Obstructive Sleep Apnea

Brent A. Senior, MDBrent A. Senior, MD

Associate Professor Associate Professor

Chief, Rhinology, Allergy, and Sinus SurgeryChief, Rhinology, Allergy, and Sinus Surgery

Otolaryngology/Head and Neck SurgeryOtolaryngology/Head and Neck Surgery

University of North CarolinaUniversity of North Carolina

What is OSA?What is OSA?

Disorder of obstructed breathing occurring during Disorder of obstructed breathing occurring during sleepsleep

Apnea: cessation of breathing with respiratory Apnea: cessation of breathing with respiratory effort lasting greater than 10seffort lasting greater than 10s

Hypopnea: Hypopnea: decreased airflow of >70% decreased airflow of >70% Any decreased airflow with desaturation <90%Any decreased airflow with desaturation <90%

Total apneas and hypopneas per hour = AHI or Total apneas and hypopneas per hour = AHI or RDI or REIRDI or REI

What is Significant OSA?What is Significant OSA?

Uh, I don’t knowUh, I don’t know Most consider significant sleep apnea to be Most consider significant sleep apnea to be

present with an REI > 15present with an REI > 15 15-25: Mild Apnea15-25: Mild Apnea 26-40: Moderate Apnea26-40: Moderate Apnea >40: Severe Apnea>40: Severe Apnea

Who’s Got It? NCSDR-1993NCSDR-1993

40 million Americans with chronic sleep disorder40 million Americans with chronic sleep disorder 20 million with occasional sleep disorder20 million with occasional sleep disorder

SDB (REI >5): 24% middle aged malesSDB (REI >5): 24% middle aged males 9% middle aged females9% middle aged females

OSA >15/hr: 4% middle aged malesOSA >15/hr: 4% middle aged males 2% middle aged females2% middle aged females

NEJM 1993; 328: 1230-35NEJM 1993; 328: 1230-35

Why is it so Important?

HypertensionHypertension 25% of hypertensives have OSA (AI>5)25% of hypertensives have OSA (AI>5) Sleep Heart Health StudySleep Heart Health Study

6000 patients corrected for bmi, neck, EtOH6000 patients corrected for bmi, neck, EtOH• Nieto, et al. JAMA 283 (14): 1829-36, April 2000Nieto, et al. JAMA 283 (14): 1829-36, April 2000

SDB (including snoring) and Htn correlateSDB (including snoring) and Htn correlate 1700 patients1700 patients

• Bixler, et al Arch IM 160 (15): 2289-95, 2000Bixler, et al Arch IM 160 (15): 2289-95, 2000

Sleep 1980; 3: 221-4Sleep 1980; 3: 221-4 BMJ 1987; 294: 16-19BMJ 1987; 294: 16-19

Health ImpactHealth Impact

MIMI REI >20 independent predictor of MIREI >20 independent predictor of MI

223 German males with angio confirmed CAD223 German males with angio confirmed CAD• Schafer, et al. Cardiology 92(2): 79-84, 1999Schafer, et al. Cardiology 92(2): 79-84, 1999

Increased mortality in CAD patientsIncreased mortality in CAD patients 5 y study (Sweden)-62 patients; 19 with OSA (RDI 5 y study (Sweden)-62 patients; 19 with OSA (RDI

17)17)• OSA mortality: 37.5%; Non-osa mortality: 9.3%OSA mortality: 37.5%; Non-osa mortality: 9.3%

• Peker, et al. Am J Resp Crit Care 162 (1): 81-6, 7/2000Peker, et al. Am J Resp Crit Care 162 (1): 81-6, 7/2000

Health ImpactHealth Impact

CVACVA REI severity is independent predictor of StrokeREI severity is independent predictor of Stroke

128 patients (UM)- 75 stroke; 53 TIA128 patients (UM)- 75 stroke; 53 TIA 62.5% with AHI >10 with stroke vs 12% controls62.5% with AHI >10 with stroke vs 12% controls

• Bassetti, C et al. Sleep 22(2): 217-23, 3/1999Bassetti, C et al. Sleep 22(2): 217-23, 3/1999

Health Impact DeathDeath

AI<20, at 8y follow-up: 4% mortalityAI<20, at 8y follow-up: 4% mortality AI>20, at 8y follow-up: 37% mortalityAI>20, at 8y follow-up: 37% mortality treatment with trach or CPAP: 0% mortalitytreatment with trach or CPAP: 0% mortality

Chest 1988; 94: 9-14Chest 1988; 94: 9-14

NCSDR 1993NCSDR 1993 38000 CV deaths related to OSA per year38000 CV deaths related to OSA per year

