SLEEPDISORDERED BREATHING

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SLEEP-DISORDERED BREATHING

• Jasmina Gabrijelcic, MD
• Golnik Hospital, Clinical department for
  pneumology
• and allergic diseases

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HISTORY

• C. Dickens The Posthumous Papers of the Pickwick
  Club Joe, the fat boy
• 1965, Gastaut et al (Etude polygraphique des
  manifestations episodique-hypnique et
  respiratoirs- diurnes et nocturnes, du syndrome
  de Pickwick)
• 1969- first tracheostomy performed
• 1980- first use of CPAP

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• Apnea cessation of airflow gt 10 sec in adults
  and gt 8 sec in children.
• Hypopnea partial (30- 50) reduction of airflow,
• or less- if desaturation (lt90) or arousal
  (EEG) is observed, lasting
• gt 10 s
• RERA episodes of decreased inspiratory airflow
  and increased respiratory effort, which culminate
  in an EEG arousal, and do not meet the definition
  of either apnea/hypopnea

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MIXED APNEA

• Initial absence of both airflow and ventilatory
  effort, followed by evidence of a return of
  effort but a continued lack of airflow

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RDI-respiratory disturbance index

• Combined total number of apneas, hypopneas,
  respiratory effort-related arousals occuring per
  hour of sleep

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OSA-obstructive sleep apnea

• Mild OSA 5-15 RDI/h of sleep
• Moderate OSA 15-30 RDI/h of sleep
• Severe OSA gt 30 RDI/h sleep

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CONTINUUM FROM SYMPTOMS TO DISEASE

• SNORING
• UPPER AIRWAY RESISTANCE SYNDROME (UARS)
• OBSTRUCTIVE SLEEP APNEA
• OBSTRUCTIVE SLEEP APNEA/HYPOPNEA SYNDROME

Increasing upper airway resistance
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DEFINITION

• Repetitive episodes of upper airway obstruction
  that occur during sleep, usually associated with
  a reduction in blood oxygen saturation and
  associated features of daytime sleepiness and
  snoring.

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CLINICAL PRESENTATION

• COMMON REASONS FOR REFERRAL
• Excessive daytime sleepiness
• Loud snoring and/or apnea observed by bed partner

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• LESS COMMON REASONS FOR REFERRAL
• Nocturnal/early morning headaches
• Enuresis
• Gastroesophageal reflux
• Impotence
• seizures at night
• Psychiatric disorders

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PREVALENCE

• Estimated to be minimaly 2 in general population
  (4 in men) higher in elderly.

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RISK FACTORS

• OBESITY- especially central type
• if BMI gt 29, then OSA 9-12 times more
  likely.
• NECK CIRCUMFERENCE
• MALE GENDER- androgenic patterns of body fat
  distribution favor fat deposition in the neck
  area
• ACROMEGALY
• HYPOTHYROIDISM
• STRUCTURAL CRANIOFACIAL ABNORMALITIES
• CONGESTIVE HEART FAILURE (cause or consequence?)
• ALCOHOL AND DRUGS

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PATHOPHYSIOLOGY

• Recurrent closure of the pharyngeal airway during
  sleep (velopharynx in 80).
• Increased collapsibilty can be due to
• LOCAL INFLUENCES
• Decreased muscle activity during sleep,
• Local pharyngeal sensory neuropathy due to
  snoring vibration trauma,
• Elevated positive surrounding pressure,
• Special anatomical abnormalities.
• CENTRAL INFLUENCES
• Reduced ventilatory motor output

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IMAGING
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DIAGNOSIS

• GOLD STANDARD In-laboratory Polysomnography
  (PSG), including
• measurement of airflow (nasal and oral prongs),
• measurement of respiratory effort (impedance,
  inductive pletysmography),
• oximetry,
• EEG,
• EOG,
• EMG (chin),
• ECG,
• snoring (microphones).

