OSAH (Obstructive sleep

apnoea/hypopnoea) ADITYA GHOSH ROY

PGT 3

NRSMCH

Respiratory Sleep Disorders include 4

1. OSAH (Obstructive sleep

apnoea/hypopnoea)

2. Central Sleep Apnoea/hypopnoea

3. Cheyne Stokes breathing

4. Sleep hypoventilation

DEFINATION Defined as 5 or more respiratory events (apnoeas /

hypopnoeas / RERAs) per hour of sleep lasting ≥10seconds in association with excessive day time somnolence, waking with gasping, choking, or breath holding spells or witnessed spells of apnoeas, snoring or both,

Usually accompanied by reduction in blood oxygen

saturations of at least 3% – 4% and is terminated by brief, unconscious arousals from sleep.

PATHOGENESIS Upper airway dilating muscle----

Hyoid position– geniohyoidTongue position– genioglossusPalate position– tensor palatini

Negative airway pressure

Nasal and laryngeal muscle stimulated

Stimulation of upper airway muscle

Features of upper airway in patients ofOSAH Upper airway muscle are more hyper trophic

Contract more powefully during wakefullness

Delay between Upper airway muscle activity and diaphragm muscle activity

Posterior displacement of tongue and mandible

Oval shaped airway

Chronic vascular over perfusion

Upper airway oedema

Snoring and recurrent upper airway obstruction

Mechanical trauma

Decreased airway size

Decreased Upper airway muscle dilating activity

obstruction

APNOEA

AROUSAL

Loud snort and compensatory phase of hyperventilation

sleep

HypoxaemiaHypercapniaNeg pressure

Stimulus to resp and reticular

Increased resp effortVasocostrictionTachycardiaInc BP

SYMPTOMS Night Time Symptoms

Loud, habitual snoring Witnessed apnoeas Nocturnal awakenings Gasping and choking

episodes during sleep Nocturia Abnormal body

movements

o Day time symptoms

o Unrefreshing sleep

o Daytime headaches

o Excessive daytime sleepiness

o Lack of concentration, poor

memory, irritability

o May lead to automobile or work

related accidents

o Decreased libido

DIAGNOSIS

HISTORY

PHYSICALEXAMINATION

INVESTIGATIONS

Overnight oximetry Home multi channel testing Overnight

polysomnography

Fibroptic nasopharngoscopy Drug induced sleep

endoscopy Esophageal manometry MRI 3D CT Cephalometry Nasal spray test

OVERNIGHT OXIMETRY

Measurement oxygen saturation

Oxygen dips

ODI ( OXYGEN DESATURATION INDEX )

ODI > 15 THEN OSA

HOME MULTI CHANNEL TESTING

Nasal flow Chest movements Abdominal movements Pulse oximetry

Advantages disadvantages

OVERNIGHT POLYSOMNOGRAPHY

Done under supervision

Hospital admission

Complex assessment

Gold standard

APNOEA HYPOPNOEA INDEX

AHI OSA

<5 NO OSA

5 – 15 MILD OSA

15 – 30 MODERATE OSA

> 30 SEVERE OSA

FIBROPTIC NASOPHARYNGOSCOPY

NasalRetro palatalRetro lingual

Awake asleep positions

Mullers maneuver

DRUG INDUCED SLEEP ENDOSCOPY

Commonly performed

Propofol

Target controlled propofol infusion

Anaesthetist

All monitors

Saturation to be maintained

SLEEP NASAL ENDOSCOPY GRADING

OESOPHAGEAL MANOMETRY

Diagnose apnoes , hypopnoea

GERD

Localization of upper airway obstruction

MRI

Localization of site of obstruction

Quantify the amount of surgical tissue volume

reduction necessary to resolve snoring

High cost

Time factor

3D CT

Evaluation of upper airway obstruction

Retropalatal space

CEPHALOMETRY

CEPHALOMETRY (relation between various soft tissue and bony landmarks based on carefully taken lateral X rays.)

