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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

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obstructive sleep apnea
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
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
What is Significant OSA?
  • Uh, I don’t know
  • Most consider significant sleep apnea to be present with an REI > 15
    • 15-25: Mild Apnea
    • 26-40: Moderate Apnea
    • >40: Severe Apnea
who s got it
Who’s 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
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
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 impact7
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 impact8
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 impact10
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 impact11
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 impact12
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
how s it diagnosed
How’s 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
History
  • Associated Complaints
    • Weight changes
    • Thyroid/Growth Hormone abnormalities
    • GERD
  • Habits
    • sleep schedule
    • EtOH
  • PMH/Meds
    • Hypertension
    • Sedatives; Antihistamines
physical exam
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
fiberoptic nasopharyngolaryngoscopy
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
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
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
How To Treat?
  • Minimal intervention
    • Drop the Weight!
    • Dental Appliances
      • Variable success rates, though probably more useful for mild apnea
      • ?compliance
  • Interventional
    • CPAP
    • Surgery
slide22
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
Surgery
  • Tracheotomy
    • An incision in the trachea
    • Cures OSA nearly 100% of the time
    • Prior to 1980, it’s all we had; still useful for severe apneics
remove tissue uvulopalatopharyngoplasty uppp
Remove Tissue- Uvulopalatopharyngoplasty(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
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 space other surgeries
Enlarge the Bony Space-Other 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
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
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
summary29
Summary
  • Treatments include
    • Conservative non-interventional techniques
      • Weight loss, dental appliances
    • CPAP
    • Surgery
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