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Obstructive Sleep Apnea Syndrome

Pickwickian Syndrome

Obstructive sleep apnea was

called the Pickwickian

syndrome in the past

because Joe the Fat Boy

who was described by

Charles Dickens in the

Pickwick papers had typical

features with snoring,

obesity, sleepiness.

DEFINITION

• Obstructive Sleep Apnea Syndrome (OSAS) is one of the most important conditions identified in the last 50 years.

• OSAS is characterized by recurrent episodes of complete or partial upper airway obstruction during sleep, usually associated with a reduction in blood oxygen saturation and daytime sleepiness (due to sleep fragmentation).

CONSEQUENCES

OF SLEEP APNEA

This recurrent breathing difficulty is associated with

increased respiratory efforts which prevent the brain

from entering the deep stages of sleep and causes:

• excessive daytime sleepiness,

• cognitive dysfunction,

• impaired quality of life,

• increased cardiovascular morbidity and mortality.

OSAS & Cardiovascular Diseases

• Uncontrolled hypertension (HT) - 83% have OSAS due to activation of sympathetic drive.

• Acute coronary syndrome- 40-50% has OSAS• Cardiac arrhythmias - mostly Atrial fibrillation• Heart Failure• Sudden cardiac death• Stroke

OSAS and diabetes

Patients with sleep apnea and AHI>10 are much more likely to have impaired glucose tolerance and diabetes

(Meslier et al Eur Respir J 2003)

Prevalence of OSAS

In USA, prevalence of OSAS among middle-aged men and women were 4% and 2% (Young et al)

Predisposing Factors of OSA

• male gender • age • obesity (defined by a high body mass index) • Increased waist/hip ratio• smoking

• Shortening of the mandible and/or maxilla (the change can be subtle and familial)

• Hypothyroidism & acromegaly by narrowing the upper airway with tissue infiltration

• Myotonic dystrophy, Ehlers-Danlos

Mechanism of OSAS

• The upper airway dilating muscles,like all striated muscles, normally relax during sleep.

• In OSAS, the dilating muscles can no longer successfully oppose negative pressure in the airway during inspiration.

• Apneas and hypopneas are caused by the airway being closed on inspiration during sleep.

Symptoms of OSA

Night time

• Snoring

• Witnessed apnoea

• Frequent nocturnal awakenings

• Waking up choking or gasping for air

• Unrefreshed sleep

• Restless sleep

• nocturia

• Dry mouth

• decreased libido

Symptoms of OSA

Daytime• Early morning headaches• Fatigue• Daytime sleepiness• Poor memory, concentration or motivation• Unproductive at work• Falling asleep during driving• Depression

Diagnosis

• A good sleep history• Assessment of obesity, • ENT• Assessment of possible predisposing

causes: hypothyroidism, acromegaly and • Polysomnography: gold standard tool• Polygraphy

The Epworth Sleepiness Score

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

• 0 = would never doze• 1 = slight chance of dozing• 2 = moderate chance of dozing

• 3 = high chance of dozing

The Epworth Sleepiness Score

Sitting and reading 2Watching TV 3Sitting in active in a public place (e.g. a theater or meeting) 3As a passenger in a car for an hour without a break 2Lying down to rest in the after noon When circumstances permit 2Sitting and talking to some one

Sitting quietly after a lunch with out alcohol 1In a car while stopped for a few minutes in traffic

Total (>12 is pathologic) 13!

DIAGNOSIS OF

SLEEP APNEA

• To diagnose OSAS, the breathing pattern during sleep is analyzed for the presence of episodes of breathing cessation (apneas).

• The total number of apneas divided by the total sleep time represents apnea index (AHI).

• The cut off level for OSAS diagnosis is:

AHI > 5/hour

Apnea-Hypopnea severity

• AHI<5 Normal

• AHI 5-15 Mild OSA

• AHI 15-30 Moderate OSA

• AHI >30 Severe OSA

DIAGNOSIS OF

SLEEP APNEA

The gold standard for diagnosis of OSAS is nocturnal polysomnography, a simultaneous recording of several physiologic parameters:

