1. Sleep Apnea Dr. Vishal Sharma

2. History Lugaresis (1970): described OSAS Stanford University (1972): Polysomnography Sleep Latency Test devised in 1976 Before 1980’s tracheostomy main treatment Ikematsu performed first UPPP in 1952 Fujita popularized UPPP Kamami developed LAUP in late 1980s

3. Definitions

4. Sleep related breathing disorders Synonym: sleep disordered breathing Consists of: A. Snoring B. Obstructive sleep apnea C. Obstructive sleep hypopnea D. Upper airways resistance syndrome

5. Arousal: Abrupt change from deep stage to lighter stage of NREM sleep, or from REM sleep to awakening Arousal index: Number of arousals per hour of sleep Apnea: Cessation of breathing for > 10 seconds Apnea Index: Number of apneas per hour of sleep Hypopnea: Decreased airflow (>50%) with oxygen desaturation (> 4% ) for > 10 seconds Snoring: breathing noise due to partial upper airway obstruction

6. Obstructive sleep apnea: Cessation of airflow for > 10 seconds even with continued respiratory effort Obstructive sleep hypopnea: Decreased airflow (>50%) with oxygen desaturation (> 4% ) for > 10 seconds even with continued respiratory effort Upper airway resistance syndrome (respiratory effort related arousal): partial airway obstruction with no apnea or hypnea, but arousal index > 15

7. Respiratory Distress Index: Number of apneas + hypopneas + respiratory effort related arousals per hour Obstructive sleep apnea syndrome: 30 or more episodes of obstructive sleep apnea during a 7- hour period of sleep or apnea index > 5 or respiratory distress index > 15

8. Types of sleep apnea 1. Obstructive: Normal respiratory chest wall movement 2. Central: No respiratory chest wall movement 3. Mixed: Partial respiratory chest wall movement

10. American Sleep association grading: 1. Mild ------------5 - 20 apneas per hour 2. Moderate ----- 20 - 40 apneas per hour 3. Severe --------more than 40 apneas per hour Grades of sleep apnea

11. Etiology of central sleep apnea

12. Cheyne-Stokes breathing-central sleep apnea due to renal failure, heart failure, stroke Diabetes mellitus, Hypothyroidism, Acromegaly, Parkinson disease, Myasthenia gravis, Idiopathic cardiomyopathy, Muscular dystrophy Medullary tumor or infarction Arnold-Chiari malformation Cervical cordotomy High-altitude periodic breathing (at > 5000m) Use of opiates & other CNS depressants

13. Cheyne-Stokes crescendo- decrescendo breathing

14. Etiology of obstructive sleep apnea

15. Nose Nasal polyps DNS  ed Turbinate Nasal packing Larynx Tumors Edema Stenosis Pharynx Nasopharyngeal tumor Adenoids  ed palatal / lingual tonsil Enlarged lingual tonsils Retropharyngeal mass Large tongue Micrognathia / Retrognathia Obesity

19. Patho-physiology

20. Increased compliance of pharyngeal tissues + Neuromuscular in-coordination &  ed muscle tone + Anatomical abnormalities Upper airway collapse  airway obstruction Hypoxia + negative intra-thoracic pressure  Arousal Increased tone of upper airway muscles + upper airway obstruction clears Patient goes to sleep Upper airway collapses again causing arousal

21. Sequelae of sleep apnea

22. Complications of sleep apnea  Systemic hypertension  Coronary artery disease  Pulmonary hypertension  Right heart failure  Cardiac arrhythmias  Cerebro-vascular accident  Polycythemia  Sleepiness accidents  Depression  Impotence  Vagal bradycardia  Sudden nocturnal death

23. Clinical Features

24. Snoring or sleep apnea?

25. Symptoms of sleep apnea Day- time  Excessive sleepiness  Morning headache  Intellectual deterioration  Personality change  Depression  Xerostomia  Abnormal movements Night- time  Snoring  Observed choking  Arousal from sleep  Repeated waking  Nocturnal sweating  Nocturnal enuresis  Impotence

26. Typical OSAS patient Synonym: Pickwickian syndrome Middle age or elderly male with hyper somnolence Obese with body mass index > 30 Short neck with its circumference > 17 inches Hypertension & right heart failure Large bulky tongue, hypertrophied tonsils, bulky soft palate, prominent posterior pharyngeal wall rugae

27. Mr. Pickwick & fat boy Joe

28. Throat in OSAS

29. History from sleep partner Bed timings Body position Snoring Apnea (choking) Arousal from sleep Alcohol consumption Sedative use

