Obstructive Sleep Apnea

Syndrome
Prof. A K Janmeja
Head, department of Pulmonary Medicine
&
Medical Superintendent,
Govt. Medical College & Hospital,
Chandigarh
 Objectives
• What is sleep?
• Common sleep disorders
• Magnitude of sleep disorder problem
• Sleep apnea
• Prevalence of OSA
• Clinical features of OSA
• Diagnosis
• Treatment options
• Prevention / control of disease
What is Sleep ?
• Sleep is NOT the absence of wakefulness
• Active
• Complex
• Highly Regulated
• Involves different areas in the brain
• Purpose is not understood
• Essential to life
• We all do it

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 Sleep
Positions

Sleep Academic Award 4
Sleep States of Human Being (adults)

Wake
2/3 of life

NREM Sleep REM Sleep

~80% of night ~20% of night

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 Sleep Stages
• Light Sleep. - Stage 1 [N1]
4-5% of total sleep time is considered normal
Increases to 15% by age 70
• Restful Sleep. - Stage 2 [N2]
45 - 55% of total time
• Deep Sleep. - Delta or Slow Wave Sleep 3 & 4 [N3]
- Range of total sleep: 10 - 20%
- % decreases with age
- about 40 - 50% in children - to total absence by age 40 - 50
- Growth hormone reaches peak levels in Stage 4
- usually appears only in the first 1/3 of the sleep episode
• REM. - Rapid Eye Movement sleep - 20 - 25% total time [R]
- get body paralysis - atonia
- mind very active
- very vivid hallucinatory, imagery or dreaming
- do problem solving
- 5 - 55% of total time
 Sleep Architecture

• Each NREM - REM couplet is equal to one cycle

• Normally go through a sleep cycle every 90 minutes
• Go through about 4 - 5 cycles in a good 7.5 hour sleep
• REM cycles get longer & closer as sleep length gets
longer
 Sleep Latency in Normal Adult
• Normally it takes 10 - 15 minutes to fall asleep
• If you are asleep in < 5 min : excessive sleepiness
• Normal REM latency ranges : 70 –120 min [90 min]
 Basic Significance of Sleep
• Good sleep: critical for overall physical-mental health
• Body compared to a battery;
-needs regular re-charge
-or it will get run down / even die!
• The body needs 7 - 8 hrs of quality sleep every night
• Overall health pays eventually for constant sleep
deprivation
• Best to go to bed at regular time each night and get up
at a regular time every morning – 7 days a week
 History of Sleep Medicine
• Charles Dickens - The Pickwick Papers
• William Osler - Pickwickian Syndrome 1918
• Sleep apnea-1965
• Guilleminault - OSAS - 1973
• Sleep stage scoring by Rechtshaffen & Kales-1968
• MSLT by American Narcolepsy Association-1978
• Fujita - UPPP - 1981
• Colin Sullivan - CPAP – 1981
• Before 1980-Tracheostomy was treatment for OSA
• 1980s-Book -Principles & Practice of Sleep Medicine
 What is sleep apnea?

• Momentary cessation of breathing / irregular breathing

while asleep
• Apnea- complete interruption in respiratory air flow
lasting ≥10 S
• Hypopnea- decreased respiratory air flow
 Types of sleep apnea?

• OSA- respiratory interruption where no air flow

despite respiratory effort due to obstruction in UA
• CSA-respiratory interruption without respiratory
effort & without obstruction in upper airways
• Mixed- respiratory interruption that is a combination
of obstructive and central sleep apnea
 Obstructive Sleep Apnea
Syndrome

• Repeated episodes of complete cessation or near

complete cessation of airflow through upper airway
• Presence of oxyhemoglobin desaturation
• Presence of hypercapnia

Apnoea:
– complete or near complete cessation of, airflow lasting at least 10 sec.
 Obstructive Sleep Apnea

• Upper airway tissue collapse

during sleep & block’s the air
passage with continued
chest and abdominal effort

• These apnoeic events ↓O2

amount in the blood which
eventually leads to gasping
for air
Pathophysiologic Cascade in Sleep Apnea
 Clinical Features of OSAS

Consequences of 3 major phenomenon in OSA:

• Mechanical obstruction/ increase airways
resistance
• Arousal from sleep
• Oxyhaemoglobin desaturation with hypercapnia
 Symptoms of OSA; Mechanical
Obstruction [A]
• Snoring
• Stop breathing while sleeping - then snort
• Witnessed Apnea
• Choking/gagging/gasping
• Dyspnoea
• Restlessness
• Diaphoresis
• Reflux
• Dry mouth upon awakening
• Mouth breathing
 Consequence of Arousal-Sleep [B]
• Excessive Daytime Sleepiness
• Fatigue
• impaired memory
• Poor concentration
• Intellectual deterioration
• Personality changes
• Depression
• Anxiety
• Impotence
• Visual - motor in coordination
• Nocturia

