S

Obstructive Sleep
Apnea
Overview
S Epidemiology
S Definitions
S Anatomy
S Conditions associated w/ OSA
S Pathophysiology
S Pathophysiologic Risk Factors
S Signs and Symptoms
S Differential Diagnosis
S Workup
S Case Presentation

Epidemiology
S Risk
S 25% of adults worldwide
S Prevalence
S 2-5% of children
S 2-9% of adults
S Age
S Prevalence increases from
18-45 yo
S Plateau at 55-65 yo
S Race
S More prevalent in African-
Americans (craniofacial
structure)




Definitions
S Apnea = breathing pause >10 seconds + >90% drop in airflow
S Hypopnea
S 3% drop in O
2
sat + >10 seconds of >50% reduction in airflow
S 4% drop in O
2
sat + > 10 seconds of >30% reduction in airflow
S Apnea Hypopnea Index (AHI) = # of apneas and hypopneas / hour of sleep
Conditions associated w/ OSA
S Obesity
S Atrial fibrillation
S Acute coronary syndrome
S Congestive heart failure
S Type 2 diabetes
S Stroke
S Nocturnal dysrhythmias
S Pulmonary hypertension
Pathophysiology
S Reduced upper airway size due to excess surrounding
soft tissue or a highly compliant airway
S Diminished neural input to the upper airway muscles
during sleep and at apnea onset
Theory: Loop Gain
Apnea
Increased respiratory
drive
Inspiration/ventilation
Decrease CO
2
Decreased respiratory
drive
Risk Factors
S Obesity
S Smoking
S Upper airway soft tissue
abnormalities
S Enlarged tonsils
S Nasal polyps
S Thyroid enlargement
S Acromegaly
S Supine
S REM Sleep
S Craniofacial abnormalities
S Micrognathia (small mandible)
S Retrognathia (posteriorly
displaced mandible)
Signs and Symptoms
S Daytime symptoms attributed to disrupted sleep
S Sleepiness, fatigue, poor concentration
S Signs of disturbed sleep
S Snoring, restlessness, resuscitative snorts
Differential Diagnosis
S Central sleep apnea
S Narcolepsy
S Alcohol or sedative abuse
S Depression
S Hypothyroidism
S Obesity-hypoventilation syndrome
S PCO
2
> 45 mmHg
Workup
S Comprehensive sleep evaluation
S Sleep-related history
S Snoring
S Choking or gasping during sleep
S Sleep amount
S Nocturia
S Morning headache
S Insomnia
S Frequent awakenings
S Concentration and memory
S Falling asleep at the wheel
S Epworth Sleepiness Scale, Stanford
Sleepiness Scale, Fatigue Severity
Scale
S Physical examination
S Evaluate for risk factors (ie. BMI,
macroglossia, micrognathia, etc.)
S If OSA suggested by history and
physical:
S Polysomnogram
S Confirm Dx
S AHI or RDI > 15/hour w/ or
w/out symptoms
S AHI or RDI > 5/hour w/
symptoms
S Determine severity
S Mild: 5-15 RDI
S Moderate: 15-30 RDI
S Severe: >30 RDI
Epworth Sleepiness Scale
S How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?
S Sitting and reading
S Watching TV
S Sitting inactive in a public place (ie. Theater or meeting)
S As a passenger in a car for an hour w/out a break
S Lying down to rest in the afternoon when circumstances permit
S Sitting and talking to someone
S Sitting quietly after a lunch w/out alcohol
S In a car, while stopped for a few minutes in traffic
S 0 = no chance of dozing, 1 = slight chance of dozing, 2 = moderate chance of dozing, 3 = high chance
of dozing
S 1-6 = good, 7-8 = average, >9 = seek sleep specialist w/out delay
Polysomnogram
Multi parametric Test
EEG
Airflow
Heart rate
Rhythm
Leg movements
Eye movements
Chin muscle muscle tone
Oxygen saturation
Chest wall movement
Treatment
S Continuous positive airway pressure (CPAP)
S Treatment of choice for OSA of all severities
S Supine position, 5 cm H
2
0 20 cm H
2
0
S Pt. education on behavioral changes
S Weight loss
S Avoidance of alcohol and sedating medications
S Modifying risk factors
S Driving precautions
S Tennis ball for supine sleeping
Treatment contd
S Oral Appliances
S Mandibular repositioning appliances (MRA)
S Tongue retaining devices (TRD)
S Surgical therapy
S Tracheostomy
S Bariatric surgery
S Pharmacologic therapy
S Treat underlying cause (ie. Hypothyroidism)