Obstructive Sleep ApnoeaHow Serious Is It ?

Sujeet Rajan, MD

Respiratory PhysicianBombay Hospital Institute Of Medical Sciences,

Mumbai

Basics

OSA – Upper Airway Collapse

Apnea – Hypopnea Index (AHI)< 5 (normal)

5 – 15 (mild)

15 – 30 (moderate)

> 30 (severe)

Risk Factors for OSA

M > F 3 x

• Obesity

• Non-obese – macroglossia, adenotonsillarhypertrophy, retrognathia

Circulation 2010

Background

Prospective cohort study (community NOT clinic based)

• Objective – CVS consequences of SDB

• Began 1994 at 7 centres in the US

• n = 6,441 Analysed = 4422

• 40 years and older ; FU for 8.7 years

OSA Predicts CHD – Men Not Women

Men ≤ 70 yrs with AHI ≥30 – 68% more likely develop CHD than AHI < 5

OSA Predicts HF – Men Not Women

Men with AHI ≥30 – 58% more likely develop HF than AHI < 5

Men vs. Women – Study Cohort

Lower prevalence of severe OSA in women

Later age of onset of OSA in women

- after menopause

- exposure to OSA than men with similar AHI

Men have physiological response to OSA

PCOS and Metabolism

• Early-onset impaired glucose tolerance

• Type 2 diabetes

• Hypertension

• Dyslipidemia

• Coronary vascular disease

• Obstructive sleep apnoea

Low Progesterone and Estrogen

Stimulates respiratory drive

Enhances upper airway dilator muscle actvity

• Progesterone protects against OSA development during pregnancy weight gain

• Estrone is normal/increased; estradioldecreased

• Pre-eclampsia

Symptomatic OSA in PCOS

PCOS more likely to suffer than controls44 % vs. 5.5% (p = 0.008)AHI 22.5 vs. 6

Fogel RB et al J Clin Endocrinol Metab 86: 1175-1180, 2001)

Healthy Sleep

• Metabolic rate

• Heart rate

• Blood pressure

• SNA All reduced in

NREM sleep

Sleep Apnoea On Heart Function

What Does The Obstruction Do ?

Kasai et al Journal Of Cardiology; 60 (2012): 78 -85

What Are The Links ?

Apnoea

Hypoxia

Increased sympathetic tone

Increased blood pressure

15 Cardiology. © ResMed

2009 06

Hypoxia

ApneaOSA: UPPER AIRWAY OBSTRUCTION

16 Cardiology. © ResMed

2009 06

Hypoxia

ApneaOSA: UPPER AIRWAY OBSTRUCTION

17 Cardiology. © ResMed

2009 06

Hypoxia

Arousal

Reduced

Oxygen

Supply

ApneaOSA: UPPER AIRWAY OBSTRUCTION

18 Cardiology. © ResMed

2009 06

SympatheticActivation

Hypoxia

Arousal

Reduced

Oxygen

Supply

ApneaOSA: UPPER AIRWAY OBSTRUCTION

19 Cardiology. © ResMed

2009 06

SympatheticActivation

Hypoxia

Arousal

Systemic

Vasoconstriction

Reduced

Oxygen

Supply

ApneaOSA: UPPER AIRWAY OBSTRUCTION

20 Cardiology. © ResMed

2009 06

SympatheticActivation

Hypoxia

Arousal

Systemic

Vasoconstriction

Reduced

Oxygen

Supply

Increased

Workload

ApneaOSA: UPPER AIRWAY OBSTRUCTION

21 Cardiology. © ResMed

2009 06

SympatheticActivation

Hypoxia

Arousal

Systemic

Vasoconstriction

Increased

Oxygen

Demand

Reduced

Oxygen

Supply

Increased

Workload

ApneaOSA: UPPER AIRWAY OBSTRUCTION

22 Cardiology. © ResMed

2009 06

SympatheticActivation

Hypoxia

Arousal

Systemic

Vasoconstriction

Increased

Oxygen

Demand

Reduced

Oxygen

Supply

Increased

Workload

ApneaOSA: UPPER AIRWAY OBSTRUCTION

Diagnosis

Loud, habitual snoring

Excess daytime sleepiness

Impaired cognition, fatigue, memory lapses

Obesity, male, genetic

Investigations

• Overnight Oximetry or Apnoealink

• Full polsomnography

Treatment

Treatment

• Weight Reduction

• Lateral position Sleeping

• Oral Devices (Mandibular advancement)

• Nasal CPAP

• Bilevel PAP (morbidly obese, pCO2 elevated, associated COPD)

Take Home Messages

• Think Of OSA when you see your next PCOS patient

• Pre-menopausal women without PCOS seem To Protected OSA nd its complications

• Use The Apnoealink (costs reduced)

• Weight reduction and CPAP remain the best treatments