Sleep Disordered Breathing

Sleep Disordered Breathing

SDB SDB Is an Umbrella Term for Many Disorders characterized by a lack of drive to breathe Results n repetitive pauses in breathing with no effort Occurs for a minimum of 10 seconds Characterized by a cyclical alternating pattern of increased and decreased periods of breathing typically followed by a central apnea. A form of another disorder that is often associated with severe heart failure patients, those who have suffered a stroke or who have experienced brain injuries. A reduced rate and depth of breathing. It occurs due to the loss of muscle tone during sleep and especially during REM sleep. Often occurs in patients with chronic obstructive pulmonary disease (COPD), neurological impairments, restrictive diseases (e.g, scoliosis) or those who are obese. most common type of sleep apnea caused by the partial or complete collapse of the upper airway. characterized by repetitive pauses in breathing during sleep despite the effort to breathe. occur for a minimum of 10 seconds The individual may not be aware of the problem

Terms Used in Diagnosing SDB Flow limitation upper airway narrowing; earliest sign of impending upper airway closure Hypopnea a >30% reduction in airflow lasting >10 seconds and with at least a 4% oxygen desaturation from baseline Apnea a cessation of airflow for >10 seconds

Prevalence of Sleep Apnea* A large, underpenetrated market: 26% of US adults age 30-70 have sleep apnea (16% mild sleep apnea, 10% moderate to severe sleep apnea) * Peppard PE et al. Am J Epidemiol 2013

Sleep Apnea Prevalence in Other Diseases Stroke 63% Heart Failure 76% Depression 45% Drug-Resistant Hypertension 83% Type 2 Diabetes 72% Coronary Artery Disease 57% Obesity 77% References: available upon request Prevalence A-fib 49%

Obstructive Sleep Main Apnea Headline (OSA) Goes Here

Obstructive Sleep Apnea (OSA)

Prevalence of OSA 1 in 4 (26%) US adults has at least mild OSA (AHI 5 apneas per hour) 1 1 in 10 (10%) US adults have moderate to severe OSA (AHI 15 apneas per hour) 1 At least 85% are undiagnosed 2 1 Peppard PE et al. Am J Epidemiol 2013 2 Young T et al. Sleep 1997

Male vs. Female: What are the Differences? Typical OSA Symptoms: snoring, witnessed apneas, EDS Epworth sleepiness scale - >10 Severe OSA Obstructive apneas More body position related (supine) CVD, type 2 diabetes, stroke Higher AHI s than women Symptoms: Insomnia, fatigue, daytime tiredness, headaches, muscle pain Epworth sleepiness scale typically lower score (have higher threshold for sleepiness Less severe, more mild and UARS Large amounts of flow limitation/uars Sleep stage related (mostly REM) CVD, Type 2 diabetes, stroke and dementia Lower AHI s than men (more episodes of UARS)

Pediatrics at Risk for SDB Obesity Adenoids or tonsil hypertrophy Craniofacial syndromes (eg, cleft palate, micrognathia) Neurodevelopmental disorders (eg, Prader-Willi syndrome, Down s syndrome) Neuromuscular disorders (eg, spinal muscle atrophy, muscular dystrophies, cerebral palsy) Mindell JA and Owens JA. Wolters Kluwer 2010

Signs and Symptoms of Pediatric OSA Night-time Symptoms Loud, continuous snoring Apneic pauses Paradoxical movements Restless sleep Sweating during sleep Abnormal sleeping position Mouth breathing Enuresis Sleep disturbance Day-time Symptoms Mouth breathing/dry mouth Chronic nasal congestion Hyponasal speech Rhinorrhea Morning headaches Frequent infections Difficulty swallowing Poor appetite Daytime sleepiness Hyperactivity Difficulty learning/focusing Failure to thrive or obesity Mood changes Mindell JA and Owens JA. Wolters Kluwer 2010

Risk Factors for OSA Smoking Obesity Alcohol or sedative use Increasing Age Family history of sleep problems Endocrine and metabolic Anatomic abnormalities of the upper airway Male Gender

Clinical Symptoms of Sleep Apnea Excessive daytime sleepiness Morning headaches Difficulty concentrating Loud or frequent snoring Irregular breathing during sleep Depression High blood pressure Weight problems

Consequences of Sleep Apnea: Personal Untreated OSA can lead to: Excessive sleepiness, which may cause problems at work. Depression, memory problems, difficulty concentrating. Less social engagement, lack of physical exercise, trouble with bed partner due to snoring, and even impotence.

Consequences of Sleep Apnea: Perioperative Risk 1 Patients with OSA who are undergoing surgical procedures are at higher risk for complications than patients who do not have OSA. Perioperative medications: May reduce muscle tone, drive to breathe and ability to wake up Upper airway narrowing: Surgical factors (e.g., swelling from breathing tube) may increase airway narrowing making collapse easier Supine positioning: Many patients have OSA that is worse when lying in a supine position 1 Kaw R et al. Chest 2012

Consequences of Sleep Apnea: Traffic Accidents Untreated sleep apnea can lead to a 15-fold increases in traffic accidents risk 1 For every dollar spent on CPAP, $3.49 would be saved in reduced collision costs 2 1 Horstmann S et al. Sleep 2000 2 Sassani A et al. Sleep 2004

Consequences of Sleep Apnea: Occupational Health 60 90% of industrial and transportation accidents occur due to human error (caused by sleep deprivation, fatigue, boredom, etc.)

Consequences of Sleep Apnea: Economic It is estimated that the total economic cost of sleep disorders in Australia in 2012 was $818 million annually Compared to patients without OSA, patients with OSA had: o o o Twice the healthcare costs 50% more physician visits Longer hospital stays. National Sleep Foundation: Sleep in America Poll_2011_Summary_of_Findings

Consequences of Sleep Apnea: Morbidity and Mortality Untreated OSA is significantly associated with increased morbidity and mortality

Types of Sleep Apnea Obstructive sleep apnea (OSA) Central sleep apnea (CSA) Complex sleep apnea (CompSA) Nocturnal hypoventilation

Treatment Main Headline Goes Here

Methods of Treatment Positive airway pressure (PAP) is the gold standard treatment for SDB Alternatives: o o o o o Behavioral modifications Dental appliances Drug therapies Surgery (UPPP, LAUP, mandibular advancement) Tracheostomy

Treatment Behavioral Modifications

Treatment Mandibular Repositioning Device (MRD) Mandibular repositioning device (MRD) is a custom made, adjustable, oral appliance available only from a dentist that maintains the lower jaw in a forward position during sleep. This mechanical protrusion widens the space behind the tongue and reduces the vibration and physical obstruction to breathing and the tendency to snore.

Narval CC Features The first and only CAD/CAM solution on the market o o o Computer-aided design (CAD) enables a high degree of customization to suit the complex dental anatomy of individual patients Computer-aided manufacturing (CAM) through selective laser sintering guarantees a consistently accurate MRD Ensures precise fit and comfort retention Narval CC is metal-free, flexible and light weight. It is made of highly resilient and durable biocompatible polymer material Narval CC is easy to reproduce with CAD/CAM Narval CC is easy to titrate; highly adjustable o 16mm protrusive range 1mm increments

Treatment Surgery Adenotonsillectomy Nasal reconstruction UPP (uvulopalatopharyngoplasty) Jaw repositioning

Treatment PAP therapy Device Transports air through a filter and provides a set air pressure Humidifier Moistens the delivered air to relieve nasal irritation and dryness Circuit Two components: Air tubing: Carries are from device to mask. Interface (mask): Delivers pressure to patient s airway.

PAP Therapy