by: john j. beneck mspa, pa-c1 sleep apnea everything you never wanted to know about…

By: John J. Beneck MSPA, PA-C 1

Sleep ApneaSleep Apnea

Everything You Never Everything You Never

Wanted to Know About…Wanted to Know About…

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Case 1Case 1

• 35 year old male with loud snoring. Spouse 35 year old male with loud snoring. Spouse states she can’t sleep in the same room with states she can’t sleep in the same room with him.him.

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Case 2Case 2

• 46 year old obese male in for annual CPE 46 year old obese male in for annual CPE observed by you to appear sleepy during the observed by you to appear sleepy during the medical interview.medical interview.

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Case 3Case 3

• In Hospital: Call at 0025 from RN that 42 In Hospital: Call at 0025 from RN that 42 year old female diabetic in with lower year old female diabetic in with lower extremity cellulitis has oxygen saturation in extremity cellulitis has oxygen saturation in the low 80s when checking vital signs. the low 80s when checking vital signs. Awoke when stimulated and SaO2 Awoke when stimulated and SaO2 improved.improved.

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ObjectivesObjectives

• Understand OSAH and CSAS in terms of the Understand OSAH and CSAS in terms of the following:following:– DefinitionDefinition

– EpidemiologyEpidemiology

– Pt. PresentationPt. Presentation

– DxDx

– PreventionPrevention

– TxTx

– PrognosisPrognosis

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AbbreviationsAbbreviations

• CO2 – Carbon dioxide

• CPAP – Continuous positive airway pressure

• CPE – Comprehensive Physical Exam

• CSAS – Central sleep apnea syndrome

• CV – Cardiovascular

• D/t – due to

• Dx – Diagnosis

• Dz - Disease

• EEG – Electroencephalogram

• HF – Heart failure

• HTN – Hypertension

• LVEF – Left ventricular ejection fraction

• MVC – Motor vehicle crash

• N-CPAP – Nasal CPAP

• O2 - Oxygen

• OSAH – Obstructive sleep apnea hypopnea syndrome

• pCO2 – partial pressure of carbon dioxide

• pO2 – Partial pressure of oxygen

• REM – Rapid eye movement

• RN – Registered Nurse

• SaO2 – Oxygen saturation

• Tx – Treatment

• W/ - With

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Neuronal Respiratory ControlNeuronal Respiratory Control

• Neuronal ControlNeuronal Control

– Rhythmic cycle of breath regulated by Rhythmic cycle of breath regulated by

medullary neuron interactionmedullary neuron interaction

– Efferent activityEfferent activity

• Cranial nerves of upper airwayCranial nerves of upper airway

• Chest wall muscle innervationChest wall muscle innervation

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Neuronal Control (cont.)Neuronal Control (cont.)

• Medullary groups influenced by pontine & Medullary groups influenced by pontine &

suprapontine descending pathwayssuprapontine descending pathways

• These pathways influenced by sleep-wake These pathways influenced by sleep-wake

cycle, particularly Reticular Activating cycle, particularly Reticular Activating

System activity System activity

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Obstructive Sleep Apnea Obstructive Sleep Apnea Hypopnea - DefinitionHypopnea - Definition

• Episodes of airway obstruction during sleep Episodes of airway obstruction during sleep

resulting in recurrent arousals associated resulting in recurrent arousals associated

with:with:

– Otherwise unexplained excessive daytime Otherwise unexplained excessive daytime

sleepiness AND...sleepiness AND...

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Definition (cont.)Definition (cont.)

