Obstructive Sleep

Apnoea

EASO Train The TrainerAnnecy, July 2019

Obesity As A Disease

Abd Tahrani @AbdTahrani

MD, MMedSci, FRCP(London), PhD, SCOPE (National Fellow)

NIHR Clinician Scientist

Senior Lecturer in Metabolic Endocrinology and Obesity Medicie

Honorary Consultant in Endocrinology, Diabetes and Bariatric Medicine

Lead for Translational and Weight Management Research

Trustee, and co-Chair of the Clinical Practice and Obesity Management Committee

I have received support for

research and meetings,

honorarium for advisory work

and equipment support from:

Sanofi Aventis

Eli Lilly

BMS

BI

Novo Nordisk

Disclosures

AZ

MSD

Janssen

Resmed

Philips Resporinics

ImpetoMedical

ANSAR

Aptiva

Outline

Overview of OSA

Is it important to screen patients for OSA in medical weight management ?

Is it important to screen patients for OSA in bariatric surgery services?

How to screen for OSA?

How to treat OSA?

What about Obesity hypoventilation syndrome?

40 year-old woman

BMI 46

12 months in medical weight management

Type 2 diabetes.

On metformin

HbA1c< 7%

RYGB

1st day post op: Patient give opiates… Cardiac arrest…patient

resuscitated dn admitted to ITU

Patient received and discharged

Clinical Case

Definition

Common 2-4%

24% of men and 9% of women have OSA

9% of men and 4% of women have moderate-severeOSA

Characterised by recurrent episodes of partial/complete obstruction of

the upper airways

Associated with O2 de-saturations, changes in sleep architecture,

intrathoracic pressure, autonomic function and episodic changes in

heart rate and hypertension

Risk Factors: Obesity, Gender, Alcohol, Smoking, Age, Ethnicity, Family hx,

Autonomic Dysfunction

Sleep Disordered Breathing

Snoring UARS OSA OSAS

UARS: Upper airway resistance syndrome

OSAS: OSA + Excessive daytime sleepiness

Pathophysiology

Tongue

Soft palate

Airway

Flo

w

Time

Airway Blocked

Flo

w

Time

Open Airway Closed Airway

Sleep (transition from wakefulness and

REM)

Hypoventilation and UA

obstruction

Apnoea/ Hypopnea

Increasing Breathing effort

Hypoxia & Hypercapenea

Arousal

Hyperventilation

Lung volumesUA size

UA dilators toneChemosensitivity

UA resistanceExternal pressure

UA tone UA re-opening

Rapid PO2

PCO2

OSA

Airway obstruction

Sleep disturbance

Intra-thoracic pressure changes

Changes in Sleep Architecture

OSA prevalence in comorbidities

http://health.yahoo.com/bloodpressure-prevention/high-blood-pressure-using-the-dash-diet/healthwise--zp3284.html

Martin et al. The Lancet, Volume 365, Issue 9464, 2005, 1046 - 1053

Cumulative percentage of individuals with new fatal (A) and non-fatal (B) cardiovascular events in each of the five groups studied

Wisconsin Sleep Cohort: OSA and Mortality: an 18 year follow-up (n =1522)

Young T. et al. Sleep 2008

Anothaisintawee et al. Sleep Med Rev. 2016 Dec;30:11-24. doi: 10.1016/j.smrv.2015.10.002

Subramanian et al. Diabetes Care 2019 May; 42(5): 954-963

PREDICTORS OF OSA IN PATIENTS WITH T2D

Risk factors aIRR (95% CI); p value*

Sex

Male 2.27 (2.09-2.47); <0.001

Female Ref

BMI categories

Underweight/normal weight (<25 kg/m2) Ref

Overweight (25-30 kg/m2) 2.02 (1.54-2.64); <0.001

Obese (>30 kg/m2) 8.29 (6.43-10.70); <0.001

Missing 3.68 (2.31-5.87); <0.001

Smoker categories

Non-smoker Ref

Previous smoker 1.13 (1.04-1.22); 0.004

Smoker 1.10 (1.00-1.22); 0.056

Missing 0.89 (0.40-1.99); 0.773

HbA1c category

≤6.5% (47.500 mmol/mol) Ref

6.5-7.5% (47.501-58.500 mmol/mol) 0.90 (0.82-1.00); 0.044

7.5-8.5% (58.501-69.400 mmol/mol) 1.00 (0.88-1.13); 0.962

≥ 8.5% (69.401 mmol/mol) 0.98 (0.87-1.10); 0.729

Missing 0.88 (0.78-0.98); 0.026

Concurrent conditions within 15 months of diabetes

diagnosis

Foot Disease 1.23 (1.07-1.42); 0.004

Heart failure 1.49 (1.24-1.77); <0.001

Ischaemic heart disease 1.22 (1.11-1.34); <0.001

Hypertension 1.32 (1.23-1.43); <0.001

Depression 1.75 (1.61-1.91); <0.001

Insulin 1.57 (1.42-1.75); <0.001

Tahrani. Diab Vasc Dis

Res. 2017 Sep;14(5):454-462.

doi:

10.1177/1479164117714397.

OSA in T2D Increases the Risk

Retinopathy

CKD

Neuropathy

Foot Disease

CVD

Mortality

OSA Risk Factors

Obesity (neck circumference)

Male gender

Increasing age

Family history

Anatomic abnormalities of the upper airway

Alcohol or sedative use

Smoking

Symptoms and Signs

Symptoms associated with Sleep Apnea:

❑Excessive daytime sleepiness, lack of energy

❑Snoring

❑Sensation of choking during the night

❑Frequent night-time urination

❑Morning headaches

❑Sexual dysfunction

Pre-existing cardiovascular and co-morbidities:

❑Arterial Hypertension

❑Diabetes

❑Heart disease

❑Metabolic Syndrome

Diagnostic studies

Type 1 device: Full Polysomnography (PSG)

– In-lab study including audio-visual.

– Over 24 channels, including EEG, EOG, EMG, ECG, thermistors and pressure transducer, respiratory effort, SaO2, body position, limb movement

Type 2 device: Ambulatory PSG

– In-lab or in-home, with cut down version of PSG and usually without audio-visual

Type 3 device: Polygraph (PG)

– Partial studies using multiple channels at home or in hospital,

– includes pressure transducer, thermistor, snore, respiratory effort, Sao2, body position

– no data on sleep staging

Type 4 device

– Screening devices

– Usually one/two channels

Treatments - General

Weight loss (including Bariatric

Surgery)

Abstain from alcohol and sedatives

Smoking cessation

Positional sleeping

Treatments - Oral Appliances

Treatments - Surgery

Tonsillectomy / Adenoidectomy

– High success rate in children

Genioglossal advancement

– Anterior advancement of tongue

Maxillomandibular advancement

– High success rate with craniofacial abnormalities

Uvulopalatopharyngoplasty (UPPP)

Continuous Positive Airway Pressure (CPAP)

BMI ≥30 kg·m−2

Sleep disordered breathing

Daytime hypercapnia (arterial carbon dioxide tension (PaCO2) ≥45 mmHg at sea

level) during wakefulness

In the absence of an alternative neuromuscular, mechanical or metabolic

explanation for hypoventilation

90% of patients with OHS have obstructive sleep apnoea (OSA)

OHS between 8% and 20% in obese patients

Obesity Hypoventilation Syndrome…. The combination of

Massa et al. European Respiratory Review 2019 28: 180097; DOI: 10.1183/16000617.0097-2018

Pathogenesis

Thank You

@AbdTahrani