ObstructiveSleepApnea_Dr.Bugnnah

8/9/2019 ObstructiveSleepApnea_Dr.Bugnnah

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Dr.Sherif Bugnah

ENT Resident

Armed Forces Hospitals Southern Region

Khamis Mushayt - Saudi Arabia


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` Physiology of Sleep

` Evaluation of Sleep

` Definition of Obstructive Sleep Apnea (OSA)` Prevalence of OSA

` Pathophysiology of OSA

` Medical Treatment of OSA

` Surgical Treatment of OSA


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` Sleep is characterized by two distinct states,

non-REM sleep and REM sleep. Non-REM

and REM sleep alternate in 90- to 110-minute

cycles. A normal sleep pattern has 4-5 cycles.


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` Non-REM Sleep

` Non-REM sleep consists of

four stages ,Approximately

75% of the sleep cycle isspent in non-REM sleep.

` (muscle activity is still

functional, breathing is low,

and brain activity is

minimal. )

` REM Sleep` Most dreaming takes place

during REM (Rapid EyeMovement) sleep. Periodic

eyelid fluttering, muscleparalysis, and irregularbreathing, body temperature,heart rate, and bloodpressure distinguish REM

from non-REM sleep stages.


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Woodson, Tucker Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment SIPAC 1996


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` Polysomnography

EMG

Airflow

EEG, EOG

Oxygen Saturation

Cardiac Rhythm

Leg Movements AI, HI, AHI, RDI


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` Polysomnography

Woodson, Tucker Obstructive Sleep Apnea Syndrome,

Diagnosis and Treatment SIPAC 1996


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` Obstructive sleep apnea (OSA) is a sleep disorder that

involves cessation or significant decrease in airflow in the

presence of breathing effort. characterized by recurrent

episodes of upper airway (UA) collapse during sleep.

` By definition, apnea episodes last 10 seconds or longer and

commonly last 30 seconds or longer. Apnea may occur

hundreds of times nightly, 1-2 times per minute in severe OSA

patients, and is often accompanied by wide swings in heart

rate, precipitous decrease in oxygen saturation,


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` RDI>5

` RDI > 20 increases risk of mortality

` RDI 20-40=moderate, >40=severe` Upper Airway Resistance Syndrome

Shares pathophysiology with OSA

No desaturation, continuous ventilatory effort

` Snoring


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The prevalence of OSAS in children (2%) is

similar to the prevalence in adults (2%-9%)

(American Academy of Pediatrics [AAP], 2002;

Young et al., 1993

approx 1 in 15 or 6.62% or 18 million people

in USA [Source statistic for calcuation:

"estimated 18 million Americans (NHLBI)"


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` Sites of Obstruction:

` Conclusion: Although there was

considerable variability in the

techniques and the results, themost common site of obstruction

detected by these studies was at

the level of the oropharynx, with

extension to the laryngopharynx

commonly observed.

Stanford University Center of Excellence for Sleep Disorders, 401 Quarry Road,Suite 3301, Stanford, CA 94305-5730, USA


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` Symptoms of OSA Snoring (most commonly noted complaint)

Daytime Sleepiness

Hypertension and Cardiovascular Disease are

Associated

Pulmonary Disease


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` Findings in Obstruction: Nasal Obstruction

Long, thick soft palate

Retrodisplaced Mandible Narrowed oropharynx

Redundant pharyngeal tissues

Large lingual tonsil

Large tongue

Large or floppy Epiglottis

Retro-displaced hyoid complex


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` Tests to determine site of obstruction: Mullers Maneuver

` an inspiratory effort against a closed airway or glottis. The effort

decreases intrapulmonary and intrathoracic pressures and expandspulmonary gas

Sleep endoscopy

Fluoroscopy

Manometry

Cephalometrics

Dynamic CT scanning and MRI scanning


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` Weight Loss

` Nasal Obstruction

` Sedative Avoidance

` Smoking cessation


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` CPAP

Pressure must be

individually titrated

Compliance is as low as50%

x Air leakage, eustachian

tube dysfunction, noise,

mask discomfort,

claustrophobia


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` BiPAP

Useful when > 6 cm H2O difference in inspiratoryand expiratory pressures

No objective evidence demonstrates improved

compliance over CPAP


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` Oral appliance

Mandibular

advancement device

Tongue retainingdevice


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` Oral Appliances May be as effective as surgical options, especially

with sx worse

Howeverlow compliance rate of about 60%,

it a worse treatment modality than surgical

procedures (in study by Walkeret alin 2002 )

Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up oftreatment with dental appliance or uvulopalatopharyngoplasty in patients withobstructive sleep apnea: a randomized study. Chest. 121(3):739-46, 2002 Mar.


