1. By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

2. 2 Case 1 35 year old male with loud snoring. Spouse states she can’t sleep in the same room with him.35 year old male with loud snoring. Spouse states she can’t sleep in the same room with him.

3. 3 Case 2 46 year old obese male in for annual CPE observed by you to appear sleepy during the medical interview.46 year old obese male in for annual CPE observed by you to appear sleepy during the medical interview.

4. 4 Case 3 In Hospital: Call at 0025 from RN that 42 year old female diabetic in with lower extremity cellulitis has oxygen saturation in the low 80s when checking vital signs. Awoke when stimulated and SaO2 improved.In Hospital: Call at 0025 from RN that 42 year old female diabetic in with lower extremity cellulitis has oxygen saturation in the low 80s when checking vital signs. Awoke when stimulated and SaO2 improved.

5. 5 Objectives Understand OSAH and CSAS in terms of the following:Understand OSAH and CSAS in terms of the following: –Definition –Epidemiology –Pt. Presentation –Dx –Prevention –Tx –Prognosis

6. 6 Abbreviations CO2 – Carbon dioxide CPAP – Continuous positive airway pressure CPE – Comprehensive Physical Exam CSAS – Central sleep apnea syndrome CV – Cardiovascular D/t – due to Dx – Diagnosis Dz - Disease EEG – Electroencephalogram HF – Heart failure HTN – Hypertension LVEF – Left ventricular ejection fraction MVC – Motor vehicle crash N-CPAP – Nasal CPAP O2 - Oxygen OSAH – Obstructive sleep apnea hypopnea syndrome pCO2 – partial pressure of carbon dioxide pO2 – Partial pressure of oxygen REM – Rapid eye movement RN – Registered Nurse SaO2 – Oxygen saturation Tx – Treatment W/ - With

7. 7 Neuronal Respiratory Control Neuronal ControlNeuronal Control –Rhythmic cycle of breath regulated by medullary neuron interaction –Efferent activity Cranial nerves of upper airwayCranial nerves of upper airway Chest wall muscle innervationChest wall muscle innervation

8. 8 Neuronal Control (cont.) Medullary groups influenced by pontine & suprapontine descending pathwaysMedullary groups influenced by pontine & suprapontine descending pathways These pathways influenced by sleep-wake cycle, particularly Reticular Activating System activityThese pathways influenced by sleep-wake cycle, particularly Reticular Activating System activity

9. 9 Obstructive Sleep Apnea Hypopnea - Definition Episodes of airway obstruction during sleep resulting in recurrent arousals associated with:Episodes of airway obstruction during sleep resulting in recurrent arousals associated with: –Otherwise unexplained excessive daytime sleepiness AND...

10. 10 Definition (cont.) …AND > 2 of the following…AND > 2 of the following Loud disruptive snoringLoud disruptive snoring Nocturnal choking/gasping/snortNocturnal choking/gasping/snort Recurrent nocturnal awakeningRecurrent nocturnal awakening Unrefreshed sleepUnrefreshed sleep Daytime fatiqueDaytime fatique Impaired concentrationImpaired concentration...AND......AND... Documented overnight sleep monitoringDocumented overnight sleep monitoring >5 episodes hypopnea and apnea per hour>5 episodes hypopnea and apnea per hour

11. 11 More Definitions ApneaApnea –<20% baseline airflow for  10 seconds in adults HypopneaHypopnea –  30% baseline airflow –  10 seconds –  90% of duration of  airflow  30% baseline flow –  airflow accompanied by  4%  oxygen saturation

12. 12 Epidemiology Overall 2-20% depending on sex and symptomsOverall 2-20% depending on sex and symptoms Estimated 3 million men and 1.5 million womenEstimated 3 million men and 1.5 million women M:F 2-4:1M:F 2-4:1 Daytime sleepiness 2-4%Daytime sleepiness 2-4% –(narcolepsy 0.02-0.06%) Up to 85% in obese personsUp to 85% in obese persons

