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Obstructive sleep apnea (OSA)


Obstructive sleep apnea (OSA) OR Obstructive sleep apnea/hypopnea syndrome (OSAHS) www.anaesthesia.co.in anaesthesia.co.in_at_gmail.com ... – PowerPoint PPT presentation

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Title: Obstructive sleep apnea (OSA)

Obstructive sleep apnea (OSA)
  • OR
  • Obstructive sleep apnea/hypopnea syndrome
  • (OSAHS)

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
  • Recurrent episodes of partial or complete
    collapse of the upper airway during sleep.
  • May be associated with arousal from sleep /or
    decrease in O2 saturation
  • Serious life threatening
  • 8yr mortality rate 40
  • Underdiagnosed

Type of disordered breathing event
  • Central
  • An event with absence of airflow with no
    respiratory effort
  • Obstructive
  • An event with absence of airflow but with
    continued respiratory effort
  • Mixed
  • An event with characteristics of an
    obstructive mixed event.
  • Start with a period that meets the criteria
    for a central event but will end with respiratory
    effort without airflow

Type of obstructive breathing event
  • OSA
  • - Total cessation of airflow for 10sec or more
    despite continued ventilatory efforts
  • - with O2 desaturation of 4 or more.
  • Obstructive sleep hypopnea
  • -Decrease of 30-50 in airflow for 10 sec or
    longer with desaturation
  • Upper airway resistance
  • - Snoring during sleep without frank apnea or
  • does not result on desaturation

  • Nocturnal
  • Loud disruptive snoring
  • Breathing pauses (apneas)
  • Sudden arousals with choking
  • Nocturnal sweating
  • Day time symptoms
  • Excessive daytime sleepiness (falling asleep at
    work, when on telephone or whilst driving)
  • Unrefreshing sleep, morning headache (?Co2,
    cerebral vasodilatation)
  • Fatigue, impaired concentration
  • Lethargy, Depression
  • Morning dry cough
  • Impotence, sexual dysfunction
  • Enuresis

  • Central sleep apnea
  • Uncommon
  • Physiological inhibition of breathing
  • Abnormal neurologic control of the diaphragm,
    resulting in the loss of respiratory drive
  • Obstructive sleep apnea
  • gt 10 over 65 yr
  • Men gt women
  • Episodic collapse blockage of the upper airway
    during sleep despite continuous respiratory

  • Airflow obstruction can occur from soft palate to
    the hypopharynx posterior to the tongue
  • Upper airway patency- muscle tone, tissue mass,
    tissue consistency
  • Pharyngeal transmural pressure- difference
    between the pressure within the airway lumen
    the pressure exerted by tissue surrounding the
    site of collapse
  • Decrease in pharyngeal transmural pressure
  • Pharyngeal dilator muscle tone prevents upper
    airway collapse. It is decreased during stage 4
    REM sleep which leads to narrowing of airway with
    turbulent airflow snoring.

Causes of OSA
  • Obesity
  • -deposition of adipose tissue within the
    muscles soft tissues surrounding the upper
    airway ex compression from the neck
  • ?
  • narrowing of the upper airway.
  • -?lung volume, restrictive pulmonary defects,
    V/Q mismatch hypoventilation
  • Pickwickian syndrome- severe form of OSA, morbid
    obese with Rt. Heart failure
  • Macroglossia, enlarged tonsils
  • ?
  • further narrowing of the pharyngeal lumen,
    increases the likelihood of airway collapse
    during inspiration
  • Gravity lateral position, by enlarging
    retropalatal retroglossal aspect of the airway

Contributing factors
  • Abnormalities in the autonomic control of the
    pharyngeal muscles - acts by changing the
    balance between forces promoting the patency
    those favouring its collapse
  • ? vagal tone, nocturnal paroxysmal asystole,
    episodic bradycardia, sinus node dysfunction
  • Autonomic chemoraceptors reacting to hypoxia,
    hypercapnia acidosis trigger an inflammatory
    cascade HTN, insulin resistance, atherosclerosis
    metabolic syndrome
  • Estrogen protection
  • Hormonal imbalance- acromegaly, cushing syndrome,
    hypothyroidism, DM
  • Airway moisture surface tension in the fluid
    lining the upper airway, alter the function of
    pharyngeal sensory receptors

Risk factors
  • Obesity BMI gt30kg/m2
  • 1. Fat deposition around the upper airway can
    decrease upper airway size.
  • 2. Neck circumference greater than 16 inches
    in female or greater than 17 inches in males
  • Male, middle age, Race,
  • Family history, Alcohol consumption (? phargl msc
  • Craniofacial abnormalities
  • Habitual snoring gasping noted by bed partner
  • Daytime sleepiness
  • Hypertension
  • High mallampati score
  • Unexplained polycythemia, room air hypoxemia or
    signs of right sided heart failure.

