Obstructive Sleep Apnea: The Silent Killer

Allen Widysanto
Overview Sleep Apnea

Sleep apnea is a condition marked by abnormal breathing during

sleep. People with sleep apnea have multiple extended pauses in
breath when they sleep. These temporary breathing lapses cause
lower-quality sleep and affect the body’s supply of oxygen, leading to
potentially serious health consequences.

Because of sleep apnea’s prevalence and potential health impact, it is

important for people to be aware of what sleep apnea is and to know
its types, symptoms, causes, and treatments.
 SLEEP RELATED BREATHING

Central Sleep Obstructive Sleep Sleep-related Sleep-related

Apnea Apnea Hypoventilation Hypoxemia

Burman D. Sleep Disorders: Sleep-Related Breathing Disorders. FP Essent. 2017 Sep;460:11-21.

 What is Sleep Apnea?

1 2 3 4
Snore much Pause while Take shallow Be restless
louder than they breathe (for breaths, gasp,
those with over 10 or choke
regular snoring seconds)
 DEFINITION

● Chronic sleep related breathing disorder characterized by recurrent episodes of partial

or complete collapse of upper airway resulting in periodic reduction (hypopnea) or
cessation (apnea) in ventilation with consequent desaturation and sleep fragmentation.

● Hypopnea = all of the following criteria:

○ Reduction in airflow ≥30%
○ The duration of the is ≥10 seconds
○ ≥3% oxygen desaturation

● Apnea = cessation in respiration for ≥ 10 seconds using a valid measure of airflow

Gottlieb, D.J. & Punjabi, N.M., 2020. Diagnosis and management of obstructive sleep apnea. JAMA, 323(14), p.1389.
AASM clarifies HYPOPNEA scoring criteria. American Academy of Sleep Medicine – Association for Sleep Clinicians and Researchers.
Gottlieb, D.J. & Punjabi, N.M., 2020. Diagnosis and management of obstructive sleep apnea. JAMA, 323(14), p.1389.
 RISK FACTOR

MODIFIABLE UNMODIFIABLE

● Obesity ● Sex (Male > Female)

● Medications à muscle relaxation Menopause women
and narrowing of the airway ● Age
(opiates, benzodiazepines, alcohol) ● Race
● Endocrine disorders ● Genetic predisposition (cranio-
(hypothyroidism, PCOS) facial anatomy)
● Smoking
● Nasal congestion or obstruction

Rundo, J.V., 2019. Obstructive sleep apnea basics. Cleveland Clinic Journal of Medicine, 86(9 suppl 1), pp.2–9.
 How Common OSA?

● 1 billion adult 30-69 years worldwide

● Most common: older male, post menopausal

15% 5%
● Children? 1-13%
● Prevalence OSA in Asia = United State
(despite lower rates obesity)

Benjafield AV, Ayas NT, Eastwood PR, Heinzer R, Ip MS, Morrell MJ, et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: A literature-based analysis. The Lancet Respiratory Medicine.
2019;7(8):687–98. doi:10.1016/s2213-2600(19)30198-5
Kang M, Mo F, Witmans M, Santiago V, Tablizo MA. Trends in diagnosing obstructive sleep apnea in Pediatrics. Children. 2022;9(3):306. doi:10.3390/children9030306
Sunwoo J-S, Hwangbo Y, Kim W-J, Chu MK, Yun C-H, Yang KI. Prevalence, sleep characteristics, and comorbidities in a population at high risk for obstructive sleep apnea: A nationwide questionnaire study in South Korea.
PLOS ONE. 2018;13(2). doi:10.1371/journal.pone.0193549
 Why Sleep Apnea is dangerous?
Neurocognitive and Neuroaffective
• Neurocognitive dysfunction
• Sleepiness Pulmonary
• Depression • Asthma exacerbation
• Fatigue • COPD respiratory dysfunction
• Attention deficit hyperactivity • Pulmonary embolism
disorder • Pulmonary hypertension
• Accident: occupational and motor
crashes
Gastrointestinal
Cardiovascular and • GERD
Cerebrovascular • Non-alcoholic fatty liver disease
• CHF (NAFLD)
• Systemic hypertension
• Coronary arterial disease
• Atrial fibrillation Obstetric and Perinatal
• Arrythmia • Pre-eclampsia
• Stroke • Gestational diabetes
• Gestational hypertension
• Surgical complication
Metabolic and Endocrine
• Low birth weight
• Diabetes mellitus
• NICU admission
• Metabolic syndrome
• Hyperbilirubinemia
• Sexual dysfunction
OSA: The Silent Killer
Complication Prevalence
Hypertension 30-70%
AHI ≥ 15 à 3 folds-increases risk hypertension
Associated with resistant hypertension (64%)
Pulmonary hypertension 10-20%
Heart failure 12-53%
↑ risk HF 140%
Coronary artery disease 30%
↑ risk CAD 30%
Stroke 60%
↑ risk stroke 60 %
Diabetes mellitus type 2 15-30% DM type 2 in patient with OSA
58-85% OSA in patient with DM type 2
 PATHOPHYSIOLOGY
Obesity, tonsillar/adenoid
OSA
Upper airway collapse
hypertrophy, macroglossia, Ventilatory effort ↑
nasal obstruction, Intrathoracic pressure change
craniofacial abnormalities Interruption of sleep cycle, REM ↓

Excessive Daytime Sleepiness (EDS)

