Sleep Apnea Herbert A Berger, MD Pulmonary Division Department of Internal Medicine University of Iowa
Disclosures No Relevant Financial Interests to Report
Objectives Learn the history and physical examination which raise the possibility of sleep disordered breathing Distinguish between obstructive and central sleep apnea Know available treatment options for sleep apnea in adults
Obstructive Sleep Apnea: Epidemiology Sleep-disordered breathing plus daytime hypersomnolence 2% women 4% men. Wisconsin Sleep Cohort Study (NEJM 1993; 328: 1230-5)
Obstructive Sleep Apnea Clinical Features Presenting symptoms: Snoring, Gasping, and Choking Loud Snoring Dry mouth Sore throat Restless Sleep / Insomnia
Obstructive Sleep Apnea Clinical Features Presenting symptoms: Mood disturbances Poor memory Impaired work performance Morning headaches Frequent nighttime urination Nighttime sweating Gastroesophageal reflux
Obstructive Sleep Apnea: The Epworth Sleepiness Scale How likely are you to doze off or fall asleep in the following situations: 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing 1) Sitting and reading 2) Watching TV 3) Sitting, inactive in a public place (e.g. a theater or a meeting) 4) As a passenger in a car for an hour without a break 5) Lying down to rest in the afternoon when circumstances permit 6) Sitting and talking to someone 7) Sitting quietly after lunch without alcohol 8) In a car, while stopped for a few minutes in the traffic Sleep 1991; 14: 540-545
Obstructive Sleep Apnea & Traffic Accidents
Obstructive Sleep Apnea Examination Increased weight High blood pressure Increased neck circumference Small jaw
Obstructive Sleep Apnea and Hypertension Odds Ratio For Hypertension Odds Ratios 3 2.5 2 1.5 1 0.5 0 0 0.1-4.9 5.0-14.9 15 Apnea-Hypopnea Index Peppard PE et al. NEJM 2000;342: 1378-84
43 cm 17 inches (men) 40 cm 16 inches (women)
Maxillary Insufficiency
Receding chin Overjet
Obstructive Sleep Apnea Examination Obstructed Nasal Patency Allergic Rhinitis Septal deviation Oralpharyngeal findings Long soft palate / uvula Large tongue Large tonsils
Kissing tonsils Sleep Academic Award Program - MEDSleep
Oral photograph: JR Sleep Academic Award Program - MEDSleep
Obstructive Sleep Apnea Examination Cardiac Findings in Severe OSA: Right-sided heart failure Prominent second heart sound Ankle edema
Obstructive Sleep Apnea Oximetry Series et al. Ann Intern Med 1993; 119: 449-453
Obstructive Sleep Apnea Oximetry Series et al. Ann Intern Med 1993; 119: 449-453
Obstructive Sleep Apnea Screening Oximetry Screening: Epstein et al. Chest 1998; 113: 97-103. The authors concluded, Screening oximetry is not cost-effective because of poor diagnostic accuracy
STOP-BANG Scoring Model Snoring Do you snore loudly (louder than talking or loud enough to be heard through closed doors)? Yes No Tired Do you often feel tired, fatigued, or sleepy during daytime? Yes No Observed Has anyone observed you stop breathing during your sleep? Yes No Pressure Do you have or are you being treated for high blood pressure? Yes No BMI BMI > 35 kg/m2? Yes No Age Age older than 50 yr old? Yes No Neck circumference Neck circumference > 40 cm? Yes No Gender Gender male? Yes No Validated in preoperative clinics (Chung, Anesthesiology, 2008; 108(5): 812) High risk of OSA: Answering yes to three or more items. Low risk of OSA: Answering yes to less than three items. Sensitivities: 84% for an AHI of > 5 / hour 93% for an AHI of > 15 / hour 100% for an AHI of > 30 / hour
Obstructive Sleep Apnea Diagnosis Polysomnogram Sleep Study
Obstructive Sleep Apnea: Definition Apnea: Air flow stops 10 seconds Hypopnea: 30 % reduction in airflow for 10 seconds Oxygen saturation drop by 4%
Obstructive Sleep Apnea: Definition Recurrent airway obstruction Mild: 5-15 Apnea + Hypopnea / Hour Moderate: 16-30 Apnea + Hypopnea / Hour Severe: 30 Apnea + Hypopnea / Hour Piccirillo et al, JAMA 2000; 284: 1492-1494
EKG Exhale Airway obstructs Airway opens Airflow Inhale Effort gradually increases Thoracic effort Paradoxing Abd. effort Paradoxing Ends SAO2 Blood oxygen levels reduce by 4% of baseline value Obstructive Apnea A complete blockage of the airway despite efforts to breath. Notice the effort gradually increasing ending in airway opening.