Acromegalic pt with without OSA
Other causes of daytime sleepiness
  • Sleep deprivation
  • Shift work
  • Depression
  • Narcolepsy
  • Hypothyroidism
  • Sedatives
  • Excessive alcohol
  • Idiopathic hypersomnolence
  • Neurological conditions previous head injury,
    previous encephalitis, parkinsonism, dystrophica

Indices on disordered breathing severity
  • Apnea-hypopnea index (AHI) (severity of OSA)
  • no. of apnea hypopneas per hr of total sleep
  • Apnea index
  • no. of apnea per hr of total sleep time
  • Hypopnea index
  • no. of hypopneas per hr of total sleep time
  • Central apnea index
  • no. of central apnea per hr of total sleep
  • Arousal index - no. of arousal per hr of sleep
  • Body position, NREM REM sleep

Indices on disordered breathing severity
  • Mild AHI 5 - 14 events per hr
  • Moderate AHI 15 30 events per hr
  • Severe AHI gt 30 per hr

The stages of snoring
  • Non REM sleep
  • High alertness to deep sleep. Stage 1 to 4
  • Changing pattern of electrical activity in the
  • Skeletal muscle start to relax
  • REM sleep
  • Brain activity looks similar to wakefulness
  • Absence of skeletal muscle tone so effectively
  • Conventional snoring
  • Stage 3-4, later in 1 2
  • Sleep apnea
  • REM sleep

  • A sleep study or a polysomnogram
  • -Standard test for OSA
  • - Identifying abnormal or disordered
    breathing pattern during sleep
  • Simultaneous recording of multiple physiological
  • rt. lt. electro-oculograms
  • submental electromyogram
  • electroencephalogram
  • Distinguish wakefulness from sleep determine
    the distribution of different sleep stages over
    the course of the night

  • Impedance plethysmography to assess breathing
    patterns with measurements of respiratory efforts
  • Airflow oronasal thermistor (temp change) or a
    nasal cannula (pressure changes)
  • Oxygen saturation
  • Body position
  • electrocardiogram arrhythmias
  • Epworth sleepiness scale (ESS) max 24
  • best available tool to guide the clinician
    as to the pts perception of his sleepiness
  • normal lt 11
  • mild subjective daytime sleepiness 11-14
  • mod subjective daytime sleepiness 15-18
  • severe subjective daytime sleepiness gt18

Polysomnogram (normal)
Polysomnogram (OSA)
Polysomnogram (central)
Polysomnogram (mixed)
Obstructive hypopnea
Upper airway resistance
  • Hypertension
  • Obesity
  • Diabetes mellitus
  • Coronary artery disease
  • Cerebral vascular disease stroke
  • Congestive heart failure
  • Cardiac dysrhythmias
  • Gastroesophageal reflux disease

Pathophysiological consequences
  • Cardiovascular
  • ?sympathetic tone
  • systemic HTN
  • pulmonary HTN
  • polycythemia
  • art. hypoxemia
  • art. hypercarbia
  • rt. heart failure
  • lt. heart failure
  • stroke
  • arrhythmia
  • myocardial ischemia
  • Cognitive
  • hypersomnolence
  • personality changes
  • cognitive deficits
  • accident prone

  • AHI gt15,
  • More than ten 4 desaturation/hr
  • 1.Behavioural interventions
  • 2.Nonsurgical
  • 3.Surgical

Behavioural interventions
  • To lose wt.
  • life modifications
  • Stop smoking
  • No alcohol esp in the evening
  • No sedatives
  • Discourage from sleeping on their back by using
    Triangular pillow space for the pts arm under
    the head to encourage sleeping on the side