• ……AND AND >> 2 of the following 2 of the following• Loud disruptive snoringLoud disruptive snoring

• Nocturnal choking/gasping/snortNocturnal choking/gasping/snort

• Recurrent nocturnal awakeningRecurrent nocturnal awakening

• Unrefreshed sleepUnrefreshed sleep

• Daytime fatiqueDaytime fatique

• Impaired concentrationImpaired concentration

• ...AND......AND...• Documented overnight sleep monitoringDocumented overnight sleep monitoring

• >5 episodes hypopnea and apnea per hour>5 episodes hypopnea and apnea per hour

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More DefinitionsMore Definitions

• ApneaApnea– <20% baseline airflow for <20% baseline airflow for 10 seconds in adults 10 seconds in adults

• HypopneaHypopnea 30% baseline airflow30% baseline airflow 10 seconds10 seconds 90% of duration of 90% of duration of airflow airflow 30% baseline flow 30% baseline flow airflow accompanied by airflow accompanied by 4% 4% oxygen saturation oxygen saturation

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EpidemiologyEpidemiology

• Overall Overall 2-20%2-20% depending on sex and symptoms depending on sex and symptoms

• Estimated 3 million men and 1.5 million womenEstimated 3 million men and 1.5 million women

• M:F 2-4:1M:F 2-4:1

• Daytime sleepiness 2-4%Daytime sleepiness 2-4%

– (narcolepsy 0.02-0.06%)(narcolepsy 0.02-0.06%)

• Up to 85% in obese personsUp to 85% in obese persons

1 - UpToDate, 2006 13

HistoryHistory

• Charles Dickens - “The Postumous Papers Charles Dickens - “The Postumous Papers of the Pickwick Club”of the Pickwick Club”– Pickwickian SyndromePickwickian Syndrome– (Obesity Hypoventilation Syndrome)(Obesity Hypoventilation Syndrome)

• ObesityObesity• HypersomnolenceHypersomnolence• Signs of Chronic Alveolar HypoventilationSigns of Chronic Alveolar Hypoventilation• PolycythemiaPolycythemia• Sleep apneaSleep apnea

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Practical PredictorsPractical Predictors

• HTNHTN

• History of habitual snoringHistory of habitual snoring

• Observed reports of nocturnal choking or Observed reports of nocturnal choking or

gaspinggasping

• Neck size > 17 inchesNeck size > 17 inches

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Airway PatencyAirway Patency

• Airway size - flow resistanceAirway size - flow resistance– Anatomic traitsAnatomic traits

• Neck sizeNeck size

• ObesityObesity

• Crowded upper airwayCrowded upper airway– Large tongueLarge tongue

– Small chinSmall chin

• Nasopharyngeal tumorsNasopharyngeal tumors

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OSAH EtiologyOSAH Etiology

• Sleep affects respiratory control systemSleep affects respiratory control system

– Reduced tonic input to upper airway musclesReduced tonic input to upper airway muscles

– Diminished reflexes that protect against airway Diminished reflexes that protect against airway

collapsecollapse

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Etiology (cont)Etiology (cont)

• Exaggerated inspiratory effortExaggerated inspiratory effort• Decreased gas exchangeDecreased gas exchange• Resolves with arousal or change in sleep Resolves with arousal or change in sleep

state state

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Recurrent ApneaRecurrent Apnea

• Instability of feedback controlInstability of feedback control

• Ventilation Ventilation cyclescycles instead of being instead of being maintainedmaintained at a constant level at a constant level

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MechanismMechanism

• Sleep…Sleep…

Upper airway tone...Upper airway tone...

• Obstruction...Obstruction...

• Apnea…Apnea…

pO2, pO2, pCO2…pCO2…

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Mechanism (cont.)Mechanism (cont.)

• ……Arousal…Arousal… Upper airway tone…Upper airway tone…• Resumption of breathing…Resumption of breathing…• Hyperventilation…Hyperventilation…• Return to sleep…Return to sleep… Upper airway tone…Upper airway tone…• This occurs HUNDREDS of times each nightThis occurs HUNDREDS of times each night

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Etiology (cont)Etiology (cont)

• Upper airway is Upper airway is destablilizeddestablilized

• Partial or Partial or complete complete obstruction of obstruction of nasopharynx, nasopharynx, oropharynx, or oropharynx, or bothboth

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PresentationPresentation

• Primarily relate to effects on pt’s sleepPrimarily relate to effects on pt’s sleep

– Typically overweight menTypically overweight men

– Awaken unrestedAwaken unrested

– Daytime somnolenceDaytime somnolence

– Disruptive snoring Disruptive snoring

• 45% men & 30% women >65 yrs old snore45% men & 30% women >65 yrs old snore

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SleepinessSleepiness(Of course we need to define sleepiness)(Of course we need to define sleepiness)

• MildMild– Sleep during times of restSleep during times of rest– Incidental functional impairmentIncidental functional impairment

• ModerateModerate– Sleep during activities requiring some attentionSleep during activities requiring some attention

• ConcertsConcerts

• MeetingsMeetings

• PresentationsPresentations

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Sleepiness (cont.)Sleepiness (cont.)

