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Sleep Apnea: Overview, Symptoms, and Treatment

Explore the history, prevalence, and risk factors of sleep apnea, including key symptoms and diagnostic criteria. Learn about the impact of obesity and familial factors on this common sleep disorder. Discover when to refer patients and how to assess daytime sleepiness.

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Sleep Apnea: Overview, Symptoms, and Treatment

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  1. Sleep Apnea: • C Tyler

  2. Sleep Apnea Kaiser SF Sleep Lab a.k.a. ‘apnea clinic’ Part 3 C Tyler, Sep 2016 Medical Director Kaiser, San Francisco

  3. History of Sleep Apnea • 1956, Burwell et al • Obesity-hypoventilation syndrome (Pickwickian) • 1966, Gastaut et al • episodic upper-airway obstruction • terminated by brief arousals • 1978, Remmers et al • airway pressure vs EMG activity of the genioglossus muscle • tracheostomy recognized as an effective treatment • 1981 Sullivan et al • CPAP prevents upper-airway collapse, normalizes nocturnal sleep, alleviates EDS • 1993 by Young et al. • Prevalence: 2% and 4% of middle-aged women and men

  4. Raising Awareness of OSA • 20,000,000 Americans • 85% undiagnosed • Health care costs: = 2x those without OSA

  5. The Chief Complaint

  6. Sleep Related Breathing Disorders (SRBD)

  7. Definitions • Apnea = • 10 seconds + 3% desat • Hypopnea = • 50% reduction in flow + 3% desat • RERA = • respiratory effort related arousal • Arousal = • Transient ‘lightening’ of EEG • Central • Crescendo/decrescendo • Cheyne-Stokes Resp • Obstructive • Effort persists through strangulation

  8. Cardinal Sx of OSA: • Snoring (+/- observed apneas) • Clinical features of Sleep Fragmentation • Daytime hypersomnolence (EDS) • Non-refreshing sleep • Insomnia • Initiation Insomnia • Maintenance Insomnia • Obvious Sx: Choking/gasping • Subtle Sx: Nocturia

  9. Prevalence: • OSA syndrome (ESS > 10, AHI > 5) • 4% of middle-aged North American men • 2% of middle-aged North American women • if ESS < 10/24 included… • 24% of North American men • 9% of North American women • these data precede current obesity epidemic

  10. The hot button items: Race Sex Age Weight Family

  11. Race and OSA • more severe in African Americans • (Same prevalence) • More severe: Severe OSA 17% vs 8% in whites • Odds ratio of 2.55 for severe SDB • more severe in Asian • For given age, sex, BMI

  12. OSA prevalence with aging:

  13. Sex and Sleep Apnea

  14. Women and OSA • Prevalence slightly less • More symptomatic at given severity • Menopause is a significant risk factor

  15. Obesity and OSA • Strongest Risk Factor • 70% of OSA • occurs in obese patients • 10% weight gain • results in 6x increase risk • 10% weight loss • results in 26% decr in severity

  16. Obesity and Airway Diameter

  17. Familial/Genetic Factors • OSA in first-degree relatives: • prevalence 22 to 84% • If OSA in family member • Odds ratio = 2 to 46 •  Whites: recessive Mendelian inheritance • Accounts for 21 to 27% • African Americans: co-dominant gene • accounting for 35% • Twin concordance for snoring • significantly higher in monozygotic than in dizygotic twins

  18. Pathogenesis: • Three factors • anatomical abnormalities • airway predisposed to collapse during sleep/anesthesia • regulation of pharyngeal dilator muscle activation • Genioglossus m. Hypoglossal nerve. • normal redux during sleep • unstable ventilatory control (high loop gain) • intrinsic stability of a negative-feedback control system • arousal – CO2 drop over-shoot (below apnea threshold)

  19. Levels of obstruction: Midretropalatal (RP) Midretroglossal (RG)

  20. Unfavorable anatomy:Recessed chin SQ fat Long soft palate

  21. The Usual Suspects:

  22. Anatomic Suspects? • Obese (BMI > 35) • Neck circumfrence (> 17 inches) • Retrognathia / underbite • High arched palate • Mallampati Score

  23. Morphologic Features • High arched palate • Nasal septal deviation • Retrognathia • Mallampati Score

  24. Who to Refer: • Cardinal Symptoms • Snoring • Observed Apneas • Daytime Hypersomnolence • Commercial Drivers / Pilots • Pre-op: • STOP-BANG

  25. Work-up of Snoring • Adjusted Neck Circ (ANC) • Add 4cm if HTN • Add 3cm if snores • Add 3cm if choking and gasping is reported

  26. Sleepiness:Vigilance Impairment Judgment Impairment Micro-sleeps

  27. SleepinessDaytime Hyper-somnolenceExcess Daytime Sleepiness (EDS) • Not fatigue! • Not amotivational state! • Not depression! • Not weakness! • Measure of propensity to fall asleep. • Sleep Latency Test (objective) • Epworth Sleepiness Scale (subjective)