Nonsurgical management
  • The American Academy of Sleep Medicine guidelines
  • Continuous positive airway pressure CPAP
  • AI gt 20, symptomatic pt with AHI gt 10
  • Function as a mechanical stent to maintain upper
    airway patency th. out all phases of sleep
  • Nasal CPAP- proper use eliminates excessive day
    time sleepiness, reduce HTN, improve
    neurocognitive function
  • Increased augmentation of lung volume
  • Increase in the tone of the upper airway
  • Improved LVF
  • Reduce morbidity in pt with CHF
  • Reduction in the sympathetic tone

Nonsurgical management
  • Nasal CPAP highly effective acceptable in
  • Bulky, noisy, difficult to bring on trips
    require electricity
  • Pts who sleeps in lt position knock the mask off.
  • Intolerance by the pts partner
  • Claustrophobia, nasal congestion, chest
    discomfort inconvenience
  • Bilevel positive airway pressure (bilevel PAP)
  • Improved pt comfort, tolerance
  • Provide ventilatory assistance for pts who
    require high CPAP(COPD)

Nonsurgical management
  • Adjustable oral appliances
  • To enlarge the airway by keeping the tongue in
    an ant position or displacing the mandible
    forward (jaw thrust technique)
  • 1.Mandibular repositioning devices (MRD)
  • snoring or mild to mod OSA, unable to tolerate
  • High compliance (50-75)
  • Xerostomia, dental pain,temporomandibular joint
    pain, excessive salivation changes on occlusion
  • 2. Drugs
  • Protriptyline, acetazolamide, progesterone,
  • Modafanil
  • Fluoxetine
  • 3. Nocturnal O2 therapy
  • Severe arterial desaturation

Surgical management
  • Aim
  • relieving site-specific problems in the upper
  • increasing pharyngeal caliber reducing
    pharyngeal resistance during sleep
  • Complete evaluation
  • recent polysomnogram,
  • head neck exam (flexible nasopharyngeal
    fiberoptic exam),
  • assessment of disproportionate anatomy (elongated
    soft palate, thickened uvula, large base of
    tongue, DNS,enlarged tonsils, hypertrophic nasal
    turbinates hypoplastic or retrognatic
  • imaging studies (cephalometrics or CT scan)

Surgical management
  • 1.Uvulopharyngopalatoplasty (UPPP)
  • 2. Tonsillectomy
  • 3. Nasal sx
  • 4. Tracheostomy
  • 5. Jaw advancement techniques
  • 6. Minimally invasive techniques
  • Genioglossus advancement
  • Multilevel radiofrequency tissue ablation
  • Tongue-base suspension
  • Future research - Muscle strengthening with
    transcutaneous neuromuscular stimulation

Preoperative assessment
  • Identifying pts questions for exploring
  • Do people tell you that you snore?
  • Do you wake up at night with a feeling of
    shortness of breath or choking?
  • Do people tell you that you that gasp, choke or
    snore while sleeping?
  • Do you awake feeling almost as or more tired than
    when you went to bed?
  • Do you often awake with a headache?
  • Do you often have difficulty breathing through
    your nose?
  • Do you fight sleepiness during day time?
  • Do you fall asleep when relaxing after meals?
  • Do other comment on your sleepiness during the

Pre anesthetic visit
  • Weight height
  • Neck circumference
  • Abnormally small size mandible
  • Nasal patency
  • Upper airway for obvious obstruction (IL)
  • Tongue (macroglossia), dentition
  • Pharynx (tonsillar size, uvula, lumen size)
  • BP
  • RS, CVS, CNS ex
  • FEV1, FVC
  • Hypothyroidism, acromegaly, Marfans syndrome

Next step
  • Nonurgent procedure
  • Evaluation by a sleep specialist
  • Primary treatment.
  • Milder conservative
  • Mod to severe - initiation of CPAP therapy
  • Advantages
  • improvement in some cardiovascular squeal within
    several wks of initiation of therapy
  • 4-6wks - ?tongue volume ? pharyngeal tone
  • reduce the risks of difficult airway
  • perioperative respiratory embarrassment
  • improve cardiovascular function

