1. Sleep apnea approach & managmen t Mohammed alessa MBBS, FRCSC Otolaryngology, Head & Neck surgery consultant Assistant professor,KSU

2. Background Pathophysiology Etiology Epidemiology Clinical Presentation DDX Work up Management

3. Background Affecting 2-4% of adult population Sleep disorders, including sleep apnea, have become a significant health issue in the KSA. 80 % of the cases of moderate and severe obstructive sleep apnea undiagnosed. Sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. It is the most common type of sleep-disordered breathing (SDB). Recurrent episodes of upper airway (UA) collapse during sleep. These episodes are associated with recurrent oxyhemoglobin desaturations and arousals from sleep.

4. If left untreated can lead to HTN, CHF, AF, stroke, and other cardiovascular problems. Associated with type 2 diabetes and depression & Obesity A factor in many MVAs with heavy machinery, The public and the health community are generally aware of the increasing obesity of KSA. Prevalence of OSA in Saudi young age female is 39 % (1) (1) Prevalence of symptoms and risk of sleep apnea in middle-aged Saudi women in primary care. Bahammam AS, Saudi Med J. 2009 Dec;30(12):1572-6.

5. Definitions of respiratory events ( AASM), 2005 Apnea, Hypopnea, RERA ( respiratory even related arousal ).

6. Sleep apnea Cessation of airflow for at least 10s leading to arousal: With thoracoabdominal effort ( Obstructive) without effort ( Central) without effort then severe effort ( Mixed)

7. Hypopnea Transient reduction of breathing (>50%) for> 10s leading to arousal. OR Oxygen desaturation >4%.

8. RERA Respiratory effort >10 s leading to an arousal No desaturation Normal PSG The criterion standard to measure RERAs is esophageal manometry.

9. AHI & RDI AHI : total number of apneic and hypopnea episodes per hour of sleep. RDI : AHI + RERA : 5-15/hr Mild 15-30/hr Moderate > 30/hr Severe

10. Pediatric OSA ( Criteria) OSAS = AHI >1 CO2 50 mmHg > 10% of sleep time CO2 45 mmHg > 60% of sleep time Minimum O2 sat <92%

11. Pathophysiology Static factors Dynamic factors

12. Static factors Surface adhesive forces Neck and jaw posture Tracheal tug Gravity Reduced diameter of the pharyngeal airway

13. Dynamic factors Bernoulli effect ( OSA increase in obese patients)

14. Etiology Structural factors Nonstructural factors.

15. Etiology structural factors Innate anatomic variations (facial elongation, posterior facial compression) Retrognathia and micrognathia Mandibular hypoplasia Brachycephalic head form - Associated with an increased AHI in whites but not in African Americans. Inferior displacement of the hyoid Adenotonsillar hypertrophy, particularly in children and young adults Nasal obstruction High, arched palate (particularly in women)

16. Etiology non structural factors Obesity ( BMI>35) Central fat distribution Male gender ( M:F) 3:1 Age ( >65 Years) Postmenopausal state Alcohol use Sedative use Smoking Habitual snoring with daytime somnolence Supine sleep position Rapid eye movement (REM) sleep Familial factors Hypothyroidism S troke

17. Sequels of OSA Hypertension Arrhythmias Myocardial infarction Heart failure Stroke Pulmonary hypertension MVA & Death

18. History Nocturnal symptoms Snoring, usually loud, habitual, and bothersome to others Witnessed apneas, which often interrupt the snoring and end with a snort Gasping and choking sensations that arouse the patient from sleep, though in a very low proportion relative to the number of apneas they experience Nocturia Insomnia Restless sleep, with patients often experiencing frequent arousals and tossing or turning during the night

19. History : Daytime symptoms Nonrestorative sleep (ie, “waking up as tired as when they went to bed”) Morning headache, dry or sore throat Excessive daytime sleepiness (EDS) that usually begins during quiet activities (eg, reading, watching television); as the severity worsens, patients begin to feel sleepy during activities that generally require alertness (eg, school, work, driving). Daytime fatigue/tiredness Cognitive deficits; memory and intellectual impairment (short-term memory, concentration)

20. History : Daytime symptoms Decreased vigilance Morning confusion Personality and mood changes, including depression and anxiety Sexual dysfunction, including impotence and decreased libido Gastroesophageal reflux Hypertension:

21. Physical exam Obesity –(BMI) 35 Large neck circumference 43 cm (17 in) in men 37 cm (15 in) in women Retrognathia or micrognathia Enlarged (ie, "kissing") tonsils (3+ to 4+) FFL : Müller maneuver Velopharynx Base of tongue Hypopharynx

22. Physical exam Abnormal (increased) Friedman score

23. Laboratory investigations TFT Iron studies ( Periodic leg movement at sleep )

24. Radiology Upper airway (UA) imaging is used primarily as a research tool. Routine radiographic imaging of the UA is not performed.

25. Polysomnography ( PSG) Accurately diagnose OSA. Assess treatment benefit. ( medical, CPAP,surgical OR Behavior)

26. PSG ( component) EEG EOG ECG EMG – Submental and tibial O2 Saturation Nasal/Oral airflow Respiratory movement Position BP Esophageal pressure (+/-, usefull for detection of RERAs)

27. PSG (examples )

30. PSG ( split night) RDI > 40 during the first 2 hours of diagnostic PSG. The final portion of the study is used for titrating the continuous positive airway pressure (CPAP) device.

31. Management AHI ≥5 in presence of symptoms of EDS. AHI ≥5 in presence of risk factors – cardiac disease, smoking, HTN, high cholesterol. AHI ≥20 – associated with increased mortality.