Chapter 30 Disorders of Sleep Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Learning Objectives  Define Obstructive Sleep Apnea (OSA)  Explain why airway closure occurs only during sleep.  State the long-term consequences of uncontrolled OSA.  Determine which group of people are at particular risk of OSA. 2 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Learning Objectives (cont.)  List the clinical features associated with OSA.  Describe how OSA is diagnosed.  Describe the treatments available for patients with OSA.  State how continuous positive airway pressure (CPAP) works. 3 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Learning Objectives (cont.)  Identify the problems associated with CPAP  Describe when bilevel pressure is useful  Define “auto-titrating” CPAP  Describe the surgical alternatives 4 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Definitions  Sleep apnea  Repeated episodes of no airflow for  10 seconds  Obstructive sleep apnea  Effort but no airflow due to upper airway obstruction  Central sleep apnea  CNS fails to signal respiratory effort  Overlap syndrome  Chronic obstructive pulmonary disease (COPD) with coexisting OSA 5 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Definitions (cont.)  Mixed apnea  Elements of obstructive & central apnea  Hypopnea  Decrease in breathing but still airflow 6 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Definitions (cont.) 7 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Definitions (cont.) 8 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

9 All of the following are types of sleep disorders, except: A.Obstructive sleep apnea B.Central sleep apnea C.Mixed apnea D.Hyperpnea

Pathophysiology  Obstructive sleep apnea (OSA)  Primary cause is small or unstable pharyngeal airway Contributing: obesity, tonsillar hypertrophy, small chin During sleep, upper airway dilator muscles relax, allowing narrowing or closure in one to many sites  OSA increases risk of systemic & pulmonary HTN Related to increased sympathetic tone Right ventricular failure may occur if not corrected  Suspect OSA in obese patients with excessive daytime sleepiness (EDS) 10 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Pathophysiology (cont.)  Central sleep apnea (CSA)  Heterogeneous group of disorders  Characterized by periodic breathing Waxing & waning of respiratory drive Noted by increase then decrease in f & V T Cheyne-Stokes respiration  Often occur in CHF or stroke  Severe type of periodic breathing  Pattern of crescendo-decrescendo with hyperpnea alternating with apnea 11 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Pathophysiology (cont.)  Overlap syndrome  COPD patients with coexisting OSA  Patients are typically obese smokers with moderate to severe nocturnal oxyhemoglobin desaturations Worst events occur during REM  Worse prognosis & ABGs, then OSA without COPD  Undiagnosed OSA complicates COPD patients with nightly arousals, dyspnea, desaturations resistant to O 2 12 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

13 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. All of the following are clinical presentations of CSA except: A.increase and respiratory rate and V t after apnea occurs B.periodic breathing C.Cheyne–Stokes respirations D.COPD patient with OSA

Clinical Features  Tend to be men (3:1 ratio men to women), >40 years of age with HTN  Report snoring that has become progressively worse, tied to sensation of choking, gasping, or snorting  Disturbed sleep leads to fatigue, EDS, irritability, depression, possible neuropsychologic deficits 14 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Clinical Features (cont.)  May have right heart failure secondary to pulmonary HTN  More common in overlap syndrome or severe obesity  Increased risk of cardiac arrhythmia associated with moderate to severe desaturations 15 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Laboratory Testing  Polysomnogram  Overnight study required for definitive diagnosis  Record several physiological parameters: EEG, EOG, chin EMG, & ECG Airflow at nose & mouth Ventilatory effort by inductive plethysmography Oxygen saturation by pulse oximetry 16 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Laboratory Testing (cont.)  Interpretation of PSG  Effort detected but no airflow, with or without desaturation, defines OSA  Effort detected with minimal airflow, with or without desaturations, defines hypopnea  No effort & no airflow, with or without desaturations, defines CSA  Scoring of PSG  Number of apneas & hypopneas per hour reported as apnea-hypopnea index (AHI) 17 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Laboratory Testing (cont.)  Severity of OSA defined:  Normal:AHI <5  Mild:AHI 5–15  Moderate:AHI 15–30  Severe:AHI >30  Additional information reported  Number of arousals/hour (arousal index)  Percentage of each sleep stage  Frequency of oxygen desaturation, mean SpO 2, lowest SpO 2 18 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Treatment  Behavioral interventions & risk counseling  Counsel on risks of uncontrolled sleep apnea  Behavioral interventions that may be useful: Weight loss if obese Avoidance of alcohol, sedatives, & hypnotics Avoid sleep deprivation  Positional therapy (avoid supine position)  If sleep study notes OSA occurs only supine—avoid  Tennis ball at nape of neck will discourage position  Typically only useful in mild OSA 19 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