• SevereSevere– Sleep during activities requiring at least Sleep during activities requiring at least

moderate attentionmoderate attention• EatingEating

• ConversationConversation

• WalkingWalking

• DrivingDriving

– Marked functional impairment Marked functional impairment

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Differential Diagnosis of Differential Diagnosis of SleepinessSleepiness

• Sleep restrictionSleep restriction

• NarcolepsyNarcolepsy

• Restless leg syndromeRestless leg syndrome

• Cardiovascular, respiratory, metabolic Cardiovascular, respiratory, metabolic disturbancesdisturbances

• Drug addictionDrug addiction

• DepressionDepression

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OSAH Diagnosis-suspicionOSAH Diagnosis-suspicion

• Presentation as abovePresentation as above

• Witnessed apneic periods, nocturnal Witnessed apneic periods, nocturnal

gasping or chokinggasping or choking

– >10 events per hr typical for symptomatic pts>10 events per hr typical for symptomatic pts

• Body habitusBody habitus

• HTNHTN

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Diagnosis-definitiveDiagnosis-definitive• Nocturnal PolysomnographNocturnal Polysomnograph

– EEGEEG– ElectromyelographElectromyelograph

• ChinChin activity during REMactivity during REM

• Limbs Limbs – checks non-respiratory causes of arousalchecks non-respiratory causes of arousal

– Electro-oculogramElectro-oculogram• Detects REMDetects REM

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DDx (cont.)DDx (cont.)

– Nasal/oral airflowNasal/oral airflow

– Thoracic/abdominal movementThoracic/abdominal movement

– Oxygen saturationOxygen saturation– Cardiac rate & rhythmCardiac rate & rhythm– Body positionBody position

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Split studiesSplit studies

• Part 1 – Definitive diagnosisPart 1 – Definitive diagnosis

• Part 2 – Optimal CPAP levelPart 2 – Optimal CPAP level

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Terms of OSA QuantificationTerms of OSA Quantification

– Apnea-hypopnea index (AHI)Apnea-hypopnea index (AHI)

– Apnea Index (AI)Apnea Index (AI)

– Respiratory Disturbance Index (RDI)Respiratory Disturbance Index (RDI)

– Respiratory Arousal Index (RAI)Respiratory Arousal Index (RAI)

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Apnea-Hypopnea Index (AHI)Apnea-Hypopnea Index (AHI)

• # episodes apnea & hypopnea / # hrs sleep# episodes apnea & hypopnea / # hrs sleep

OSAH = AHI > 15 / hrOSAH = AHI > 15 / hr

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Apnea IndexApnea Index

• # apneic episodes / # hrs sleep# apneic episodes / # hrs sleep

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Respiratory Disturbance Index Respiratory Disturbance Index (RDI)(RDI)

• # times per hour SaO2 drops > 3%# times per hour SaO2 drops > 3%

– <5 - No OSA<5 - No OSA

– 5-15 - Mild OSA5-15 - Mild OSA

– 16-30 - Moderate OSA16-30 - Moderate OSA

– >30 - Severe OSA>30 - Severe OSA

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Respiratory Arousal Index (RAI)Respiratory Arousal Index (RAI)

• Computed with EEG measurementComputed with EEG measurement

• # inspiratory associated arousals per hour of # inspiratory associated arousals per hour of

sleepsleep

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OSAH ComplicationsOSAH Complications

• SleepinessSleepiness

– Somnolence during activitiesSomnolence during activities

– Impaired concentrationImpaired concentration

• Systemic hypertensionSystemic hypertension

• Vascular diseaseVascular disease

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OSAH and CV DiseaseOSAH and CV Disease

