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A CPMC Regional CME Event. The unified Airway . - An Integrated Approach. Saturday October 1, 2011. Sleep Apnea: the silent airway contributor. Brandon Lu, M.D., M.S. San Francisco Critical Care Medical Group. Obstructive Sleep Apnea. 1. Young et al., Am J Respir Crit Care Med 2002;165

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a cpmc regional cme event
A CPMC Regional CME Event

The unified Airway

- An Integrated Approach

Saturday October 1, 2011

sleep apnea the silent airway contributor
Sleep Apnea: the silent airway contributor

Brandon Lu, M.D., M.S.

San Francisco Critical Care Medical Group

obstructive sleep apnea
Obstructive Sleep Apnea

1. Young et al., Am J Respir Crit Care Med 2002;165

2. Hiestand et al., Chest 2006;130

3. Iber et al., The AASM Manual for the Scoring of Sleep and Associated Events. 2007.

  • Repetitive upper airway closure during sleep resulting in repeated reversible blood oxygen desaturation and fragmented sleep1,2
  • Severity measured by Apnea-Hypopnea Index (AHI):
    • Apnea: ≥ 90% decrease in airflow from baseline, for ≥ 10 sec
    • Hypopnea: ≥ 30% decrease in airflow from baseline, for ≥ 10 sec; accompanied by ≥ 4% desaturation from baseline
osa scope of the problem
OSA: Scope of THE Problem

1.Young et al., N Engl J Med 1993;328 2.Bixler et al., Am J Respir Crit Care Med 2001;163

3.Nieto et al., JAMA 2000;283 4. Bixler et al., Am J Respir Crit Care Med 198;157

5. Young et al., Sleep 1997;20

  • Estimated prevalence:
  • Up to 90% of people with OSA are undiagnosed5
osa associated morbidities
OSA: Associated Morbidities
  • Cardiovascular disease
    • Hypertension, CAD, CHF, arrhythmias, stroke
  • Metabolic syndrome, diabetes
  • Daytime sleepiness, e.g. motor vehicle accidents
  • Dementia
  • Mood disorder
  • Mortality
osa and the sympathetic system
OSA and the Sympathetic System

Somers et al., J ClinInvest 1995;96

osa symptoms and associated findings

Loud snoring

Witnessed apneas

Daytime sleepiness

Unrefreshing sleep




Memory and learning impairments



Nasal obstruction

Craniofacial abnormalities (i.e., Down’s syndrome, Pierre-Robin syndrome)

OSA: Symptoms and Associated Findings
physical examination
Neck size greater than 17.5 inches (men)

BMI greater than 30

Pharynx - Thick side walls

Uvula - Long

Soft palate - Low

Tonsils - Large

Nasal Obstruction


Physical Examination

Mallampati classification

epworth sleepiness scale
Epworth Sleepiness Scale
  • How likely are you to fall asleep in the following situations, in contrast to feeling just tired?
  • 0 = would never doze
  • 1 = slight chance of dozing
  • 2 = moderate chance of dozing
  • 3 = high chance of dozing
  • >10 indicates daytime sleepiness


Sitting and Reading ____

Watching TV ____

Sitting inactive in a public place (e.g. in a theater or a meeting) ____

As a passenger in a car without a break for an hour ____

Lying down in the afternoon when circumstances permit ____

Sitting and talking with someone ____

Sitting quietly after lunch without alcohol ____

In a car, while stopped for a few minutes in traffic ____

Johns, Sleep 1994

when to refer for sleep study
When to Refer for Sleep Study

Loud snoring, witnessed apneas, etc.

