A case of daytime sleepiness Francesco Angelico Day Service di Medicina Interna e Malattie Metaboliche I Clinica Medica CLMM B

The Fat Boy The Fat Boy Joe — the "fat boy" who consumes great quantities of food and constantly falls asleep in any situation at any time of day Joe — the "fat boy" who consumes great quantities of food and constantly falls asleep in any situation at any time of day The Pickwick Papers Charles Dickens 1836

Case report A 67-year-old man with a long-standing history of snoring noted that, in recent years, the snoring had worsened so much that his wife banned him from their bedroom. A 67-year-old man with a long-standing history of snoring noted that, in recent years, the snoring had worsened so much that his wife banned him from their bedroom.

2006 American Academy of Sleep Medicine

Since his retirement, he gained 20 pounds, and knee problems reduced his physical activity. His nasal allergies also had worsened. Since his retirement, he gained 20 pounds, and knee problems reduced his physical activity. His nasal allergies also had worsened. He noted increased fatigue, daytime sleepiness, and some trouble concentrating. He reported following a medication regimen as treatment for hypertension, but he otherwise denied having any medical problems. He noted increased fatigue, daytime sleepiness, and some trouble concentrating. He reported following a medication regimen as treatment for hypertension, but he otherwise denied having any medical problems.

Physical examination showed nasal congestion with moderately swollen, pale turbinates and no purulent discharge. The septum was midline. Physical examination showed nasal congestion with moderately swollen, pale turbinates and no purulent discharge. The septum was midline. Oropharyngeal examination showed no tonsils and a low soft palate with elongated uvula that tended to collapse against the posterior aspect of the pharynx and abutted the base of tongue. Oropharyngeal examination showed no tonsils and a low soft palate with elongated uvula that tended to collapse against the posterior aspect of the pharynx and abutted the base of tongue. Fiberoptic laryngeal examination showed a normal larynx with moderate collapse of the lateral pharyngeal walls in “blocked” inspiration He had a short, thick neck and was overweight. Fiberoptic laryngeal examination showed a normal larynx with moderate collapse of the lateral pharyngeal walls in “blocked” inspiration He had a short, thick neck and was overweight.

OSA and daytime sleepiness People with obstructive sleep apnoea can be very drowsy during the day and fall asleep during inappropriate times. People with obstructive sleep apnoea can be very drowsy during the day and fall asleep during inappropriate times. Sleep apnoea makes people tired because of lack of a good night’s sleep. Sleep apnoea makes people tired because of lack of a good night’s sleep. OSA causes sleepiness because of the high levels of carbon dioxide in the blood. OSA causes sleepiness because of the high levels of carbon dioxide in the blood.

Snoring is a common symptom of sleep apnea and results from obstruction, usually by the soft palate and uvula Snoring is a common symptom of sleep apnea and results from obstruction, usually by the soft palate and uvula However, snoring itself does not involve cessation of breathing, and many “snorers” have normal results of sleep studies. However, snoring itself does not involve cessation of breathing, and many “snorers” have normal results of sleep studies.

Snoring is part of the spectrum of sleep-disordered breathing that may be a symptom of obstructive sleep apnea, but not all patients who snore have clinically significant sleep apnea. Snoring is part of the spectrum of sleep-disordered breathing that may be a symptom of obstructive sleep apnea, but not all patients who snore have clinically significant sleep apnea. Snoring may be present in 30% to 50% of the general adult population, whereas 2% of women and 4% of men have clinically significant (moderate to severe) obstructive sleep apnea. Snoring may be present in 30% to 50% of the general adult population, whereas 2% of women and 4% of men have clinically significant (moderate to severe) obstructive sleep apnea. Treatment for snoring may include weight loss, avoidance of supine sleeping position, sleeping with head elevated, avoidance of alcohol or sedatives at night, and treatment of nasal symptoms. Treatment for snoring may include weight loss, avoidance of supine sleeping position, sleeping with head elevated, avoidance of alcohol or sedatives at night, and treatment of nasal symptoms.

