Sleep Disordered Breathing

SDB Is an Umbrella Term for Many Disorders

SDB

• Characterized by a cyclical

alternating pattern of increased

and decreased periods of

breathing typically followed by

a central apnea.

• A form of another disorder that

is often associated with severe

heart failure patients, those

who have suffered a stroke or

who have experienced brain

injuries.

• A reduced rate and depth of

breathing.

• It occurs due to the loss of

muscle tone during sleep and

especially during REM sleep.

• Often occurs in patients with

chronic obstructive

pulmonary disease (COPD),

neurological impairments,

restrictive diseases (e.g,

scoliosis) or those who are

obese.

• most common type

of sleep apnea

• caused by the

partial or complete

collapse of the

upper airway.

• characterized by

repetitive pauses

in breathing during

sleep despite the

effort to breathe.

• occur for a

minimum of 10

seconds

• The individual may

not be aware of

the problem

• characterized by

a lack of drive to

breathe

• Results n

repetitive

pauses in

breathing with

no effort

• Occurs for a

minimum of 10

seconds

Terms Used in Diagnosing SDB

• Flow limitation — upper airway narrowing; earliest sign of impending upper

airway closure

• Hypopnea — a >30% reduction in airflow lasting >10 seconds and with at

least a 4% oxygen desaturation from baseline

• Apnea — a cessation of airflow for >10 seconds

A large, underpenetrated market: 26% of US adults age 30-70 have sleep apnea

(16% mild sleep apnea, 10% moderate to severe sleep apnea)

* Peppard PE et al. Am J Epidemiol 2013

Prevalence of Sleep Apnea*

Depression

Heart Failure

Coronary

Artery Disease

Drug-Resistant

Hypertension

Obesity

Type 2

Diabetes

A-fib

76%

57%

49%

72%

77%

83%45%

Prevalence

Stroke

63%

References: available upon request

Sleep Apnea Prevalence in Other Diseases

Main Headline Goes HereObstructive Sleep Apnea (OSA)

Obstructive Sleep Apnea (OSA)

• 1 in 4 (26%) US adults has at least mild OSA

• (AHI≥5 apneas per hour)1

• 1 in 10 (10%) US adults have moderate to severe OSA

(AHI≥15 apneas per hour)1

• At least 85% are undiagnosed2

Prevalence of OSA

1 Peppard PE et al. Am J Epidemiol 2013

2 Young T et al. Sleep 1997

Male vs. Female: What are the Differences?

‘Typical’ OSA Symptoms: snoring, witnessed apneas, EDS

Epworth sleepiness scale - >10

Severe OSA

Obstructive apneas

More body position related (supine)

CVD, type 2 diabetes, stroke

Higher AHI’s than women

Symptoms: Insomnia, fatigue, daytime tiredness, headaches, muscle pain

Epworth sleepiness scale – typically lower score (have higher threshold for sleepiness

Less severe, more mild and UARS

Large amounts of flow limitation/UARS

Sleep stage related (mostly REM)

CVD, Type 2 diabetes, stroke and dementia

Lower AHI’s than men (more episodes of UARS)

• Obesity

• Adenoids or tonsil hypertrophy

• Craniofacial syndromes

(eg, cleft palate, micrognathia)

• Neurodevelopmental disorders

(eg, Prader-Willi syndrome,

Down’s syndrome)

• Neuromuscular disorders (eg, spinal muscle atrophy, muscular

dystrophies, cerebral palsy)

Pediatrics at Risk for SDB

Mindell JA and Owens JA. Wolters Kluwer 2010

Signs and Symptoms of Pediatric OSA

Mindell JA and Owens JA. Wolters Kluwer 2010

• Mouth breathing/dry mouth

• Chronic nasal congestion

• Hyponasal speech

• Rhinorrhea

• Morning headaches

• Frequent infections

• Difficulty swallowing

• Poor appetite

• Daytime sleepiness

• Hyperactivity

• Difficulty learning/focusing

• Failure to thrive or obesity

• Mood changes

Day-time Symptoms

• Loud, continuous snoring

• Apneic pauses

• Paradoxical movements

• Restless sleep

• Sweating during sleep

• Abnormal sleeping position

• Mouth breathing

• Enuresis

• Sleep disturbance

Night-time Symptoms

Risk Factors for OSA

Obesity

IncreasingAge

Endocrineand

metabolic

Male Gender

Anatomic abnormalities of the upper

airway

Family history of

sleep problems

Alcohol or sedative use

Smoking

Clinical Symptoms of Sleep Apnea

• Excessive daytime sleepiness

• Morning headaches

• Difficulty concentrating

• Loud or frequent snoring

• Irregular breathing during sleep

• Depression

• High blood pressure

• Weight problems

Consequences of Sleep Apnea: Personal

Untreated OSA can lead to:

• Excessive sleepiness, which may cause problems at work.

• Depression, memory problems, difficulty concentrating.

• Less social engagement, lack of physical exercise, trouble with bed partner due to snoring, and even impotence.

Consequences of Sleep Apnea: Perioperative Risk1

Patients with OSA who are undergoing surgical procedures are at higher risk

for complications than patients who do not have OSA.

Perioperative medications:

May reduce muscle tone,

drive to breathe and ability to

wake up

Upper airway narrowing:

Surgical factors (e.g., swelling

from breathing tube) may

increase airway narrowing

making collapse easier

Supine positioning:

Many patients have OSA that

is worse when lying in a

supine position

1 Kaw R et al. Chest 2012

Consequences of Sleep Apnea: Traffic Accidents

Untreated sleep apnea can lead to a 15-fold increases in traffic accidents risk1

For every dollar spent on CPAP, $3.49 would be saved in reduced collision costs2

1 Horstmann S et al. Sleep 2000

2 Sassani A et al. Sleep 2004

Consequences of Sleep Apnea: Occupational Health

60 – 90% of industrial and transportation

accidents occur due to human error

(caused by sleep deprivation, fatigue, boredom, etc.)

Consequences of Sleep Apnea: Economic

• It is estimated that the total economic cost of sleep disorders in Australia in

2012 was $818 million annually

• Compared to patients without OSA,

patients with OSA had:

o Twice the healthcare costs

o 50% more physician visits

o Longer hospital stays.

National Sleep Foundation:

Sleep in America Poll_2011_Summary_of_Findings

Consequences of Sleep Apnea: Morbidity and Mortality

Untreated OSA is

significantly

associated with

increased

morbidity and

mortality

Types of Sleep Apnea

Nocturnal

hypoventilation

Complex

sleep apnea

(CompSA)

Obstructive

sleep apnea

(OSA)

Central

sleep apnea

(CSA)

Main Headline Goes HereTreatment

• Positive airway pressure (PAP) is the gold standard treatment

for SDB

• Alternatives:

o Behavioral modifications

o Dental appliances

o Drug therapies

o Surgery (UPPP, LAUP, mandibular advancement)

o Tracheostomy

Methods of Treatment

Treatment – Behavioral Modifications

Treatment – Mandibular Repositioning Device (MRD)

• Mandibular repositioning device (MRD) is a custom made, adjustable, oral

appliance available only from a dentist that maintains the lower jaw in a

forward position during sleep.

• This mechanical protrusion widens the space behind the tongue and

reduces the vibration and physical obstruction to breathing and the

tendency to snore.

Narval CC Features

• The first and only CAD/CAM solution on the market

o Computer-aided design (CAD) enables a high degree of customization to suit

the complex dental anatomy of individual patients

o Computer-aided manufacturing (CAM) through selective laser sintering

guarantees a consistently accurate MRD

o Ensures precise fit and comfort retention

• Narval CC is metal-free, flexible and light weight. It is made of highly

resilient and durable biocompatible polymer material

• Narval CC is easy to reproduce with CAD/CAM

• Narval CC is easy to titrate; highly adjustable

o 16mm protrusive range–1mm increments

Treatment – Surgery

• Adenotonsillectomy

• Nasal reconstruction

• UPP (uvulopalatopharyngoplasty)

• Jaw repositioning

Treatment – PAP therapy

Device

Transports air through a filter and provides a set air pressure

Humidifier

Moistens the delivered air to relieve nasal irritation and dryness

Circuit

Two components:• Air tubing: Carries are

from device to mask.• Interface (mask): Delivers

pressure to patient’s airway.

PAP Therapy