Sleep apnoea

Prof.Dr K.K.PERUMAL
MD,PhD(Diabetes),DIP,IN,DIAB&
DMRD
 Sleep apnoea
•  Sleep apnoea, is a sleep disorder
 characterized by pauses in breathing or
periods of shallow breathing during sleep. 
• Each pause can last for a few seconds to a few
minutes and they happen many times in the
nights.  
• This follows loud snoring.
 Sleepapnoea
• Any condition that compromise the pharyngeal
lumen predisposes to OSA.
• In any person the pharyngeal tone is decreased
during sleep and the pressure in its lumen becomes
sub-atmospheric during inspiration predisposes to
narrowing and collapse.
• Any disease that leads to abnormal tissue deposition
will reduce the lumen caliber further.
 Obstructive Sleep Apnoea
• Obstructive Sleep Apnoea (OSA) is defined as
the cessation of airflow during sleep
preventing air entering into the lungs caused
by an obstruction( upper air way collapse).
These periods of 'stopping breathing' only
become clinically significant if the cessation
lasts for more than 10 seconds each time and
occur more than 5 times every hour.
 Pathogenesis
• During sleep ,muscle tone is reduced and the
airway narrows so that airway obstruction
develops between the level of the soft palate
and the base of the tongue.
• Breathing continues but airflow stops due to
the obstructed airways.
 Sleep apnea
• Apnea-without breath:>10 second cessation.
• Hypopnoea:decrement in airflow with drop in
hemoglobin saturation of at least 4%.
• Central: brain fails to signal breathing(Respiratory
muscles).
• Mixed: combination of two.
• Narcolepsy:Excessive day time
sleepiness(irreversible tendency to sleep) and
results from neurological disorder.
 Common Sleep Disorders
• Insomnia: wants to sleep but cannot
• Sleep Deprivation: does not want to sleep but
can; problem of sleep quantity.
• Sleep deprivation in normal young people
leads to a diabetic state .
• Sleep apnea: sleepy (somnolence)during day,
snores at night because of obstruction in
throat; problem of sleep quality.
 OSA
• OSA causes hypertension and neurocognitive
impairment whilst severe OSA predisposes to
coronary artery disease, stroke and increased
mortality.
 Sleep Apnea: Risk Factors
• Family history
• Obesity: 80 % of sleep apnea patients; central (visceral,
apples) obesity
• Increasing age
• Male gender/ Marfan syndrome(cranio-facial abnormality)
• Large tonsils / adenoids
• Small mandible, large neck
• (43 cm or 17 inches)
• Smoking, alcohol, sedatives.
• Hypothyroidism &Acromegaly are also recognized causes.
 Symptoms
• Day time:
• 1.Excessive sleepiness.
• 2.Impaired concentration.
• 3.Early morning headache.
• 4.Memory loss.
• 5.Irritability.
• 6.Depression.
 Symptoms
• Night times:
• 1.Heavy snoring.
• 2.Restless sleep.
• 3.Nocturnal choking.
• 4.Sweating.
• 5.Impotence.
• 6.Witnessed apnea.
• 7.Nocturia.
 Potential complications
• Motor vehicle accidents.
• High BP.
• Cardiovascular problems.
• Stroke/cognitive impairment.
• Job impairment/Depression.
• Promotes obesity and diabetes.
 Risk of untreated SA
• Stroke-4× more likely.
• Heart disease-4× more likely.
• 50% have hypertension.
 Cardiovascular complications

• Systemic hypertension.
• Pulmonary Hypertension.
• Left ventricular dysfunction.
• Arrhythmia.
• Myocardial ischemia.
 CVS complications
• Cerebro-vascular accident).
• Congestive heart failure.
• Prolonged hypoxia- angina, heart attacks.
• Increased Nor epinephrine-High BP and
arrhythmia.
• can elevate systolic BP>200 mm Hg.
 Ghrelin
• Ghrelin is a hormone produced in the fundus of the
stomach and in the pancreas.
• Ghrelin increases hunger..
• Ghrelin level increase before meals and decrease
afterwards.
• Receptors for Ghrelin are found in the Arcuate
nucleus  of the hypothalamus. 
• Leptin decreases hunger.
•
 OBESITY

