Sleep Apnea Syndromes

Suleiman M. Momany, MD, FCCP

School of Medicine / Jordan University of Science & Technology & King Abdullah University Hospital

Normal Sleep Fraction

How Much Sleep?

Normal sleep fraction(Average Adult) ~ 33 % of the day

About 8 hours of sleep per 24 days: Some People Less Than 4 hrs Others More Than 10 hrs

2/3 WAKE

1/3 SLEEP

Refreshing Restorative Sleep (Adequate)

Adequate Time
Adequate Depth Adequate Continuity

Consolidated (Non-Fragmented) Sleep

Animals do sleep

Stage Zero (W)

Sleep Staging
Non-REM Sleep = 75 - 85%
Light Sleep Stage 1 = 1- 2.5% Stage 2 = 45 -55% Deep Sleep ( Sleep) Stage 3 = 3 -8%

REM Sleep = 20 - 25%

Stage 5 : Occurring in 4
to 6 Discrete Periods

Stage 4 = 10 -15%

N1 N2

N3

The Sleep Switch

The transition between sleep and wakefulness is fast and smooth

Sleep Studies All-night polysomnogram

8 hours of sleep to score 1 record (3 hours @ least)
Epochs: each = 30 sec

2 lead electroencephalography 2 lead electrooculography Submental EMG EKG Oral and nasal airflow (thermistors) Chest & abdominal respiratory effort (impedance plethysmography) Bilateral anterior tibialis EMG

Apnea- Hypopnea
Apnea:
cessation breathing of (airflow) lasting greater then ten seconds

Hypopnea
Reduction in the amplitude of breathing flow >50% Or < 50% Reduction of flow + 3% Reduction in SpO2

Sleep apnea syndrome More then 5 apneas- hypopneas /hour during sleep

Sleep Apneas

Obstructive apnea

Cessation of airflow @ the nose & mouth despite continuous respiratory effort

Central apnea

Cessation of airflow @ the nose & mouth with no respiratory effort

Mixed apnea

Initial central component followed by an obstructive apnea event

Apnea Hypopnea Index (AHI)

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

Pathogenesis

Functional Abnormalities

Pharyngeal dilator muscle dysregulation Intrinsically unstable ventilatory control( High Loop Gain)
Other mechanisms

Increased lung volumes: longitudinal tethering of pharyngeal muscles Upper airway sensory impairment

Anatomic Abnormalities
compromising pharyngeal lumen dimensions

Obesity Soft Tissues Craniofacial Structures

Presentation: Symptoms of OSA in Adults

EDS

Other Non-specific symptoms

Restless sleep High blood pressure Morning headache Dry mouth upon awakening Depression Severe Anxiety Short term memory loss Intellectual deterioration Temperamental behavior Poor job performance Impotence

Snoring

Witnessed apneas

Non-specific

Neck size and BMI

A neck size over 16 inches and / or a body mass index (BMI) over 25 puts an individual at risk for sleep apnea.

Body Mass Index

Normal = 18.5 to 24.9 Overweight = 25.0 29.9 Obese = 30.0 39.9 Extremely obese = >40

Mortality in the Obstructive Sleep Apnea syndrome

Treatment Modalities For OSA

Nonsurgical

Surgical

Weight

Loss

nCPAP Positional changes Orthodontic appliances

Equalizer Tongue retaining

Pharmacologic Protriptyline Progesterone Oxygen Nicotine doxapram

Uvulopalatopharygoplasty (UPPP) Tracheotomy Mandibular Advancement Hyoid bone suspension Tonsillectomy & adenoidectomy Thyroidectomy Nasal septal deviation repair

Weight Loss
140 120
DBE/ hr TST

100 80 60 40 20 0 pre wt loss post wt loss

Apnea + Hypopnea index

Treatment of morbidly obese patients with obstructive sleep apnea with gastric bypass surgery
The mean body mass index decreased from 50.3 + 3.5 to 38.6 + 3.4 (p<0.02). This was accompanied by decrease in their respiratory disturbance index of 53.7 + 14.4 to 7.5 + 1.9 (p<0.03).

Conclusions

Gastric bypass/ stapling resulted in significant degrease in BMI and AHI. Patients with OSA who are morbidly obese and have failed dietary weight reduction measures should be considered for gastric bypass/ banding surgery.

A. Vazir, R, Goldenkranz, J. Nahmias, M. Karetzky Newark Beth Israel Medical Center & UMDNJ Newark, NJ

Treatment Modalities For OSA

Nonsurgical

Weight Loss

nCPAP
Positional changes Orthodontic appliances

Picture of CPAP

Treatment Modalities For OSA

Nonsurgical
Weight Loss nCPAP Nasopharyngeal Tube

Positional

changes

Orthodontic appliances

Treatment Modalities For OSA

Nonsurgical
Weight Loss nCPAP Nasopharyngeal Tube Positional changes

Orthodontic
Equalizer Tongue retaining

appliances

OSA Treatment Modalities (cont.)

Surgical
Uvulopalatopharygoplasty (UPPP) Tracheotomy Mandibular Advancement Hyoid bone suspension Tonsillectomy & adenoidectomy Thyroidectomy Nasal septal deviation repair

UPPP

50% effective in curing OSA. Greater than 90% effective in alleviating snoring Patient selection criteria to improve effectiveness
Cephalometrics Mueller maneuver CT scan of Neck

Complications: nasopharyngeal regurg., nasal quality of voice

UPPP and Tonsillectomy

Genio-Glossus Advancement

Hyoid Suspension

Avoid Alcohol or any other CNS depressants within 4 to 6 hours of sleep.

Pre Surgical Warning

Quiz
1.

The most accurate determination of severity for obstructive sleep apnea is made by : .....................