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Sleep Apnea

Sleep Apnea. Dr. Vishal Sharma. History. Lugaresis (1970): described OSAS Stanford University (1972): Polysomnography Sleep Latency Test devised in 1976 Before 1980’s tracheostomy main treatment Ikematsu performed first UPPP in 1952 Fujita popularized UPPP

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Sleep Apnea

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  1. Sleep Apnea Dr. Vishal Sharma

  2. History Lugaresis (1970): described OSAS Stanford University (1972): Polysomnography Sleep Latency Test devised in 1976 Before 1980’s tracheostomy main treatment Ikematsu performed first UPPP in 1952 Fujita popularized UPPP Kamami developed LAUP in late 1980s

  3. Definitions

  4. Sleep related breathing disorders Synonym: sleep disordered breathing Consists of: A. Snoring B. Obstructive sleep apnea C. Obstructive sleep hypopnea D. Upper airways resistance syndrome

  5. Arousal:Abrupt change from deep stage to lighter stage of NREM sleep, or from REM sleep to awakening Arousal index:Number of arousals per hour of sleep Apnea:Cessation of breathing for > 10 seconds Apnea Index:Number of apneas per hour of sleep Hypopnea:Decreased airflow (>50%) with oxygen desaturation (> 4% ) for > 10 seconds Snoring:breathingnoise due to partial upper airway obstruction

  6. Obstructive sleep apnea:Cessation of airflow for > 10 seconds even with continued respiratory effort Obstructive sleep hypopnea:Decreased airflow (>50%) with oxygen desaturation (> 4% ) for > 10 seconds even with continued respiratory effort Upper airway resistance syndrome (respiratory effort related arousal):partial airway obstruction with no apnea or hypnea, but arousal index > 15

  7. Respiratory Distress Index: Number of apneas + hypopneas + respiratory effort related arousals per hour Obstructive sleep apnea syndrome: 30 or more episodes of obstructive sleep apnea during a 7- hour period of sleep or apnea index > 5 or respiratory distress index > 15

  8. Types of sleep apnea 1. Obstructive:Normal respiratory chest wall movement 2. Central:No respiratory chest wall movement 3. Mixed:Partial respiratory chest wall movement

  9. Grades of sleep apnea American Sleep association grading: 1. Mild ------------ 5 - 20 apneas per hour 2. Moderate ----- 20 - 40 apneas per hour 3. Severe -------- more than 40 apneas per hour

  10. Etiology of central sleep apnea

  11. Cheyne-Stokes breathing-central sleep apnea due to renal failure, heart failure, stroke • Diabetes mellitus, Hypothyroidism, Acromegaly, Parkinson disease, Myasthenia gravis, Idiopathic cardiomyopathy, Muscular dystrophy • Medullary tumor or infarction • Arnold-Chiari malformation • Cervical cordotomy • High-altitude periodic breathing (at > 5000m) • Use of opiates & other CNS depressants

  12. Cheyne-Stokes crescendo-decrescendo breathing

  13. Etiology of obstructive sleep apnea

  14. Nose Nasal polyps DNS ed Turbinate Nasal packing Larynx Tumors Edema Stenosis Pharynx Nasopharyngeal tumor Adenoids ed palatal / lingual tonsil Enlarged lingual tonsils Retropharyngeal mass Large tongue Micrognathia / Retrognathia Obesity

  15. Patho-physiology

  16. Increased compliance of pharyngeal tissues + Neuromuscular in-coordination & ed muscle tone + Anatomical abnormalities Upper airway collapse  airway obstruction Hypoxia + negative intra-thoracic pressure Arousal Increased tone of upper airway muscles + upper airway obstruction clears Patient goes to sleep Upper airway collapses again causing arousal

  17. Sequelae of sleep apnea

  18. Complications of sleep apnea  Systemic hypertension  Coronary artery disease  Pulmonary hypertension  Right heart failure  Cardiac arrhythmias  Cerebro-vascular accident  Polycythemia  Sleepiness accidents  Depression  Impotence  Vagal bradycardia  Sudden nocturnal death

  19. Clinical Features

  20. Snoring or sleep apnea?

  21. Symptoms of sleep apnea Day- time  Excessive sleepiness  Morning headache  Intellectual deterioration  Personality change  Depression  Xerostomia  Abnormal movements Night- time  Snoring  Observed choking  Arousal from sleep  Repeated waking  Nocturnal sweating  Nocturnal enuresis  Impotence

  22. Typical OSAS patient • Synonym: Pickwickian syndrome • Middle age or elderly male with hyper somnolence • Obese with body mass index > 30 • Short neck with its circumference > 17 inches • Hypertension & right heart failure • Large bulky tongue, hypertrophied tonsils, bulky soft palate, prominent posterior pharyngeal wall rugae

  23. Mr. Pickwick & fat boy Joe

  24. Throat in OSAS

  25. History from sleep partner • Bed timings • Body position • Snoring • Apnea (choking) • Arousal from sleep • Alcohol consumption • Sedative use

  26. Epworth daytime sleepiness scale Score > 16 = moderate to severe sleep apnea

  27. Physical examination General appearance, weight, body mass index Blood pressure, cardiovascular examination Cranio-facial: retrognathia, hypoplastic maxilla Nasal: airway patency, DNS, turbinate hypertrophy Tongue: macroglossia, lingual tonsil Nasopharynx: adenoids, polyp, cyst, tumor

  28. Physical examination Oropharynx: Soft palate, palatine tonsil, base of tongue, posterior pharyngeal wall Hypopharynx: tumor Larynx: cyst, tumor, vocal cord mobility Neck: short wide neck (circumference > 17 inches) Thyroid enlargement, features of hypothyroidism

  29. Investigations

  30. General Investigations • Complete blood count: anemia, polycythemia • Chest x-ray: cardiomegaly, pulmonary disorder • Lung function:portable spirometry flow volume loop  saw-tooth pattern • Thyroid function tests: hypothyroidism • Electro-cardiography: cardiac arrhythmias • Arterial blood gas analysis

  31. Portable spirometer

  32. Investigations for confirmation of sleep apnea • Polysomnography • Portable sleep monitoring • Overnight pulse oximetry recording • Multiple sleep latency test

  33. Polysomnography parameters 1. Electro-encephalogram (EEG) 2. Electro-myogram (EMG): submental, anterior tibialis 3. Electro-oculogram (EOG) / Electro-nystagmogram 4. Electro-cardiogram (ECG) 5. Oxygen saturation 6. Nasal & oral airflow 7. Chest + abdominal movement detector 8. Sleeping position detector 9. Tracheal microphone 10. Esophageal manometer

  34. Polysomnogram

  35. Polysomnogram

  36. Polysomnogram

  37. Polysomnogram in arousal

  38. Portable polysomnogram

  39. Investigations to assess site of airway obstruction Awake patientSleeping patient Muller maneuverFlexible nasendoscopy Lateral cephalometrySomno-fluoroscopy C.T. scan of neck Cine C.T. scan Pharyngeal manometry

  40. Flexible endoscopy

  41. Muller’s maneuver • After a forced expiration, pt attempts inspiration with closed mouth & nose, whereby negative pressure leads to collapse of airway • Previously introduced flexible endoscope (via nasal cavity) identifies weakened sections of airway at levels of soft palate & tongue base, during this maneuver

  42. Muller’s maneuver in snoring shows no airway narrowing Before Muller After Muller

  43. Muller’s maneuver in apnea shows airway narrowing Before Muller After Muller

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