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