Societal ImpactSocietal Impact

Societal Impact 75% of 75000 screened will be diagnosed 75% of 75000 screened will be diagnosed

with OSA ($275 million)with OSA ($275 million) Fragmentation of sleep occurring with SDBFragmentation of sleep occurring with SDB

increased daytime sleepiness, decreased increased daytime sleepiness, decreased intellect, behavioral and personality changes, intellect, behavioral and personality changes, enuresis, sexual dysfunctionenuresis, sexual dysfunction Am J Resp Crit Care Med 1996; 153: 1328-32Am J Resp Crit Care Med 1996; 153: 1328-32

Societal Impact Increased Traffic AccidentsIncreased Traffic Accidents

simulated driving: SDB ~100x more likely to simulated driving: SDB ~100x more likely to drive off the roaddrive off the road Acta Otolaryn 1990; 110: 136ffActa Otolaryn 1990; 110: 136ff

7x increased risk of auto accidents7x increased risk of auto accidents Clin Chest Med 1992; 13: 427-34Clin Chest Med 1992; 13: 427-34

Societal Impact Reaction times Reaction times

with OSA equivalent to a normal control who with OSA equivalent to a normal control who was legally intoxicated (ABL >0.8)was legally intoxicated (ABL >0.8) Powell NB et al. Laryngoscope. 109(10):1648-54, Powell NB et al. Laryngoscope. 109(10):1648-54,

19991999

UPPP decreases the number of MVAUPPP decreases the number of MVA ORL 1991; 53: 106-111ORL 1991; 53: 106-111 Laryngoscope 1995; 105: 657-61Laryngoscope 1995; 105: 657-61

How’s it Diagnosed?How’s it Diagnosed?

History, Physical Examination, and Sleep History, Physical Examination, and Sleep StudyStudy

HistoryHistory Disrupted sleep, restless sleep, awaken with Disrupted sleep, restless sleep, awaken with

gasping and chokinggasping and choking Loud snoringLoud snoring Tired, inappropriate falling asleepTired, inappropriate falling asleep Witnessed apneasWitnessed apneas

HistoryHistory Associated ComplaintsAssociated Complaints

Weight changesWeight changes Thyroid/Growth Hormone Thyroid/Growth Hormone

abnormalitiesabnormalities GERDGERD

HabitsHabits sleep schedulesleep schedule EtOHEtOH

PMH/MedsPMH/Meds HypertensionHypertension Sedatives; AntihistaminesSedatives; Antihistamines

Physical Exam Height and Weight (BMI)Height and Weight (BMI)

BMI=[703.1 x weight(pounds)] / [Height (in)BMI=[703.1 x weight(pounds)] / [Height (in)22]] neck sizeneck size Face-retrognathiaFace-retrognathia NoseNose Oral cavity- palate, uvula, tonsils/pillars, Oral cavity- palate, uvula, tonsils/pillars,

tongue, occlusiontongue, occlusion

Physical ExaminationPhysical Examination

Physical ExaminationPhysical Examination

Fiberoptic Nasopharyngolaryngoscopy Determines level of obstructionDetermines level of obstruction Provides estimate of degree of Provides estimate of degree of

obstructionobstruction TechniqueTechnique

supine (i.e., in a sleeping position)supine (i.e., in a sleeping position) at FRC-point of maximal at FRC-point of maximal

relaxationrelaxation snore maneuversnore maneuver Mueller maneuver- inspire against Mueller maneuver- inspire against

a closed airwaya closed airway

Evaluation Key Features of the History and ExamKey Features of the History and Exam

History (105 patients)History (105 patients) apnea reported by bed partner (p<0.01)apnea reported by bed partner (p<0.01) awakes with choking (p<0.005)awakes with choking (p<0.005) hypertension: dias >95 (p<0.01)hypertension: dias >95 (p<0.01)

ExamExam BMI>30 (p<0.01)BMI>30 (p<0.01)

All: sensitivity 92%; specificity 51%All: sensitivity 92%; specificity 51% Am Rev Resp Dis 1990; 142: 14-18Am Rev Resp Dis 1990; 142: 14-18

Objective Sleep Monitoring

Rationale: Difficulty Rationale: Difficulty predicting OSA by predicting OSA by H&P with no EDSH&P with no EDS Loud snoring and Loud snoring and

witnessed apneas witnessed apneas identify OSA 54-64% of identify OSA 54-64% of the timethe time Sleep 1988; 11: 430-36Sleep 1988; 11: 430-36

H&P predict OSA only H&P predict OSA only 60% of the time60% of the time Sleep 1993; 16: 118-22Sleep 1993; 16: 118-22

How To Treat?How To Treat?

