OBSTRUCTIVE SLEEP-RELATED

BREATHING DISORDERS IN ADULTS

DR. MOHSEN PAZOOKI

Obstructive sleep-related breathing disorders

Snoring Upper Airway Resistant Syndrome

Obstructive Sleep Apnea Syndrome

Snoring Incidence 40% M20% F

Often (but not always) accompanies sleep disordered breathing

Not ass. With excessive daytime sleepiness or insomnia

Snoring AHI < 5 without daytime symptoms

PSG is not required for DxNo ass. With :- Arousals- Desaturations- Airflow limitation- Arrhythmias

Upper airway resistant syndromeDo not meet OSA criteria but experience excessive daytime somnolence and other debilitating somatic complaints

Upper airway resistant syndromecharacterized by respiratory effort related arousals (RERAs)

RERA is detected using esophageal pressure manometry, which reveals a pattern of progressively increasing negative esophageal pressure followed by an arousal.

Upper airway resistant syndromePSG : - Frequent arousals associated with snoring, abnormally negative intrathoracic pressure, or increased diaphragmatic electromyogram activity.

OSASIncident : 2% of F & 4% of M > 50y

OSASfive or more respiratory events (apneas, hypopneas, or RERAs)

Ass. with - excessive daytime somnolence, - Waking with gasping, choking, or brearh-holding, or

- witnessed reports of apneas, loud snoring, or both

OSASapnea or hypopnea commonly accompanied by:

- Reductions in blood oxygen saturation of at least 3% to 4%

- Usually terminated by brief, unconscious arousals

OSASSnoring: - frequent complaint of bed partners

- often the symptom that prompts these patients to seek medical attention

Excessive daytime somnolence : common presenting complaint

OSASOther complaints : - Automobile accidents - increased cardiovascular morbidity and mortality

- morning headache, sore throat- fatigue or a feeling of being unrefreshed regardless of the duration of sleep

OSASExacerbation : - ingestion of alcohol- Sedative use- weight gain

Sleep disordered breathing sympRestless sleepLoud snoringObserved apnea,choking or gasping episodes

Excessive daytime sleepiness(E DS)Morning fatigue or irritabilityMemory lossDecreased cognitive function

Sleep disordered breathing sympDepressionPersonality or mood changesDecreased libido and impotenceMorning and nocturnal headaches

Nocturnal sweatingNocturnal enuresis

Pathophysiology collapse of the pharyngeal airway during sleep due to relaxation of the pharyngeal dilator muscles

Obesity soft tissue hypertrophycraniofacial characteristics such as retrognathia

Major areas of obstructionNosePalate Hypopharynx

laryngeal obstruction from bilateral laryngeal paralysis, laryngomalacia, and obstructing laryngeal lesions has also been reported.

Obesity major risk factor for OSAdeleterious effects on metabolism, ventilation, and lung volume, resulting in V/Q mismatch

Significantly reduce lung volume, which results in a reduction of functional residual capacity

Adenotonsillar hypertrophy : major cause in children

In adults : multiple craniofacial variations

Consequences of untreated OSASincreased mortality increase in cardiovascular disease:- hypertension, coronary heart disease, congestive heart failure, arrhythmias, sudden death, pulmonary hypertension, and stroke

neurocognitive difficultiesincreased risk of motor vehicle accidents by 2.5-fold

Consequences of untreated OSASindependent risk factor for insulin resistance

contribute to the development of diabetes and metabolic syndrome,the term used to describe the commonly occurring conditions of obesity, insulin resistance, hypertension, and dyslipidemia.

Consequences of untreated OSASGERD : (Treatment with CPAP decreases the occurrence of GERD)

problems with attention, working memory, and executive function (all of which are improved with CPAP treatment)

Diagnosis most common symptoms :- loud snoring- restless sleep- daytime hypersomnolence

Diagnosis Obesity :70% of adult patientsScreening, including a detailed sleep history and physical examination, is recommended for all obese patients

Epworth Sleepiness Scale

Epworth Sleepiness ScaleOSA may be suspected in patients with an ESS greater than 10

Dxpatients with HTN, CAD, CHF, CVA, and DM, must be carefully screened for the signs and symptoms of OSA

Women : insomnia, heart palpitation, ankle edema

P.E.P.E. strengthens the DxBMI , BP , Neck circumference

DxFiberoptic Flexible Nasopharyngoscopy (with Muller’s Maneuver)

Drug induced sleep videoendoscopy

Nocturnal PSG : gold standard

Sleep related breathing disorders

Sleep related breathing disorders

Medical Tx.a stepwise manner begins with

conservative medical measures.'Weight loss” for all overweight

patients Consultation with a bariatric surgeon

in morbidly obese patientssurgically induced weight loss

significantly improves obesity-related OSA and parameters of sleep quality as early as 1 month after surgery.

Medical Tx.CPAP : gold standard for moderate to

severe OSASReduction in AHI, sleepiness, CVA,

motor vehicle accidents & improvement in QOL

Decreased inflammation as measured by a decrease in the inflammatory markers CRP and IL-6, improved endothelial function, and reduced diurnal sympathetic activity.

Medical Tx.BiPAPAPAP

Oral appliances for mild, moderate OSA (greater satisfaction)

Pharmacologic therapy: alternative in CPAP intolerance: Modafinil, Fluticazone, Montelukast, nasal dilator strips, topical decongestants

Indications of Surgical Tx.

Sx. options

Sx. options

Sx. options