30. Epworth daytime sleepiness scale Score > 16 = moderate to severe sleep apnea

31. General appearance, weight, body mass index Blood pressure, cardiovascular examination Cranio-facial: retrognathia, hypoplastic maxilla Nasal: airway patency, DNS, turbinate hypertrophy Tongue: macroglossia, lingual tonsil Nasopharynx: adenoids, polyp, cyst, tumor Physical examination

32. Oropharynx: Soft palate, palatine tonsil, base of tongue, posterior pharyngeal wall Hypopharynx: tumor Larynx: cyst, tumor, vocal cord mobility Neck: short wide neck (circumference > 17 inches) Thyroid enlargement, features of hypothyroidism

33. Investigations

34. General Investigations Complete blood count: anemia, polycythemia Chest x-ray: cardiomegaly, pulmonary disorder Lung function: portable spirometry flow volume loop  saw-tooth pattern Thyroid function tests: hypothyroidism Electro-cardiography: cardiac arrhythmias Arterial blood gas analysis

35. Portable spirometer

36. Investigations for confirmation of sleep apnea Polysomnography Portable sleep monitoring Overnight pulse oximetry recording Multiple sleep latency test

37. 1. Electro-encephalogram (EEG) 2. Electro-myogram (EMG): submental, anterior tibialis 3. Electro-oculogram (EOG) / Electro-nystagmogram 4. Electro-cardiogram (ECG) 5. Oxygen saturation 6. Nasal & oral airflow 7. Chest + abdominal movement detector 8. Sleeping position detector 9. Tracheal microphone 10. Esophageal manometer Polysomnography parameters

39. Polysomnogram

42. Polysomnogram in arousal

43. Portable polysomnogram

45. Awake patientSleeping patient Muller maneuver Flexible nasendoscopy Lateral cephalometry Somno-fluoroscopy C.T. scan of neck Cine C.T. scan Pharyngeal manometry Investigations to assess site of airway obstruction

46. Flexible endoscopy

47. Muller’s maneuver After a forced expiration, pt attempts inspiration with closed mouth & nose, whereby negative pressure leads to collapse of airway Previously introduced flexible endoscope (via nasal cavity) identifies weakened sections of airway at levels of soft palate & tongue base, during this maneuver

49. Muller’s maneuver in snoring shows no airway narrowing Before MullerAfter Muller

50. Muller’s maneuver in apnea shows airway narrowing Before MullerAfter Muller

51. Degree of airway obstruction 0 = no collapse 1+ = minimal collapse 2+ = collapse  es cross-sectional area by 50% 3+ = collapse  es cross-sectional area by 75% 4+ = collapse obliterates airway 3+ or 4+ score at soft palate level with 0 score at tongue base level is ideal for UPPP Score of > 2+ at tongue base level is not suitable for Uvulo-palato-pharyngo-plasty (UPPP)

52. Muller’s obstruction types Oropharynx obstruction (soft palate) Hypopharynx obstruction (tongue base) I3+, 4+0, 1+ II a3+, 4+1+, 2+ II b3+, 4+ III0, 1+3+, 4+

53. Lateral cephalometry

55. Measurements in obstructive sleep apnea: Posterior airway space (PAS) or narrowest width of hypopharynx is < 5 mm Distance b/w mandibular plane to hyoid bone (MP-H) is > 24 mm

56. Somno-fluoroscopy Sleeping pt observed with polysomnography & during apneic episode visualized with fluoroscopy for upper airway obstruction Type I = obstruction at soft palate level only Type II = obstruction at soft palate level followed by obstruction at tongue base level Type III = obstruction at tongue base level

58. Cine C.T. scan: Rapid CT scanning of 8 cm of upper airway in 240 msec during apneic episode to study anatomical changes during apneic episode. Research tool. Pharyngeal manometry: Measurement of intra-luminal pressure at level of soft palate, tongue base & hypopharynx

59. D/D of excessive daytime sleepiness (hyper somnolence)  Sleep apnea syndrome  Narcolepsy  Sleep deprivation  Hypoglycemia  Hypothyroidism  Severe anemia  Cerebral tumors  Depression  Sedative drugs  Nocturnal myoclonus  Idiopathic

60. Non-surgical Tx for OSAS Lifestyle modifications Sleep hygiene Medications Nasal valve dilator Positioning device Nasal positive airway pressure device

61. Lifestyle modifications Weight reduction for obese patients Body mass index = weight in kg / (height in metres) 2 Ideal BMI: male < 27.8; female < 27.3 Stop smoking Stop alcohol consumption Avoid sedative drugs

62. Sleep hygiene Elevate head-end of bed by 30 0 : decreases pressure of abdominal contents on diaphragm & improves upper airway patency Avoid lying supine: T-shirt with tennis ball at back Avoid sleep deprivation Have regular sleep cycle