Approach to guide anesthetic management
  • Management of the airway should be conservative,
    with measures taken to minimize hypoxia secondary
    to airway obstruction or apnea
  • Cautious, titrated administration of sedatives,
    monitoring observation of pt.
  • Adequate preoxygenation if plan is to ablate
    spontaneous ventilation
  • LMA emergency airway devices s/b immediately
  • Regional anesthesia with careful sedation

Approach to guide anesthetic management
  • Maintenance of general anesthesia s/b with the
    use of newer, shorter acting drugs to minimize
    the duration of postoperative ventilatory
  • Extubation in difficult airway, in conservative
    fashion, pt. strength level of consciousness
  • Adequate postoperative analgesia
  • NSAIDS, local anesthetics for incision
    infiltration, epidural analgesia, peripheral
    nerve blocks
  • Minimize administration of large dose of narcotics

Anesthesia technique
  • Regional anesthesia
  • - min affecting resp drive
  • - maintain arousal response during apneic
  • Sedation must be carefully administered
    monitored, it will worsen hypoventilation
  • General anesthesia with regional anestheisa allow
    rapid restoration of consciousness
  • Outcome depends on type of sx.
  • Neuraxial opioid have been ass with unexpected
    degree of ventilatory depression

Anesthetic management
  • Anesthetic drugs profoundly influence control of
    the respiratory system, which is already
  • Exaggerated responses
  • Thiopentone, propofol, opioids, benzodiazepines
    nitrous oxide- reduce the tone of the pharyngeal
    musculature that acts to maintain airway patency.
  • Response to Co2 in children with OSA tonsillar
    hypertrophy is diminished
  • Depressed ventilation 50 apnea after 0.5µg/kg
    of fentanyl
  • Shorter acting drugs

Rapid sequence induction
  • To reduce the risk of pulmonary aspiration
  • Pharmacological agent with or without gastric
  • Reduce gastric volume acidity
  • Rapid acting hypnotic agent MR to limit apneic
    time providing non hypoxemic apneic period
  • Absence of mask ventilation after a
    preoxygenation FRC is reduced ? faster
    desaturation ? safe apneic pr. is reduced from
    gt5min to lt 2-3min.
  • Absence of mask ventilation ? atelectasis.
    Constant CPAP during preoxygenation gentle
    ventilation with PEEP during induction
    significantly reduce atelectasis

Rapid sequence induction
  • Cricoid pressure correct application
  • Initiate with a forceof 20N as the induction
    started to increase the force to 30N as loss of
    consciousness occurs
  • Adversely affect mask ventilation (directly
    posterior with gradual release)
  • Adversely affect laryngoscopy view (backward
    upward laryngeal displacement)
  • More difficult LMA insertion
  • Less successful intubating LMA
  • Trendelenburg position, suction available
    graded release of cricoid pressure

Rapid sequence induction
  • Difficult airway
  • Sp. Alteration in airway anatomy physiology
    difficult mask ventilation intubation
  • Diabetes mellitus (limited jt mobility syndrome)
  • paramount concern - Ability to assure oxygenation
  • Secondary concern difficult airway inadequate
    anesthetic depth during difficult airway

Muscle relaxant
  • Succinylcholine
  • 0.6mg/kg
  • Fasciculation rise in gastric pressure (40mmHg)
  • Rapid onset short duration of action
  • Rapid return of spontaneous ventilation
  • Rocuronium
  • Faster onset
  • Longer duration not for pts with difficult
  • Less side effects

Intraoperative monitoring
  • According to type of sx, comorbidities
  • TEE ventricular filling function
  • Intra-arterial catheter to monitor blood pressure
  • Metabolic alkalosis can result in mild
    hypoventilation. Maintenance of baseline

  • Challenging
  • Deep extubation occasionally practiced
  • Fully conscious
  • Intact upper airway reflexes
  • Adequate muscle strength
  • In the OT or in ICU with facility for
  • Difficult intubation cart
  • Noninvasive mechanical ventilation immediately
    after extubation

Postoperative consideration
  • Immediate PACU
  • Most complications first 2hr
  • continuous monitoring, depending on I/O
  • frequent assessment of s/s of airway problems
  • 1 in 500 pt will require reintubation
  • Difficult intubation
  • Continuous O2 thr. Face mask or nasal CPAP (if
    nasogastric tube in place then seal of nasal CPAP
    is not adequate)
  • Posture positioning HOB 300 (? stability of
    the upper airway)
  • Adequate blood pressure control
  • HTN due to pain, hypercarbia, anxiety.
    VASOTRAC device for BP monitoring

