Proportion Of Obstructive Sleep apneu (Osa) Risk in Stroke patients in General Hospital Sanglah Denpasar *** Triatmoko, Indira Chadijah*, Buadiarsa, IGN **, Utami, DK Indrasari**, Widyadharma, Putu Eka ** Neurology Department, Faculty of Medicine, Udayana University/Sanglah General Hospital Denpasar, Bali ABSTRACT BACKGROUND Obstructive Sleep Apnea (OSA) has been associated with a number of diseases, which has been associated with the incidence of stroke. The incidence of OSA in Indonesia is estimated to be around 1-4% of the general population. Patients with cardiovascular disease have a high prevalence of OSA, an estimated 50% of patients with acute stroke. Many hospitals in Indonesia do not yet have sleep clinic therefor OSA diagnosis by polysomnography can not be established, including in Sanglah Hospital. We used Berlin questionnaire to determine risk of OSA in patients with stroke that were hospitalized in stroke unit. PURPOSE To determine the proportion risk of OSA in patients with stroke in General Hospital Sanglah Denpasar. METHOD A descriptive study using primary data. Sampling was done by consecutive sampling method. The research using Berlin Questionnaire for risk OSA. Data obtained from this study were analyzed descriptively with SPSS 16.00 for windows. RESULTS Total Sample of 44 stroke patients were taken during the period of May 2015 with the proportion of men is 32 people (72.7%) and women is 12 people (27,3%) with the mean age of subjects 55,23+12,76 years old. Proportion of high risk OSA is 29 people (65,9%) and low risk is 15 people (34,1%). CONCLUSION This study finds a large proportion of high risk OSA in stroke patients. Keywords: obstructive sleep apneu, stroke, stroke unit ================================================================== *Resident of Neurology Department, Faculty of Medicine, Udayana University/ Sanglah General Hospital Denpasar **Lecturer of Neurology Department, Faculty of Medicine, Udayana University/ Sanglah General Hospital Denpasar *** Presented at KONAS PERDOSSI MAKASSAR, Augustus, 7-9th 2015
INTRODUCTION Obstructive Sleep Apnea (OSA) is a form of abnormality that is a part of a complex sleep disorder breathing syndrome. The symptoms of OSA are common but often they are not diagnosed early in routine examination. Most people have experienced OSA but they are unaware of it and don t really pay attention to the symptoms as these are considered as non-dangerous, with no adverse effect. The first article about OSA was published in 1956 by Sidney Burwell. The prevalence of OSA in developed countries is estimated to be 2-4% in males and 1-2% in females. The prevalence of OSA in males is 2-3 times higher than female. It hasn t been fully understood why OSA is less common in females. 1,3 The incidence of OSA is estimated to be 1 4% in general population. Individuals with OSA who have snoring habit usually have more frequent apnea, hipopnea and decreased oxyhemoglobin saturation during sleep compared to those who don t snore. The frequency of OSA reaches its peak at the fifth and sixth decade of life, and decreases after 60s. In general, however, the frequency of OSA increases progressively with advancing age. 1,2,3,4, 5 Patients with cardiovascular diseases have high rate of OSA. The prevalence is around 50% in patients with hypertension, 50% in patients with atrial fibrillation that requires cardioversion, 33% in patients with only atrial fibrillation, 33% in patients with coronary artery disease, 50% in patients with acute stroke and 30-40% in patients with heart failure and systolic dysfunction. High OSA incidence (45-90%) was found in stroke patients. The potential role of OSA in the pathogenesis of stroke among others are through the process of atherosclerosis, hypertension, reduced cerebral perfusion due to thickening of carotid artery, low heart output, increased intracranial pressure, increased coagulopathy and increased risk of the formation of blood clot due to arrhythmia. Due to the high incidence of OSA and its potential effect on morbidity and mortality, the examination to diagnose and manage OSA is highly advised in patients with stroke. 1 Obstructive sleep apnea is defined as the cessation of air flow in the nose and mouth during sleep for more than 10 seconds followed by decreased oxygen for more than 4%, that happens repetitively up to 20-60 times per hour. OSA is the most common breathing disorder found during sleep, marked by the presence of apnea and hipopnea caused by the obstruction of respiratory tract during sleep. 1 There are some diagnostic criteria in sleep disordered breathing (OSA) according to the American Academy of sleep apnea. This condition is marked by the complaint of being sleepy in the daytime that can t be described by other factors followed by 5 episodes or more of breathing obstruction during sleep. Apnea-Hypopnea Index (AHI) is used to determine the degree of severity of OSA. The definitive diagnosis of OSA can be established using polysomnography. 1 The classification of severity of OSA is assessed by the scores of Apnea-Hypopnea Index (AHI) using polysomnography. The degree of severity of OSA is divided to: 6,7 NO Degree of OSA Score of apnea-hypopnea index (AHI) 1 Mild 5-14 2 Moderate 15-29 3 Severe > 30 Snoring is both social and health problem. Snoring might disturb sleeping partner, cause disturbances in socialization, decrease productivity, increase the risk of traffic incidents and increase the health spending in patients with OSA. People who snores severely are more prone to suffer from hypertension, stroke, and heart disease compared to those who don t snore with same age and weight. 3 Based on the available study, snoring and OSA increases the risk of hypertension up to twice and three times, and increase the risk of coronary artery disease or heart attack twice. Those who snore and patients with OSA are also at risk on having stroke attack twice higher than those who don t have OSA nor snore. Snoring and OSA are commonly found in adults, especially males,
