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Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a disorder characterized by pauses in breathing or shallow breaths during sleep. It is diagnosed based on a sleep study that monitors breathing and oxygen levels. Left untreated, OSA is associated with serious health issues like hypertension, heart attack, and stroke. While CPAP is often effective, surgery can also widen the airway to treat OSA in some cases.

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23 views

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a disorder characterized by pauses in breathing or shallow breaths during sleep. It is diagnosed based on a sleep study that monitors breathing and oxygen levels. Left untreated, OSA is associated with serious health issues like hypertension, heart attack, and stroke. While CPAP is often effective, surgery can also widen the airway to treat OSA in some cases.

Uploaded by

Opi SaNg MadRidistas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPT, PDF, TXT or read online on Scribd
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Obstructive Sleep Apnea

Brent A. Senior, MD
Associate Professor
Chief, Rhinology, Allergy, and Sinus Surgery
Otolaryngology/Head and Neck Surgery
University of North Carolina

What is OSA?
Disorder of obstructed breathing occurring during
sleep
Apnea: cessation of breathing with respiratory effort
lasting greater than 10s
Hypopnea:

decreased airflow of >70%


Any decreased airflow with desaturation <90%

Total apneas and hypopneas per hour = AHI or RDI


or REI

What is Significant OSA?


Uh, I dont know
Most consider significant sleep apnea to be
present with an REI > 15

15-25: Mild Apnea


26-40: Moderate Apnea
>40: Severe Apnea

Whos Got It?

NCSDR-1993
40 million Americans with chronic sleep disorder
20 million with occasional sleep disorder

SDB (REI >5): 24% middle aged males


9% middle aged females

OSA >15/hr: 4% middle aged males


2% middle aged females

NEJM 1993; 328: 1230-35

Why is it so Important?

Hypertension
25% of hypertensives have OSA (AI>5)
Sleep Heart Health Study

6000 patients corrected for bmi, neck, EtOH


Nieto, et al. JAMA 283 (14): 1829-36, April 2000

SDB (including snoring) and Htn correlate

1700 patients
Bixler, et al Arch IM 160 (15): 2289-95, 2000

Sleep 1980; 3: 221-4


BMJ 1987; 294: 16-19

Health Impact

MI
REI >20 independent predictor of MI

223 German males with angio confirmed CAD


Schafer, et al. Cardiology 92(2): 79-84, 1999

Increased mortality in CAD patients

5 y study (Sweden)-62 patients; 19 with OSA (RDI


17)
OSA mortality: 37.5%; Non-osa mortality: 9.3%
Peker, et al. Am J Resp Crit Care 162 (1): 81-6, 7/2000

Health Impact

CVA
REI severity is independent predictor of Stroke

128 patients (UM)- 75 stroke; 53 TIA


62.5% with AHI >10 with stroke vs 12% controls

Bassetti, C et al. Sleep 22(2): 217-23, 3/1999

Health Impact

Death
AI<20, at 8y follow-up:

4% mortality
AI>20, at 8y follow-up: 37% mortality
treatment with trach or CPAP: 0% mortality

Chest 1988; 94: 9-14

NCSDR 1993
38000 CV deaths related to OSA per year

Societal Impact

Societal Impact
75% of 75000 screened will be diagnosed
with OSA ($275 million)
Fragmentation of sleep occurring with SDB

increased daytime sleepiness, decreased

intellect, behavioral and personality changes,


enuresis, sexual dysfunction

Am J Resp Crit Care Med 1996; 153: 1328-32

Societal Impact

Increased Traffic Accidents


simulated driving: SDB ~100x more likely to

drive off the road

Acta Otolaryn 1990; 110: 136ff

7x increased risk of auto accidents

Clin Chest Med 1992; 13: 427-34

Societal Impact

Reaction times
with OSA equivalent to a normal control who

was legally intoxicated (ABL >0.8)