Postoperative consideration
  • Disposition from PACU
  • Preop AHI, CPAP dependence
  • RVF, LVF, Lung disease, Degree of obesity, Nature
    of sx
  • Mild OSA min comorbidities for minor sx
  • ?
  • discharge on the day of sx
  • Mod OSA intermediate comorbidities for
    interm.risk sx
  • ?
  • admission to a standard M or Sx unit
  • Severe OSA with CPAP at home multiple
  • ?
  • closer observation on ICU or intermediate care
    unit depending on the nature of the sx

Perioperative issues for OSA sx
  • Max with in 2hrs of sx
  • Airway obstruction, laryngospasm, desaturation
    postop pul oedema
  • Postop. Hemorrhage
  • HTN

Postoperative pain managment
  • Narcotics use is dangerous
  • After GA- Propensity of REM sleep during the
    first several days
  • After iv opioid, epidural opioid, PCA ? resp
    depression culminating to resp arrest
  • Prevention HOB, CPAP, limit narcotics
  • NSAIDS 20-35 decrease in opioid use
  • Resp depression supplemental O2, iv naloxone
  • nasal or oral airway
  • CPAP
  • endotracheal intubation (difficult)
  • emergency cricothyroidotomy (difficult)

Postop. additional consideration
  • Early ambulation
  • Proper position in bed
  • Sleeping position
  • Physical therapy
  • Skin breakdown (lack of adequate oxygen delivery,
    poor vascularity of adipose tissue)
  • Pressure sore (proper padding)

OSA in children
  • Preschoolers, equal in boys girls
  • Pathophysiology
  • Airway anatomy upper airway narrowing
    (Adenotonsillar hyperthrophy, craniofacial
    anomalies, obese BMI gt28)
  • Obesity
  • Neuromotor factors reduced, centrally mediated
    activation of their upper airway muscles

OSA in children
  • Clinical features
  • Snoring, labored breathing, paradoxical resp
    effort, observed apnea, restlessness, sweating,
    unusual sleep position, enuresis
  • Day time mouth breathing, poor school
    performance, excessive day time somnolence,
    morning headache, fatigue, hyperactivity,
    aggression social withdrawal
  • Failure to thrive, developmental delay
  • Physical - mouth breathing, nasal voice quality,
    retrognathia or micrognathia, pul HTN

OSA in children
  • Treatment
  • 1.Adenotonsillectomy
  • 2.CPAP - if adenotonsillectomy is C/I or
    sypmtomatic after sx
  • 3.Tracheostomy
  • craniofacial anomalies
  • neuromuscular syndromes
  • can not tolerate CPAP or BiPAP

Risk factors for resp distress after sx
  • Age lt 3yr
  • Bleeding
  • Concurrent resp infection
  • CHD, craniofacial disease
  • Failure to thrive
  • H/O cor pulmonale, premature birth
  • Neuromuscular disease
  • Obesity
  • Other cong abnormalities or syndrome
  • Severe OSA
  • Throat pack not removed

Syndrome associated with OSA
OSA in children
  • Complications
  • Due to ch. Nocturnal hypoxemia sleep
  • Pul HTN, cor pulmonale, heart failure
  • Hypertrophy of ventricles
  • Dysregulation of the mean blood pressure
    end-organ damage ? risk for CV disease
  • Neurocognitive deficits, learning problems,
    behavioral problems attention deficit
    hyperactivity disorder.
  • Evaluation
  • Polysomnography age appropriate interpretation
  • differentiate primary
    snoring OSAS

PAC in children
  • History detailed birth medical history
  • Growth assessment, recent RTI, behavioral
    school performance
  • Polysomnography review
  • CXR, ECG, echo
  • ABG comp metabolic alkalosis in response to chr
    hypercarbia to identifying prolong OSAS
  • Severe anatomical malformation of the airway or
    morbid neurological disease ASAIII IV
  • Alternative airway devices including emrg
  • Anticipation of need of postop ventilation
  • Prevention of gastroesophageal reflux
  • Management of neurological disease - seizure

