1. Obstructive Sleep Apnea Brent A. Senior, MD Associate Professor Chief, Rhinology, Allergy, and Sinus Surgery Otolaryngology/Head and Neck Surgery University of North Carolina

2. What is OSA? n Disorder of obstructed breathing occurring during sleep n Apnea: cessation of breathing with respiratory effort lasting greater than 10s n Hypopnea: u decreased airflow of >70% u Any decreased airflow with desaturation <90% n Total apneas and hypopneas per hour = AHI or RDI or REI

3. What is Significant OSA? n Uh, I don’t know n Most consider significant sleep apnea to be present with an REI > 15 u 15-25: Mild Apnea u 26-40: Moderate Apnea u >40: Severe Apnea

4. Who’s Got It? n NCSDR-1993 u 40 million Americans with chronic sleep disorder u 20 million with occasional sleep disorder n SDB (REI >5): 24% middle aged males u 9% middle aged females n OSA >15/hr: 4% middle aged males u 2% middle aged females F NEJM 1993; 328: 1230-35

5. Why is it so Important? n Hypertension u 25% of hypertensives have OSA (AI>5) u Sleep Heart Health Study F 6000 patients corrected for bmi, neck, EtOH Nieto, et al. JAMA 283 (14): 1829-36, April 2000Nieto, et al. JAMA 283 (14): 1829-36, April 2000 u SDB (including snoring) and Htn correlate F 1700 patients Bixler, et al Arch IM 160 (15): 2289-95, 2000Bixler, et al Arch IM 160 (15): 2289-95, 2000 F Sleep 1980; 3: 221-4 F BMJ 1987; 294: 16-19

6. Health Impact n MI u REI >20 independent predictor of MI F 223 German males with angio confirmed CAD Schafer, et al. Cardiology 92(2): 79-84, 1999Schafer, et al. Cardiology 92(2): 79-84, 1999 u Increased mortality in CAD patients F 5 y study (Sweden)-62 patients; 19 with OSA (RDI 17) OSA mortality: 37.5%; Non-osa mortality: 9.3%OSA mortality: 37.5%; Non-osa mortality: 9.3% Peker, et al. Am J Resp Crit Care 162 (1): 81-6, 7/2000Peker, et al. Am J Resp Crit Care 162 (1): 81-6, 7/2000

7. Health Impact n CVA u REI severity is independent predictor of Stroke F 128 patients (UM)- 75 stroke; 53 TIA F 62.5% with AHI >10 with stroke vs 12% controls Bassetti, C et al. Sleep 22(2): 217-23, 3/1999Bassetti, C et al. Sleep 22(2): 217-23, 3/1999

8. Health Impact n Death u AI<20, at 8y follow-up: 4% mortality u AI>20, at 8y follow-up: 37% mortality u treatment with trach or CPAP: 0% mortality F Chest 1988; 94: 9-14 n NCSDR 1993 u 38000 CV deaths related to OSA per year

9. Societal Impact

10. n 75% of 75000 screened will be diagnosed with OSA ($275 million) n Fragmentation of sleep occurring with SDB u increased daytime sleepiness, decreased intellect, behavioral and personality changes, enuresis, sexual dysfunction F Am J Resp Crit Care Med 1996; 153: 1328-32

11. Societal Impact n Increased Traffic Accidents u simulated driving: SDB ~100x more likely to drive off the road F Acta Otolaryn 1990; 110: 136ff u 7x increased risk of auto accidents F Clin Chest Med 1992; 13: 427-34

12. Societal Impact n Reaction times u with OSA equivalent to a normal control who was legally intoxicated (ABL >0.8) F Powell NB et al. Laryngoscope. 109(10):1648-54, 1999 u UPPP decreases the number of MVA F ORL 1991; 53: 106-111 F Laryngoscope 1995; 105: 657-61

13. How’s it Diagnosed? n History, Physical Examination, and Sleep Study n History u Disrupted sleep, restless sleep, awaken with gasping and choking u Loud snoring u Tired, inappropriate falling asleep u Witnessed apneas

