Polysomnography Intepretation

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17 Dec 2016, 17 th Int Congress & Scientific Seminar, Bangladesh Society of Medicine, Radisson Blu, Dhaka

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Sleep Apnea- Interpretation of Plysomnography and Management Options:

Sleep Apnea- Interpretation of Plysomnography and Management Options Prof. AKM Mosharraf Hossain PhD FCPS Professor & Head, Respiratory Medicine Bangabandhu Sheikh Mujib Medical University 17 Dec 2016, 17 th Int Congress & Scientific Seminar, Bangladesh Society of Medicine, Radisson Blu , Dhaka

Sleep Disordered Breathing :

Sleep Disordered Breathing Sleep-disordered breathing (SDB) are- Obstructive sleep apnea (OSA) Central sleep apnea (CSA) Cheyne -Stokes respiration and Sleep-related hypoventilation 2 BSM 17/12/16

OSAS?:

3 OSAS? OSAS is characterized by recurrent episodes of complete or partial upper airway obstruction during sleep, usually presents with snoring, apnea during sleep and EDS Commonest type of SDB BSM 17/12/16

Anatomy of OSA:

4 NORMAL SNORING SLEEP APNEA Anatomy of OSA BSM 17/12/16

Historically Pickwickian Syndrome :

5 Historically Pickwickian Syndrome Joe the Fat Boy who was described by Charles Dickens in the Pickwick papers had typical features with snoring, obesity, sleepiness and “dropsy”. BSM 17/12/16

Burden of OSAS:

6 Burden of OSAS In USA, prevalence of OSAS among middle-aged men and women were 4% and 2% (Young et al) In India, among 30-60 yrs aged semi-urban prevalence of OSAS was 3.57% In Bangladesh, among 30-60 yrs aged urban prevalence was 3.29% BSM 17/12/16

Predisposing Factors:

7 Predisposing Factors male gender age obesity Increased waist/hip ratio smoking Shortening of the mandible and/or maxilla Hypothyroidism & acromegaly Myotonic dystrophy Ehlers- Danlos BSM 17/12/16

Symptoms of OSA:

8 Symptoms of OSA Night time Snoring Witnessed apnoea Frequent nocturnal awakenings Waking up choking or gasping for air Unrefreshed sleep Restless sleep nocturia Dry mouth decreased libido BSM 17/12/16

Symptoms of OSA:

9 Symptoms of OSA Daytime Early morning headaches Fatigue Daytime sleepiness Poor memory, concentration or motivation Unproductive at work Falling asleep during driving Depression BSM 17/12/16

Slide 10:

10 BSM 17/12/16

OSA & Cardiovascular Diseases:

11 OSA & Cardiovascular Diseases Uncontrolled HTN- 83% have OSAH; activation of sympathetic drive. Acute coronary syndrome- 40-50% has OSA Cardiac arrhythmias mostly Af Heart Failure Sudden cardiac death Stroke BSM 17/12/16

OSA and DM:

12 OSA and DM Patients from the sleep clinic with AHI>10 are much more likely to have impaired glucose tolerance and diabetes (Meslier et al Eur Respir J 2003) BSM 17/12/16

Slide 13:

13 BSM 17/12/16 A 50-yr-old male presented with snoring, breathing pauses during sleep, daytime sleepiness and uncontrolled HTN

Sleep History: “BEARS”:

14 Sleep History: “BEARS” B edtime E xcessive daytime sleepiness A wakenings: night wakings early morning waking R egularity and duration of sleep S noring BSM 17/12/16

The Epworth Sleepiness Score:

15 The Epworth Sleepiness Score How often are you likely to doze off or fall asleep in the following situations, in contrast to feeling just tired? 0 = would never doze 1 = slight chance of dozing 2 = moderate chance of dozing 3 = high chance of dozing BSM 17/12/16

The Epworth Sleepiness Score:

16 The Epworth Sleepiness Score Sitting and reading 2 Watching TV 3 Sitting in active in a public place (e.g. a theater or meeting) 3 As a passenger in a car for an hour without a break 2 Lying down to rest in the after noon When circumstances permit 2 Sitting and talking to some one Sitting quietly after a lunch with out alcohol 1 In a car while stopped for a few minutes in traffic Total 13 ! BSM 17/12/16

Diagnosis:

17 Diagnosis A good sleep history Assessment of obesity, oral cavity Assessment of possible predisposing causes: HTN, hypothyroidism, acromegaly and Polysomnography: gold standard tool BSM 17/12/16

Physiologic Monitoring during Polysomnography :

18 Physiologic Monitoring during Polysomnography EOG - Electrooculogram EEG - Electroencephalogram EMG – Electromyogram (chin & limb) EKG - Electrocardiogram Snore volume Nasal and oral airflow Thoracic and abdominal respiratory effort Pulse oximetry Body position BSM 17/12/16

Slide 19:

19 C3 O1 EEG G1 G2 Paper or computer screen A2 Differential Amplifier C3-A2 O1-A2 G1 G2 Sleep staging Arousal BSM 17/12/16

Slide 20:

