Nasal Evaluation & Non-surgical Nasal Therapy in SDB

Transcription

1 Nasal Evaluation & Non-surgical Nasal Therapy in SDB Edward M. Weaver, MD, MPH Seattle VA Medical Center University of Washington Harborview Medical Center Acknowledgments This material is the result of work supported in part by resources from the VA Puget Sound Health Care System, Seattle, Washington. Dr. Weaver is a staff physician, surgery service line, Dept of Veterans Affairs Medical Center, Seattle, Washington. K23 HL68849 & R01 HL (Weaver) 1

2 Disclosures No industry disclosures No off label therapies Notes Adults Split audience: Otolaryngologists Others 2

3 Topics Significance of nasal obstruction Effect of nasal treatment Nasal evaluation Nasal medical treatment Nasal Obstruction Is common in sleep apnea (30%) Can affect whole upper airway Increases intrapharyngeal pressure gradient Activates nasopulmonary reflex Mouth opening tongue base obstruction 3

4 Upper Airway Anatomy Nasal Obstruction Mouth Opening 4

5 Lee, Laryngoscope 2007; 117: Mouth Closed Mouth Open Retro- Glossal Area (mm 2 ) 137±58 78±36 P<

6 McLean, Eur Resp J 2005; 25:

7 Septoplasty and/or turbinate reduction. Pre-Op Post-Op AHI (/h) LSAT (%) CPAP Pressure (cm H2O) Friedman, OtoHNS 2000; 122:71-4 7

8 Nasal Obstruction & CPAP Use Research Questions Does nasal obstruction CPAP use? Does nasal treatment CPAP use? CPAP Use (hrs/nt) r = 0.34 p < 0.01 Nasal Minimum Cross-sectional Area (cm 2 ) Figure 5 Li, Sleep 2005; 28:

9 CPAP Use Abnormal Nasal Exam Nasal Symptoms Nasal Med. 0 Not Using 1 2 Using 3 4 Adjusted Odds Ratio Husen, Sleep 2003; 26:A240 Nasal Surgery & CPAP Question Does turbinate reduction improve CPAP use and outcome? 9

10 Method: 22 met inclusion criteria R Sham n=5 RF n=17 Powell, Laryngoscope 2001; 111: * 1.50 Effec ct Size CPAP P Use CPAP Tolera ance CPAP Adhere S ence Adapted from Table IV 10

11 11

12 Zeng, Sleep 2008; 31:543-7 Topics Significance of nasal obstruction Common Worsens retrolingual airway in some Decreases CPAP tolerance & use Decreases OA tolerance & effect 12

13 Topics Effect of nasal treatment Reduces mouth breathing Improves AHI in some Reduces CPAP pressure Increases CPAP use Complements other OSA treatments Topics Significance of nasal obstruction Effect of nasal treatment Nasal evaluation Nasal medical treatment 13

14 Subjective Stewart, OtoHNS 2004; 130:

15 NOSE Scale Scoring Add all five answers Multiply by 5 Range = no problem 100 = severe problem Stewart, OtoHNS 2004; 130: NOSE Scale Normal score 11 Minimal clinically important difference: 6-19 Septoplasty: 68±20 23±20 RF Turbinate: 61±23 41±23 Stewart, OtoHNS 2004; 130: Stewart, OtoHNS 2004; 130:

16 Visual Analog Scale Please mark on this line how troublesome it is breathing through your nose on average: Stewart, OtoHNS 2004; 130: Nasal Valve 16

17 Septum Nasal Valve Inferior Turbinate Upper Lateral Cartilage Nasal Valve Upper lateral cartilage Septum Turbinate 17

18 Anatomy: Nasal Valve y Upper lateral cartilage Septum Inferior turbinates Point of greatest t resistance Regulates airflow Valve disorders important Nasal Valve Collapse 18

19 Cottle Test Nasal Pillows 19

20 20

21 Nasal Medication Treat intranasal congestion nasal caliber neg force Bernoulli s Law Indirect effect on valve collapse Otolaryngology Consultation Nasal airway evaluation Surgery evaluation 21

22 Rhee, OtoHNS 2010; 143:48-59 Nasal Cavity 22

23 Nasal Cavity Exam Speculum & headlight Septum Turbinates* Polyps* Mucosal disorders* *Medically treatable (partial) 23

24 Middle Turbinate Inferior Turbinate Septum Nasal Valve Septum 24

25 25

26 Septum Treatment Surgical 26

27 Valve Turbinate 27

28 Turbinate Treatment Irritant avoidance Elevate head of bed CPAP heated humidity Nasal saline Nasal steroid Anti-histamine t i Oral decongestant Nasal decongestant Surgery 28

29 29

30 Polyp Treatment Allergen avoidance Nasal steroid (head-down) Anti-histamine Oral steroid Surgery 30

31 Mucosal Treatment Rule out serious disorder Irritant avoidance Nasal saline Nasal steroid Antibiotic ointment Antibiotic irrigation Otolaryngology evaluation Topics Significance of nasal obstruction Common Worsens retrolingual airway in some Decreases CPAP tolerance & use Decreases OA tolerance & effect 31

32 Topics Effect of nasal treatment Reduces mouth breathing Improves AHI in some Reduces CPAP pressure Increases CPAP use Complements other OSA treatments Topics Nasal evaluation Everyone can do basic evaluation Otolaryngology for advanced eval Nasal medical treatment Safe & available Often helpful Surgical treatment backup 32

33 Nasal Evaluation and Non-Surgical Nasal Therapy in SDB REFERENCES 1. Lee SH, Choi JH, Shin C, Lee HM, Kwon SY, Lee SH. How does open-mouth breathing influence upper airway anatomy? Laryngoscope 2007;117(6): McLean HA, Urton AM, Driver HS, et al. Effect of treating severe nasal obstruction on the severity of obstructive sleep apnoea. Eur Respir J 2005;25(3): Friedman M, Tanyeri H, Lim JW, Landsberg R, Vaidyanathan K, Caldarelli D. Effect of improved nasal breathing on obstructive sleep apnea. Otolaryngol Head Neck Surg 2000;122(1): Li HY, Engleman H, Hsu CY, et al. Acoustic reflection for nasal airway measurement in patients with obstructive sleep apnea-hypopnea syndrome. Sleep 2005;28(12): Husen AN, Weaver EM, Kapur V, Watson N, Maronian NC. Abnormalities on nasal exam associated with decreased CPAP tolerance and use. Sleep 2003;26:A240 (Abstract). 6. Powell NB, Zonato AI, Weaver EM, et al. Radiofrequency treatment of turbinate hypertrophy in subjects using continuous positive airway pressure: a randomized, double-blind, placebo-controlled clinical pilot trial. Laryngoscope 2001;111: Zeng B, Ng AT, Qian J, et al. Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea. Sleep 2008;31: Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) Scale. Otolaryngology-Head & Neck Surgery 2004;130(2): Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: Results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg 2004;130(3): Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg 2010;143:48-59.