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` Measures of success No further need for medical or surgical therapy

Response = 50% reduction in RDI

Reduction of RDI to < 20

Reduction in arousals and daytime sleepiness


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` Perioperative Issues High risk in patients with severe symptoms

Associated conditions ofHTN, CVD

Nasal CPAPoften required after surgery

Nasal CPAPbefore surgery improves

postoperative course

Risk of pulmonary edema after relief of

obstruction


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` Tracheostomy Primary treatment modality

Temporary treatment while other surgery is done

(leads to quick reduction in sequelae of OSA, few complications)Laryngoscope. 113(2):201-4, 2003 Feb. Study

D\A Once placed, uncommon to decannulate

Thatcher GW. Maisel RH. The long-term evaluation oftracheostomy in the

management of severe obstructive sleep apnea. [Journal Article]Laryngoscope. 113(2):201-4, 2003 Feb.


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` Nasal Surgery Limited efficacy when used alone

15.8% success rate when used alone in patients with

OSA and day-time nasal congestion with snoring

(RDI


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` Uvulopalatopharyngoplasty


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` Uvulopalatopharyngoplasty The most commonly performed surgery for OSA

Severity of disease is poor outcome predictor

up to 80% initial success decreased to 46%

success rate at 12 months - Levin and Becker(1994)

success rate of 80% at 6 months in Friedman et alshowed a carefully selected patients

Friedman M, Ibrahim H, Bass L. Clinical stagingfor sleep-disordered breathing. Otolaryngol HeadNeck Surg 2002; 127: 1321.


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` UP3 Complications

Minor

x Transient VPI

x

Hemorrhage


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` Lateral

Pharyngoplasty for

patients with

significant lateralnarrowing (Cahali,

2003 )

Cahali MB. Lateral pharyngoplasty: anew treatment for obstructive sleepapnea hypopnea syndrome.Laryngoscope. 113(11):1961-8, 2003Nov.


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` Lateral Pharyngoplasty


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` Laser Assisted

Uvulopalatoplasty

High initial success rate

for snoring

Rates decrease, as for

UP3 at twelve months


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` Radiofrequency

Ablation Fischeret

al 2003

Radiofrequency device isinserted into various partsof palate, tonsils andtongue base at variousthermal energies


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` Tongue Base Procedures Lingual Tonsillectomy

x

may be useful in patients withhypertrophy, but usually in conjunction

with other procedures


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` Tongue Base Procedures

Lingualplasty

x success rate of 77% (RDI


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` MandibularProcedures

Genioglossus

Advancement

x Rarely performedalone

x Increases rate of

efficacy of other

procedurers


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` Lingual

Suspension:


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LingualSuspension:


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` Hyoid Myotomy and

Suspension Advances hyoid bone

anteriorly and inferiorly

Advances epiglottis and

base of tongue

Performed in conjunction

with other procedures

Dysphagia may result


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` Maxillary-Mandibular Advancement Severe disease

Failure with more conservative measures

Midface, palate, and mandible advanced

anteriorly

Limited by ability to stabilize the segments and

aesthetic facial changes


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` Maxillary-

Mandibular

Advancement

Performed inconjunction with oral

surgeons


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Friedman, Michael MD; Ibrahim, Hani MD; Joseph, Ninos J. BS Staging ofObstructive SleepApnea/Hypopnea Syndrome: A Guide to Appropriate Treatment. Laryngoscope. 114(3):454-459,March 2004.

Riley RW, Powell NB, Li KK, Guilleminault C. Surgical therapy for obstructive sleep apneahypopneasyndrome. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine.Philadelphia, Pa: WB Saunders Co; 2000:913-928.

Cahali MB. Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopneasyndrome. Laryngoscope. 113(11):1961-8, 2003 Nov.

Thatcher GW. Maisel RH. The long-term evaluation oftracheostomy in the management of severeobstructive sleep apnea. [Journal Article] Laryngoscope. 113(2):201-4, 2003 Feb.

Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol HeadNeck Surg 2002; 127: 1321.

Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up of treatment withdental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: arandomized study. Chest. 121(3):739-46, 2002 Mar.Woodson, Tucker Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment SIPAC 1996

Anonymous. Cost justification for diagnosis and treatment of obstructive sleep apnea: positionstatement of the American Academy of Sleep Medicine. Sleep 23(8):1017-8, 2000 Dec.


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ObstructiveSleepApnea_Dr.Bugnnah