middle age, and obese. Around 50 millions Americans snore, and 20 millions Americans have sleep apnea syndrome. 1,3 In Indonesia, there haven t been many centers established with sleep clinic, so the definite diagnosis of OSA using polysomnography haven t been able to be properly established. This includes Sanglah hospital, Denpasar, in which the sleep clinic is not yet available. The most common approach is to use questionnaires to determine the presence or absence of the risk of OSA in patients with stroke that are being hospitalized in the stroke unit. This research aimed at determining the proportion of OSA risk in Sanglah General Hospital, Denpasar. METHODS This research is a descriptive research using primary data that were collected from all stroke patients being hospitalized in stroke unit Sanglah General Hospital in May 2015. Samples in the research were those stroke patients who were cooperative, and consented to participate in this research. The sample was obtained consecutively. This research used Berlin questionnaire as the measurement tool. The Berlin questionnaire was a questionnaire arranged by Netzer et al. in 1999, which consists of development of interview results with patients with OSA. Berlin questionnaire consists of 10 questions and is divided into three categories. Category one assesses the snoring factor which is the presence or absence of snoring and the severity of snore. Category 2 assesses the factor of fatigue and the feeling of being sleepy at noon. Category three assess the factor of blood pressure and body mass index. Response for these questions were categorized in three groups, which was category one positive if for questions 1 to 5 there are two or more positive responses. Category 2 positive was when questions 6 to 8 contains two or more positive response. Category 3 positive if question 9 and 10 has one positive response. The end result were two categories of high risk for OSA and low risk for OSA. High risk for OSA was when two or more categories were positive. Low risk for OSA was when one or no category was positive. 8,9 Research in India testing the validity of Berlin questionnaire to identify patients who were at risk for OSA, stated that this questionnaire was easier to use and more accurate due to its ability to distinguish high risk from low risk OSA. In predicting high risk of OSA, Berlin questionnaire has sensitivity of 86% and specificity of 95%. This questionnaire can be used in classifying risks of OSA in general population. 10 Ekasari et al. in 2014 conducted a research for testing the reliability of Berlin questionnaire in Indonesian translation and showed that the value of Kappa Cohen coefficient in Berlin questionnaire was 0.75 (p = 0.001) with very good agreement of interpretation. 11 Data that were gathered were then analyzed statistically using SPSS. Descriptive analysis was conducted to determine the proportions of OSA risk. This would categorize OSA risk to high OSA risk and low OSA risk. RESULTS This research gathered 44 patients who were hospitalized in the stroke unit in Sanglah General Hospital Denpasar in May 2015. Characteristics of the research subjects are presented in the table. A. Characteristics of the research subjects Table 1. Characteristics of Research Subjects Variables Numbers % Age Age (mean ± SB) 55.23 (±12.76) Sex Male 32 Female 12 72.7 27.3 Table 1 shows that research subjects consisted of 32 (72.7%) males and 12 (27.3%) females with mean age of 55.23+12.76 years.
Table 2. Proportions of OSA risks in research subjects No OSA risk Number Percentage (%) (Subjects) 1 2 High Low 29 15 65.9 34.1 Total 44 100 Table 2 shows the proportion of high OSA risk was found in 29 (65.9%) subjects and low OSA risk in 15 (34.1%) subjects. DISCUSSIONS Obstructive Sleep Apnea (OSA) is an abnormality that is a part of the complex sleep disorder breathing syndrome. The symptoms of OSA often happen but many times they were not properly diagnosed at early stage in routine examination. OSA strongly correlates to some diseases, including the occurrence of stroke. The results of this research showed that the high OSA risk was prevalent in the stroke patients being hospitalized in the stroke unit. This was in concordance with the data of patients with cardiovascular diseases who have high prevalence of OSA, which is estimated to be about 50% in patients with acute stroke. There haven t been any previous studies assessing the proportion of high OSA risk in patients with stroke being hospitalized in the stroke unit stroke unit Sanglah General Hospital Denpasar. This research obtained high rate of high OSA risk in stroke patients. The result of this research can be used as a basic data to conduct further research. This descriptive research had some weaknesses. This research only assessed the proportion of OSA risk in patients with stroke being hospitalized using a questionnaire without proper monitoring of the value of Apneu-Hypopneu Index (AHI) and without the use of polysomnography. CONCLUSION This study finds a large proportion of high risk OSA in stroke patients in stroke unit Sanglah General Hospital.
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