Intermittent Hypoxia Chronic sleep

↑ Morbidity and Mortality
fragmentation

Sympathetic Oxidative Systemic HPA Coagulation Adipokine

activation stress inflammation activation activation dysregulation
↑ Catecholamine ↑ ROS ↑ IL-6, TNF-𝛼, ↑ Cortisol PAI1-2, D-dimer ↑ Leptin, Ghrelin
HIF-𝛼 Fibrinogen ↓ Adiponectin
Endothelial dysfunction
Microvascular complication
Insulin resistance Retinopathy, Neuropathy, Nephropathy
Hypertension, CHF 𝛽 cell dysfunction
Atherosclerosis, Metabolic Glucose intolerance Macrovascular complication
arrhythmia Dysfunction Type 2 DM CAD, PAD, CVD
Gottlieb, D.J. & Punjabi, N.M., 2020. Diagnosis and management of obstructive sleep apnea. JAMA, 323(14), p.1389.
 DIAGNOSIS
1 2 3

SCREENING Physical Examination Sleep Studies

Sleep history
Risk factor, comorbid
Epworth Sleepiness Scale
STOP BANG
Berlin Questionnaire
● Neck circumference (>41 cm) Polysomnography (Gold Standard)
● BMI >30 Home Sleep Apnea Testing
● Friedman class tongue position ≥3
● Mouth feature (enlarged tonsils, macroglossia,
jaw misalignment)
● Nasal abnormalities (turbinate hypertrophy,
deviated septum)

Rundo, J.V., 2019. Obstructive sleep apnea basics. Cleveland Clinic Journal of Medicine, 86(9 suppl 1), pp.2–9.
POLYSOMNOGRAPHY
Obstructive sleep apnea. Note the absence of flow (red arrow) despite paradoxical respiratory effort (green arrow).
Central sleep apnea (thick areas). Note the absence of both flow and respiratory effort (green double arrows).
Comparison of a central apnea (box) and obstructive apnea (circle).
Mixed sleep apnea. The apnea (orange arrow) begins as a central apnea (effort absent; red double arrow) and ends as an
obstructive apnea (effort present; green double arrow). Note the arousal (blue arrow) that terminates the apnea and the
desaturation (purple arrow) that follows.
4 hypopneas (thick arrows) and associated oxygen desaturations (red arrows)
 DIAGNOSTIC CRITERIA

Polysomnogram or home sleep apnea test reveals

● ≥ 15 obstructive respiratory events per hour of sleep OR
● ≥ 5 obstructive respiratory events per hour of sleep and at least 1 of following:
○ Daytime sleepiness, nonrestorative sleep, fatigue, or insomnia
○ Waking with breath holding, gasping, or choking
○ Observed loud snoring, breathing interruption, or both
○ Hypertension, mood disorder, cognitive dysfunction, ischemic heart disease, stroke, congestive
heart failure, atrial fibrillation, or diabetes type 2

Rundo, J.V., 2019. Obstructive sleep apnea basics. Cleveland Clinic Journal of Medicine, 86(9 suppl 1), pp.2–9.
 OSA SEVERITY

PSG

HSAT

AHI, RDI, REI

Simple snoring <5
OSA
• Mild: 5-14.9
• Moderate: 15-29.9
• Severe: > 30

Rundo, J.V., 2019. Obstructive sleep apnea basics. Cleveland Clinic Journal of Medicine, 86(9 suppl 1), pp.2–9.
 Phenotyping of OSA

● Pathophysiology à bad upper airway physiology,

poor muscle responsiveness, loop gain, and arousal
treshold
● Clinical presentation à heterogeneity of symptoms
● Associated biomarkers such as inflammation,
microRNA, vascular and polysomnographic
parameters predicting prognosis and response to
treatment
● Comorbidities recognised to be highly associated
with OSA

Carberry JC, Amatoury J, Eckert DJ. Personalized Management Approach for osa. Chest. 2018;153(3):744–55. doi:10.1016/j.chest.2017.06.011
 BAVENO CLASSIFICATION

Guide indication and optimization of

treatment independent of the AHI
• Group A: Lifestyle
• Group B and C: may warrant treatment
either due to reduced QoL or presence
relevance comorbidities
• Group D: strongly suggest treatment

Randerath WJ, Herkenrath S, Treml M, Grote L, Hedner J, Bonsignore MR, et al. Evaluation of a multicomponent grading system for obstructive sleep apnoea:
THE BAVENO CLASSIFICATION. ERJ Open Research. 2021;7(1):00928–2020.
 TREATMENT
MEDICAL

BEHAVIORAL ● Treatment of nasal congestion

● Pharmaceutical agents
● Good sleep hygiene ● NIPAP ( CPAP, Auto-PAP )
● Adequate sleep time ● Bi-level PAP
● Positional therapy (avoid the
supine position) SURGICAL
● Avoid alcohol prior to bedtime
● Appreciate untoward effects of ● Uvulopalatopharyngoplasty (UPPP)
sedatives and hypnotics and related soft tissue procedures
● Benefits of weight loss ● Maxillomandibular advancement
● Drowsiness driving precautions ● Tracheostomy
● Hypoglossal nerve stimulation

Gottlieb, D.J. & Punjabi, N.M., 2020. Diagnosis and management of obstructive sleep apnea. JAMA, 323(14), p.1389.
Chang HP, Chen YF, Du JK. Obstructive sleep apnea treatment in adults. The Kaohsiung Journal of Medical Sciences. 2019;36(1):7–12.
Randerath W, Bassetti CL, Bonsignore MR, et al. Challenges and Perspectives in Obstructive Sleep Apnoea. Eur Respir J 2018; in press
Conclusion
Obstructive Sleep Apnea (OSA) is not recognized as a deadly disease

Sleep apnea can cause serious health problems. The effects of OSA does not occur immediately
so people are not aware. Long-term effects of untreated sleep apnea may lead to pulmonary,
metabolic, heart and vascular disease.

The effects of OSA involve pathomechanisms of hormonal, autonomic, coagulation, and metabolic
disturbances

New paradigm of phenotyping of OSA