Obstructive Sleep Apnea One minute segment / Non REM Sleep Aldrich MS. Sleep Medicine 1999, p 208
Obstructive Sleep Apnea Paradoxical Effort Aldrich MS. Sleep Medicine 1999, p 209.
Obstructive Sleep Apnea Hypopnea Aldrich MS. Sleep Medicine 1999, p212.
Home Sleep Apnea Testing Consider in patients with: High pre-test probability of sleep apnea Negative Home Sleep Study: Follow up with a polysomnography Patients who are not candidates: Comorbid medical conditions: Chronic Obstructive Pulmonary Disease GOLD stage II or higher Class III or IV Heart Failure Hypoventilation Syndromes Comorbid sleep disorders Narcolepsy, insomnia, parasomnias
Obstructive Sleep Apnea Treatment Nasal CPAP Treatment of choice Functions as an air splint Effective in 90% Long term compliance rates 60% Kribbs et al. Am Rev Resp Dis 1993;147:887-895
Obstructive Sleep Apnea Sullivan et al. Principles and Practice of Sleep Medicine. 3 rd Ed. p895
Obstructive Sleep Apnea Treatment Benefits of Nasal CPAP Improved alertness Fewer traffic accidents Better work efficiency Fewer nocturnal cardiac arrhythmias Lower blood pressure Fewer depressive symptoms Engleman et al. Chest 1996; 109:1470
Obstructive Sleep Apnea Treatment Avoid Alcohol: Alcohol causes airway narrowing Alcohol increases apnea duration Avoid Sleep deprivation: Sleep deprivation prolongs apneas
Obstructive Sleep Apnea Treatment Diet & behavior modification for obesity Positional Therapy: Raise the HOB Avoid Supine Position Aldrich MS. Sleep Medicine Tee shirt 1999, p213. and tennis ball technique
Sleep Hygiene Keep a consistent sleep schedule. Get up at the same time every day, even on weekends or during vacations. Set a bedtime that is early enough for you to get at least 7 hours of sleep. Don t go to bed unless you are sleepy. If you don t fall asleep after 20 minutes, get out of bed. Establish a relaxing bedtime routine. Use your bed only for sleep and sex. Make your bedroom quiet and relaxing. Keep the room at a comfortable, cool temperature. Limit exposure to bright light in the evenings. Turn off electronic devices at least 30 minutes before bedtime. Don t eat a large meal before bedtime. If you are hungry at night, eat a light, healthy snack. Exercise regularly and maintain a healthy diet. Avoid consuming caffeine in the late afternoon or evening. Avoid consuming alcohol before bedtime. Reduce your fluid intake before bedtime. American Academy of Sleep Medicine
Obstructive Sleep Apnea: Region Specific Obstruction Kuna et al. Principles and Practice of Sleep Medicine. 3 rd Ed. p854
Obstructive Sleep ApneaTreatment: Region Specific Surgery Nose: Nasal surgery Retropalatal pharynx: UPPP (Uvulopalatopharyngoplasty) Retrolingual pharynx: Genioglossus Advancement with Hyoid Myotomy & Suspension (GAHM) Maxillary & Mandibular Advancement Osteotomy(MMO) Hypoglossal Nerve Stimulation Trachea Bypass the upper airway obstruction
Uvulopalatopharyngoplasty
UPPP with large pharyngeal opening UPPP with small pharyngeal opening
Obstructive Sleep Apnea Treatment Uvulopalatopharyngoplasty 54% have a 50% decrease in Apnea and Hypopnea Difficult to predict response Multiple levels of airway obstruction
