Obstructive Sleep Apnea

Pahel M. Soibam

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Obstructive Sleep Apnea

 Obstructive Sleep Apnea is a sleep-related disorder

defined as Apnea-Hypopnea Index (AHI) of 5 or
more.

 AHI: number of obstructive apnea/hypopnea per

hour of sleep
AHI<5 Normal
AHI 5-15 Mild OSA
AHI 15-30 Moderate OSA
AHI >30 Severe OSA
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 Obstructive apnea: absence of air flow for ≥10 secs in
presence of active ventilatory efforts reflected by
thoracoabdominal movements.

 Obstructive hypopnea: ˃50% decrease in

thoracoabdominal movements ≥10 secs associated with
˃4% decrease in oxygen saturation.

 OSAHS is diagnosed when there is association of

unexplained excessive daytime sleepiness with specific
abnormalities on testing (PSG).

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The Problem
 OSA is only one end of a spectrum of SDB (sleep-
disordered breathing) that includes snoring, upper
airway resistance syndrome and OSA.
 Mostly underdiagnosed.

 Indian prevalence (Udwadia et al):

SDB 19.5%
OSAHS 7.5%
 Prevalence becomes higher with age:
5-15% 40-65 years
24% ˃65 years
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Predisposing Factors
 male gender
 age
 obesity
 Smoking, Alcoholism, Sedatives-Hypnotics
 macroglossia
 retruded chin and/or maxilla
 hypothyroidism & acromegaly

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Mechanism of OSAS

 The upper airway dilating muscles, like all striated

muscles-normally relax during sleep.

 In OSAS, the dilating muscles can no longer

successfully oppose negative pressure in the airway
during inspiration.

 Apneas and hypopneas are caused by the airway

being sucked and closed on inspiration during
sleep.

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 Sites of obstruction
Upper airway anatomy during sleep apnea

Hard Palate
Tongue
Tongue

Hyoid bone

Larynx

Soft Palate

Nasopharynx

Epiglottis Oropharynx
Laryngopharynx
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Pathophysiology: OSA & CVDs

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 OSA & Cardiovascular Diseases

Prevalence of OSA

 HTN 50%
 Acute Stroke 50%
 AF requiring version 50%
 Lone AF 33%
 CAD 33%
 HF with SD 30-40%

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 Others
 DM: Patients from the sleep clinic with AHI>10 are much
more likely to have impaired glucose tolerance and
diabetes (Meslier et al Eur Respir J 2003)
@ OSAHS can aggravate DM, and treatment of OSAHS
decreases insulin requirement (HPIM).

 NAFLD: Increased steatosis and fibrosis independent of

body weight

 Anaethetic Risks: Increased

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 Symptoms

Night time Daytime

 Snoring  Early morning headaches

 Witnessed apnoea  Fatigue
 Waking up choking or  Daytime sleepiness
gasping for air  Poor memory,
concentration or motivation
 Nocturia  Unproductive at work
 Unrefreshening sleep  Falling asleep during driving
 Dry mouth  Depression
 Decreased libido

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Signs of Obstructive Sleep Apnea

 Bradycardia during apneic event

 Tachycardia after airflow restored
 Systemic hypertension
 Pulmonary hypertension
 Polycythemia
 Cor pulmonale
 Typically no respiratory abnormality while awake
 Arterial blood gasses while awake may show
metabolic alkalosis
Diagnosis

 A good sleep history

 Assessment of obesity, oral cavity
 Assessment of possible predisposing causes: HTN,
hypothyroidism, acromegaly and
 Polysomnography: gold standard tool

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The Epworth Sleepiness Score

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The Epworth Sleepiness Score

Patients with total Score >11 or those for whom

sleepiness during work or driving poses problems
need to be referred to a sleep specialist.

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Polysomnography

 EOG - Electrooculogram
 EEG - Electroencephalogram
 EMG - Electromyogram
 EKG - Electrocardiogram
 Tracheal noise
 Nasal and oral airflow
 Thoracic and abdominal respiratory effort
 Pulse oximetry

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Current Treatment for OSA

A.General C. SURGICAL
– Wt loss. – Tracheostom
– Avoid alcohols, y
sedatives – UPPP
– Raise Head-End of bed – Glossectomy
– Sleep in lateral position – Hyoid
B.CPAP
advancement
– Mandibular
advancement
 CPAP Therapy

 Works as a pneumatic splint

 1st choice in moderate to severe OSAHS
 Indication:
AHI≥15 or
AHI ≥5 with symptoms (EDS, Impaired cognition,
mood disorders), HTN, CAD or CVA.
 Success rate 95-100%
 Long term compliance 60-70%

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CPAP Therapy- Side Effects

 Nasal congestion
 Rhinorrhoea
 Oronasal dryness
 Skin abrasions/ rash
 Conjunctivitis from
air leak
 Chest discomfort
 Claustrophobia

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Oral Appliances

MAD
Mandibular & tongue retaining devices

□ Appropriate first-line treatment for Mild OSA, primary

snoring, upper airway resistance syndrome ( UARS )

□ Not as effective as CPAP TRD

□ Young, non-obese

□ Patient’s choice - Not tolerating / refuse to use CPAP,

or are not surgical candidates
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 Surgery

 Bariatric Sx

 Tonsillectomy

 Retrolingual pharynx: mandibular advancement, lingual plasty and

resection, mandibular osteotomy, genioglossus advancement with hyoid
myotomy & suspension, and maxillary & mandibular advancement
osteotomy(MMO)

 UPPP
 Tracheostomy: Severe cases
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Conclusion

Screening patients with obesity, HTN, CAD, DM,

CVA, dementia, NAFLD, GERD for sleep apnea is
worthwhile.

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