Intraoperative anesthetic plan
  • Collapse of upper-airway structures diminished
    arousal response to elevation of CO2 under
  • Inhalational induction dose dependent
    relaxation of genioglossus muscle
  • Exaggeration of the blunted resp drive in
    response to opioid benzodiazepine adm at risk
    for resp obstruction
  • Jaw thrust to tr obstruction is the most useful
    superior to chin lift. Lateral position
  • Monitoring
  • Standard
  • Invasive heart failure, pul HTN, severe
    bronchospasm, ABG

  • Challenging
  • Deep extubation occasionally practiced
  • Laryngospasm Mg, midazolam premedication
  • Adequate muscle strength, age app resp rate
    without assisted ventilation
  • In the OT or in ICU with facility for
  • Noninvasive mechanical ventilation immediately
    after extubation
  • Post op care
  • Resp failure, ? apea episodes, ac airway obs,
    atelectasis, pul edema
  • Circulatory failure pul HTN, COR pulmonale
  • Ped. ICU severe OSA, cvs disease, airway sx,
    craniofacial sx
  • 2-3 days post sx bec OSA may recur along with the
    return of REM sleep

Respiratory support
  • Supplemental O2 may prolong apnea time
    prevent the frequency of hypoxemic episodes
  • Postop hypoxemia
  • hypoventilation,
  • pul oedema,
  • atelectasis,
  • pneumonia
  • CPAP or BiPAP
  • Mechanical ventilation
  • ABG can guide extubation decisions

Respiratory support
  • Postop pul oedema
  • ? pul blood flow pul microvascular pressures
    which occur as pt generates an exceeding high
    negative inspiratory force while inhaling against
    a collapsed pharynx or closed glottis
  • Diffuse punctate hemorrhages
  • S/S hypoxemia, cough,
  • serous, frothy or bloody sputum
  • crepts in the lung field
  • diffuse haziness on CXR
  • Reintubation, invasive or non invasive positive
    pressure ventilation, O2, diuretic

Surgical management
  • 1.Uvulopharyngopalatoplasty (UPPP)
  • removal of a rim of the soft palate the
    uvula (1964)
  • combined with tonsillectomy
  • Result enlarge oropharyngeal airway
  • Success rate 40-50 (drop in the RDI gt50 or an
    absolute RDI lt20)
  • Drop in success rate if retrolingual narrowing in
    present from an enlarged tongue or crowding in
    the region of the hypopharynx
  • Side effect Decrease ability to use nasal CPAP

Surgical management
  • 2. Tonsillectomy
  • Airway blockage palatine tonsils
  • ? AHI lt 50
  • Children with adenoidectomy
  • Temperature controlled radiofrequency tissue
    ablation in office setting under LA
  • Electrocautery
  • 3. Nasal sx-
  • Improve compliance of CPAP
  • After max medical therapy
  • Septoplasty turbinate reduction
  • ? nasal resistance or obstruction may ?the
    negative pressure of the airway during
    inspiration ? collapse of the velopharyngeal area
    the hypopharyngeal regions

Surgical management
  • 4. Tracheostomy
  • Last measure
  • Life threatening severe OSA
  • Inability to tolerate CPAP
  • Pickwickian syndrome nighttime ventilatory
  • 5. Jaw advancement techniques
  • Enlarging the posterior airway
  • Le fort I bilateral mandibular osteotomies to
    move tongue entire midface forward, typically
    app. 10mm
  • Success rate 97
  • Alter facial appearance
  • With other sx

Surgical management
  • 6. Minimally invasive techniques
  • a. Genioglossus advancement
  • retropalatal retrolingual obstruction
  • Guided trephine system
  • With UPPP
  • 67 success rate
  • gt50 reduction in the resp disturbances
  • b. Multilevel radiofrequency tissue ablation
  • Multilevel obstruction tongue base soft palate
  • Office based, LA
  • Significantly improve the AHI AI

Surgical management
  • c. Tongue-base suspension
  • ? post obstruction of the tongue base during
  • With UPPP
  • Titanium screw is inserted into the post aspect
    of the mandible at the floor of the mouth
  • Loop of permanent suture extending thr the tongue
    base is att to the mandible screw
  • d. Future research
  • Muscle strengthening with transcutaneous
    neuromuscular stimulation to counteract muscle
    dysfunction that may be contributing to the
    collapse of the upper airway

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