13. 1 - UpToDate, 200613 History Charles Dickens - “The Postumous Papers of the Pickwick Club”Charles Dickens - “The Postumous Papers of the Pickwick Club” –Pickwickian Syndrome –(Obesity Hypoventilation Syndrome) ObesityObesity HypersomnolenceHypersomnolence Signs of Chronic Alveolar HypoventilationSigns of Chronic Alveolar Hypoventilation PolycythemiaPolycythemia Sleep apneaSleep apnea

14. 14 Practical Predictors HTNHTN History of habitual snoringHistory of habitual snoring Observed reports of nocturnal choking or gaspingObserved reports of nocturnal choking or gasping Neck size > 17 inchesNeck size > 17 inches

15. 15 Airway Patency Airway size - flow resistanceAirway size - flow resistance –Anatomic traits Neck sizeNeck size ObesityObesity Crowded upper airwayCrowded upper airway –Large tongue –Small chin Nasopharyngeal tumorsNasopharyngeal tumors

16. 16

17. 17 OSAH Etiology Sleep affects respiratory control systemSleep affects respiratory control system –Reduced tonic input to upper airway muscles –Diminished reflexes that protect against airway collapse

18. 18 Etiology (cont) Exaggerated inspiratory effortExaggerated inspiratory effort Decreased gas exchangeDecreased gas exchange Resolves with arousal or change in sleep stateResolves with arousal or change in sleep state

19. 19 Recurrent Apnea Instability of feedback controlInstability of feedback control Ventilation cycles instead of being maintained at a constant levelVentilation cycles instead of being maintained at a constant level

20. 20 Mechanism Sleep…Sleep…  Upper airway tone...  Upper airway tone... Obstruction...Obstruction... Apnea…Apnea…  pO2,  pCO2…  pO2,  pCO2…

21. 21 Mechanism (cont.) …Arousal……Arousal…  Upper airway tone…  Upper airway tone… Resumption of breathing…Resumption of breathing… Hyperventilation…Hyperventilation… Return to sleep…Return to sleep…  Upper airway tone…  Upper airway tone… This occurs HUNDREDS of times each nightThis occurs HUNDREDS of times each night

22. 22 Etiology (cont) Upper airway is destablilizedUpper airway is destablilized Partial or complete obstruction of nasopharynx, oropharynx, or bothPartial or complete obstruction of nasopharynx, oropharynx, or both

23. 23 Presentation Primarily relate to effects on pt’s sleepPrimarily relate to effects on pt’s sleep –Typically overweight men –Awaken unrested –Daytime somnolence –Disruptive snoring 45% men & 30% women >65 yrs old snore45% men & 30% women >65 yrs old snore

24. 24 Sleepiness (Of course we need to define sleepiness) MildMild –Sleep during times of rest –Incidental functional impairment ModerateModerate –Sleep during activities requiring some attention ConcertsConcerts MeetingsMeetings PresentationsPresentations

25. 25 Sleepiness (cont.) SevereSevere –Sleep during activities requiring at least moderate attention EatingEating ConversationConversation WalkingWalking DrivingDriving –Marked functional impairment

26. 26 Differential Diagnosis of Sleepiness Sleep restrictionSleep restriction NarcolepsyNarcolepsy Restless leg syndromeRestless leg syndrome Cardiovascular, respiratory, metabolic disturbancesCardiovascular, respiratory, metabolic disturbances Drug addictionDrug addiction DepressionDepression

27. 27 OSAH Diagnosis-suspicion Presentation as abovePresentation as above Witnessed apneic periods, nocturnal gasping or chokingWitnessed apneic periods, nocturnal gasping or choking –>10 events per hr typical for symptomatic pts Body habitusBody habitus HTNHTN

28. 28 Diagnosis-definitive Nocturnal PolysomnographNocturnal Polysomnograph –EEG –Electromyelograph ChinChin –  activity during REM LimbsLimbs –checks non-respiratory causes of arousal –Electro-oculogram Detects REMDetects REM

29. 29 DDx (cont.) –Nasal/oral airflow –Thoracic/abdominal movement –Oxygen saturation –Cardiac rate & rhythm –Body position

30. 30 Split studies Part 1 – Definitive diagnosisPart 1 – Definitive diagnosis Part 2 – Optimal CPAP levelPart 2 – Optimal CPAP level