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EXAMPLE OF A PSG
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CONSEQUENCES OF OSA

• REPETITIVE INTERMITTENT HYPOXIA

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CONSEQUENCES OF OSA

• Mood, neurocongnitive and behavioral effects
• Systemic hypertension
• Ischemic heart disease and arrhythmias
• Cerebrovascular disease
• Pulmonary artery hypertension
• CORRELATION OSA and POLYMETABOLIC SYNDROME?

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Signs of increased atherosclerosis in OSA

• Measurements of structural/functional changes
  pulse wave velocity (PWV), intima media thickness
  (IMT)
• Measurements of increased oxidative stress,
  increased inflammation, vascular smooth cell
  activation (VEGF), platelet activation
• OSA is an independent risk factor for
  atherosclerosis progression

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CONSEQUENCES OF OSA

• 4 times increased risk of systemic hypertension
• 2 times increased risk of myocardial infarction
  and stroke

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MANAGEMENT

• Sleep hygiene, including weight reduction
• Oral (dental) appliances
• Positive pressure therapy- CPAP
• Surgical management

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MANAGEMENT-mechanisms

• Raising pharyngeal pressure above Pclose (CPAP)
• Changing the tube law of the passive pharynx
  (oral appliances)
• Increasing pharyngeal muscle tone (avoidance of
  alcohol, hypnotics)

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ORAL APPLIANCES

• CHIN STRAP
• MANDIBULAR REPOSITIONING APPLIANCES
• TONGUE REPOSITIONING APPLIANCES
• INDICATED IN SNORING/MILD OSA OR IN MODERATE OSA
  WHEN OTHER THERAPIES FAILED

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SURGICAL MANAGEMENT

• UVULOPALATOPHARYNGOPLASTY (UPPP)
• MAXILLOMANDIBULAR ADVANCEMENT
• TRACHEOSTOMY
• PARTIAL OSTEOTOMY (MANDIBLE, MAXILLA)
• ONLY IN SELECTED PATIENTS OR WHEN CPAP THERAPY
  FAILED

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Continuous positive airway pressure-CPAP

• System consists of a blower unit that generates
  and directs airflow downstream to the patient
  and of a mask (nasal, combined, oral).
• Fixed pressure CPAP, AutosetCPAP, C-flex CPAP,
  BiPAP
• First line therapy for moderate/heavy OSA.

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• CPAP therapy was shown to be effective in
  reversing all structural/inflammation
  abnormalities in OSA patients

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CPAP
OSA
OSA CPAP
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CPAP
15 cm H2O
0 cm H2O
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Examplebefore CPAP
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Example with CPAP
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RISK FACTORS

• OBESITY- especially central type
• if BMI gt 29, then OSA 9-12 times more
  likely.
• NECK CIRCUMFERENCE
• MALE GENDER- androgenic patterns of body fat
  distribution favor fat deposition in the neck
  area
• ACROMEGALY
• HYPOTHYROIDISM
• STRUCTURAL CRANIOFACIAL ABNORMALITIES
• CONGESTIVE HEART FAILURE (cause or consequence?)
• ALCOHOL AND DRUGS

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2 TYPES OF OSA PATIENTS?
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PATHOPHYSIOLOGY

• Recurrent closure of the pharyngeal airway during
  sleep (velopharynx in 80).
• Increased collapsibilty can be due to
• LOCAL INFLUENCES
• Decreased muscle activity during sleep,
• Local pharyngeal sensory neuropathy due to
  snoring vibration trauma,
• Elevated positive surrounding pressure,
• Special anatomical abnormalities.
• CENTRAL INFLUENCES
• Reduced ventilatory motor output

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IMAGING
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DIAGNOSIS

• GOLD STANDARD In-laboratory Polysomnography
  (PSG), including
• measurement of airflow (nasal and oral prongs),
• measurement of respiratory effort (impedance,
  inductive pletysmography),
• oximetry,
• EEG,
• EOG,
• EMG (chin),
• ECG,
• snoring (microphones).

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