Sleep Apnea… The Not so Silent Killer

Dominic A. Munafo, M.D., F.ABSM Medical Director

Your Lucky Day

Insidious condition of repetitive partial or complete airway collapse during sleep Frequently associated with: • intermittent hypoxemia • sleep fragmentation • sympathetic activation

What is Obstructive Sleep Apnea (OSA)

The Obstructed Airway

Spectrum of Disease

• Snoring

• Upper Airway Resistance Syndrome

• Sleep Apnea – Obstructive – Central

• Obesity Hypoventilation Syndrome -

(OHS)

Scope of the Problem

• 20 - 30 million Americans

• Wisconsin sleep cohort study

– 626 subjects age 30-60

– AHI > 5 in 9% of women

– AHI > 5 in 24% of men

Scope of the Problem

• OSA Prevalence in other disease states – Obesity – 75%

– Type II DM – 72% (moderate & severe – 66%)

– Hypertension – 50 to 75%

– CAD & A. Fib. – 50%

– CHF – 50 to 75%

– Depression – 40 to 45%

• Most common symptoms

– Loud snoring

– Witnessed apnea

– Excessive daytime sleepiness

– Waking up choking & gasping

– Cognitive impairment

Obstructive Sleep Apnea

• Most common signs – Obesity – Neck size ≥ 17 men ≥ 16 women – Nasopharyngeal narrowing – Maxillo-mandibular anomalies – Hypertension – Stroke – Heart failure

Obstructive Sleep Apnea

True prevalence of OSA in the general obese population difficult to ascertain…

However; Moderate OSA found to be significantly

associated with obesity* Odds ratio = 4.59, (95% CI – 1.58-13.33) For every increment in BMI of 1 over the mean

BMI the risk of OSA increased by 12%

Obesity as a Risk Factor for OSA

* Redline, AJRCCM 1999;159:1527-32

• Clinical suspicion

• Consistent signs and symptoms

• Overnight sleep study looking

for respiratory events (HST vs.

PSG)

How to Diagnose Obstructive Sleep Apnea

Apnea – no airflow ≥ 10 seconds Hypopnea – reduced airflow ≥ 10

seconds, usually associated with oxygen desaturation or evidence of arousal

What are Respiratory Events

Diagnosing OSA

Severity Scale of OSA

• Apnea Hypopnea Index = Apneas + Hypopneas /

hr – Mild sleep apnea - 5 – 15 events / hour – Moderate sleep apnea - 16 – 30 events / hour – Severe sleep apnea - > 30 events / hour

• Who to Treat ? – AHI ≥ 30 – AHI 5 - 29 ⇒ if symptomatic or if co-morbidities

present

OSA is associated with: • Nocturnal blood pressure elevation • Independent risk factor for hypertension • Changes in LV geometry and function • Sustained sympathetic activation

Consequences of Untreated OSA

OSA is associated with: Metabolic syndrome Asthma severity Endothelial dysfunction – synergistic

with risk from obesity ADHD – as many as 25%?

Consequences of Untreated OSA

Increasing prevalence of childhood obesity and it’s complications could actually result in the current generations of children living less well and for a shorter time than previous generations

Ultimate Consequences

* Daniels, The Future of Children 2006;16:47-67

Treatment Options for OSA

• Permanent weight loss

• Continuous positive airway pressure (CPAP)

• Oral appliances

• Oral and/or maxillo-facial surgeries

• Tracheostomy

CPAP Therapy for OSA

• Applied via nasal mask

• Acts as pneumatic splint

• Compliance limits utility

• Mask fit crucial

Why Bother?

• Improves overall care of patients

• Identify patients at increased operative risk

• Effective treatment may help reduce peri-op complications

Thank You!

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