• Arousals – bursts of sympathetic activityArousals – bursts of sympathetic activity– Not goodNot good

SaO2 / SaO2 / SaO2 causes ischemia then reperfusion SaO2 causes ischemia then reperfusion– Oxydative stressOxydative stress

• SubsequentSubsequent– HTNHTN– Insulin resistanceInsulin resistance– InflammationInflammation

• Ultimately leading to…Ultimately leading to…– CV endothelial dysfunctionCV endothelial dysfunction

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Other Potential ComplicationsOther Potential Complications

• StrokeStroke

• Cardiac arrhythmiaCardiac arrhythmia

• Pulmonary HTNPulmonary HTN

• Morning head acheMorning head ache

• Peri-operative complicationsPeri-operative complications

– Impaired intubationImpaired intubation

– Impaired arousal from sedativesImpaired arousal from sedatives

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PreventionPrevention

• Modifiable Modifiable risk factorsrisk factors::– ObesityObesity– Exacerbative medicationsExacerbative medications– Inadequate sleepInadequate sleep

• Modifiable Modifiable complicationscomplications::– Machinery/motor vehicle operationMachinery/motor vehicle operation– Inform Anesthesiologist before elective Inform Anesthesiologist before elective

proceduresprocedures

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Treatment - GeneralTreatment - General

• Depends on severity of diseaseDepends on severity of disease

– No Tx for < 15 events per hourNo Tx for < 15 events per hour

• Behavioral ModificationsBehavioral Modifications

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Treatment - General (Cont.)Treatment - General (Cont.)

• Weight lossWeight loss

– 5-10% 5-10% body weight may be effective body weight may be effective

• Nasal CPAPNasal CPAP

• Oral appliancesOral appliances

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Treatment - MedicalTreatment - Medical

• Vasoconstrictive spraysVasoconstrictive sprays

• Weight loss medsWeight loss meds

• Oxygen (select patients)Oxygen (select patients)

• Chemical avoidanceChemical avoidance– Sedative hypnoticsSedative hypnotics– AlchoholAlchohol– AntihistaminesAntihistamines

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Treatment - SurgicalTreatment - Surgical

• HyoplastyHyoplasty

• LinguloplastyLinguloplasty

• Mandibular advancementMandibular advancement

• UvulopalatopharyngoplastyUvulopalatopharyngoplasty

• TracheostomyTracheostomy

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Treatment - SurgicalTreatment - Surgical

• For loud snoring:For loud snoring:

– Laser-assisted uvuloplastyLaser-assisted uvuloplasty

– Radiofrequency tissue ablationRadiofrequency tissue ablation

– May May apnea and/or delay definitive treatment apnea and/or delay definitive treatment

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PrognosisPrognosis

• Natural history largely unknownNatural history largely unknown• IF dz progresses, it does so slowlyIF dz progresses, it does so slowly• Implications with death:Implications with death:

– ? ? in-hospital mortality d/t: in-hospital mortality d/t:• Cardiorespiratory failureCardiorespiratory failure• Pulmonary embolusPulmonary embolus• Case reports complications of anesthesiaCase reports complications of anesthesia

– Accidents Accidents • 2-7 times greater chance of MVC2-7 times greater chance of MVC• Equipment operationEquipment operation

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CentralCentral Sleep Apnea Syndrome Sleep Apnea Syndrome

• > 10 second cessation of breathing in the > 10 second cessation of breathing in the absence of respiratory effort.absence of respiratory effort.

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CentralCentral Sleep Apnea Syndrome Sleep Apnea Syndrome

• Airflow stops without obstructionAirflow stops without obstruction

• Interruption of central respiratory driveInterruption of central respiratory drive

• Airflow AND respiratory effort are absentAirflow AND respiratory effort are absent

• Disorder of Apneic Threshold Disorder of Apneic Threshold

• Relation to OSA (Mixed Apnea)Relation to OSA (Mixed Apnea)

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CSAS - EtiologyCSAS - Etiology

• Neural disordersNeural disorders

– PoliomyelitisPoliomyelitis

– Posterior fossa tumorsPosterior fossa tumors

– Idiopathic failure of Idiopathic failure of

central breathing central breathing

controlcontrol

• Complication of Complication of OSAHOSAH

• Narcotic induced Narcotic induced CSASCSAS

• High altitude induced High altitude induced periodic breathingperiodic breathing

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CSAS – Etiology (Cont.)CSAS – Etiology (Cont.)