31. 31 Terms of OSA Quantification –Apnea-hypopnea index (AHI) –Apnea Index (AI) –Respiratory Disturbance Index (RDI) –Respiratory Arousal Index (RAI)

32. 32 Apnea-Hypopnea Index (AHI) # episodes apnea & hypopnea / # hrs sleep# episodes apnea & hypopnea / # hrs sleep OSAH = AHI > 15 / hr

33. 33 Apnea Index # apneic episodes / # hrs sleep# apneic episodes / # hrs sleep

34. 34 Respiratory Disturbance Index (RDI) # times per hour SaO2 drops > 3%# times per hour SaO2 drops > 3% –<5 - No OSA –5-15 - Mild OSA –16-30 - Moderate OSA –>30 - Severe OSA

35. 35 Respiratory Arousal Index (RAI) Computed with EEG measurementComputed with EEG measurement # inspiratory associated arousals per hour of sleep# inspiratory associated arousals per hour of sleep

36. 36 OSAH Complications SleepinessSleepiness –Somnolence during activities –Impaired concentration Systemic hypertensionSystemic hypertension Vascular diseaseVascular disease

37. 37 OSAH and CV Disease Arousals – bursts of sympathetic activityArousals – bursts of sympathetic activity –Not good  SaO2 /  SaO2 causes ischemia then reperfusion  SaO2 /  SaO2 causes ischemia then reperfusion –Oxydative stress SubsequentSubsequent –HTN –Insulin resistance –Inflammation Ultimately leading to…Ultimately leading to… –CV endothelial dysfunction

38. 38 Other Potential Complications StrokeStroke Cardiac arrhythmiaCardiac arrhythmia Pulmonary HTNPulmonary HTN Morning head acheMorning head ache Peri-operative complicationsPeri-operative complications –Impaired intubation –Impaired arousal from sedatives

39. 39 Prevention Modifiable risk factors:Modifiable risk factors: –Obesity –Exacerbative medications –Inadequate sleep Modifiable complications:Modifiable complications: –Machinery/motor vehicle operation –Inform Anesthesiologist before elective procedures

40. 40 Treatment - General Depends on severity of diseaseDepends on severity of disease –No Tx for < 15 events per hour Behavioral ModificationsBehavioral Modifications

41. 41 Treatment - General (Cont.) Weight lossWeight loss –5-10%  body weight may be effective Nasal CPAPNasal CPAP Oral appliancesOral appliances

42. 42 Treatment - Medical Vasoconstrictive spraysVasoconstrictive sprays Weight loss medsWeight loss meds Oxygen (select patients)Oxygen (select patients) Chemical avoidanceChemical avoidance –Sedative hypnotics –Alchohol –Antihistamines

43. 43 Treatment - Surgical HyoplastyHyoplasty LinguloplastyLinguloplasty Mandibular advancementMandibular advancement UvulopalatopharyngoplastyUvulopalatopharyngoplasty TracheostomyTracheostomy

44. 44 Treatment - Surgical For loud snoring:For loud snoring: –Laser-assisted uvuloplasty –Radiofrequency tissue ablation –May  apnea and/or delay definitive treatment

45. 45 Prognosis Natural history largely unknownNatural history largely unknown IF dz progresses, it does so slowlyIF dz progresses, it does so slowly Implications with death:Implications with death: –?  in-hospital mortality d/t: Cardiorespiratory failureCardiorespiratory failure Pulmonary embolusPulmonary embolus Case reports complications of anesthesiaCase reports complications of anesthesia –Accidents 2-7 times greater chance of MVC2-7 times greater chance of MVC Equipment operationEquipment operation

46. 46 Central Sleep Apnea Syndrome > 10 second cessation of breathing in the absence of respiratory effort.> 10 second cessation of breathing in the absence of respiratory effort.

