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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

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Obstructive sleep apnea l.jpg

Obstructive Sleep Apnea

Brent A. Senior, MD

Associate Professor

Chief, Rhinology, Allergy, and Sinus Surgery

Otolaryngology/Head and Neck Surgery

University of North Carolina


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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


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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


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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


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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


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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


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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


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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


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Societal Impact


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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


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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


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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


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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


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History

  • Associated Complaints

    • Weight changes

    • Thyroid/Growth Hormone abnormalities

    • GERD

  • Habits

    • sleep schedule

    • EtOH

  • PMH/Meds

    • Hypertension

    • Sedatives; Antihistamines


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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


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Physical Examination


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Physical Examination


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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


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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


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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


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How To Treat?

  • Minimal intervention

    • Drop the Weight!

    • Dental Appliances

      • Variable success rates, though probably more useful for mild apnea

      • ?compliance

  • Interventional

    • CPAP

    • Surgery


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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


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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


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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


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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


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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


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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


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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


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Summary

  • Treatments include

    • Conservative non-interventional techniques

      • Weight loss, dental appliances

    • CPAP

    • Surgery


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