Powell NB et al. Laryngoscope. 109(10):1648-54,


1999

UPPP decreases the number of MVA

ORL 1991; 53: 106-111


Laryngoscope 1995; 105: 657-61

Hows it Diagnosed?
History, Physical Examination, and Sleep
Study
History

Disrupted sleep, restless sleep, awaken with

gasping and choking


Loud snoring
Tired, inappropriate falling asleep
Witnessed apneas

History

Associated Complaints

Habits

Weight changes
Thyroid/Growth Hormone
abnormalities
GERD
sleep schedule
EtOH

PMH/Meds

Hypertension
Sedatives; Antihistamines

Physical Exam

Height and Weight (BMI)


BMI=[703.1 x weight(pounds)] / [Height (in)2]
neck size
Face-retrognathia
Nose
Oral cavity- palate, uvula, tonsils/pillars,

tongue, occlusion

Physical Examination

Physical Examination

Fiberoptic
Nasopharyngolaryngoscopy

Determines level of obstruction


Provides estimate of degree of
obstruction
Technique

supine (i.e., in a sleeping position)


at FRC-point of maximal
relaxation
snore maneuver
Mueller maneuver- inspire against
a closed airway

Evaluation

Key Features of the History and Exam


History (105 patients)

apnea reported by bed partner (p<0.01)


awakes with choking (p<0.005)
hypertension: dias >95 (p<0.01)

Exam

BMI>30 (p<0.01)

All: sensitivity 92%; specificity 51%

Am Rev Resp Dis 1990; 142: 14-18

Objective Sleep Monitoring

Rationale: Difficulty
predicting OSA by H&P
with no EDS

Loud snoring and


witnessed apneas identify
OSA 54-64% of the time

Sleep 1988; 11: 430-36

H&P predict OSA only


60% of the time

Sleep 1993; 16: 118-22

How To Treat?

Minimal intervention
Drop the Weight!
Dental Appliances

Variable success rates, though


probably more useful for mild apnea
?compliance

Interventional
CPAP
Surgery

CPAP

The Gold Standard in the treatment of OSA


Works the best in the most people
Positive pressure ventilation functions as a

pneumatic splint for the collapsing upper airway

But... compliance is very poor


159/214 (74%); mean 5.6 h/night; 77-89%

compliance (!)

Krieger. Sleep 15 (6 Suppl) S42-6, 1992

Surgery

Tracheotomy
An incision in the trachea
Cures OSA nearly 100% of the time
Prior to 1980, its all we had; still useful for

severe apneics

Remove TissueUvulopalatopharyngoplasty
(UPPP)

First successful alternative


to tracheotomy

12 individuals

preop AI 54 +/- 28
postop AI 28 +/- 28
8/12 with post-op AI<20
Fujita et al. Otolaryngol
HNS 1981; 89:923-34

Remove Tissue-Other Surgeries

Laser Midline Glossectomy


Palatal Somnoplasty
LAUP
Radiofrequency tongue base
reduction

Woodson, et al, AAO 2000,


Washington DC

18 patients completed protocol,


average 15,696 J
REI decreased from 45.3 to
33.3

Enlarge the Bony SpaceOther Surgeries

Genioglossus Advancement/
Hyoid Repositioning

Success ~80% (11-18mm)


Less effective with RDI >60

Maxillo-mandibular Advancement

Particularly useful in the setting of


hypopharyngeal obstruction (Fujita
2 or 3)
Best results when performed
following Stage 1 surgery

Complication Avoidance
All OSA patients are at risk of Airway Obstruction (even
mild)
Minimize risk:

Expect intubation disaster


Pharyngeal procedure with nasal procedure increases risk

regardless of apnea severity

Mickelson and Hakim, Oto HNS 119: 352-6, 1998

Amount of intraoperative narcotic- worse with greater apnea

severity

Esclamado, Laryngoscope 99: 11-29, 1989

Monitor post-op with continuous oximetry

Summary
OSA is a potentially life-threatening
disorder that demands proper evaluation
Components of that proper evaluation
include detailed sleep history, PE, and
endoscopic evaluation
Objective sleep evaluation is required prior
to intervention

Summary

Treatments include
Conservative non-interventional techniques

Weight loss, dental appliances

CPAP
Surgery

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