Evaluating a Case of Sleep Apnoea

Dr J.M. Joshi Professor and Head Department of Pulmonary Medicine T.N. Medical College B.Y.L. Nair Hospital Mumbai

SAS
Sleep apnoea syndromes (SAS) represent a
group of conditions with abnormal respiration during sleep 3 forms of sleep apnea: OSA, CompSAS and CSA constitute 84% 15% and 0.4%, of cases respectively Obstructive sleep apnea syndrome-OSAS (objective sleeping respiratory disturbance with daytime sleepiness) Nasal continuous positive airway pressure (CPAP) is the most effective treatment for patients with moderate to severe OSAS

Obstructive Apnoea
Obstructive Apnoea when complete
closure of the upper airway

The respiratory efforts continue

airflow chest abdomen

Central Apnoea
Central Apnoea complete cessation of effort to
breathe Airway still open but no respiratory drive, hence no respiratory muscle activity

airflow chest abdomen

CLINICAL FEATURES
Snoring is the cardinal symptom, cyclical with periods of loud snoring exceeding 100 decibels or snoring alternating with quieter intervals of apnoeas

Diagnosis of OSA
A) EDS B) 2 of the following Snoring Witnessed apnoeas Unrefreshing sleep Daytime fatigue Poor concentration And c) Sleep Study showing AHI > 5 Ref: PSG Task Force, ASDA. Sleep 1997;20:406-22.

Polysomnography (PSG)
Neurological EEG EOG EMG Cardio-Respiratory Snoring Thoraco-abdominal movements Airflow Type 4 Oximetry

Type 3

Type 1,2

Ref: Clinical guidelines for unattended PM in the diagnosis of OSA in adult patients. J Clin Sleep Med 2007; 3:737747

PSG Before and After CPAP

Severity Grading of OSAS

Mild: 515 events/hour of sleep Moderate: 1530 events/hour of sleep and Severe: more than 30 events/hour of sleep

Conventional Diagnostic Therapeutic Approach

Full polysomnography (PSG) is currently the gold
standard for the diagnosis of OSAS and titration of effective continuous positive airway pressure (CPAP)

Technicians should titrate CPAP pressures overnight

until most of the apnoeas and arousals are abolished, as monitored by PSG

Alternative Ambulatory Diagnostic Therapeutic Approach

Urgent need to evaluate approaches to
management that did not unduly rely on sleep laboratorybased PSG studies led to

Diagnostic-therapeutic approach using home

based limited PSG (cardio-respiratory variables only) or oximetry with ambulatory CPAP titration

Clinical Probability of OSAS

Ambulatory diagnostic-therapeutic approach
requires accurate identification of probable cases of OSAS

Sleepy snorer by Epworth Sleepiness Score Sleep Apnea Clinical Score (SACS) based on
snoring, witnessed episodes of apnea, neck circumference, and systemic hypertension

Epworth Sleepiness Score

Clinical Probability of OSAS

Sleepy Snorer by Epworth Sleepiness Score Sleep Apnea Clinical Score (SACS)

Ref: Likelihood ratios for a sleep apnea clinical prediction rule. AJRCCM 1994;150:1279-85.

Summary
Magnitude of OSA and paucity of sleep labs needs
simplified approaches for physicians Enough evidence now exists that simple ambulatory diagnostictherapeutic strategies have equivalent clinical outcome in cases with high pretest probability Patients who have a low probability, have comorbidities or have difficulties during ambulatory management should be referred to a sleep centre for detailed evaluation/in-laboratory attended full PSG and further management