11

Lecture on Sleep ApneaLecture on Sleep ApneaAbimbola Farinde,PhDAbimbola Farinde,PhD

11/15/1511/15/15

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ObjectivesObjectives

Define and understand sleep apnea

Provide assessments and diagnosis for sleep apnea

Discuss the treatment options available for sleep apnea

Discuss a patient case presentation on sleep apnea

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Background/OriginBackground/Origin

Definition: Apnea: cessation of airflow at the nose

and mouth lasting at least 10 seconds

Classifications: obstructive or central apnea Obstructive-episodic upper airway obstruction during sleep

• Complete or partial obstruction • Causation: obesity, polyps, enlarged tonsils)• Varying degree of O2 desaturation, hypercarbia,

and sleep fragmentation

Central-repeated episodes of apnea causes by temporary loss of respiratory effort during somnolence

• >10% of all apnea with numerous idiopathic presentations

44

Sleep PhysiologySleep Physiology

Circadian rhythm Controlled by 2 oscillators with different period lengths

• 1st oscillator: biologic clock (suprahiasmic nucleus)

• 2nd oscillator: neurobiologic mechanism• Involvement of delta-sleep-inducing peptide

and factor S

Synchronization of sleep-wake cycle• Last 25 hours with 24-hour cycle imposed by earth’s

rotation

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Pathophysiology Of OSA & Pathophysiology Of OSA & CSACSA

OSA Disordered breathing during sleep Respiratory efforts with no airflow (upper airway

obstruction)CSA Interruption of both airflow /breathing efforts

Note: Mixed apneas can have both central and obstructive components. 1st central apnea followed by 1 or more obstructed breaths

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EpidemiologyEpidemiology

12 million Americans OSA affects approximately 4% men and 2%

women in U.S Prevalence in U.S children: 2% Male-to-Female ratio:

Children: 1:1

Adulthood: 2:1 or more African Americans and Hispanics >Whites African Americas are 3.5 times for likely to develop

OSA

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DSM-IV Classification of SleepDSM-IV Classification of SleepDisordersDisorders Primary Sleep Disorders

Dyssomnias

Primary Insomnia

Primary hyersomnia

Breathing-related sleep disordersBreathing-related sleep disorders

Narcolepsy

Circadian rhythm sleep disorder

Delayed sleep phase type

Jet lag type

Unspecified type

Dyssomnias not otherwise specified Parasomnias

Nightmare disorder

Sleep terror disorder

Sleepwalking disorder

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DSM-IV Classification of SleepDSM-IV Classification of SleepDisorders (cont’d)Disorders (cont’d)

Parasomnias not otherwise specified Sleep disorders Related to Another Mental

Disorder

Insomnia related to another mental disorder

Hypersomnia related to another mental disorder Other Sleep Disorder

Sleep disorder due to a general medical condition

Substance-induced sleep disorder

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Risk FactorsRisk Factors

Morbidly obese (esp. neck size >17in) Anatomical disproportion (e.g. small

jaw, large tongue) Men >40 years of agePostmenopausal womenFamily history of sleep apneaSmoking/Alcohol useAbnormalities in structure of upper

airway

1010

Signs and Symptoms of OSASigns and Symptoms of OSA

Airway occlusion lightened depth of sleep, arousal from sleep

Repetitive bouts of hypoxia Heightened peripheral vascular constriction Tachycardic-bradycardic events during sleep Daytime symptoms (morning headache, poor

memory, and irritability) High blood pressure and other cardiovascular

complications Feelings of depression Reflux/Nocturia/Impotence

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Diagnostic TestsDiagnostic Tests Polysomnography (standard for diagnosis)

o Overnight and during usual bedtimeo Gauge severity of OSA

Inclusion in polysomnography:

o Electroculographyo Chin and leg surface electromyographyo Two EEG channelso Breathing assessments (nasal/oral airflow sensor or pulse oximetry)o 1 ECG channel (heart rate and rhythm)o Others: seizure activity, esophageal ph measurements

Daytime nap studies (specific not sensitive) Imaging Studies

o Anteroposterior and lateral neck radiographyo CINE MRI during sleep

1212

Diagnostic TestsDiagnostic Tests

Other testso CBC, multiple sleep latency test, MRI of brain

and brainstem

1313

Treatments for Sleep ApneaTreatments for Sleep Apnea Medical Care Medical Care

Positional therapy (1.e., avoidance of sleeping on back) Encourage sleep in prone position Weight loss Oral appliances (aid with bringing lower jaw and tongue forward during

sleep) improvement of OSA Surgery: tonsillectomy and adenoidectomy (common in pediatric patients Continuous positive airway pressure (CPAP) Amount of CPAP Mainstay of therapy in most adults Over-the-counter disposable adhesive covered nasal strips

1414

Treatments for Sleep ApneaTreatments for Sleep Apnea Surgical Care Surgical Care

Adenotonsillectomyo Curative in some instanceso Demonstrates improvement in neurocognitive function

Uvulopalatopharyngoplasty (UPPP)o removal of uvula, posterior margins of the soft palate, and lateral pharyngeal wall mucosa via scalpel or laser ablation o Likely to resolve OSA is obstruction is localized to soft palate o Successful reduction of apnea in 50% of patients and snoring in 90%

Tongue reduction procedures (midline partial glossectomy) Trachectomy

o Effective for life-threatening obstructive apnea

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Treatments for Sleep ApneaTreatments for Sleep Apnea Pharmacological Interventions Pharmacological Interventions OSA

o Avoidance of CNS depressants (i.e., alcohol, anxiolytics, hypnotics, narcotics)o Protriptyline (mild OSA without hypercapnia) -Dose: 10-30mg/day -Anticholinergic side effectso Fluoxetine -Dose:20mg/day -Reduction of apnea in some patientso Respiratory stimulants: theophylline and clonidine(males) o Medroxyprogesterone -Dose: 60mg -Improvement of sleep apnea and obesity- hypoventilation