WHAT IS OSA? Sleep disorder characterized by recurrent episodes of narrowing or collapse of pharyngeal airway during sleep despite ongoing breathing efforts. Sleep disorder characterized by recurrent episodes of narrowing or collapse of pharyngeal airway during sleep despite ongoing breathing efforts. These often lead to These often lead to Acute derangements in blood gas disturbances Acute derangements in blood gas disturbances Surges of sympathetic activation Surges of sympathetic activation Periodic arousal from sleep (fragmented sleep) Periodic arousal from sleep (fragmented sleep)

OSA IS : Common Common Dangerous Dangerous Easily recognized Easily recognized Treatable Treatable

EPIDEMIOLOGY Disease prevalence = 2 – 4 % of US adult population Disease prevalence = 2 – 4 % of US adult population Higher in population subsets Higher in population subsets 1980’s = morbidity associated with OSA became more widely appreciated 1980’s = morbidity associated with OSA became more widely appreciated Majority of cases still undiagnosed Majority of cases still undiagnosed  = increase knowledge = recognize risk factors = identify affected individuals

RISK FACTORS Obesity Obesity Age Age Sex Sex Race Race Craniofacial anatomy Craniofacial anatomy Smoking and alcohol consumption Smoking and alcohol consumption

CRANIOFACIAL ANATOMY Mandibular body length Mandibular body length Retrognathia Retrognathia Tonsilar hypertrophy Tonsilar hypertrophy Enlarged tongue or soft palate Enlarged tongue or soft palate Inferiorly positioned hyoid bone Inferiorly positioned hyoid bone Maxillary and mandibular retro position Maxillary and mandibular retro position Decreased posterior airway space Decreased posterior airway space

Diagnosis of Obstructive Sleep Apnea The reference standard for diagnosis of sleep disorders is to perform polysomnography (a sleep study), during which the sleeping patient is observed for oxygen saturation level, amount of oral and nasal airflow, degree of respiratory effort, electrocardiographic measurements, body position, and overall body movement. The reference standard for diagnosis of sleep disorders is to perform polysomnography (a sleep study), during which the sleeping patient is observed for oxygen saturation level, amount of oral and nasal airflow, degree of respiratory effort, electrocardiographic measurements, body position, and overall body movement. This examination can be done both “inhouse” in a sleep laboratory and with home sleep studies for which the patient is connected to monitors and observed in the patient's natural sleep environment. This examination can be done both “inhouse” in a sleep laboratory and with home sleep studies for which the patient is connected to monitors and observed in the patient's natural sleep environment.

Polysomnography Recurrent episodes of complete or partial collapse of Recurrent episodes of complete or partial collapse of the upper airway are recorded as apnea or hypopnea the upper airway are recorded as apnea or hypopnea events. events.  Apnea = complete cessation of airflow for at least 10 seconds for at least 10 seconds  Hypopnea = 25 – 50% reduction in oro-nasal airflow associated with desaturation or an arousal from sleep.

Polysomnography Sleep apnea severity index: Sleep apnea severity index: AHI = apnea-hypopnea index AHI = apnea-hypopnea index = # of apneas and hypopneas / hour of sleep = # of apneas and hypopneas / hour of sleep Mild: 5 – 15 events/hour of sleep Mild: 5 – 15 events/hour of sleep Moderate: 15 – 30 event/hour of sleep Moderate: 15 – 30 event/hour of sleep Severe: > 30 events/hour of sleep Severe: > 30 events/hour of sleep

On the basis of the apnea-hypopnea index, the severity of sleep apnea is categorized as: Mild sleep apnea is defined by an apnea-hypopnea index score anywhere from 5 to 14, oxygen saturation level of at least 86%, and minimal daytime disability. Mild sleep apnea is defined by an apnea-hypopnea index score anywhere from 5 to 14, oxygen saturation level of at least 86%, and minimal daytime disability. Moderate sleep apnea is defined by an index score anywhere from 15 to 30 or an oxygen saturation level of 80% to 85% and clinically significant dysfunction at work or socially because of daytime somnolence and loss of concentration. Moderate sleep apnea is defined by an index score anywhere from 15 to 30 or an oxygen saturation level of 80% to 85% and clinically significant dysfunction at work or socially because of daytime somnolence and loss of concentration. Severe sleep apnea is defined by an index score >30 or an oxygen saturation level of ≤79% and incapacitation caused by the sleep disorder. Severe sleep apnea is defined by an index score >30 or an oxygen saturation level of ≤79% and incapacitation caused by the sleep disorder.

DIAGNOSIS American Academy of Sleep Medicine criterias: American Academy of Sleep Medicine criterias: A. Excessive daytime sleepiness that is not better A. Excessive daytime sleepiness that is not better explained by other factors explained by other factors B. Two or more of the following that are not better explained by other factors: B. Two or more of the following that are not better explained by other factors: choking during sleep; recurrent awakenings; choking during sleep; recurrent awakenings; unrefreshing sleep; daytime fatigue; impaired concentration. unrefreshing sleep; daytime fatigue; impaired concentration. C. AHI (five or more obstructed breathing C. AHI (five or more obstructed breathing events per hour during sleep). events per hour during sleep).

