my cab driver?

Overnight limited sleep study showed Overnight limited sleep study showed significant OSAsignificant OSA

Patient given information about weight Patient given information about weight reduction, referred to dietician reduction, referred to dietician

Patient referred urgently for CPAPPatient referred urgently for CPAP

Patient advised Patient advised NOTNOT to drive and to inform to drive and to inform

DVLA until established on CPAPDVLA until established on CPAP

Now what about you?Now what about you?

Do you snore?Do you snore?

What is you ESS?What is you ESS?

If you snore and your ESS is > If you snore and your ESS is > 12…………12…………

Central Sleep ApnoeaCentral Sleep Apnoea

Absent/reduced ventilatory driveAbsent/reduced ventilatory drive

CongenitalCongenitalOndine’s curseOndine’s curse

AcquiredAcquiredDestructive brain lesionsDestructive brain lesionsNeuromuscular diseaseNeuromuscular diseaseSevere obesitySevere obesityChest wall abnormalitiesChest wall abnormalities

ConclusionsConclusions

OSA is common. Need increased awareness (especially GP’s) and OSA is common. Need increased awareness (especially GP’s) and referral for sleep studyreferral for sleep study

Pulse oximetry suitable for majority with OSA but will miss UARS Pulse oximetry suitable for majority with OSA but will miss UARS and mild OSA, or patients with hypoxia for other reasonsand mild OSA, or patients with hypoxia for other reasons

Limited sleep study can be done at home and will be sufficient for Limited sleep study can be done at home and will be sufficient for the majority with OSA but may miss other problemsthe majority with OSA but may miss other problems

Increasing evidence that OSA is a significant risk factor for Increasing evidence that OSA is a significant risk factor for systemic hypertension, cardiovascular disease, pulmonary systemic hypertension, cardiovascular disease, pulmonary hypertension and all cause mortalityhypertension and all cause mortality

Evidence that treatment of OSA reduces risk Evidence that treatment of OSA reduces risk

OSA responsible for a significant number of road traffic accidentsOSA responsible for a significant number of road traffic accidents

CPAP is the treatment of choice for OSACPAP is the treatment of choice for OSA