1616

Treatments for Sleep ApneaTreatments for Sleep Apnea Pharmacological Interventions (cont’d) Pharmacological Interventions (cont’d)

CSAo Hypercapnic CSA:

-Ventillatory support with O2 and CPAP -Acetazolamide, theophylline, and medroxyprogesterone

o Non-hypercapnic CSA - Benzodiazepines (triazolam or temazepam)

- Acetazolamide, CPAP, and O2

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Patient Case: History of Present Patient Case: History of Present IllnessIllness

CC: “complaints of snoring, apneic episodes

during sleep, disturbed sleep at night, daytime hypersomnolence and fatigue”

RB is a 79 year old African American male who currently admitted to 3J who received work-up for “spells” from an inpatient sleep consult. Patient has had complaints for last few years but recently got worse.

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Past Medical HistoryPast Medical History

Coronary artery disease Hypothyroidism Colonic Polyps Hematochezia Hypertension Hyperlipidemia

1919

Social/Occupational/Military Social/Occupational/Military HistoryHistory

Part time horse rancher >80 pack year history of smoking Rarely smokes presently Lives with wife 3 children Vietnam Veteran

2020

Review of SystemsReview of Systems

Vital Signs Temp: 96.7oF BP: 123/66 R:16 P:95 Ht: 70in

Wt:74.5KG(163.8lbs)

HEAD: PERRLA, EOMI MOUTH: no lesions NECK: supple no lymph nodes palpable LUNGS: course breath sounds HEART: no murmurs ABDOMEN: soft mildly tender diffusely, no bowel sounds,

nondistended EXTREMITIES: great toe with patchy heterogeneous flat

multicolored dark lesion NEUROLOGICAL: delayed tendon reflex

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MedicationsMedications

Clopidogrel 75mg daily to prevent blood clots Dilitiazem 240mg daily for blood pressure Etodolac 300mg at bedtime Levothyroxine 0.137mg daily for hypothyroidism Lisinopril 20mg/HCTZ 25MG every morning for

blood pressure Metoprolol tartrate 25mg twice a day for blood

pressure Simvastatin 20mg at bedtime for cholesterol Fluticasone nasal inh once daily in both nostrils for

allergies

2222

Pertinent Laboratory ValuesPertinent Laboratory ValuesGlucose 102H Anion gap 9BUN 40H Alkphos 69Creatinine 1.6H T.Protein 6.7Sodium 136 AST 25Potassium 4.4 ALT 21Chloride 104 T. Bilirubin 0.8CO2 29.0 Urea

Nitrogen40

Albumin 3.7 WBC 6.9TSH RBC 4.63LCalcium 9.8 HGB 11.9LCholesterol 157 HCT 36.4L

2323

Pertinent Laboratory Values Pertinent Laboratory Values (cont’d)(cont’d)

BUN 40H

HgA1C 5.7

Plts 234LDL 96

HDL 35L

TG 130

INR-R/PT 1.02/13.7

2424

Assessment/PlanAssessment/Plan

Assessment: clinical features suggestive of obstructive sleep apnea syndrome. Episodes of “spells” need not be secondary to sleep-related breathing disorder. History is indicative of central sleep apnea

2525

Assessment/Plan (cont’d)Assessment/Plan (cont’d)

Plan:

Perform ECHO and full PFT Overnight sleep study and CPAP titration Advised patient to keep ideal body weight and

avoid driving when sleepy Advised patient to follow sleep hygiene measures Avoid driving and operating dangerous equipment

until elimination of daytime sleepiness Cautioned patient about exacerbations of sleep-

related breathing problems: alcohol, sedatives, and hypnotics

Scheduled for follow-up visit

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Results of Pulmonary Function TestResults of Pulmonary Function Test

FVC = 3.13L or 75% predicted.FEV1 = 2.14L or 81% predicted.FEV1/FVC ratio 68FEF 25-75% = 1.56L/sec or 69%

predicted. TLC = 10.00L or 146% predicted.

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Results of Sleep StudyResults of Sleep Study

Sleep efficiency (total sleep time/recording time):48% (normal >85%)

Sleep onset latency: 62 minutes (normal 3-30 minutes)

REM sleep latency: 108 minutes (normal 60-120 minutes)

101 obstructive apneas and 24 hypopneas) apnea-hyponea index of 41 events/hr (normal <5)

Minimum o2 saturation by pulse oximetry: 92% and baseline oxygen saturation : 96%

Mild Snoring during sleep study

No EEG or EKG abnormalities

Final ImpressionFinal Impression: Obstructive Sleep Apnea Syndrome

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ReferencesReferences Dipiro, JT et al. Pharmacotherapy: A Pathophysiologic

Approach. 5TH edition. New York: The McGraw-Hill Companies, Inc; 2005. p.1327-1328.

Colin, Wayne & Duval, Susan. Surgical treatment of obstructive sleep apnea. AORN journal. Sept. 25, 2005.

Steffan, Michael. Sleep Apnea. E-medicine from the WebMD. 2006

Guilleminault, C. et al. Maxillomandibular expansion for the treatment of sleep-disordered breathing: preliminary result. Laryngoscope. 2004;114(5):893-6.

Young, T, Peppard, PE, Gottlieb, DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165(9):1217-39.

Paje, Dama  T. & Kremer, Michael. The Perioperative Implications of Obstructive Sleep Apnea. Orthopaedic Nursing. 2006;25(5):291-297.