Complications of untreated obstructive sleep apnea can include cardiovascular changes such as Complications of untreated obstructive sleep apnea can include cardiovascular changes such as hypertension, hypertension, ventricular dysfunction ventricular dysfunction pulmonary hypertension pulmonary hypertension

CARDIOVASCULAR RISK Stressors arise from Stressors arise from Hypoxemia Hypoxemia Reoxygenation Reoxygenation Changes in intrathoracic pressure Changes in intrathoracic pressure CNS arousals CNS arousals Stimulation of sympathetic nervous system Stimulation of sympathetic nervous system Acute peripheral vasoconstriction  elev BP Acute peripheral vasoconstriction  elev BP persist even in waking hours  elev BP persist even in waking hours  elev BP

Cardiovascular Risk HYPERTENSION HYPERTENSION  Most studies suggest that OSA contributes to systemic HTN to systemic HTN  Treatment of OSA may improve systemic HTN (Consider this especially in the patient with risk (Consider this especially in the patient with risk factors and clinical features of OSA, and the factors and clinical features of OSA, and the HTN has been difficult to treat) HTN has been difficult to treat)

Cardiovascular Risk Cardiac arrhythmias Cardiac arrhythmias - bradycardia (increase vagal tone with hypoxemia) - bradycardia (increase vagal tone with hypoxemia) - asystole - asystole - atrial fibrillation - atrial fibrillation - NSVT - NSVT - ectopic ventricular beats - ectopic ventricular beats (bigeminy, trigeminy) (bigeminy, trigeminy)

Consequences: Excessive Daytime Sleepiness Increased motor vehicle crashes Increased motor vehicle crashes Increased work-related accidents Increased work-related accidents Poor job performance Poor job performance Depression Depression Family discord Family discord Decreased quality of life Decreased quality of life

Car accidents Accident / driver / 5 yrs Adapted from Findley LJ et al. Am Rev Respir Dis 1988; American Academy of Sleep Medicine

BEHAVIORAL TREATMENT Weight loss Weight loss Avoid alcohol and sedatives Avoid alcohol and sedatives Avoid sleep deprivation Avoid sleep deprivation Avoid supine sleep position Avoid supine sleep position Stop smoking Stop smoking

SLEEP POSITION TRAINING Lying in the supine position results in a decrease in the size of the pharynx because of the effects of gravity.66,67 As a result, some people experience sleep apnea only when sleeping on their backs.

CPAP Patients with moderate to severe sleep apnea are treated with continuous positive airway pressure (CPAP). Patients with moderate to severe sleep apnea are treated with continuous positive airway pressure (CPAP). This therapy requires the patient to wear a mask over their nose during sleep, when the pressure is adjusted to keep the airway open at night. This therapy requires the patient to wear a mask over their nose during sleep, when the pressure is adjusted to keep the airway open at night. Although CPAP therapy is the most effective treatment for obstructive sleep apnea, this therapy is often unsuccessful because of patient noncompliance: Some studies have reported compliance rates lower than 70%. Although CPAP therapy is the most effective treatment for obstructive sleep apnea, this therapy is often unsuccessful because of patient noncompliance: Some studies have reported compliance rates lower than 70%.

Otherwise snore and this will happen to you…. Or sleep alone….

Surgical procedures Uvulopalatopharyngoplasty (UPPP), a procedure which removes soft tissue at the back of the throat—uvula, tonsils (if present), and part of the redundant soft palate—but does not address problems originating at the base of tongue or hypopharynx; Uvulopalatopharyngoplasty (UPPP), a procedure which removes soft tissue at the back of the throat—uvula, tonsils (if present), and part of the redundant soft palate—but does not address problems originating at the base of tongue or hypopharynx; Tonsillectomy and adenoidectomy (effective in some children); Tonsillectomy and adenoidectomy (effective in some children); Mandibular and hyoid advancement procedures (operations which are difficult, risky, and inconsistently successful); Mandibular and hyoid advancement procedures (operations which are difficult, risky, and inconsistently successful); Radiofrequency ablation procedures (effective treatment for snoring but inconsistently successful for treating sleep apnea). Radiofrequency ablation procedures (effective treatment for snoring but inconsistently successful for treating sleep apnea).

2006 American Academy of Sleep Medicine The patient described in the present case report was treated with CPAP and noted substantial reduction in both fatigue and daytime somnolence. The patient described in the present case report was treated with CPAP and noted substantial reduction in both fatigue and daytime somnolence.