OBSTRUCTIVE SLEEP-RELATED BREATHING DISORDERS IN ADULTS DR. MOHSEN PAZOOKI

Obstructive sleep-related breathing disorders  Snoring  Upper Airway Resistant Syndrome  Obstructive Sleep Apnea Syndrome

Snoring  Incidence  40% M  20% F  Often (but not always) accompanies sleep disordered breathing  Not ass. With excessive daytime sleepiness or insomnia

Snoring  AHI < 5 without daytime symptoms  PSG is not required for Dx  No ass. With : - Arousals - Desaturations - Airflow limitation - Arrhythmias

Upper airway resistant syndrome  Do not meet OSA criteria but experience excessive daytime somnolence and other debilitating somatic complaints

Upper airway resistant syndrome  characterized by respiratory effort related arousals (RERAs)  RERA is detected using esophageal pressure manometry, which reveals a pattern of progressively increasing negative esophageal pressure followed by an arousal.

Upper airway resistant syndrome  PSG : - Frequent arousals associated with snoring, abnormally negative intrathoracic pressure, or increased diaphragmatic electromyogram activity.

OSAS  Incident :  2% of F & 4% of M > 50y

OSAS  five or more respiratory events (apneas, hypopneas, or RERAs)  Ass. with - excessive daytime somnolence, - Waking with gasping, choking, or brearh-holding, or - witnessed reports of apneas, loud snoring, or both

OSAS  apnea or hypopnea commonly accompanied by: - Reductions in blood oxygen saturation of at least 3% to 4% - Usually terminated by brief, unconscious arousals

OSAS  Snoring: - frequent complaint of bed partners - often the symptom that prompts these patients to seek medical attention  Excessive daytime somnolence : common presenting complaint

OSAS  Other complaints : - Automobile accidents - increased cardiovascular morbidity and mortality - morning headache, sore throat - fatigue or a feeling of being unrefreshed regardless of the duration of sleep

OSAS  Exacerbation : - ingestion of alcohol - Sedative use - weight gain

Sleep disordered breathing symp  Restless sleep  Loud snoring  Observed apnea,choking or gasping episodes  Excessive daytime sleepiness(E DS)  Morning fatigue or irritability  Memory loss  Decreased cognitive function

Sleep disordered breathing symp  Depression  Personality or mood changes  Decreased libido and impotence  Morning and nocturnal headaches  Nocturnal sweating  Nocturnal enuresis

Pathophysiology  collapse of the pharyngeal airway during sleep due to relaxation of the pharyngeal dilator muscles

 Obesity  soft tissue hypertrophy  craniofacial characteristics such as retrognathia

Major areas of obstruction  Nose  Palate  Hypopharynx  laryngeal obstruction from bilateral laryngeal paralysis, laryngomalacia, and obstructing laryngeal lesions has also been reported.

Obesity  major risk factor for OSA  deleterious effects on metabolism, ventilation, and lung volume, resulting in V/Q mismatch  Significantly reduce lung volume, which results in a reduction of functional residual capacity

 Adenotonsillar hypertrophy : major cause in children  In adults : multiple craniofacial variations

Consequences of untreated OSAS  increased mortality  increase in cardiovascular disease: - hypertension, coronary heart disease, congestive heart failure, arrhythmias, sudden death, pulmonary hypertension, and stroke  neurocognitive difficulties  increased risk of motor vehicle accidents by 2.5-fold

Consequences of untreated OSAS  independent risk factor for insulin resistance  contribute to the development of diabetes and metabolic syndrome,the term used to describe the commonly occurring conditions of obesity, insulin resistance, hypertension, and dyslipidemia.

Consequences of untreated OSAS  GERD : (Treatment with CPAP decreases the occurrence of GERD)  problems with attention, working memory, and executive function (all of which are improved with CPAP treatment)

Diagnosis  most common symptoms : - loud snoring - restless sleep - daytime hypersomnolence

Diagnosis  Obesity :70% of adult patients  Screening, including a detailed sleep history and physical examination, is recommended for all obese patients

Epworth Sleepiness Scale

 OSA may be suspected in patients with an ESS greater than 10

Dx  patients with HTN, CAD, CHF, CVA, and DM, must be carefully screened for the signs and symptoms of OSA  Women : insomnia, heart palpitation, ankle edema

P.E.  P.E. strengthens the Dx  BMI, BP, Neck circumference

Dx  Fiberoptic Flexible Nasopharyngoscopy (with Muller’s Maneuver)  Drug induced sleep videoendoscopy  Nocturnal PSG : gold standard

Sleep related breathing disorders

Medical Tx.  a stepwise manner begins with conservative medical measures.  'Weight loss” for all overweight patients  Consultation with a bariatric surgeon in morbidly obese patients  surgically induced weight loss significantly improves obesity-related OSA and parameters of sleep quality as early as 1 month after surgery.

Medical Tx.  CPAP : gold standard for moderate to severe OSAS  Reduction in AHI, sleepiness, CVA, motor vehicle accidents & improvement in QOL  Decreased inflammation as measured by a decrease in the inflammatory markers CRP and IL-6, improved endothelial function, and reduced diurnal sympathetic activity.

Medical Tx.  BiPAP  APAP  Oral appliances for mild, moderate OSA (greater satisfaction)  Pharmacologic therapy: alternative in CPAP intolerance: Modafinil, Fluticazone, Montelukast, nasal dilator strips, topical decongestants

Indications of Surgical Tx.

Sx. options