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Obstructive sleep apnea

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Obstructive sleep apnea

  1. 1. Obstructive sleep apnea Ammarin wichitpan 5th year medical student 23 August 2018
  2. 2. Outline • CASE • Definition • Pathophysiology • Approach to the patient
  3. 3. CASE A 67-year-old man with a long-standing history of snoring noted that, in recent years, the snoring had worsened so much that his wife banned him from their bedroom. Since his retirement, he gained 20 pounds, and knee problems reduced his physical activity. His nasal allergies also had worsened. He noted increased fatigue, daytime sleepiness, and some trouble concentrating. He reported following a medication regimen as treatment for hypertension, but he otherwise denied having any medical problems. He had a
  4. 4. Physical examination showed nasal congestion with moderately swollen, pale turbinates and no purulent discharge. The septum was midline. Oropharyngeal examination showed no tonsils and a low soft palate with elongated uvula that tended to collapse against the posterior aspect of the pharynx and abutted the base of tongue. Fiberoptic laryngeal examination showed a normal larynx with moderate collapse of the lateral pharyngeal walls in “blocked” inspiration (a reverse Müller's maneuver whereby the patient holds his nose, closes his mouth, and attempts to breathe inward). He had a short, thick neck and was overweight.
  5. 5. Definition Obstructive sleep apnea (OSA) is complete upper airway obstruction for at least 10 seconds with preserve respiratory effort SLEEP-DISORDERED BREATHING Apnea—is define by AASM as The complete cessation of airflow for at least 10 seconds. Apneas may be central, obstructive, or mixed. Hypopnea—definition is variable —The airflow reduction of at least 30% that lasts for 10 seconds or longer associated with a 3% decrease in oxygen saturation
  6. 6. Risk Factors Obesity (BMI > 30 kg/m 2 ) Neck size (collar size >17 inches in males, >16 inches in females) Gender (male/female 2–3:1) Genetic factors/family history Upper airway and craniofacial anatomy Macroglossia Lateral peritonsillar narrowing Elongation/enlargement of the soft palate Tonsillar hypertrophy Nasal septal deviation Retrognathia, micrognathia Narrowing of the hard palate Class III/IV modified Mallampati airway Specific genetic disorders, e.g., Treacher Collins, Down syndrome, syndrome, etc. Endocrine disorders, i.e., hypothyroidism, polycystic ovarian
  7. 7. Retrognathia Elongated uvula Tonsillar hypertrophy
  8. 8. Pathophysiology Sleep Obstructive apnea ChemoreceptorSleep arousal Upper airway tone Upper airway tone Resumption of airflow Upper airway resistance/collap sibility Hypoxia, Hypercapnia, Acidosis
  9. 9. Consequences of obstructive sleep apnea Obstructive apnea Intermittent hypoxia Sleep fragmentation Inflammation Sympathetic activation Oxidative stress Endothelial dysfunction Metabolic dysregulation Insulin resistance B cell function Type 2 DM Excessive daytime sleepiness - Neurocognitive function - Behavioral change - Personality change Cardiovascular disease - Hypertension - CAD - CHF - Pulmonary hypertension - Arrhythmia
  10. 10. APPROACH TO THE PATIENT •HISTORY •PHYSICAL FINDINGS •LABORATORY INVESTIGATION •DIAGNOSTIC TESTING
  11. 11. Clinical feature Nocturnal symptoms • Snoring • Witnessed apneas • Nocturnal choking or gasping • Restless sleep
  12. 12. Clinical feature Daytime symptoms • Excessive daytime sleepiness • Unrefreshing sleep, morning headaches • Irritability, memory loss, personality change • Decreased libido • Impotence
  13. 13. Questionnaire • STOP-BANG • Epworth Sleepiness Scale • Berlin questionnaire STOP-BANG
  14. 14. Physical examination • Vital signs • General appearance • Body habitus • BMI • Neck circumference • Head and neck • Craniofacial structure • Nasal and oral cavity • Systemic examination • CVS • RS • Neurological
  15. 15. Laboratory investigation • CBC • TFT • Arterial blood gas • CXR • Cephalometric study
