1. Obstructive Sleep Apnea Babak Saedi.M.D Imam Khomeini Hospital

2. What is OSA? n Disorder of obstructed breathing occurring during sleep n Apnea: cessation of breathing with respiratory effort lasting greater than 10s n Hypopnea refers to a greater than 50% reduction in air flow

3. Epidemiology of OSA n Prevalence - 2% in women, 4% in men n In the elderly, estimates range from 28% to 67% in men and 20% to 54% in women n two thirds are obese

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

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

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

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

8. Societal Impact

9. 2006 American Academy of Sleep Medicine

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

12. PATENT Vs COLLAPSED AIRWAY 2006 American Academy of Sleep medicine

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

14. Who gets it? n Men who snore and who are overweight

15. n adenotonsillar hypertrophy n nasal obstruction n hypothyroidism n acromegaly n Down syndrome n sedative use n Alcohol n Smoking n micrognathia n retrognathia n Obesity n Neck circumference n vocal cord paralysis n H&N masses Risk factors

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

17. SITUATION CHANCE OF DOZING Sitting and reading Watching TV Sitting inactive in a public place (e.g a theater or a meeting) As a passenger in a car for an hour without a break Lying down to rest in the afternoon when circumstances permit Sitting and talking to someone Sitting quietly after a lunch without alcohol In a car, while stopped for a few minutes in traffic

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

20. OBESITY n Strongest risk factor for OSA u Present in > 60% of patients referred for a diagnostic sleep evaluation a diagnostic sleep evaluation u Wisconsin Sleep Cohort Study F A one standard deviation difference in BMI was associated with a 4-fold increase in disease prevalence

21. Obesity n Alters upper airway mechanics during sleep 1. Increased parapharyngeal fat deposition: neck circumference: > 17” males neck circumference: > 17” males > 16” females > 16” females With subsequent: With subsequent:  smaller upper airway  smaller upper airway  increase the collapsibility of the pharyngeal airway

22. obesity 2. Changes in neural compensatory mechanisms that maintain airway patency:  diminished protective reflexes which otherwise would increase upper airway dilator muscle activity to maintain airway patency would increase upper airway dilator muscle activity to maintain airway patency

23. obesity 3. waist circumference Fat deposition around the abdomen produces Fat deposition around the abdomen produces  reduced lung volumes (functional residual capacity) which can lead to loss of caudal  reduced lung volumes (functional residual capacity) which can lead to loss of caudal traction on the upper airway traction on the upper airway  low lung volumes are associated with diminished oxygen stores

25. Physical Examination

26. Evaluation n thyroid function tests n Poly somnography is the gold standard

27. n History and physical examination identify only 52% of OSA patients, with a specificity of 70% n Clinic of North America 1999

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

30. UpToDate

31. How To Treat? n Minimal intervention u Drop the Weight !

32. Continuous Positive Airway Pressure (CPAP) n Continuous Positive Airway Pressure pneumatically splints open the patient’s airway during sleep by delivering pressurized air into the throat n Effective at eliminating apneas and hypopneas n Considered the gold standard in the treatment of OSA

33. CPAP Side Effects  Despite its high efficacy, patients frequently cannot tolerate its usage every night for life and thus long-term acceptance has been found to be low (~50%)  Side effects:  Oronasal dryness  Conjuctivitis from air leak  Noise  Claustrophobia  Mask discomfort  Skin abrasions/rash

34. Appliance Design  Patients find appliances that encroach the tongue space and open the bite uncomfortable  No differences in efficacy between greater or lesser mandibular opening in reducing AHI  No difference in treatment success between 1-piece and 2-piece appliances

35. Oral Appliance Therapy  There are no strict guidelines in the design of oral appliances for OSA management and there is a plethora of them in use  There are 1-piece or 2-piece appliances made from soft elastomeric material or hard acrylic  2-piece appliances have the advantage of allowing for titratable mandibular advancement

36. Surgical Treatment Options  Septoplasty  Turbinoplasty  Partial turbinectomy  Polypectomy  Excision of nasal tumours  Adenoid tonsils excision  Uvulopalatopharyngoplasty  Tonsillectomy  Uvulectomy  Partial glossectomy/tongue base reduction  Genioglossal advancement  Lingual tonsils excision  Hyoid advancement/suspension  Maxillomandibular advancement  Excision of laryngeal tumours  Tracheotomy

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

38. Which Surgical Treatment Option?  When an obvious anatomical abnormality is detected, the appropriate surgical procedure is performed accordingly  Unfortunately, even with sound imaging modalities, it is still difficult to ascertain the pathophysiology of OSA  It is often a combination of multiple sites affecting the upper airway that contribute to OSA

39. n Nasal Reconstruction ? n The Journal of Craniofacial Surgery & Volume 21, Number 6, November 2010

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

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

42. n UPPP has been considered to be effective only in approximately 50% of patients with OSA

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

44. Maxillomandibular Advancement

45. Palatal Expansion  RPE treatment widens the maxillary bone via distraction osteogenesis at the midpalatal suture  Increases the volumetric space of the nasal cavity, which helps reduce nasal resistance  Promotes spontaneous repositioning of the tongue to a normal position

46. Which Surgical Treatment Option?  Retropalatal and retroglossal openings are common areas that are obstructed in the upper airway  Maxillomandibular advancement has been shown to be very successful at treating OSA with retropalatal and retroglossal obstructions  However, some believe that maxillomandibular advancement is too invasive and should only be performed following a poor response to a procedure involving uvulopalatopharygoplasty, genioglossal advancement, and hyoid suspension  These clinicians argue that it would be overly aggressive to submit a patient who would have responded to a less invasive surgery to the risks/complications from maxillomandibular advancement

47. What is Successful Treatment?  In surgical studies, the definition of success is mainly based on objective measures  Common objective parameters are the apnea-hypopnea index and lowest oxygen saturation  Current accepted definition for surgical cure:  AHI less than 20 with a reduction greater than 50%  Few desaturations less than 90%  Reason for setting the success less than 20 is that several studies have found that an index >20 translates to increased morbidity and mortality

48. Risks of Surgical Treatment  Surgery in the upper airway results in postoperative edema, which has acute adverse effects on breathing  Several medications used during surgery are respiratory depressants and can remain in the body in low amounts for hours/days  OSA can be dangerously aggravated by these drugs thus these patients need prolonged monitoring following surgery  There is also a concern with postoperative analgesics that are respiratory depressants  Other complications: nerve damage, excessive bleeding

50. 2006 American Academy of Sleep Medicine Sleep Apnea

51. Otherwise snore and this will happen to you…. Or sleep alone…. www.corbett.com.au