20 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Which of the following is a common feature of OSA patients? A.approximately 75% of population with OSA are males B.report snoring which progressively diminishes over time C.will present with left heart failure secondary to pulmonary HTN D.will always present with overlap syndrome

Treatment (cont.)  Oral appliances (second-line therapy)  Devices that enlarge airway by: Moving mandible forward Keeping tongue forward  May be useful with mild OSA if cannot tolerate CPAP Regarded as second-line intervention, particularly for severe OSA  Fitted by dentists, fairly well tolerated 21 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Treatment (cont.) 22 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Treatment (cont.)  Medications  Ineffective for most patients with sleep apnea  Antidepressants may be useful for mild cases (rare)  Oxygen helps avoid desaturations 23 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Medical Interventions ●Positive pressure therapy (first-line therapy for OSA)  CPAP of 7.5–12.5 cm H 2 O alleviates upper airway obstruction in most patients  Best titrated during sleep study  Shown to: Decrease EDS & improve neurocognitive testing Decrease incidence of pulmonary hypertension & right heart failure Decrease ventilation-related arousals & nocturnal cardiac events Improved daytime oxygenation & ventilation 24 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Medical Interventions (cont.)  CPAP therapy (cont.)  CPAP primarily works by pressure splinting airway open  CPAP titration should stop all apneic episodes & reduce number of hypopneas  Improved sleep occurs with obliteration of breathing related EEG arousals microarousals  Patient compliance is key to CPAP success (80%) 25 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Medical Interventions (cont.) 26 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Medical Interventions (cont.)  Bilevel pressure therapy (BiPAP)  Better tolerated by patients with high CPAP levels  Assists in ventilation & airway splinting  Autotitrating devices (smart CPAP)  Adjust to varying patient needs  Use computer algorithm to adjust CPAP to changes in airflow and/or vibration (snoring)  Average pressures may decrease 27 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Medical Interventions (cont.)  Side effects & troubleshooting strategies (PPT)  Claustrophobia & skin irritation: change interface  Nasal congestion, rhinorrhea, nasal dryness, irritation Topical steroids, antihistamines, nasal saline sprays, lotions  Sensation of too much pressure Ramp-up of pressure over number of minutes MAY be useful (no evidence)  Pressure leaks Mouth breathers have problems with nasal masks Add chin strap to close mouth or change to full mask (oronasal) 28 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

29 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc. Which of the following are characteristics of auto- titrating devices (smart CPAP)? A.Adjust to varying patient needs B.Use computer algorithm to adjust CPAP to changes in airflow C.Use computer algorithm to adjust CPAP to changes in vibration (snoring) D.Average pressures may be increased to 50 cm H 2 O

Surgical Interventions  Uvulopalatopharyngoplasty (UPPP)  Reconstructs portions of uvula, soft palate, soft tissue of pharynx  Success is less than 50%  Not currently recommended for management of OSA  Maxillofacial surgery (more promising)  Phase I: UPPP, genioglossal advancement, hyoid bone resuspension  Phase II: Only if phase I is unsuccessful, then advance maxilla & mandible 30 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Surgical Interventions (cont.) 31 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Surgical Interventions (cont.)  In worst cases (nonresponsive to all other management techniques), tracheostomy may be performed that bypasses obstruction in OSA 32 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.

Role of Respiratory Therapist  Management of patients with sleep disorders  Observe evidence of abnormal breathing during sleep  Recommend testing of patients  Team member of sleep laboratory  Assist in titration of CPAP, interface fitting & management 33 Copyright © 2013, 2009, 2003, 1999, 1995, 1990, 1982, 1977, 1973, 1969 by Mosby, an imprint of Elsevier Inc.