OBSTRUCTIVE SLEEP APNOEA

Professor Dato’ Dr Abdullah Sani Mohamed Dept of ORL HNS Faculty of Medicine Universiti Kebangsaan Malaysia

Introduction

Sleep apnoea is disruption of breathing during sleep

This results in fragmented sleep

The commonest form is Obstructive sleep apnoea

The rarest form is Central sleep apnoea

There is also a combined Central and Obstructive form

Introduction

Patients with sleep apnoea characteristically exhibit the following Snoring Daytime sleepiness Frequent waking up / fragmented sleep Uncharacteristic irritability Morning headache Lack of concentration, disorientation,

forgetfulness Inability to perform

Obstructive sleep apnoea

The main patho physiology is upper airway obstruction during sleep

When obstruction is complete, the oxygen deprived brain “wakes up” the patient, making him breath voluntarily

This disruptive cycle of obstruction, waking up to breath, falling back to sleep results in fragmented sleep

Pathophysiology

In the morning patients will complain

Does not have a good night sleep

Has a headache (due to CO2 retention)

Wakes up several times to pass urine

Does not understand why he has the above

Snoring

“Thou dost snore distinctly…… there is meaning in thy snores” William Shakespeare in The Tempest

Simple snoring is rhythmic

In Sleep Apnoea, snoring is non rhythmic, loud and causes distress to the sleeping partner

sleepapnoea.mpg

Daytime somnolence

Patients are sleepy in the morning (1130), afternoon in fact anytime, in the severe cases, all the time!

When not doing physical work, during meetings, conferences, watching TV…… listening to my lecture…..

Daytime somnolence

Of particular concern, during driving and handling of heavy machinery

Or driving a bus….

Other symptoms

They get upset easily, no “energy” easily get tired

All symptoms are attributable to the nocturnal struggle for breath

Sleep is a struggle of Life and Death

They do not “die peacefully in their sleep”

The Signs

Most patients are obese

It’s the fat deposited in the neck

A receding chin (micrognathia)

Swollen uvula

Enlarged tongue

Enlarged tonsils

Sites of obstruction

How is it diagnosed?

History, physical exam, polysomnography

Polysomnography : to document, to see how severe and how urgent to treat

Hospital based or ambulatory (home based)

Polysomnogram

Full attended hospital PSG

Multiple leads, multiple data

Most reliable, expensive

Unattended hospital PSG

Fairly reliable, has first night effect

Unattended home PSG

Fairly reliable, more “at home”

PAT Respiratory

Events

Oxygen

Saturation

Pulse Rate

Body Position

Snoring

Wake /Sleep

state

REM/ Non

REM sleep

stages

Report including Snoring & Body Position

Definitions

Apnoea : cessation (stoppage) of air flow > 10 sec.

Breathing efforts continue

Hypopnoea : reduction of airflow by 50% or more lasting > 10 sec.

Apnoea : Hypopnoea index (AHI) is apnoea AND hypopnea per hour

PSG results

AHI

0-5 normal

6-15 mild

16-30 moderate

>30 severe

Lowest O2 saturation

DISE (drug induced sleep endoscopy)

OT, anaesthetist and ORL surgeon

Propofol infusion to induce sleep

Monitoring of sleep (sedation)

Flexible scope

Evaluation of level and severity of obstruction

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Muller’s manouver

Muller’s Manouver with obstruction at soft palate

Muller’s manouver after surgery

Treatment

The first line of treatment is to ask the patient to lose weight

Try sleeping on the side, raise the head end of the bed

Most patients cannot lose weight

treatment

For mild to moderate OSA we can try Mandibular advancement device

The idea is to protrude the lower jaw forwards

This brings the tongue forward and improves the airway

Treatment

Continuous positive airway pressure device (CPAP) : control rate of >90%

This is the Gold standard treatment

This is the first choice

Everyone deserves a trial

Treatment

If the patient refuse CPAP

Or if the tonsils are enlarged, if there is a deviated nasal septum and enlarged turbinates

We can do surgery to the nose and palate

Historically: UPPP

Uvulopalatopharyngo

plasty (UPPP)

UPPP

CAPSO

In Malaysia we have stopped doing UPPP

We now do Modified Cautery assisted palatal stiffening operation

No complication of nasopharyngeal stenosis and incompetence

Easier to teach and learn

How does CPAP compare to CAPSO? CPAP is more “powerful” provided the patient

is compliant

Provided there is no nasal obstruction

CAPSO is more popular amongst the younger patients

CAPSO is very2 useful if the tonsils are enlarged

How severe is this OSA problem? Young et al (1993) found 24% of middle aged

males and 9% of females in the US

It is severe because it affects the most productive sector of the population

It is severe because it is complicated by cardiovascular, cerebral events and diabetes if left untreated

The UKM Study

From November 2000 till October 2002 we did a clinic based study of sleep apnoea

We found 76 patients

61 males, 15 females

51 Malays, 13 Chinese and 12 Indians

The UKM study

94.7% were either overweight or obese

53% had severe sleep apnoea

40% had hypertension

Collar size and loudness of snoring showed significant correlation to severity of disease

Age, sex, race, waist size, weight did not correlate with severity of disease

UKM study

Collar size of more than 17 inches is associated with 90% chance of OSA

The louder the snoring the higher the chance of OSA

The UKM Study

Normally blood pressure levels fall during sleep

Blood pressure levels of patients with sleep apnoea remain high during sleep

This correlates with the severity of the disease

2011 UKM – MIROS study on bus drivers We studied 289 bus drivers

We found 44% have OSA!

Many drivers denied increased risk of MVA

We found on record no significant association to MVA

Future Plans and Strategy

All health care workers must be made aware of this condition

Sleep apnoea is now incorporated in the syllabus of all medical schools in Malaysia

Public talks, seminars, TV Talk shows publicize this syndrome

Vendors of CPAP source funds and assistance for patients

Future Plans and Strategy

Study obesity in schoolchildren

Study the incidence of sleep apnoea amongst obese children

Study the effect of sleep apnoea on academic performances

Take home message

Family medicine can diagnose OSA

Snoring and day time somnolence are the major symptoms

Look at their oral cavity

Large tonsils and edematous uvula

Request for sleep study

Many companies are willing to do home sleep tests (RM350)

Refer with sleep study results, its saves time

Conclusion

There is a real need to increase awareness of everyone on the dangers od OSA

Sleep apnoea syndrome is a serious health problem

If left untreated patients develop hypertension, diabetes, stroke, Ischemic heart disease

A sleepy person is a dangerous driver

conclusion

OSA needs to be diagnosed

It can be treated

It needs the cooperation of the patients to control weight and to be compliant to CPAP

Need to control the obesity epidemic

You can do the sleep study and refer with the results ready

The obesity epidemic

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Thank you for your kind attention