Minimal interventionMinimal intervention Drop the Weight!Drop the Weight! Dental AppliancesDental Appliances

Variable success rates, though Variable success rates, though probably more useful for mild apneaprobably more useful for mild apnea

?compliance?compliance

InterventionalInterventional CPAPCPAP SurgerySurgery

CPAPCPAP The “Gold Standard” in the treatment of OSAThe “Gold Standard” in the treatment of OSA

Works the best in the most peopleWorks the best in the most people Positive pressure ventilation functions as a Positive pressure ventilation functions as a

pneumatic splint for the collapsing upper airwaypneumatic splint for the collapsing upper airway But... compliance is very poorBut... compliance is very poor

159/214 (74%); mean 5.6 h/night; 77-89% 159/214 (74%); mean 5.6 h/night; 77-89% compliance (!) compliance (!) Krieger. Sleep 15 (6 Suppl) S42-6, 1992Krieger. Sleep 15 (6 Suppl) S42-6, 1992

SurgerySurgery

TracheotomyTracheotomy An incision in the tracheaAn incision in the trachea Cures OSA nearly 100% of the timeCures OSA nearly 100% of the time Prior to 1980, it’s all we had; still useful for Prior to 1980, it’s all we had; still useful for

severe apneicssevere apneics

Remove Tissue- Uvulopalatopharyngoplasty(UPPP)

Remove Tissue- Uvulopalatopharyngoplasty(UPPP)

First successful alternative First successful alternative to tracheotomyto tracheotomy 12 individuals12 individuals

preop AI 54 +/- 28preop AI 54 +/- 28 postop AI 28 +/- 28postop AI 28 +/- 28 8/12 with post-op AI<208/12 with post-op AI<20

• Fujita et al. Otolaryngol Fujita et al. Otolaryngol HNS 1981; 89:923-34HNS 1981; 89:923-34

Remove Tissue-Other SurgeriesRemove Tissue-Other Surgeries

Laser Midline GlossectomyLaser Midline Glossectomy Palatal SomnoplastyPalatal Somnoplasty LAUPLAUP Radiofrequency tongue base Radiofrequency tongue base

reductionreduction Woodson, et al, AAO 2000, Woodson, et al, AAO 2000,

Washington DCWashington DC 18 patients completed protocol, 18 patients completed protocol,

average 15,696 Javerage 15,696 J• REI decreased from 45.3 to REI decreased from 45.3 to

33.333.3

Enlarge the Bony Space-Other SurgeriesEnlarge the Bony Space-Other Surgeries

Genioglossus Advancement/ Genioglossus Advancement/ Hyoid RepositioningHyoid Repositioning Success ~80% (11-18mm)Success ~80% (11-18mm) Less effective with RDI >60Less effective with RDI >60

Maxillo-mandibular Maxillo-mandibular AdvancementAdvancement Particularly useful in the setting of Particularly useful in the setting of

hypopharyngeal obstruction (Fujita hypopharyngeal obstruction (Fujita 2 or 3)2 or 3)

Best results when performed Best results when performed following “Stage 1” surgeryfollowing “Stage 1” surgery

Complication AvoidanceComplication Avoidance All OSA patients are at risk of Airway Obstruction (even All OSA patients are at risk of Airway Obstruction (even

mild)mild) Minimize risk:Minimize risk:

Expect intubation disasterExpect intubation disaster Pharyngeal procedure with nasal procedure increases risk Pharyngeal procedure with nasal procedure increases risk

regardless of apnea severityregardless of apnea severity Mickelson and Hakim, Oto HNS 119: 352-6, 1998Mickelson and Hakim, Oto HNS 119: 352-6, 1998

Amount of intraoperative narcotic- worse with greater apnea Amount of intraoperative narcotic- worse with greater apnea severityseverity Esclamado, Laryngoscope 99: 11-29, 1989Esclamado, Laryngoscope 99: 11-29, 1989

Monitor post-op with continuous oximetryMonitor post-op with continuous oximetry

Summary OSA is a potentially life-threatening OSA is a potentially life-threatening

disorder that demands proper evaluationdisorder that demands proper evaluation Components of that proper evaluation Components of that proper evaluation

include detailed sleep history, PE, and include detailed sleep history, PE, and endoscopic evaluationendoscopic evaluation

Objective sleep evaluation is required prior Objective sleep evaluation is required prior to interventionto intervention

SummarySummary

Treatments includeTreatments include Conservative non-interventional techniquesConservative non-interventional techniques

Weight loss, dental appliancesWeight loss, dental appliances

CPAPCPAP SurgerySurgery