NASAL SPAY TEST

Nasal decongestant

Alternate nights

Severity of snoring

TREATMENT

Specific Medical therapies

Positional therapy – (LATERAL POSITION) Positive Airway pressure

CPAP – mainstay of treatment, acts as pneumatic splint(prevents collapse of airway and avoids OSA)

Bi-level systems Auto CPAP

Oral Appliances Tongue retaining devices Mandibular advancing devices Snore guard Palatal Lifting devices NAPA (Nocturnal Airway Patency Device)

CPAP(CONTINOUS POSITIVE AIRWAY PRESSURE )

Acts as pneumatic splint

whereby blowing air via a tube and mask through

the nasal and/or oral passageway

support the pharyngeal and palatal walls

preventing collapse of the airway.

METHOD OF TITRATION

Admit a patient for overnight diagnostic Polysomnography, and halfway through the night, when the severity and the diagnosis of OSA have been confirmed, to commence CPAP for the second half of the night. This is referred to as a SPLIT NIGHT.

CPAP titration technique – The starting pressure is usually approximately 4 cm H20 and the pressure is increased quickly until all apnoeas and hypopnoeas are eliminated.

Another technique increasingly used is to send the subject home with an autoCPAP machine. Most autoCPAP machines will collect data on compliance, leaks and pressure profile.

CPAP

SIDE EFFECTS

Claustrophobia

Nasal Stuffiness

Skin abrasions and leaks

Ulceration of bridge of nose

Air swallowing

Pulmonary barotrauma

ORAL APPLIANCES

Tongue retaining devices

Mandibular advancing

devices

Snore guard

Palatal Lifting devices

NAPA (Nocturnal Airway

Patency Device)

UVULOPALATOPHARYNGOPLASTY Where obstruction is at upper pharyngeal or velopharyngeal

level

Remove tonsils, trimming faucial pillars, removal of uvula and variable amount of soft palate mucosa

then suturing anterior and posterior faucial pillars and anterior and posterior soft palate mucosa

Stiffen soft palate by scarring

Increase space behind soft palate

Reduction in obstruction

UVULOPALATOPHARYNGOPLASTY

SUCCESS OF UPPP Friedman staging for success of

UPPP Palate position BMI Tonsil size

Friedman staging for success of UPPP Stage 1 80% Stage 2 40% Stage 3 8%

PALATAL IMPLANTS

Placement of three woven

implants which stiffen the

palate

Fibrotic bands within capsule

which stiffens palate further

RADIOFREQUENCY TISSUE VOLUME REDUCTION

Submucosal application of the

radiofrequency energy to the midline soft

palate.

Initial treatment directed at a point

approximately midway between the hard

and soft palate junction and the base of the

muscular uvulae.

Carried out as a day care or OPD procedure

Less complications

LASER MIDLINE GLOSSECTOMY

Approximately 2.5 x 5cm midline tongue tissue is excised.

Might also require lingual tonsillectomy, reduction of aryepiglottic folds and partial epiglottectomy.

Usually combined with tracheostomy for airway protection.

LINGUAL TONSILLECTOMY

Radiofrequency ablation of lingual tonsil

HYPOGLOSSAL NERVE STIMULATION

GENIOGLOSSAL ADVANCEMENT anterior attachment of

genioglossus genial tubercle of mandible

Mobilized by osteotomy

Segment advanced

Fixed in inferior aspect of

osteotomy

Increases retro lingual space

GENIOGLOSSAL ADVANCEMENT

HYOID MYOTOMY AND SUSPENSION

Hyoid mobilized by inferior

myotomy and fixed anteriorly

and inferiorly to thyroid

cartilage

Advances the hyoid and

epiglottis anteriorly

Increases retro lingual space

Maxillomandibular Advancement

Maxillomandibular

Advancement

Le fort 1 maxillary

osteotomy and advancing

maxilla forwards.

move maxilla and

mandible as far forwad

as possible

Increases the retropalatal and retrolingual space

Complications

Malocclusion

Relapse

Nerve paresthesia

Nonunion , malunion

TM joint dysfunction

Bleeding

Subsequent dental work

COMPLICATIONS

Pain

Hemorrhage

Airway problem

Palatal incompetence

Wound infection

Wound dehiscence

dysphagia

Dry throat

Inc pharyngeal secretion

Dysphagia

Loss of taste

Globus symptoms

Voice changes

Velopharyngeal stenosis

Velopharyngeal fistula