Sleep Disordered Breathing

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Sleep Disordered Breathing
CHOL SHIN, MD. PhD. FCCP PULMONARY AND CRITICAL
CARE DEPT PULMONARY SLEEP DISORDER CENTER KOREA
UNIVERSITY ANSAN HOSPITAL
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• 1. Definition
• 2. Types and Diagnosis
• 3. Epidemiology
• 4. Clinical manifestations
• 5. Pathophysiology
• 6. Treatments

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Sleep Disorder Breathing
Snoring
UARS
Sleep Apnea
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Criteria(1)

• MILD SAS
• AI 5-10
• RDI 10-20
• LOUD SNORING AND/OR HYPERSOMNOLENCE
• MODERATE SAS
• AI 10-20
• RDI 20-40
• SEVERE SAS
• AI 20
• RDI 40

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1.OSA(Obstructive Sleep Apnea)Upper Airway
2.CSA(Central Sleep Apnea) CNS
3.Mixed CSAOSA
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OSA
Awake Asleep
STATE
Airflow
Expiration Inspiration
Effort
Pes
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CSA
STATE
Awake Asleep
Airflow
Expiration Inspiration
Effort
Pes
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Mixed
STATE
Awake Asleep
Airflow
Apnea
Expiration Inspiration
Effort
Pes
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Prevalence of Sleep-Disordered Breathing
N3513 questionnaires (1843F, 1670M) 602
underwent PSG (250F, 352M), Age 30-60 year

• AHIgt5EDS
• AHIgt5

Percent
N Engl J Med,Young et al,1993171230-35
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Obstructive Sleep Apnea Syndrome

• SYMPTOMS
• Excessive Sleepiness
• Snoring
• Apneic Episodes
• Choking or Gasping in Sleep
• Nocturia
• Tiredness upon Awakening

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Features of Excessive Sleepiness

• Motor vehicle crashes
• Work related accidents
• Impaired school or work performance
• Social embarrassment
• Marital problems
• Memory and concentration difficulties
• Depression
• Impaired quality of life

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Driving and Sleep Apnea
Sleep Apnea
Controls
P Value
29
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Accident Rate
0.06
lt0.01
0.41
Accident At fault rate
0.24
0.03
lt0.01
At least 1 accident
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6
lt0.01
Citation Rate
0.86
0.34
lt0.05
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Predisposing Factors

• Age (4060 years)
• Obesity
• Gender (male female / 21)
• Anatomical abnormalities
• Upper airway obstruction
• Craniofacial abnormalities
• Medications
• Alcohol
• Smoking
• Family history

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Examination Findings

• Short fat neck
• Obesity
• Upper airway narrowing
• Large tonsils / adenoids
• Enlarged uvula
• Long soft palate
• Micrognathia / retrognathia

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Associated Disorders

• Hypothyroidism
• Acromegaly
• Marfans Syndrome
• Amyloidosis
• Shy Drager Disorder
• Myotonic Dystrophy

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Physiologic Consequences of Sleep Apnea

• Asphyxia
• hypoxemia, hypercapnia, acidosis
• Cardiac dysrhythmias
• Hypertention - systemic,pulmonary artery
• Hypotention - in older patients
• Sleep fragmentation
• Excessive daytime sleepiness

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Physiology of OSA syndrome
Obesity
VIQ mismatch
Cardiac Arrhythmias
Structural Factor Anatomical Neural
Apnea
Pharyngeal Obstruction
Hypoxemia
Snoring
Pulmonary Hypertension
Reduced pharyngeal muscle tone
Excessive Sleepiness
Sleep
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Systemic Hypertension

• 33 of OSA patients have systemic
  hypertension
• 33 of Hypertensive patients have OSA

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Pulmonary Hypertension

• Over 10 of OSA patients have pulmonary
  hypertension.
• Pulmonary hypertension is most likely to occur in
  sleep apnea patients who have daytime oxygen
  desaturation.

