Abdussalam Alahmari ENT Resident R2 KAUH 15/12/2015

Transcription

1 Abdussalam Alahmari ENT Resident R2 KAUH 15/12/2015

2 Physiology of sleep Snoring mechanism, causes, sites, symptoms, and management. Sleep apnea definitions, pathophysiology, risk factors, evaluation of sleep apnea,complications, and managment

3 A normal healthy adult sleeps for 7 8 h. Sleep occurs in two phases: non-rem and REM. The two phases occur in semiregular cycles, each cycle lasting for min. There are thus three or four cycles of sleep.

4 It forms 75 80% of sleep and occurs in four stages: Stage I. Transition from wakefulness to sleep. It constitutes 2 5% of sleep. EEG shows decrease of alpha and increase of theta waves. Muscle tone is less. Person can be easily aroused from this stage.

5 Stage II. Characterized by sleep spindles or K complexes and decrease in muscle tone. It constitutes 45 55% of sleep. Stage III. Forms 3 8% of sleep, characterized by delta waves. It is deep sleep. Stage IV. Forms 10 15% of sleep, characterized by delta waves. It is deep, most restful sleep.

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7 Forms 20 25% of total sleep, characterized by rapid eye movements, increased autonomic activity with erratic cardiac and respiratory movements. Dreaming occurs in this stage but muscular activity is decreased so that dreams are not enacted.

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9 is an undesirable disturbing sound that occurs during sleep. It is estimated that 25% of adult males and 15% of adult females snore. Its prevalence increases with age.

10 Muscles of pharynx are relaxed during sleep and cause partial obstruction. Breathing against obstruction causes vibrations of soft palate, tonsillar pillars and base of tongue producing sound.

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12 Snoring may be primary, i.e. without association with obstructive sleep apnoea (OSA) or complicated, i.e. associated with OSA. Primary snoring is not associated with excessive daytime sleepiness and has apnoea hypnoea index of less than five.

13 In children most common cause is adenotonsillar hypertrophy. In adults cause of snoring could be in 1. the nose or nasopharynx such as septal deviation, turbinate hypertrophy, nasal valve collapse, nasal polypi or tumours; 2. in oral cavity and oropharynx such as elongated soft palate and uvula, tonsillar enlargement, macroglossia, retrognathia, large base of tongue; or its tumour; 3. in the larynx and laryngopharynx such as laryngeal stenosis or omega-shaped epiglottis

14 Other causes include obesity and thick neck with collar size exceeding 42 cm. Use of alcohol, sedatives and hypnotics aggravates snoring due to muscle relaxation.

15 Sites of snoring may be soft palate, tonsillar pillars or hypopharynx. It may vary from patient to patient and even in the same patient thus making surgical correction a difficult decision. Sometimes sites of snoring are multiple even in the same patient.

16 Excessive loud snoring is socially disruptive and forms snoring-spouse syndrome and is the cause of marital discord sometimes leading to divorce. In addition, a snorer had may had hypopnea and obstructive sleep apnoea.

17 1. Avoidance of alcohol, sedatives and hypnotics. 2. Reduction of weight. 3. Sleeping on the side rather than on the back. 4. Removal of obstructing lesion in nose, nasopharynx,oral cavity, hypopharynx and larynx. 5. Performing uvulopalatoplasty (UPP) surgically with cold knife or assisted with radiofrequency (RAUP) or laser (LAUP).

18 Apnea is defined by the American Academy of Sleep Medicine (AASM) as the cessation of airflow for at least 10 seconds. Apnea may last for 30 seconds or even longer. Hypopnea is defined as a recognizable transient reduction (but not complete cessation) of breathing for 10 seconds or longer, a decrease of greater than 50% in the amplitude of a validated measure of breathing, or a reduction in amplitude of less than 50% associated with oxygen desaturation of 4% or more. An arousal is unnecessary to score a hypopnea.

19 Respiratory effort related arousal (RERA) is an event characterized by increasing respiratory effort for 10 seconds or longer leading to an arousal from sleep but one that does not fulfill the criteria for a hypopnea or apnea.

20 Respiratory disturbance index (RDI). Also called apnoea hypopnoea index. It is the number of apnoea and hypopnoea events per hour. Normally RDI is less than five. Based on RDI, severity of apnoea has been classified as mild, 5 14; moderate, 15 29; and severe 30.

21 1. Obstructive. There is collapse of the upper airway resulting in cessation of airflow. Other factors may be obstructive conditions of nose, nasopharynx, oral cavity and oropharynx, base of tongue or larynx. 2. Central. Airways are patent but brain fails to signal the muscles to breathe. 3. Mixed. It is combination of both types.

22 Apnoea during sleep causes hypoxia and retention of carbon dioxide which leads to pulmonary constriction leading to congestive heart failure, bradycardia and cardiac hypoxia leading to left heart failure, and cardiac arrhythmias sometimes leading to sudden death. During sleep apnoea, there are frequent arousals which cause sleep fragmentation, daytime sleepiness and other manifestations.

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26 Patient s bed partner gives more reliable information than the patient himself because latter does not know what happened during sleep.

27 History should include snoring during sleep, restless disturbed sleep, gasping, choking or apnoeic events and sweating. In the daytime, there is history of excessive daytime sleepiness (Epworth sleepiness scale is more often used) and fatigue, irritability, morning headaches, memory loss and impotence.