  28. Epworth Sleepiness Score • How likely are you to doze off or fall asleep in the following situations? • 0=No chance of dozing • 1=Slight chance of dozing • 2=Moderate chance of dozing • 3=High chance of dozing • Sitting and reading • Watching TV • Sitting inactive in public • Passenger in a car • Lying down to rest • Sitting and talking • Sitting quietly after lunch • In a car, stopped in traffic

  29. Epworth Sleepiness Score • 0=No chance of dozing • 1=Slight chance of dozing • 2=Moderate chance of dozing • 3=High chance of dozing • Sitting and reading my kids won’t read a book • Watching TV my kids watch TV constantly (until sleep) • Sitting inactive in public I’ve never seen my kids do this • Passenger in a car they’re usually driving • Lying down to rest not sure – that usually occurs around 3am • Sitting and talking they don’t talk, they text or snap-chat • Sitting quietly after lunch lunch is in front of video games • In a car, stopped in traffic I’m pretty sure they don’t stop

  30. Dept of Motor VehiclesCommercial License • BMI > 40; Neck Circ. > 17” • Triggers testing or license is suspended • Mandatory efficacy and compliance requirements • AHI • Rx must result in AHI < 5 (10 if UPPP or dental device) • Compliance • > 4 hours use, > 70% of nights

  31. OSA and Commercial Drivers • 6x more likely to have a crash • 7x more likely to have multiple accidents • Year 2000: • 800,000 drivers involved in OSA-related car crashes • $15.9 billion in damage • 1,400 lives

  32. Peri-op Medicine • STOP-BANG questionnaire • Expedited Evaluation • Expedited Treatment • Peri-op safety strategies: • Oximetry / CO2 monitor • InptvsOutpt surgery • Narcotic and PCA management

  33. 1. Snoring? Yes / No 2. Tired? Yes / No 3. Observed Apneas? Yes / No 4. Blood Pressure? Yes / No 5. BMI - > 35kg/m2? Yes / No 6. Age - > 50? Yes / No 7. Neck ? > 40cm? Yes / No 8. Gender -male? Yes / No HIGH RISK: 2 or more (STOP) 3 or more (STOP/BANG) STOP-BANG questionnaire

  34. Intermission:

  35. Diagnostic Treatment Initiation Titration Prescription Follow-Up Special Situations DMV BMI>37, Neck >17” Compliance Monitoring POM (Peri-op Medicine) STOP-BANG questionnaire Types of Studies: PSG (Polysomnogram) WatchPAT (Pulse Tonometery) Embletta Oximetry CPAP titrations CPAP device interrogation Other supporting data: Questionnaires: Initial F/U Sleep Lab Processes

  36. Measuring sleep/wake:behavior vs stimulus threshold vs EEG

  37. Polysomnogram • Obstruction of airflow + progressive effort • Explosive release (intermittent snore) • Desaturation

  38. Embletta • Oximetry • Actigraph • Nasal Thermistor • Microphone • Inductance Coils • Abdominal Excursion • Thoracic Excursion

  39. WatchPAT • Arterial Tonometry • Surrogate for Sympathetic Tone • Pulse Oxymetry • Heart Rate • Actigraphy • RDI and AHI correlate with PSG

  40. Sympathetic Tone and OSA

  41. Auto-CPAP titration(incl advanced devices) • Data Download: • Pressure Histogram • AHI • Hours used • Daily • Average • Days > 4hr use

  42. Obstructive hypopnea - snoring • Vibration on inspiratory flow • Progressive resp effort (Pesoph) with constant flow • Mild hypoxemia

  43. Definitions: • Apnea-Hypopnea Index: AHI • Apnea (10 seconds of no airflow) • Hypopnea (10 sec > 50% redux) • Or < 50% + 4% O2 desat • REM-AHI • (REM atonia + reduced hypoxic drive) • Resp Disturb Index: RDI = AHI + RERA • RERA (Resp Effort Related Arousal) • Oxygen Desat Index: ODI

  44. Central vs Obstructive

  45. Diagnostic Criteria: • Apnea-Hypopnea Index: • <5 events per hour: normal • 5-15 events per hour: mild • 15-30 events per hour: moderate • > 30 events per hour: SEVERE • Resp Disturb Index: • Same

  46. Severity criteria:what do they mean? • Arbitrary Cuttoffs • AHI>20: • inflection point for increased health risks • Alternately classify SRBD as • ‘CPAP responsive’ vs CPAP unresponsive’

  47. Who to Treat? • Mild OSA(S) (AHI/RDI 5-15) • (‘S’ is for Syndrome which includes EDS, sleep fragmentation) • Presence of Cardiovascular Co-morbidities • Moderate and Severe OSA (AHI/RDI >15)

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