Left and Right Electrooculogram LOC ROC Eye Blinks REM sleep staging BSM 17/12/16

Slide 21:

21 Differential Amplifier G1 G2 Combination of two dissimilar metals Voltage changes are seen with exhalation and inhalation Thermocouple- Oronasal airflow BSM 17/12/16

Slide 22:

22 Snoring Respiratory Effort Leg movement BSM 17/12/16

Slide 23:

23 Scoring Respiratory Events Obstructive Apnea Central Apnea Mixed Apnea Hypopneas BSM 17/12/16

Slide 24:

Obstructive Apnea 90 percent or greater decrease in airflow, at least 10 despite efforts to breath. Blood oxygen levels reduce to < 3% of basline value Inhale Exhale Airway obstructs Airway opens Paradoxing Paradoxing Ends EKG Airflow Thoracic effort Abd. effort SAO2 Effort gradually increases

Slide 25:

25 Central Apnea : These are central apneas with minimal oxygen desaturation , no respiratory effort Airflow Thor. Effort Abd. Effort SAO 2 ECG

Slide 26:

26 Mixed Apnea: No respiratory effort in the beginning, later resumption of effort EKG Airflow Thoracic Effort Abdominal Effort SAO2

Slide 27:

27 Hypopnea : Airflow decreases at least 30 %, at least 10 secs , 3% oxygen desaturation or an EEG arousal Airflow reduction SAO2 desaturation > effort with paradox Paradox ends Inhale Exhale

Slide 28:

RERA: An event lasting at least 10 seconds associated with flow limitation and/or evidence of increasing respiratory effort, terminating in an arousal but not otherwise meeting criteria for apnea or hypopnea . Normally 10-25/hr of sleep.

Slide 29:

29 BSM 17/12/16

Slide 30:

30 Visual summary of polysomnographic da

Apnoea-Hypopnoea index (AHI):

31 Apnoea-Hypopnoea index (AHI) Apnoea-hypopnoea index (AHI)= number of apnea/ hypopnea per hour of sleep AHI<5 Normal AHI 5-15 Mild OSA AHI 15-30 Moderate OSA AHI >30 Severe OSA BSM 17/12/16

Respiratory Disturbance Index (RDI):

32 Respiratory Disturbance Index (RDI) Respiratory Disturbence Index (RDI) = number of apnea/ hypopnea , RERAs per hour of sleep More interobserver variablity Associated with neurocognitive disability BSM 17/12/16

Summary Report:

Summary Report A 50-yr-old male presented with snoring, breathing pauses during sleep, daytime sleepiness and uncontrolled HTN. His ESS is 13. The diagnostic sleep study shows evidence for OSA. His AHI was 18.1 events/hr. He also had oxygen desaturation ; for 11% of sleep time his SaO2 was between 80% and 90%. The titration study shows definite improvement on CPAP at 10 cm H 2 O. His AHI was normal at 4 events/hr. and low SaO 2 was 89%. BSM 17/12/16 33

Current Treatment for OSA:

BSM 17/12/16 Current Treatment for OSA NON - SURGICAL Wt loss CPAP Positional Tx Oral appliances Drugs SURGICAL Tracheostomy UPPP Glossectomy Hyoid advancement Mandibular advancement 34

Weight Loss:

35 Weight Loss Peppard PE et al. JAMA 2000; 284: 3015-21 10% weight loss predicted a 26% reduction in AHI BSM 17/12/16

Body Position:

36 Body Position Raise HOB Avoid supine position Strategies- Tennis ball in pajamas Backpacks BSM 17/12/16

CPAP Therapy:

37 CPAP Therapy Works as a pneumatic Splint 1 st choice of treatment in moderate to severe OSAHS Success rate 95-100% Long term compliance 60-70% Retitrate pressure if needed BSM 17/12/16

CPAP Therapy- Side Effects:

38 CPAP Therapy- Side Effects Nasal congestion Rhinorrhoea Oronasal dryness Skin abrasions/ rash Conjunctivitis from air leak Chest discomfort Claustrophobia BSM 17/12/16

Oral Appliances :

39 Oral Appliances □ Not yet available in Bangladesh □ Appropriate first-line treatment for Mild OSA, primary snoring, upper airway resistance syndrome ( UARS ) □ Not as effective as CPAP, 52% OSA have AHI<10% □ Young, non-obese □ Second line therapy for moderate-severe OSA □ Patient’s choice - Not tolerating / refuse to use CPAP, or are not surgical candidates MAD TRD BSM 17/12/16

Side Effects:

BSM 17/12/16 Side Effects Excessive Salivation TMJ discomfort Proprioceptive malocclusion Xerostomia Myofacial pain Pantin et al . Sleep , 1999 40

Surgery:

41 Surgery Nose: nasal surgery UPPP, 54% of patients have 50% decrease in AHI Retrolingual pharynx: mandibular advancement, lingual plasty and resection, mandibular osteotomy, genioglossus advancement with hyoid myotomy & suspension (GAHM), and maxillary & mandibular advancement osteotomy(MMO) High perioperative risk BSM 17/12/16

THANKS:

THANKS 42

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