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Obstructive Sleep Apnea

Obstructive Sleep Apnea. Brent A. Senior, MD Associate Professor Chief, Rhinology, Allergy, and Sinus Surgery Otolaryngology/Head and Neck Surgery University of North Carolina. What is OSA?. Disorder of obstructed breathing occurring during sleep

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Obstructive Sleep Apnea

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

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

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

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

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

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

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

  9. Societal Impact

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

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

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

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

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

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

  16. Physical Examination

  17. Physical Examination

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

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

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

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

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

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

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

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

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

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

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

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

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