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Neurologic Consequences

• Cognitive Aspects
• Cerebral Anoxia
• Papilledema
• Cerebrovascular Disease

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Cognitive Aspects
IQ Scores
Cassell et al. 1989
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PATHOPHYSIOLOGY
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Cephalometric X-ray
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POLYSOMNOGRAPHY

• The two main polysomnographic tests performed
  to diagnoses obstructive sleep apnea
  syndrome are the
• 1.All night polysomnogram
• 2.Split night polysomnogram

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At Home Polysomnography

A sleep study performed at home in the
patients own bedroom utilizing portable
equipment.
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POLYSOMNOGRAPHY MONTAGE

• Sleep staging
• Respiratory measures
• Electrocardiography
• Oxygen saturation
• Limb movement activity
• Video monitoring
• End-tidal carbon dioxide

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DIFFERNTIAL DIAGNOSIS

• Upper Airway Resistance Syndrome
• Central Sleep Apnea Syndrome
• Central Alveolar Hypoventilation
• Syndrome
• Primary Snoring

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UPPER AIRWAY RESISTANCE SYNDROME

• Excessive daytime sleepiness
• Transient repetitive alpha EEG arousals
• Arousal gt10 per hour
• Sleep fragmentation
• With or without snoring
• Without oxygen desaturation
• Occurs equally in males and females

Clinical Features
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UPPER AIRWAY RESISTANCE SYNDROME
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Treatment
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TREATMENT OF OBSTRUCTIVE SLEEP APNEA SYNDROME

• Behavioral Treatment
• Medical Treatment
• Oral Appliance Treatment
• Surgical Treatment

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BEHAVIORAL TREATMENT

• 1.Attain an ideal body weight
• 2.Sleep on the side
• 3.Avoid sedative medications before sleep
• 4.Avoid being sleep deprived
• 5.Avoid alcohol before sleep
• 6.Elevate the head of the bed
• 7.Promptly treat colds and allergies
• 8.Avoid large meals before bedtime
• 9,Stop smoking

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MEDICAL TREATMENT

• 1.Weight Loss
• 2.Pharmacological
• 3.Oxygen Therapy
• 4.Nasopharyngeal Intubation
• 5Nasall CPAP
• 6.BiLevel CPAP
• 7.Automatic CPAP
• 8.Oral Appliances

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CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

• Compliance
• Patient compliance varies between 60 and 75 by
  subjective reports.
• Occult monitoring has shown lower rates of
  compliance.
• Reasons for poor compliance
• Cosmetic reasons,skin abrasion,nasal
  stuffiness,eye discomfort,claustrophobia,
  nocturnal awakenings, mask pressure, noise, and
  poor motivation

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Continuous Positive Airway Pressure(CPAP)
1
2
3
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Case report

• - Name ? oo
• - Sex Male
• - Age 45 years
• - Medical history HTN(), UPPP (before 5 years)
• - Indication
• Snoring, Wittness apneic events, Obesity,
  Headache, Concentration dysfunction, Chronic
  fatigue , excessive daytime sleepiness

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• Physical exam
• - Height 163 cm
• - Weight 83 kg
• - Blood pressure 180/115 mmHg
• - BMI 31.1 WHR 1.03
• - Neck circumference 39 cm
• - Chest circumference 100 cm
• - Abdomen circumference 101 cm
• Epworth Sleepiness Scale score 19

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Polysomnography
PSG CPAP application
Sleep architecture () stage 1 Stage 2 SWS (34) stage REM Sleep efficiency() RDI(apnea hypopnea) Average O2 while non-REM Average O2 while REM Lowest desaturation point Arousal index (/hours) 54.7 6.3 0.5 28 71.2 75.7 84 79 46 60.8 10 42 5.8 31 87.4 6 98 98 85 18.1
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General PSG( hypnogram, O2 saturation, body
position, Arousals )
CPAP application
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CONCLUSION

• SDB is an important medical disorder
• Treatment is essential, not only to improve the
  symptoms that include sleepiness, but also to
  prevent the development of cardiovascular
  complications.
• Effective treatments exist

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The End