14. History n Associated Complaints u Weight changes u Thyroid/Growth Hormone abnormalities u GERD n Habits u sleep schedule u EtOH n PMH/Meds u Hypertension u Sedatives; Antihistamines

15. Physical Exam n Height and Weight (BMI) u BMI=[703.1 x weight(pounds)] / [Height (in) 2 ] u neck size u Face-retrognathia u Nose u Oral cavity- palate, uvula, tonsils/pillars, tongue, occlusion

16. Physical Examination

18. Fiberoptic Nasopharyngolaryngoscopy n Determines level of obstruction n Provides estimate of degree of obstruction n Technique u supine (i.e., in a sleeping position) u at FRC-point of maximal relaxation u snore maneuver u Mueller maneuver- inspire against a closed airway

19. Evaluation n Key Features of the History and Exam u History (105 patients) F apnea reported by bed partner (p<0.01) F awakes with choking (p<0.005) F hypertension: dias >95 (p 95 (p<0.01) u Exam F BMI>30 (p 30 (p<0.01) u All: sensitivity 92%; specificity 51% F Am Rev Resp Dis 1990; 142: 14-18

20. Objective Sleep Monitoring n Rationale: Difficulty predicting OSA by H&P with no EDS u Loud snoring and witnessed apneas identify OSA 54-64% of the time F Sleep 1988; 11: 430-36 u H&P predict OSA only 60% of the time F Sleep 1993; 16: 118-22

21. How To Treat? n Minimal intervention u Drop the Weight! u Dental Appliances F Variable success rates, though probably more useful for mild apnea F ?compliance n Interventional u CPAP u Surgery

22. CPAP n The “Gold Standard” in the treatment of OSA u Works the best in the most people u Positive pressure ventilation functions as a pneumatic splint for the collapsing upper airway n But... compliance is very poor u 159/214 (74%); mean 5.6 h/night; 77-89% compliance (!) F Krieger. Sleep 15 (6 Suppl) S42-6, 1992

23. Surgery n Tracheotomy u An incision in the trachea u Cures OSA nearly 100% of the time u Prior to 1980, it’s all we had; still useful for severe apneics

24. Remove Tissue- Uvulopalatopharyngoplasty (UPPP) n First successful alternative to tracheotomy u 12 individuals F preop AI 54 +/- 28 F postop AI 28 +/- 28 F 8/12 with post-op AI<20 Fujita et al. Otolaryngol HNS 1981; 89:923-34Fujita et al. Otolaryngol HNS 1981; 89:923-34

25. Remove Tissue-Other Surgeries n Laser Midline Glossectomy n Palatal Somnoplasty n LAUP n Radiofrequency tongue base reduction u Woodson, et al, AAO 2000, Washington DC F 18 patients completed protocol, average 15,696 J REI decreased from 45.3 to 33.3REI decreased from 45.3 to 33.3

26. Enlarge the Bony Space- Other Surgeries n Genioglossus Advancement/ Hyoid Repositioning u Success ~80% (11-18mm) u Less effective with RDI >60 n Maxillo-mandibular Advancement u Particularly useful in the setting of hypopharyngeal obstruction (Fujita 2 or 3) u Best results when performed following “Stage 1” surgery

27. Complication Avoidance n All OSA patients are at risk of Airway Obstruction (even mild) n Minimize risk: u Expect intubation disaster u Pharyngeal procedure with nasal procedure increases risk regardless of apnea severity F Mickelson and Hakim, Oto HNS 119: 352-6, 1998 u Amount of intraoperative narcotic- worse with greater apnea severity F Esclamado, Laryngoscope 99: 11-29, 1989 u Monitor post-op with continuous oximetry

28. Summary n OSA is a potentially life-threatening disorder that demands proper evaluation n Components of that proper evaluation include detailed sleep history, PE, and endoscopic evaluation n Objective sleep evaluation is required prior to intervention

29. Summary n Treatments include u Conservative non-interventional techniques F Weight loss, dental appliances u CPAP u Surgery