SLEEP APNEA SYNDROME &

SLEEP DISORDER IN D.M.

CANDIDATE : DR. SUMIT PULORIA
HISTORY

• Charles Dickens – provided first comprehensive description

of it in Posthumous Papers of the PickWick Club.
• APNOEA : Complete cessation of oronasal flow lasting more
than 10 seconds.

• HYPOPNOEA : marked reduction in tidal volume , without

complete cessation of respiratory flow.

• AHI : total no : apnoeas and hypopnea per hr of sleep.

• Mild sleep apnoea: AHI 5-15/hr

• Moderate sleep apnoea: AHI 15-30/ hr

• Severe sleep apnoea: AHI more than 30 /hr

• CENTRAL SLEEP APNOEA : respiratory interruption without
respiratory effort and without obstruction.

• OBSTRUCTIVE SLEEP APNOEA: It is a sleep related breathing

disorder that involves a decrease or complete halt in airflow
despite an ongoing effort to breath.

• MIXED - respiratory interruption that is a combination of

obstructive and central sleep apnoea.
PREVALANCE :

• Increases between middle and old age.

• 80 to 90 % adults with OSA remain undiagnosed.
• Occurs in 2% of childrens.
• M> F (2 to 3 times)
RISK GROUPS:

• Overweight and Obese

• Men and women with large neck size ( M > 17 inches and F> 16 inches ).
• Middle aged and older men and post menopausal women
• Family history of OSA.
• Children with large tonsil and adenoids
• Endocrine disorders – acromegaly and hypothyroidism
• Smokers
• Down Syndrome
DIAGNOSTIC CRITERION

• Individuals must fulfil A or B , plus C to be diagnosed with OSAS :

A.) Excessive daytime sleepiness that is not explained by other factors

B.) 2 or more that are not explained by other factors :

• Choking or gasping during sleep
• Recurrent awakening from sleep
• Unrefreshing sleep
• Daytime fatigue
• Impaired concentration
C.) Overnight monitoring demonstrate 5 -10 or more
obstructive breathing events per hour during sleep or greater
than 30 events/ 6 hrs of sleep.

These events may include any combination of obstructive

apnoea, hypopnoea .
• CLINICAL FEATURES :
• Snoring : cardinal complain of the pt. with sleep apnoea. Bed
partners are the crucial informants of nocturnal events.

• Excessive daytime sleepiness: OSA pt. fall asleep easily

under most inappropriate circumstances like talking, eating,
driving short distance etc.

• Daytime sleepiness directly related to severity of sleep

apnoea.
• Morning symptoms: morning tiredness, fatigue and lack of
refreshing sleep.
• Restless sleep : agitation, restlessness and abnormal body
movements are common.

• Others : intellectual deterioration, depression , impotence,

sleep walking , sexual dysfunction.
SIGNS :
• Overweight and Obese
• Neck circumference : greater than 40 cm predicts OSA with a
sensitivity 61 % and specificity of 93 % regardless of gender.
• Anatomical abnormality : DNS, nasal valve obstruction
tonsillar hypertrophy, enlarged adenoids, macroglossia and
retro or micrognathia.
• Systemic HTN may be present , usually young person who
snores and is obese.
DIAGNOSIS :

• Overnight sleep study to be carried out in a sleep laboratory

• Parameters recorded are :
1.) EEG
2.) EOG
3.) EMG
4.) EMG of anterior tibialis muscle to monitor for presence of
periodic leg movements.
5.) Respiratory airflow by nasal probes
6.) Respiratory effort by band placed around chest and
abdomen.
7.) Arterial oxygen saturation.
TREATMENT :
• Avoidance of factors which aggravate or precipitate apnoes
• Weight loss
• CPAP
• Surgery
• Sedative , antihistamincs and alcohol have shown to increase
the number of disordered breathing episodes during sleep.

• 60-70 % of OSA pt. are obese, even 5-10 kg of weight loss is

beneficial.

• 1% of change in weight leads to 3 % change in AHI.

• Bariatric surgery for all BMI > 35 to be considered.

CPAP

• Described by SULLIVAN.
• Can be applied through nasal mask, nasal inserts and full face mask
• Noninvasive and decreases apnoeic and hypoxic episodes during sleep.
• 100% effective in not only abolishing obstructive apnoeas, but also
unexpectedly central ones as well
• Usual pressure 5 cm to 15 cm water.
• Side effects : irritation of the conjunctiva, due to air leak
SURGERY :

• Septoplasty
• Tonsillectomy with/without adenoidectomy
• Uvalopalatopharyngoplasty
• Laser assisted uvuloplasty
• Maxillomandibular advancement osteotomy.
SLEEP DISORDER IN TYPE 2 DM

• More common in person of DM as compared to normal

individuals.

• They report higher rate of insomnia , poor sleep quality,

excessive daytime sleepiness and higher use of sleeping
medications.
Factors contributing :
• Discomfort and pain associated with peripheral neuropathy
• Restless legs syndrome
• Periodic limb movements
• Nocturia
• Rapid change in blood sugar level during nights leading to
hypoglycaemia and hyperglycemia episodes.
TYPE 2 DIABETES , RISK OF OBESITY &
SLEEP DISTURBANCES
• Obesity is the main confounding factor in the analysis of
insulin resistance in OSA.

• Higher risk of obesity and type 2 DM in individuals with

shoter sleep duration <5/6 hr /night, as well as poor sleep
quality.
• Higher risk of type 2 DM in ppl with long duration sleep > 9
hrs/ day.
• Difficulty initiating sleep increased the risk of type 2 dm by
55 %

• Difficulty in maintain sleep increases risk by 74 %.

SLEEP DISTURBANCE – NEURAL AND
HORMONAL EFFECTS:
• Weight gain with sleep deprivation is likely hyper activity of
orexin system.

• Orexin system is over active during sleep deprivation which

along with sympathetic nervous system leads to over
feeding.
• Increases in circulation of ghrelin , hungher promoting
hormone as well as decrease in leptin , the satiety factor.
DM & OSA

• Prevalance of OSA in DM is 23 %.
• OSA is itself linked to increase risk of variety of negative
health outcome like HTN, insulin resistance, CVD.
• OSA may be the reason why there is suboptimal response to
t/t of DM.
MANAGEMENT:

Mutifactorial approach.

• Sleep hygiene:
• Establish a regular bed time and rise time’
• Exercise in late afternoon or early evening
• Comfortable sleep environment
• Cell phone should be put on silence or shut off.
• DON’T
• Take a daytime nap
• Too much caffeine or nicotine
• Drink alcohol before bedtime
• Sleeping too hungry
• Spicy food at night
• Late night television
CPAP IN DM

• Conflicting evidences.
• One study found improved insulin resistance with CPAP, but it
used lean pt. with BMI < 30.
• In a double RCT , no improvement was noted.

• Needs long term large rct , to determine its efficacy.

CONCLUSION

• Independent association b/w DM and OSA.

• We must look for possibility of OSA in pt with DM