Daytime sleepiness

Physical exam, including obesity

Comorbidities (cardiovascular, metabolic, etc)

what to do before sleep study
What to do before sleep study
  • Treat nasal obstruction/congestion
  • Startling Resistor: upstream obstruction leads to suction force downstream
  • Oral breathing vs. nasal breathing
  • Oral breathing results in increased upper airway resistance (12.4 vs. 5.2 cmH2O∙L-1∙s-1) and collapse during sleep

Smith et al., J Appl Physiol. 1988 Meuriceet al., Am J RespirCrit Care Med. 1996

Fitzpatrick et al., EurRespir J. 2003.

types of sleep study
Types of sleep study

Diagnostic study

Split night study

CPAP titration study

Home study

when to refer to a sleep physician
When to refer to a sleep physician
  • No guideline
  • Troubleshoot
    • Mask, pressure, alternate therapeutic options
  • Follow-up
    • Medicare guideline requires documentation within 90 days of CPAP initiation:
      • Face-to-face evaluation documenting benefit
      • Objective evidence of adherence reviewed by treating physician (>4 hr use on 70% of nights)
  • Critical mass
comfort features of cpap c flex epr






Comfort features of CPAP: C-Flex / EPR
  • PEF sensing allows a reduction in flow during exhalation
  • Comfort mode
  • Not for ventilation, only for maintenance of a patent upper airway
surgical options for osa
Surgical Options for OSA

Uvulopalatopharyngoplasty (UPPP)

Genioglossus advancement

Shortens uvula, trims soft palate, and sutures back the anterior and posterior pharyngeal pillars; tonsillectomy is performed if indicated.

Enlarges the hypopharyngeal space by pulling forward the tongue base at the geniotubercle through a mandibular osteotomy

Won et al., Proc Am Thorac Soc. 2008

surgical options for osa1
Surgical Options for OSA

Maxillomandibular advancement



First-line therapy for obstructive sleep apnea in children; both adenoid and tonsillar tissue are removed, and the lateral pharyngeal walls are sutured to prevent collapse

Advances the maxilla and mandible to enlarge the retrolingual and retropalatal spaces

Won et al., Proc Am Thorac Soc. 2008

palatal implants
Palatal Implants


surgical options for osa2
Surgical Options for OSA

Practice Parameters for the Surgical Modifications of the Upper Airway for Obstructive Sleep Apnea in Adults. AASM 2010

  • Tracheostomy: effective; last resort
  • MMA: severe OSA who can’t use CPAP and OA not an option
  • UPPP: does not reliably normalize AHI in mod/sev OSA; try CPAP or OA first
  • Multi-level or stepwise surgery: acceptable in patients with narrowing of multiple sites in the upper airway
  • LAUP: not routinely recommended (standard)
  • RFA: can be considered in mild/mod OSA who can’t use CPAP or OA
  • Palatal implants: may be effective in mild OSA who can’t use CPAP or OA
oral appliances
Oral Appliances

“Oral appliances are indicated for use in patients with mild to moderate OSA who prefer them to CPAP therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP…Follow-up polysomnography or an attended cardiorespiratory (Type 3) sleep study is needed to verify efficacy…” AASM, SLEEP, 2006.

osa and cough
OSA and cough

Chan et al., EurRespirJ. 2010

Sundar et al., Cough 2010

108 consecutive referrals for suspected OSA: 33% of OSA pts reported chronic cough (>2 mos.) - predominantly females (61% vs. 17%), more nocturnal heartburn (28% vs. 5%) and rhinitis (44% vs. 14%) compared to those without SDB.

75 chronic cough pts without pulmonary pathology; 35/38 (92%) who underwent sleep study had OSA; 93% given CPAP and had improvement in cough

osa and gerd
OSA and gerd

Shepherd et al., J Sleep Res 2011

Kuribiyashi et al., NeurogastroenterolMotil2010

  •  1116 patients with PSG-diagnosed OSA and 1999 participants in a general health survey:
    • Weekly nocturnal reflux symptoms present in 10.2% OSA pts vs. 5.5% general population (p<0.001) and 13.9% severe versus 5.1% mild OSA
    • Frequent nocturnal reflux symptoms were associated with severity of OSA (OR 3.0, severe versus mild OSA, P<0.001) after correcting for multiple factors
  • Nocturnal reflux associated with transient lower esophageal sphincter relaxation (TLESR) but not by negative intra-esophageal pressure during OSA
osa and gerd1
OSA and gerd
  • Patient with OSA and GER showed decreased 24-hr acid contact time after treatment with CPAP

Tawk et al., Chest 2006