FAT DEPOSIT IN UPPER AIRWAY LUMEN

REDUCED PHYSICAL ACTIVITY FAT DEPOSIT IN UPPER AIRWAY
INCRESED INSULIN RESISTANCE MUSCLE.
INCREASED GHRELIN LEVEL REDUCED TRACHEAL TRACTION

OSA
 Obesity & Sleep Apnea
• Sleep apnea, obesity promote each other
• BMI: Body Mass Index
• Underweight: <19
• Normal : 19 – 24
• Overweight : 25 – 29
• Obese : 30 – 39
• Morbid Obesity: 40 or above.
• Increased BMI(30-39) is a risk for sleep apnoea.
 Control Sleep Apnea:
Better Diabetes Control
• Diabetes is worsened by Sleep Apnea
• Better control of Sleep Apnea leads to better
control of Diabetes.
• Improve insulin sensitivity
• Lower blood sugars
• Lower HbA1-c
• Lower dosages of oral hypoglycemic agents or
less medicines
 Diagnosis
• Polysomnography-Night sleep study.
• Brain activity,
• Eye movement,
• Muscle activity,
• Heart rate,
• Blood oxygen levels.
 Diagnosis-Instruments used
• EEG:Brain waves,
• EOG (electro-oculogram): Eye/chin movement.
• ECG:Heart rate/rhythm,
• Chest bands: breathing movements.
• Oxygen &Co2 levels.
 Diagnosis
• Diagnosis based on clinical features:
• Day time somnolence(sleepiness).
• A history of loud snoring with witnessed apnoeic events
in the night sleep.
• Diagnosis by investigations:
• By the demonstration of oxygen desaturation (SaO2
below 90%) which is associated with a rise in heart rate.
• Overnight polysmnography demonstrating apnoeic
episodes with hypoxemia.
 Treatment
• Weight loss and strict avoidance of alcohol
and hypnotic medications(CNS depressant) are
the first step in the management.
• Weight loss is curative but most patients are
unable to lose the 10-20% of body weight
required.
 Treatment
• Positional therapy-sleep on one side(Lateral
positioning significantly improves passive
airway) ,
• Head raised(FDA approved pillow)
• Avoid alcohol/CNS depressant drugs.
• Weight loss/gastric bypass surgery.
• Avoid sedatives.
 CPAP
• By far CPAP is the most common therapy
particularly for more moderate to severe sleep
apnea
• It works ( as this slide illustrates by pressurizing
the upper airway and preventing collapse
&eliminating the cycle of sleep apnea.
• It significantly decreases EDS(Excessive Day
time sleep) , improves quality of life and has
been demonstrated to reduce motor vehicle
accidents.
Positive Airway Pressure
(CPAP)
 Surgery
• Goal: To remove excess tissue from nose or
throat that may be vibrating –causing to
snore,
 Surgery( minor)
• Somnoplasty:radio-frequency to reduce soft
tissue growth in upper airway.
• Uvulo palato pharyngoplasty(UPPP):removes
soft tissue, tonsils/ palate, uvula: increasing
the width of airway.
• Nasal surgery: deviated septum.
 Major Surgery
• Major surgery:Mandibular maxillar
advancement surgery-corrects facial
abnormalities/throat obstructions,
recommended in those intolerant of CPAP.
• Tracheostomy-opening in the throat-by passes
blocked air passage.
Medical management
 Modafinil
• Modafinil is a wake-promoting drug licensed to treat
residual sleepiness in CPAP-treated OSA.
• Modafinil promotes wakefulness by stimulating the
brain.
• The exact mechanism of action of modafinil is
unknown.
• It may work by increasing the amount of dopamine
in the brain by reducing the reuptake of dopamine
into nerves.
 Summary of the treatment
• Weight loss.
• Nocturnal continuous positive airways
pressure(CPAP) administered via a nasal mask.
• Tonsillectomy if tonsils are thought to be the cause.
• Correction of the underlying medical disorders(eg
hypothyroidism).
• Mandibular repositioning devices are useful in some
patients.
• Tracheostomy (only as a last resort).