47. 47 Central Sleep Apnea Syndrome Airflow stops without obstructionAirflow stops without obstruction Interruption of central respiratory driveInterruption of central respiratory drive Airflow AND respiratory effort are absentAirflow AND respiratory effort are absent Disorder of Apneic ThresholdDisorder of Apneic Threshold Relation to OSA (Mixed Apnea)Relation to OSA (Mixed Apnea)

48. 48 CSAS - Etiology Neural disordersNeural disorders –Poliomyelitis –Posterior fossa tumors –Idiopathic failure of central breathing control Complication of OSAHComplication of OSAH Narcotic induced CSASNarcotic induced CSAS High altitude induced periodic breathingHigh altitude induced periodic breathing

49. 49 CSAS – Etiology (Cont.) Heart FailureHeart Failure –37% of Pts with HF & LVEF < 45% have CSAS –12% have OSAH

50. 50 CSAS - Presentation InsomniaInsomnia Nocturnal awakeningsNocturnal awakenings Nocturnal polysomnographNocturnal polysomnograph –No evidence of obstruction –No respiratory movement

51. 51 CSAS – Definitive Dx Pleural pressure monitoringPleural pressure monitoring Airflow monitoringAirflow monitoring Both recorded and at least one shown to be abnormal during events

52. 52 CSAS - Treatment Tx underlying causeTx underlying cause AcetazolamideAcetazolamide O2 for non-HF ptsO2 for non-HF pts Phrenic nerve stimulationPhrenic nerve stimulation Inspired CO2Inspired CO2 N-CPAP (? w/ CO2)N-CPAP (? w/ CO2) CV med optimizationCV med optimization

53. 53 In Review… 3 types of sleep apnea3 types of sleep apnea –Obstructive (common) –Central (less common) –Mixed (very common) Possibly serious implicationsPossibly serious implications Multiple effective tx optionsMultiple effective tx options Awareness is keyAwareness is key

54. 54 Remember the Cases? 35 year old male with loud snoring. Spouse states she can’t sleep in the same room with him.35 year old male with loud snoring. Spouse states she can’t sleep in the same room with him. 46 year old obese male in for annual CPE observed by you to appear sleepy during the medical interview.46 year old obese male in for annual CPE observed by you to appear sleepy during the medical interview. In Hospital: Call at 0025 from RN that 42 year old female diabetic in with lower extremity cellulitis has oxygen saturation in the low 80s when checking vital signs. Awoke when stimulated and SaO2 improved.In Hospital: Call at 0025 from RN that 42 year old female diabetic in with lower extremity cellulitis has oxygen saturation in the low 80s when checking vital signs. Awoke when stimulated and SaO2 improved.

55. 55 References Westbrook, PR. An overview of Obstructive Sleep Apnea: Epidemiology, Pathophysiology, Clinical Presentation, and Treatment in Adults. In UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2006.Westbrook, PR. An overview of Obstructive Sleep Apnea: Epidemiology, Pathophysiology, Clinical Presentation, and Treatment in Adults. In UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2006. Kingman, PS. Sleep Disordered Breathing in Adults – Definitions. In UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2008.Kingman, PS. Sleep Disordered Breathing in Adults – Definitions. In UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2008. Eckert DJ, Jordan AS, Mercha P, Malhotra A. Central Sleep Apnea: Pathophysiology and Treatment. Chest 2007 Feb: 131(2): 595-607Eckert DJ, Jordan AS, Mercha P, Malhotra A. Central Sleep Apnea: Pathophysiology and Treatment. Chest 2007 Feb: 131(2): 595-607 Douglas NJ. Harrison’s online. http://www.merckmedicus.com/pp/us/hcp/frame_textbooks.jsp?pg=http://www.accessmedicine.com/ content.aspx?aid=2869600. Accessed 8/12/08Douglas NJ. Harrison’s online. http://www.merckmedicus.com/pp/us/hcp/frame_textbooks.jsp?pg=http://www.accessmedicine.com/ content.aspx?aid=2869600. Accessed 8/12/08 http://www.merckmedicus.com/pp/us/hcp/frame_textbooks.jsp?pg=http://www.accessmedicine.com/ content.aspx?aid=2869600 http://www.merckmedicus.com/pp/us/hcp/frame_textbooks.jsp?pg=http://www.accessmedicine.com/ content.aspx?aid=2869600