Snoring Incidence 40% M 20% F Often (but not always) accompanies sleep disordered breathing Not ass. With excessive daytime sleepiness or insomnia
Snoring AHI < 5 without daytime symptoms PSG is not required for Dx No ass. With : - Arousals - Desaturations - Airflow limitation - Arrhythmias
Upper airway resistant syndrome Do not meet OSA criteria but experience excessive daytime somnolence and other debilitating somatic complaints
Upper airway resistant syndrome characterized by respiratory effort related arousals (RERAs) RERA is detected using esophageal pressure manometry, which reveals a pattern of progressively increasing negative esophageal pressure followed by an arousal.
OSAS five or more respiratory events (apneas, hypopneas, or RERAs) Ass. with - excessive daytime somnolence, - Waking with gasping, choking, or brearh-holding, or - witnessed reports of apneas, loud snoring, or both
OSAS apnea or hypopnea commonly accompanied by: - Reductions in blood oxygen saturation of at least 3% to 4% - Usually terminated by brief, unconscious arousals
OSAS Snoring: - frequent complaint of bed partners - often the symptom that prompts these patients to seek medical attention Excessive daytime somnolence : common presenting complaint
OSAS Other complaints : - Automobile accidents - increased cardiovascular morbidity and mortality - morning headache, sore throat - fatigue or a feeling of being unrefreshed regardless of the duration of sleep
OSAS Exacerbation : - ingestion of alcohol - Sedative use - weight gain
Sleep disordered breathing symp Restless sleep Loud snoring Observed apnea,choking or gasping episodes Excessive daytime sleepiness(E DS) Morning fatigue or irritability Memory loss Decreased cognitive function
Sleep disordered breathing symp Depression Personality or mood changes Decreased libido and impotence Morning and nocturnal headaches Nocturnal sweating Nocturnal enuresis
Pathophysiology collapse of the pharyngeal airway during sleep due to relaxation of the pharyngeal dilator muscles
Obesity soft tissue hypertrophy craniofacial characteristics such as retrognathia
Major areas of obstruction Nose Palate Hypopharynx laryngeal obstruction from bilateral laryngeal paralysis, laryngomalacia, and obstructing laryngeal lesions has also been reported.
Obesity major risk factor for OSA deleterious effects on metabolism, ventilation, and lung volume, resulting in V/Q mismatch Significantly reduce lung volume, which results in a reduction of functional residual capacity
Adenotonsillar hypertrophy : major cause in children In adults : multiple craniofacial variations
Consequences of untreated OSAS increased mortality increase in cardiovascular disease: - hypertension, coronary heart disease, congestive heart failure, arrhythmias, sudden death, pulmonary hypertension, and stroke neurocognitive difficulties increased risk of motor vehicle accidents by 2.5-fold
Consequences of untreated OSAS independent risk factor for insulin resistance contribute to the development of diabetes and metabolic syndrome,the term used to describe the commonly occurring conditions of obesity, insulin resistance, hypertension, and dyslipidemia.
Consequences of untreated OSAS GERD : (Treatment with CPAP decreases the occurrence of GERD) problems with attention, working memory, and executive function (all of which are improved with CPAP treatment)
Diagnosis most common symptoms : - loud snoring - restless sleep - daytime hypersomnolence
Diagnosis Obesity :70% of adult patients Screening, including a detailed sleep history and physical examination, is recommended for all obese patients
Epworth Sleepiness Scale
OSA may be suspected in patients with an ESS greater than 10
Dx patients with HTN, CAD, CHF, CVA, and DM, must be carefully screened for the signs and symptoms of OSA Women : insomnia, heart palpitation, ankle edema
Dx Fiberoptic Flexible Nasopharyngoscopy (with Muller’s Maneuver) Drug induced sleep videoendoscopy Nocturnal PSG : gold standard
Sleep related breathing disorders
Medical Tx. a stepwise manner begins with conservative medical measures. 'Weight loss” for all overweight patients Consultation with a bariatric surgeon in morbidly obese patients surgically induced weight loss significantly improves obesity-related OSA and parameters of sleep quality as early as 1 month after surgery.
Medical Tx. CPAP : gold standard for moderate to severe OSAS Reduction in AHI, sleepiness, CVA, motor vehicle accidents & improvement in QOL Decreased inflammation as measured by a decrease in the inflammatory markers CRP and IL-6, improved endothelial function, and reduced diurnal sympathetic activity.
Medical Tx. BiPAP APAP Oral appliances for mild, moderate OSA (greater satisfaction) Pharmacologic therapy: alternative in CPAP intolerance: Modafinil, Fluticazone, Montelukast, nasal dilator strips, topical decongestants