Fragmentation
Consequences of Nocturnal
Hypoxia / Hypercapnia [C]
• Pulmonary HTN
• Corpulmonale
• Cardiac dysarrhythmias
• Nocturnal angina
• Systemic HTN
• Chronic Hypercapnia
• Morning and nocturnal headache
• Polycythemia
Loss of vigilance;
Car Accidents in SAHS
n=913
ACCIDENTS single/5yr multiple/5yr

POPULATION
SNORERS RDI>15

ODDS 3.4 7.3

Young T. SLEEP 1997;20(8):608-13
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 Diagnosis

• History • Polysomonography
• Establishing the risk measures brain
factors waves, heart rate,
• Physical examination body movements and
breathing in an
• ENT examination overnight sleep study
• Genetics and • MSLT (Multiple Sleep
Craniofacial Latency Test)
Dysmorphism in Family measures daytime
Studies of OSA sleepiness
• Laboratory and x-ray
Differential Diagnosis
 RISK FACTORS for OSA

• Obesity • M>F
• Alcohol • Hypertension
• Drugs • Hypothyroidism
• Smoking • Family History
• Large neck
circumference
• Polyps in upper
airway
• Enlarged tonsils
 Physical Examination
• Obesity
• Nasal obstruction
• Vocal cord paralysis
• Adeno-tonsillar hypertrophy
• Micro-gnathia
• Retro-gnathia
• Acromegaly
• Hypothyroidism
Patient with OSA; Neck size &
BMI
• A neck size
over 16 inches
and [20”]
• Body mass
index (BMI)
over 25 puts
an individual
at risk for
sleep apnea.
 Oral Examination
•Note very elongated soft palate

•Massive tongue; patient severe OSA

•Massive tonsils could obstruct airway
Seeking medical help at a sleep
center
Polygraphic Monitoring

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 Polysomnography

– EEG – Oxygen
– EOG saturation
– Submental EMG – Anterior tibialis
– ECG EMG
– Nasal and oral airflow – Sleep position
– Respiratory muscle – Video recording
effort [thoracic]
– Abdominal movement
Obstructive Sleep Apnoea
 Apnea Hypopnea Index
(AHI);Severity
• Normal: less than 5 events per hour
• Mild: 5 - 15 events per hour
• Moderate: 16 - 30 events per hour
• Moderately severe: 31 - 39 events per hour
• Severe: over 40 events per hour
 Treatment
• Lifestyle Modifications
-weight loss
-avoid sedatives/alcohol
-lateral body position during sleep
• Continuous positive airway pressure [CPAP]
• Surgery
• Orthodontic devices
Continuous Positive Airway Pressure 
(CPAP)

95% effective – usually first line treatment for severe disease

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CPAP: Positive Airway Pressure
Devices
• Most efficacious
• CPAP (commonly
used)
• Auto-PAP
• BIPAP
CPAP

• Minimum of five
nights a week, 3 - 4
h/night for effective
treatment
• 90% obtained
benefit from
treatment
 CPAP Complaints; solutions

Complaint Management
•Claustrophobia Nasal Prongs
•Air Pressure Ramping Mechanism
•Air Leaks Chin Straps, mask refit
•Loss of Intimacy Partner communication
•Irritating to Airways Humidification, heat
•Noisy Check for leaks
•Obtrusive Mask Different mask, nasal prongs
 Oral Appliances
• For patients with no response to lifestyle
modification
• Alternative: who cannot tolerate PAP devices
Dental orthotic or mandibular repositioning
devices: surprisingly effective in many cases
 Surgical Procedures
• Adeno-tonsillectomy - preferred treatment
in children
• Turbinoplasty
• Septoplasty
• Pillar Procedure
• Nasal Polypectomy
• Uvulopalatopharyngoplasty (UPPP)
• Tracheostomy
Uvulopalatopharyngoplasty
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 Prevention & Progression of
Disease
• Early detection & Treatment of SA
;Weight reduction & control
;Eliminate factors causing of nasal congestion
• Considering risk groups in primary care
• Good initial treatment and motivating the patient
• Preventing the aggravation of SA
• Good treatment of concomitant illnesses
 Conclusion

• Sleep disorders are common

• Sleep disorders are serious
• Sleep disorders are treatable
• Sleep disorders are underdiagnosed
 Untreated OSA : ↑morbidity & mortality through
- heart, circulatory diseases
- accidents
THANK YOU