• brain waves, • eye movements, • muscle activity, • chest movements, • air flow, and • blood oxygen saturation - that must be performed by

trained technologists using expensive equipment

• Airflow

• Tracheal mycrophone

• ECG

• Thoracic belt

• Abdominal belt

• Pulse-oxymeter

• Tibial EMG

POLYGRAPHY

Spitalul Clinic de Pneumologie Iasi – D.Boisteanu

"Gr. T. Popa" University of Medicine and Pharmacy

Current Treatment for OSAS

NON - SURGICAL– Weight loss– CPAP– Body position – Oral appliances– Drugs

SURGICAL– Tracheostomy– UPPP– Glossectomy– Hyoid

advancement– Mandibular

advancement

Weight Loss

• 10% weight loss predicted a 26% reduction in AHI

Peppard PE et al. JAMA 2000; 284: 3015-21

Body Position

• Raise head of bed• Avoid supine

position

Strategies• Tennis ball in

pajamas• Backpacks

CPAP Therapy• Works as a pneumatic

splint• 1st choice of treatment in

moderate to severe OSAS

• Success rate 95-100%• Long term compliance

60-70% • Retitrate pressure if

needed

CPAP Therapy- Side Effects

• Nasal congestion• Rhinorrhoea• Oronasal dryness

Skin abrasions/ rash• Conjunctivitis from

air leak• Chest discomfort• Claustrophobia

Oral Appliances □ Appropriate first-line treatment for

Mild OSA, primary snoring,

upper airway resistance

syndrome (UARS)

□ Not as effective as CPAP,

52% OSA have AHI<10%

□ Young, non-obese

□ Second line therapy for

moderate-severe OSA

□ Patient’s choice - Not tolerating /

refuse to use CPAP, or are not

surgical candidates

MAD

TRD

Heinzer

Esmarch

Spitalul Clinic de Pneumologie Iasi – D.Boisteanu

Oral Appliances

"Gr. T. Popa" University of Medicine and Pharmacy

Side Effects

• Excessive Salivation

• Temporo-mandibular joint discomfort

• Proprioceptive malocclusion

• Xerostomia

• Myofacial pain

Pantin et al. Sleep, 1999

Surgery• Nose: nasal surgery• UPPP (uvulo-palato-pharingo-plasty)• Retrolingual pharynx:

- mandibular advancement, - lingual plasty and resection, - mandibular osteotomy, - genioglossus advancement with hyoid

myotomy & suspension (GAHM), - maxillary & mandibular advancement osteotomy(MMO)

• High perioperative risk

TREATMENT OF

SLEEP APNEA

• Nasal continuous positive airway pressure (CPAP), is

the treatment of choice for obstructive sleep apnoea

(OSAS) syndrome.

• Treatment of OSAS by fixed positive airway pressure

(CPAP) requires an in-laboratory titration procedure to

determine the effective pressure level (Peff).

INSUFLATION OF AIR WITH POSITIVE PRESSURE ON A NASAL MASK MENTAINS

THE PERMEABILITY OF THE NOSE AND THROAT DURING SLEEP

EFFECTIVE

PRESSURE LEVEL

• The effective pressure level is the one that abolishes obstructive breathing disorders, including apneas, in every sleep stage and body position.

• It is usually determined during a sleep study with continuous acquisition of electrophysiologic parameters, respiratory flow, respiratory efforts and pulse oximetry.

INTELLIGENT AIRFLOW

GENERATORS (1)

In 1993 Berthon-Jones explored the possibility

of using computer power to drive a turbine

according to the analysis of physiologic signals

to construct an intelligent, very fast-reacting

airflow generator named auto-titrating positive

pressure device (APAP).

INTELLIGENT AIRFLOW

GENERATORS (2)

These devices will deliver pressures only when

necessary: changes of pressure will take place

gradually to minimize potential sleep disruption, the

unit will effectively compensate mask leaks, will detect

all known variations of sleep related airway

obstruction and will detect the transition from

abnormal to normal breathing and reduce pressure

accordingly.

INTELLIGENT AIRFLOW

GENERATORS (3)

The ability to respond to a variety of breathing

conditions is an advantage for the patient at home

because his respiration can change during one night

(in relation to sleep position, alcohol intake, sleep

stage, etc) and from night to night due to changes in

weight and lifestyle.

AIRFLOW GENERATORS

USED BY SLEEP APNEA PATIENTS

Many patients get APAP devices for long-term treatment and can be monitored for compliance

and efficacy using the memory capability in the APAP units.

VPAP: ADAPT SERVO-

VENTILATION

CONCLUSION

Both automatic (APAP) and fixed pressure (CPAP)

devices are comparable in terms of patients benefit,

use hours and mean pressure.

Intelligent CPAPs are modern, reliable tools which

allow remote monitoring of the patient in terms of

treatment compliance and effectiveness, with fewer

visits to the doctor and lower costs and labor.