Obstructive Sleep Apnea Syndrome

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Obstructive Sleep Apnea Syndrome Management Approach : 

Obstructive Sleep Apnea Syndrome Management Approach AKM Mosharraf Hossain Assoc Prof Respiratory Diseases Bangabandhu Sheikh Mujib Medical University

Pickwickian Syndrome : 

2 Pickwickian Syndrome Obstructive sleep apnea was called the Pickwickian syndrome in the past because Joe the Fat Boy who was described by Charles Dickens in the Pickwick papers had typical features with snoring, obesity, sleepiness and “dropsy”.

The Problem : 

3 The Problem Obstructive Sleep Apnea Syndrome (OSAS) is one of the most important conditions identified in the last 50 years. OSAS is characterized by recurrent episodes of complete or partial upper airway obstruction during sleep, along with daytime sleepiness

OSA & Cardiovascular Diseases : 

4 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

OSA and DM : 

5 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)

Prevalence of OSAS : 

6 Prevalence 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, the prevalence of OSAHS was 3.29%.

Predisposing Factors of OSA : 

7 Predisposing Factors of OSA male gender age obesity (defined by a high body mass index) Increased waist/hip ratio smoking Shortening of the mandible and/or maxilla (the change can be subtle and familial) Hypothyroidism & acromegaly by narrowing the upper airway with tissue infiltration Myotonic dystrophy, Ehlers-Danlos

Mechanism of OSAS : 

8 Mechanism of OSAS The upper airway dilating muscles,like all striated muscles-normally relax during sleep. In OSAS, the dilating muscles can no longer successfully oppose negative pressure in the airway during inspiration. Apneas and hypopneas are caused by the airway being sucked and closed on inspiration during sleep.

Anatomy of OSA : 


Symptoms of OSA : 

10 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

Symptoms of OSA : 

11 Symptoms of OSA Daytime Early morning headaches Fatigue Daytime sleepiness Poor memory, concentration or motivation Unproductive at work Falling asleep during driving Depression

Diagnosis : 

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

Sleep History: “BEARS” : 

13 Sleep History: “BEARS” Bedtime Excessive daytime sleepiness Awakenings: night wakings early morning waking Regularity and duration of sleep Snoring

The Epworth Sleepiness Score : 

14 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

The Epworth Sleepiness Score : 

15 The Epworth Sleepiness Score

Polysomnography : 

16 Polysomnography EOG - Electrooculogram EEG - Electroencephalogram EMG - Electromyogram EKG - Electrocardiogram Tracheal noise Nasal and oral airflow Thoracic and abdominal respiratory effort Pulse oximetry

Slide 17: 

17 C3 O1 Electroencephalography in the Overnight Sleep Study G1 G2 Paper or computer screen A2 Differential Amplifier C3-A2 O1-A2 G1 G2

Slide 18: 

18 Left and Right Electrooculogram LOC ROC Eye Blinks Electrooculography picks up the inherent voltage of the eye. The cornea has a positive voltage output, while the retina has a negative polarity. Sleep Academic Award 18

Slide 19: 

19 Differential Amplifier G1 G2 Combination of two dissimilar metals Voltage changes are seen with exhalation and inhalation Thermocouple- Oronasal airflow

Slide 20: 

20 Differential Amplifier Differential Amplifier Differential Amplifier Tracheal Sound Respiratory Effort Leg movement

Overnight PSG : 

21 Overnight PSG

Slide 22: 


Apnea-Hypopnea Index : 

23 Apnea-Hypopnea Index 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

Current Treatment for OSA : 

APB 16/03/09 Current Treatment for OSA NON - SURGICAL Wt loss CPAP Positional Tx Oral appliances Drugs SURGICAL Tracheostomy UPPP Glossectomy Hyoid advancement Mandibular advancement

Weight Loss : 

25 Weight Loss Peppard PE et al. JAMA 2000; 284: 3015-21 10% weight loss predicted a 26% reduction in AHI

Body Position : 

26 Body Position Raise HOB Avoid supine position Strategies- Tennis ball in pajamas Backpacks

CPAP Therapy : 

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

CPAP Therapy- Side Effects : 

28 CPAP Therapy- Side Effects Nasal congestion Rhinorrhoea Oronasal dryness Skin abrasions/ rash Conjunctivitis from air leak Chest discomfort Claustrophobia

Oral Appliances : 

29 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

Side Effects : 

APB 16/03/09 Side Effects Excessive Salivation TMJ discomfort Proprioceptive malocclusion Xerostomia Myofacial pain Pantin et al. Sleep, 1999

Surgery : 

31 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

Conclusion : 

32 Conclusion With the increasing problem of obesity, the impact of undetected OSAS as a public health burden cannot be undermined among our population, It merits appropriate preventive and treatment strategies.

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