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

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”.

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

4. OSA & Cardiovascular Diseases
Uncontrolled HTN- 83% have OSAH; activation of sympathetic drive.
Acute coronary syndrome % has OSA
Cardiac arrhythmias mostly Af
Heart Failure
Sudden cardiac death
Stroke

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)

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 yrs aged semi-urban prevalence of OSAS was 3.57%
In Bangladesh, the prevalence of OSAHS was 3.29%.

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

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.

9. Anatomy of OSA
NORMAL SNORING SLEEP APNEA

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

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

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

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

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

15. The Epworth Sleepiness Score
Sitting and reading 2
Watching TV 3
Sitting in active in a public place (e.g. a theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the after noon When circumstances permit
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!

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

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

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
1818

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

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

21. Overnight PSG

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 Moderate OSA
AHI >30 Severe OSA

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

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

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

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

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

29. Oral Appliances MAD TRD □ Not as effective as CPAP,
□ 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

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

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

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.