  16. 16. Diagnostic Testing Options for Sleep-Disordered Breathing Polysomnography • Full-night study • Split-night
  17. 17. Polysomnography LEVELS Parameters Measured I [Standard attend in-lab PSG] EEG, EOG, EMG, ECG, airflow, respiratory effort, O2 saturation, usually video (all conducted in a sleep laboratory with a sleep professional present) II [Comprehensive portable Minimum of seven channels including EEG, EOG, chin EMG, ECG/HR, respiratory effort, and O2 saturation III [Modified portable sleep apnea testing] Minimum of four channels including ECG/HR, O2 saturation and at least The American Academy of Sleep medicine [AASM] has defined four levels of sleep studies.
  18. 18. Standard attended PSG o Total sleep time o Sleep efficiency o Sleep stage percentage o Sleep latency o Arousals o Apnea o Hypopnea o Respiratory effort related arousal[RERA]
  19. 19. Diagnostic criteria for OSA in adults The combination of either (A + B) or of (C) satisfies the criteria for OSA A. At least one of the following applies: 1.Patient complains of unintentional sleep episodes, daytime sleepiness, unrefreshing sleep, fatigue, or insomnia. 2.Patient awakens with breath-holding, gasping, or choking. 3.Bed partner reports loud snoring, interrupted breathing, or both as patient sleeps. B. Polysomnography recording shows the following: 1.≥5 scoreable respiratory events (apneas, hypopneas, or RERAs) per hour of sleep. C. Polysomnography recording shows the following: 1.≥15 scoreable respiratory events (apneas, hypopneas, RERAs) per hour of sleep. Apnea-hypopnea index (AHI): Number of apneas plus hypopneas per
  20. 20. Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS): Quantification and Severity Scale
  21. 21. TREATMENT • The decision to treat OSA should be based on its severity, related symptoms, and medical comorbidities. Treating moderate-to-severe disease (defined as AHI ≥15) Behaviora l modificati ons Continuous Positive Airway Pressure Surgery
  22. 22. Behavioral modifications • Weight reduction • Positional therapy • Sleep hygiene • Oral appliance
  23. 23. Oral appliance
  24. 24. Continuous Positive Airway Pressure • CPAP is the gold standard treatment for OSAS
  25. 25. Improved sleep quality: ↓ Arousal index, ↑ sleep efficiency ↓ Stage 1 sleep, ↑ stages 3 & 4 sleep Improved neurocognitive function: ↑ Driving simulator performance ↑ Vigilance Decreased daytime somnolence Improved cardiovascular function: ↑ Left ventricular function ↓ Systemic & pulmonary hypertension ↑ Exercise performance ↓ Endothelial dysfunction ↑ Transplant-free survival time (?) Improved subjective work performance Improved self-reported health status Improved glycemic control, insulin sensitivity Reversed deficiencies in: Plasma IGF-1, SHBG Serum testosterone Multisystem benefits of CPAP therapy for OSAS
  26. 26. Complications Associated with CPAP Nasal congestion Aerophagia Mask and mouth leaks (dry mouth in morning) Facial rash or irritation Difficulty with exhalation Claustrophobia
  27. 27. Surgery • Nasal surgery (septoplasty, sinus surgery, and others) • Tonsillectomy ± adenoidectomy • Uvulopalatopharyngoplasty(UPPP) • Laser-assisted uvulopalatopharyngoplasty(LAUP) • Hyoid myotomy and suspension • Tongue suspension • maxillomandibular advancement : MMA • Tracheostomy • Radiofrequency volumetric tissue reduction
  28. 28. Uvulopalatopharyngoplasty(UPPP)
  29. 29. Hyoid myotomy and suspension
  30. 30. Maxillomandibular advancement
  31. 31. Radiofrequency tissue volume reduction : RFTVR Thermal injury to specific submucosal sites in the soft palate resulting in fibrosis of the muscular layer and volumetric tissue reduction
  32. 32. TAKE HOME MESSAGE Snoring and excessive daytime sleepiness History and physical examination Polysomno graphy Many options treatment multidiscipl inary team
  33. 33. References
  • vindhuvindhu

    Feb. 1, 2021
  • GaganMarsur

    May. 13, 2019
  • ToxinToxin

    Sep. 15, 2018

for presenting in ENT department

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