Obstructive Sleep Apnea Mandibular Osteotomy and Genioglossus Advancement Powell et al. Clinics in Chest Med 1998; 19: 77-86
Obstructive Sleep Apnea Maxillary and Mandibular Advancement Powell et al. Clin in Chest Med 1998; 19: 77-86
Obstructive Sleep Apnea Treatment Stanford Protocol Phase 1: UPPP / GAHM - 61% RDI < 20 Phase 2: MMO - 97% RDI < 20
Obstructive Sleep Apnea Oral Appliances Mandibular advancement Advances tongue / soft palate Increases airway space Indicated in CPAP intolerance Mild to Moderate Disease Improvement in AHI
Obstructive Sleep Apnea Oral Appliances
Central Sleep Apnea
Central Apnea Air flow stops 10 seconds Absence of respiratory effort
EC G Airflow Thor. Effort Abd. Effort SAO 2 Central Apnea: These are two central apneas with minimal oxygen desaturation.
Central Sleep Apnea Congestive Heart Failure About 50 % of CHF patients have sleepdisordered breathing Most have central sleep apnea Crescendo-decrescendo respiratory pattern (Cheyne-Stokes) Independent risk (four-fold increase) for death
Classic Periodic Breathing Cheyne-Stokes Pattern Chokroverty, Atlas of Sleep Medicine, 2 nd Edition,
Central Sleep Apnea Treatment of Cheyne-Stokes Treatment of underlying heart failure Oxygen administration CPAP for Obstructive Sleep Apnea Avoid Adaptive Servo Ventilation Left Ventricular Ejection Fraction 45% N Engl J Med 2015;373:1095-105
Central Sleep Apnea and Chronic Opioid Use Opioid's cause ventilatory depression Precipitates Central Sleep Apnea Worsen Obstructive Sleep Apnea Stable Methadone Maintenance Treatment 30% had Central Sleep Apnea Ataxic Biot breathing pattern Chaotic breathing Breaths of differing amplitude Without regular rhythm Random apneic periods, variable duration Chowdhuri et al, Sleep Med Clin 12 (2017) 573 586
Biot Breathing Chokroverty, Atlas of Sleep Medicine, 2 nd Edition,
Chronic Opioid Use and Sleep Disordered Breathing Treatment: Treat underlying disorders Review need / amount of opioid drug Avoid benzodiazepines, sedatives, hypnotics Avoid alcohol Practice good sleep hygiene Avoid prescribing opioids to patients with moderate or severe sleep disordered breathing Positive Airway Pressure (PAP) Therapies Chokroverty, Atlas of Sleep Medicine, 2 nd Edition,
Chronic Opioid Use and Sleep Disordered Breathing Positive Airway Pressure (PAP) Therapies: Continuous PAP (CPAP) Bilevel PAP (BPAP) with and without backup rate Adaptive Sevo-Ventialtion: Impact on morbidity and mortality not known Chowdhuri et al, Sleep Med Clin 12 (2017) 573 586
Review the Objectives Learn the history and physical examination which raise the possibility of sleep disordered breathing Excessive Daytime Sleepiness Unrefreshing Sleep Snoring Witnessed Apneas Hypertension Congestive Heart Failure Excessive / Redundant Pharyngeal Tissue
Review the Objectives Distinguish between obstructive and central sleep apnea
Review the Objectives Know available treatment options for sleep apnea in adults Avoid Alcohol Avoid Sleep deprivation Diet & behavior modification for obesity Positional Therapy Nasal Continuous Positive Airway Pressure (CPAP) Region Specific Surgery
Questions?