Evaluating a case of sleep apnoea
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Evaluating a Case of Sleep Apnoea. Dr J.M. Joshi Professor and Head Department of Pulmonary Medicine T.N. Medical College B.Y.L. Nair Hospital Mumbai. SAS. Sleep apnoea syndromes (SAS) represent a group of conditions with abnormal respiration during sleep

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Evaluating a Case of Sleep Apnoea

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Evaluating a case of sleep apnoea

Evaluating a Case of Sleep Apnoea

Dr J.M. Joshi

Professor and Head

Department of Pulmonary Medicine

T.N. Medical College

B.Y.L. Nair Hospital

Mumbai


Evaluating a case of sleep apnoea

SAS

  • Sleep apnoea syndromes (SAS) represent a group of conditions with abnormal respiration during sleep

  • 3 forms of sleep apnea: OSA, CompSAS and CSA constitute 84% 15% and 0.4%, of cases respectively

  • Obstructive sleep apnea syndrome-OSAS (objective sleeping respiratory disturbance with daytime sleepiness)

  • Nasal continuous positive airway pressure (CPAP) is the most effective treatment for patients with moderate to severe OSAS


Obstructive apnoea

Obstructive Apnoea

  • ObstructiveApnoea when complete closure of the upper airway

  • The respiratory efforts continue

airflow

chest

abdomen


Central apnoea

Central Apnoea

  • Central Apnoea complete cessation of effort to breathe

  • Airway still open but no respiratory drive, hence no respiratory muscle activity

airflow

chest

abdomen


Clinical features

CLINICAL FEATURES

Snoring is the cardinal symptom,cyclical with periods of loud snoring exceeding 100 decibels or snoring alternating with quieter intervals of apnoeas


Diagnosis of osa

Diagnosis of OSA

A) EDS

B) 2 of the following

  • Snoring

  • Witnessed apnoeas

  • Unrefreshing sleep

  • Daytime fatigue

  • Poor concentration

    And

    c) Sleep Study showing AHI > 5

    Ref: PSG Task Force, ASDA. Sleep 1997;20:406-22.


Polysomnography psg

Polysomnography (PSG)

Neurological

EEG

EOG

EMG

Cardio-Respiratory

Snoring

Thoraco-abdominal movements

Airflow

Oximetry

Type 1,2

Type 3

Type 4

Ref: Clinical guidelines for unattended PM in the diagnosis of OSA in adult patients. J Clin Sleep Med 2007; 3:737–747


Psg before and after cpap

PSG Before and After CPAP


Severity grading of osas

Severity Grading of OSAS

  • Mild: 5–15 events/hour of sleep

  • Moderate: 15–30 events/hour of sleep and

  • Severe: more than 30 events/hour of sleep


Conventional diagnostic therapeutic approach

Conventional Diagnostic Therapeutic Approach

  • Full polysomnography (PSG) is currently the “gold standard’’ for the diagnosis of OSAS and titration of effective continuous positive airway pressure (CPAP)

  • Technicians should titrate CPAP pressures overnight until most of the apnoeas and arousals are abolished, as monitored by PSG


Alternative ambulatory diagnostic therapeutic approach

Alternative Ambulatory Diagnostic Therapeutic Approach

  • Urgent need to evaluate approaches to management that did not unduly rely on sleep laboratory–based PSG studies led to

  • Diagnostic-therapeutic approach using home based limited PSG (cardio-respiratory variables only) or oximetry with ambulatory CPAP titration


Clinical probability of osas

Clinical Probability of OSAS

  • Ambulatory diagnostic-therapeutic approach requires accurate identification of probable cases of OSAS

  • Sleepy snorer by Epworth Sleepiness Score

  • Sleep Apnea Clinical Score (SACS)based on snoring, witnessed episodes of apnea, neck circumference, and systemic hypertension


Epworth sleepiness score

Epworth Sleepiness Score


Clinical probability of osas1

Clinical Probability of OSAS

  • “Sleepy Snorer” by Epworth Sleepiness Score

  • Sleep Apnea Clinical Score (SACS)

    Ref: Likelihood ratios for a sleep apnea clinical prediction rule. AJRCCM 1994;150:1279-85.


Summary

Summary

Magnitude of OSA and paucity of sleep labs needs simplified approaches for physicians

Enough evidence now exists that simple ambulatory diagnostic–therapeutic strategies have equivalent clinical outcome in cases with high pretest probability

Patients who have a low probability, have co-morbidities or have difficulties during ambulatory management should be referred to a sleep centre for detailed evaluation/in-laboratory attended full PSG and further management


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