• Heart FailureHeart Failure– 37% of Pts with HF & LVEF < 45% have 37% of Pts with HF & LVEF < 45% have

CSASCSAS– 12% have OSAH12% have OSAH

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CSAS - PresentationCSAS - Presentation

• InsomniaInsomnia

• Nocturnal awakeningsNocturnal awakenings

• Nocturnal polysomnographNocturnal polysomnograph

– No evidence of obstructionNo evidence of obstruction

– No respiratory movementNo respiratory movement

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CSAS – Definitive DxCSAS – Definitive Dx

• Pleural pressure Pleural pressure

monitoring monitoring

• Airflow Airflow

monitoringmonitoring

Both recorded and at Both recorded and at least one shown to be least one shown to be abnormal during abnormal during eventsevents

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CSAS - TreatmentCSAS - Treatment

• Tx underlying causeTx underlying cause

• AcetazolamideAcetazolamide

• O2 for non-HF ptsO2 for non-HF pts

• Phrenic nerve Phrenic nerve

stimulationstimulation

• Inspired CO2Inspired CO2

• N-CPAP (? w/ CO2)N-CPAP (? w/ CO2)

• CV med optimizationCV med optimization

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In Review…In Review…

• 3 types of sleep apnea3 types of sleep apnea– Obstructive (common)Obstructive (common)– Central (less common)Central (less common)– Mixed (very common)Mixed (very common)

• Possibly serious implicationsPossibly serious implications

• Multiple effective tx optionsMultiple effective tx options

• Awareness is keyAwareness is key

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Remember the Cases?Remember the Cases?

• 35 year old male with loud snoring. Spouse states she can’t 35 year old male with loud snoring. Spouse states she can’t sleep in the same room with him.sleep in the same room with him.

• 46 year old obese male in for annual CPE observed by you 46 year old obese male in for annual CPE observed by you to appear sleepy during the medical interview.to appear sleepy during the medical interview.

• In Hospital: Call at 0025 from RN that 42 year old female In Hospital: Call at 0025 from RN that 42 year old female diabetic in with lower extremity cellulitis has oxygen diabetic in with lower extremity cellulitis has oxygen saturation in the low 80s when checking vital signs. saturation in the low 80s when checking vital signs. Awoke when stimulated and SaO2 improved.Awoke when stimulated and SaO2 improved.

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ReferencesReferences

• Westbrook, PR. An overview of Obstructive Sleep Apnea: Epidemiology, Pathophysiology, Clinical Westbrook, PR. An overview of Obstructive Sleep Apnea: Epidemiology, Pathophysiology, Clinical Presentation, and Treatment in Adults. In UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, Presentation, and Treatment in Adults. In UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2006.2006.

• Kingman, PS. Sleep Disordered Breathing in Adults – Definitions. In UpToDate, Rose, BD (Ed), Kingman, PS. Sleep Disordered Breathing in Adults – Definitions. In UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2008.UpToDate, Waltham, MA, 2008.

• Eckert DJ, Jordan AS, Mercha P, Malhotra A. Central Sleep Apnea: Pathophysiology and Treatment. Eckert DJ, Jordan AS, Mercha P, Malhotra A. Central Sleep Apnea: Pathophysiology and Treatment. Chest 2007 Feb: 131(2): 595-607Chest 2007 Feb: 131(2): 595-607

• Douglas NJ. Harrison’s online. Douglas NJ. Harrison’s online. http://www.merckmedicus.com/pp/us/hcp/frame_textbooks.jsp?pg=http://www.accessmedicine.com/content.aspx?aid=2869600. Accessed 8/12/08. Accessed 8/12/08