63. Medications Amitriptyline & Protriptyline: suppress REM sleep, respiratory stimulant, increase pharyngeal muscle tone Nasal decongestant, antihistamine, steroid spray Fenfluramine to reduce obesity Thyroxin for hypothyroidism

64. Nasal valve dilator Adhesive strip placed over bridge of nose at bedtime

65. Nasal valve dilator Plastic spring ends inserted into nostrils

66. Nasal valve dilator

67. Positioning devices Tongue retaining device Mandibular advancement device Optimized mandible retention Thornton adjustable positioner

68. Effect of positioning devices

69. Mandible advancement device

70. Tongue retaining device Prevents falling back of tongue

71. Optimized mandible retention

72. Thornton adjustable positioner

73. Positive airway pressure devices Gold standard treatment Prevents apneas in 99-100% patients C.P.A.P.: Continuous positive airway pressure Bi.P.A.P.: Bi-level positive airway pressure (less pressure given during expiration) A.P.A.P.: Automatic positive airway pressure (adjusts pressure breath by breath)

74. Continuous positive airway pressure

79. Polysomnogram before CPAP

80. Polysomnogram after CPAP

81. Surgical Tx of OSAS 1.Nasal surgery 2.Palatal surgery 3.Tongue base surgery 4.Maxillo-facial surgery 5.Tracheostomy: last resort, 100% cure; relieves all levels of airway obstruction

82. Nasal & nasopharyngeal surgery More effective for snoring than sleep apnea 1. Septo-turbinoplasty 2. Radio-frequency turbinate somnoplasty 3. Nasal polypectomy 4. Nasal valve reconstruction 5. Nasal mass excision 6. Adeno-tonsillectomy

83. Somnoplasty Small probe delivers radiofrequency energy into tissue bulk, causing coagulative lesions which shrink on healing Body absorbs these lesions over 4-8 weeks leading to tissue volume reduction Used for enlarged base of tongue / soft palate / turbinates causing snoring / sleep apnea

84. Turbinate Somnoplasty

85. Palatal Surgery Relieve palato-pharyngeal level obstruction 1. Uvulo-palato-pharyngo-plasty (UPPP) 2. Laser-assisted Uvulo Palato-plasty (LAUP) 3. Radio-frequency uvulo-palato-plasty (RFUP) 4. Uvulo-palatal flap 5. Lateral pharyngoplasty 6. Palatal stiffening operations

86. Uvulo Palato Pharyngo Plasty

87. Remove palatine tonsils Trim tonsillar pillars (optional) Remove uvula & variable amount of soft palate Suture posterior tonsillar pillar to anterior tonsillar pillar Suture posterior soft palate mucosa to anterior soft palate mucosa

88. Uvulo-palato-pharyngo-plasty

90. Post excision & suturing

91. Structures removed in UPPP

92. Uvulo-palato-pharyngo-plasty

93. Post-UPPP healing

94. Laser-assisted uvulopalatoplasty

96. Soft palate Somnoplasty

98. Uvulo-palatal flap

99. Lateral Pharyngoplasty

101. Palatal stiffening surgery Done primarily for snoring Injection of sclerosing agents into soft palate Laser-assisted palatal stiffening operation: longitudinal strip of palatal mucosa removed lesion heals by scarring Cautery-assisted palatal stiffening operation Pillar procedure

104. Tongue base surgery 1. Radiofrequency tongue base somnoplasty 2. Submucosal Minimally Invasive Lingual Excision or Coblation tongue base ablation 3. Laser–assisted tongue base ablation 4. Lingual tonsillectomy 5. Linguloplasty 6. Tongue base suspension

105. Tongue base Somnoplasty

106. Coblation partial glossectomy

108. Coblation lingual tonsillectomy

109. Linguloplasty

110. Tongue base suspension

113. Maxillofacial Procedures Relieve tongue base level obstruction 1. Maxillo-mandibular osteotomy & advancement 2. Genioglossus advancement 3. Maxillary expansion 4. Mandibular expansion 5. Infra-hyoid myotomy & superior suspension 6. Supra-hyoid myotomy & anterior advancement

114. Mandibular advancement

115. Maxillo-mandibular advancement

116. Genioglossus advancement

118. Maxillary expansion

119. Mandibular expansion

120. Infra-hyoid myotomy + superior suspension to mandible

121. Supra-hyoid myotomy & anterior advancement to thyroid cartilage

122. Tracheostomy

123. Treatment of central sleep apnea Acetazolamide: induces metabolic acidosis & increases baseline ventilation Theophylline: respiratory stimulant Zolpidem: sedative hypnotic, consolidates sleep Continuous positive airway pressure Adaptive servo ventilation: provides a fixed CPAP of 5 cm water. Better than nasal CPAP.

124. Thank You