Published on March 20, 2009
Obstructive Sleep Apnea Syndrome Management Approach : Obstructive Sleep Apnea Syndrome Management Approach AKM Mosharraf Hossain Assoc Prof Respiratory Diseases Bangabandhu Sheikh Mujib Medical University Pickwickian Syndrome : 2 Pickwickian Syndrome Obstructive sleep apnea was called the Pickwickian syndrome in the past because Joe the Fat Boy who was described by Charles Dickens in the Pickwick papers had typical features with snoring, obesity, sleepiness and “dropsy”. The Problem : 3 The Problem Obstructive Sleep Apnea Syndrome (OSAS) is one of the most important conditions identified in the last 50 years. OSAS is characterized by recurrent episodes of complete or partial upper airway obstruction during sleep, along with daytime sleepiness OSA & Cardiovascular Diseases : 4 OSA & Cardiovascular Diseases Uncontrolled HTN- 83% have OSAH; activation of sympathetic drive. Acute coronary syndrome- 40-50% has OSA Cardiac arrhythmias mostly Af Heart Failure Sudden cardiac death Stroke OSA and DM : 5 OSA and DM Patients from the sleep clinic with AHI>10 are much more likely to have impaired glucose tolerance and diabetes (Meslier et al Eur Respir J 2003) Prevalence of OSAS : 6 Prevalence of OSAS In USA, prevalence of OSAS among middle-aged men and women were 4% and 2% (Young et al) In India, among 30-60 yrs aged semi-urban prevalence of OSAS was 3.57% In Bangladesh, the prevalence of OSAHS was 3.29%. Predisposing Factors of OSA : 7 Predisposing Factors of OSA male gender age obesity (defined by a high body mass index) Increased waist/hip ratio smoking Shortening of the mandible and/or maxilla (the change can be subtle and familial) Hypothyroidism & acromegaly by narrowing the upper airway with tissue infiltration Myotonic dystrophy, Ehlers-Danlos Mechanism of OSAS : 8 Mechanism of OSAS The upper airway dilating muscles,like all striated muscles-normally relax during sleep. In OSAS, the dilating muscles can no longer successfully oppose negative pressure in the airway during inspiration. Apneas and hypopneas are caused by the airway being sucked and closed on inspiration during sleep. Anatomy of OSA : 9 NORMAL SNORING SLEEP APNEA Anatomy of OSA Symptoms of OSA : 10 Symptoms of OSA Night time Snoring Witnessed apnoea Frequent nocturnal awakenings Waking up choking or gasping for air Unrefreshed sleep Restless sleep nocturia Dry mouth decreased libido Symptoms of OSA : 11 Symptoms of OSA Daytime Early morning headaches Fatigue Daytime sleepiness Poor memory, concentration or motivation Unproductive at work Falling asleep during driving Depression Diagnosis : 12 Diagnosis A good sleep history Assessment of obesity, oral cavity Assessment of possible predisposing causes: HTN, hypothyroidism, acromegaly and Polysomnography: gold standard tool Sleep History: “BEARS” : 13 Sleep History: “BEARS” Bedtime Excessive daytime sleepiness Awakenings: night wakings early morning waking Regularity and duration of sleep Snoring The Epworth Sleepiness Score : 14 The Epworth Sleepiness Score How often are you likely to doze off or fall asleep in the following situations, in contrast to feeling just tired? 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing The Epworth Sleepiness Score : 15 The Epworth Sleepiness Score Polysomnography : 16 Polysomnography EOG - Electrooculogram EEG - Electroencephalogram EMG - Electromyogram EKG - Electrocardiogram Tracheal noise Nasal and oral airflow Thoracic and abdominal respiratory effort Pulse oximetry Slide 17: 17 C3 O1 Electroencephalography in the Overnight Sleep Study G1 G2 Paper or computer screen A2 Differential Amplifier C3-A2 O1-A2 G1 G2 Slide 18: 18 Left and Right Electrooculogram LOC ROC Eye Blinks Electrooculography picks up the inherent voltage of the eye. The cornea has a positive voltage output, while the retina has a negative polarity. Sleep Academic Award 18 Slide 19: 19 Differential Amplifier G1 G2 Combination of two dissimilar metals Voltage changes are seen with exhalation and inhalation Thermocouple- Oronasal airflow Slide 20: 20 Differential Amplifier Differential Amplifier Differential Amplifier Tracheal Sound Respiratory Effort Leg movement Overnight PSG : 21 Overnight PSG Slide 22: 22 Apnea-Hypopnea Index : 23 Apnea-Hypopnea Index Apnoea-hypopnoea index (AHI)= number of apnea/hypopnea per hour of sleep AHI<5 Normal AHI 5-15 Mild OSA AHI 15-30 Moderate OSA AHI >30 Severe OSA Current Treatment for OSA : APB 16/03/09 Current Treatment for OSA NON - SURGICAL Wt loss CPAP Positional Tx Oral appliances Drugs SURGICAL Tracheostomy UPPP Glossectomy Hyoid advancement Mandibular advancement Weight Loss : 25 Weight Loss Peppard PE et al. JAMA 2000; 284: 3015-21 10% weight loss predicted a 26% reduction in AHI Body Position : 26 Body Position Raise HOB Avoid supine position Strategies- Tennis ball in pajamas Backpacks CPAP Therapy : 27 CPAP Therapy Works as a pneumatic Splint 1st choice of treatment in moderate to severe OSAHS Success rate 95-100% Long term compliance 60-70% Retitrate pressure if needed CPAP Therapy- Side Effects : 28 CPAP Therapy- Side Effects Nasal congestion Rhinorrhoea Oronasal dryness Skin abrasions/ rash Conjunctivitis from air leak Chest discomfort Claustrophobia Oral Appliances : 29 Oral Appliances ? Not yet available in Bangladesh ? Appropriate first-line treatment for Mild OSA, primary snoring, upper airway resistance syndrome ( UARS ) ? Not as effective as CPAP, 52% OSA have AHI<10% ? Young, non-obese ? Second line therapy for moderate-severe OSA ? Patient’s choice - Not tolerating / refuse to use CPAP, or are not surgical candidates MAD TRD Side Effects : APB 16/03/09 Side Effects Excessive Salivation TMJ discomfort Proprioceptive malocclusion Xerostomia Myofacial pain Pantin et al. Sleep, 1999 Surgery : 31 Surgery Nose: nasal surgery UPPP, 54% of patients have 50% decrease in AHI Retrolingual pharynx: mandibular advancement, lingual plasty and resection, mandibular osteotomy, genioglossus advancement with hyoid myotomy & suspension (GAHM), and maxillary & mandibular advancement osteotomy(MMO) High perioperative risk Conclusion : 32 Conclusion With the increasing problem of obesity, the impact of undetected OSAS as a public health burden cannot be undermined among our population, It merits appropriate preventive and treatment strategies.