28 history of body position during sleep, use of alcohol, sedatives and caffeine intake, mouth breathing and history of menopause or having hormonal replacement therapy.

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30 1. Body mass index. 2. Collar size. Neck circumference at the level of cricothyroid membrane is measured. 3. Complete head and neck examination. 4. Muller s manoeuvre. A flexible endoscope is passed through the nose and the patient asked to inspire vigorously with nose and mouth completely closed. Look for collapse of the soft tissues at the level of base of tongue and just above the soft palate.

31 4- Systemic examination is done to look for hypertension, congestive heart failure, pedal oedema, truncal obesity and any sign of hypothyroidism. 5- Cephalometric radiographs are taken for craniofacial anomalies and tongue base obstruction. 6- Polysomnography. It is the gold standard for diagnosis of sleep apnoea and records various parameters which include:

32 EEG (electroencephalography) to look for non-rem or REM sleep and stages of non-rem sleep. ECG (electrocardiography) for heart rate and rhythm. EOM (electroculogram) for rolling eye movements. EMG (electromyography) recorded from submental and tibialis anterior muscle. Pulse oximetry to assess oxygen saturation of blood to know lowest SaO2 during sleep. Nasal and oral airflow for episodes of apnoea and hypopnoea. Sleep position helps to know whether apnoea/hypopnoea episodes occur in supine or lateral recumbent position. Blood pressure.

33 Polysomnography can differentiate between primary snoring, pure OSA and central sleep apnoea.

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35 Change in lifestyle. Those with mild disease and minimal symptoms can be treated with weight loss and dietary changes. Smoking, Sedatives/hypnotics and alcohol should be avoided. Positional therapy. Patient should sleep on the side as supine position may cause obstructive apnoea.

36 Intraoral devices. They alter the position of mandible or tongue to open the airway and relieve snoring and sleep apnoea. Mandible advancement device (MAD) keeps the mandible forward while tongue retaining device (TRD) keeps tongue in anterior position during sleep. They help improve or abolish snoring. MAD is also useful in retrognathic patients.

37 CPAP (continuous positive airway pressure). It provides pneumatic splint to airway and increases its calibre. Optimum airway pressure for device to open the airway is determined during sleep study. When CPAP is not tolerated, a BiPAP (bilevel positive airway pressure) device is used. It delivers positive pressure at two fixed levels a higher inspiratory and a lower expiratory pressure.

38 Surgical management of snoring and OSA is indicated when a surgically correctable abnormality is believed to be the source of the problem the patient has tried continuous positive airway pressure (CPAP) without success.

39 Rhinological procedures Palatal reduction Tongue base suspension/reduction Genioglossus advancement Hyoid suspension Maxillomandibular advancement Tracheotomy

40 1. Tonsillectomy and/or adenoidectomy. 2. Nasal surgery. Nasal obstruction may be the primary or the aggravating factor for OSA. Septoplasty to correct deviated nasal septum, removal of nasal polyps and reduction of turbinate size help to relieve nasal obstruction. Sometimes nasal surgery is also indicated for efficient use of CPAP.

41 Oropharyngeal surgery. Uvulopalatoplasty (UPP) is the most common procedure performed for snoring and OSA. It is 80% effective in snoring but OSA is relieved only in 50%.

42 UPPP involves the removal of the tonsils, followed by removal of the anterior surface of the soft palate and uvula, folding of the uvula toward the soft palate and suturing it together

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44 Advancement genioplasty with hyoid suspension. It is done in patients where base of tongue also contributes to OSA. Patients with retrognathia and micrognathia are also the candidates. Osteotomy of anterior mandible with advancement and rotation to prevent retraction Reduces tongue collapse Hyoid dissected inferiorly and advanced over thyroid cartilage.

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50 Maxillomandibular advancement osteotomy. Osteotomies are performed on mandibular ramus and maxilla. Osteotomy of the maxilla is like a Le Fort I procedure. These osteotomies are then fixed in anterior position with plates and screws. This surgical procedure is effective in selected cases but has the disadvantage of causing aesthetic facial changes.

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52 Indicated for presence of severe, lifethreatening OSA. Only procedure that will consistently show 100% success rates for severe OSA. Not completely curative for patients with cardiopulmonary decompensation.

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56 Need for comparison of procedures alone or in combination. Procedures should be tailored to specific sites of obstruction. Definition of success should include oxygen desaturation time, number of episodes, lowest value. Postoperative sleep study important

57 National Sleep Foundation. How much sleep do we really need? Washington, DC: National Sleep Foundation; Adult Obstructive Sleep Apnea:Pathophysiology and Diagnosis Susheel P. Patil, MD, PhD, Hartmut Schneider, MD, PhD, Alan R. Schwartz, MD, and Philip L. Smith, MD Chest July ; 132(1): 325 Sleep Apnea and Snoring, Surgical and Nonsurgical Therapy, Friedman, Michael 2009 Elsevier Inc. overview sleep apnea. Clinical staging for sleep-disordered breathing., Friedman M, Ibrahim H, Bass L. Otolaryngol Head Neck Surg Jul;127(1):13-21.

58 Thank you..