Sleep Disordered BreathingMark Howell, MD, FACS

Ear,Nose and Throat Associates

Johnson city ,Tennessee

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• Snoring is the act of breathing with a grunting or snorting sound while asleep

• Snoring is involuntary, and can be disruptive to your own sleep or to bed partner’s sleep

• Snoring can be embarrassing and a source of friction between partners

• Snoring can be a sign of worrisome medical problems.

Problems with SnoringProblems with Snoring

• Snoring is caused by obstructed airflow through the nose and throat.

• It is often intermittent throughout the night and can be as noisy as loud conversation

• Problems include lack of sleep by yourself or your bed partner, but many snorers do not know that they snore

Who Snores? Who Snores?

• British survey: ~40% of population surveyed snored; Male:female was 2:1

• US study: 44% of males and 28% females; ages 30-60 yrs old

General points

• 70 million people suffer from sleep disorders.• 70% are primary sleep disorders• Up to 50% of these are related to Sleep

disordered breathing• It costs millions of dollars in health care per

year• At least 2300 sleep studies/ 100000

people/year needed to adequately address the demand for diagnosis and treatment.

• <14% of medical interns questioned patients about sleep. (Haponik 1996)

Airflow obstructionAirflow obstruction

• Noisiness in snoring is related to obstruction of the airflow at one or more locations:–The nose–The soft palate and uvula–The base, or back part, of the tongue–The tissues on the sidewalls of the throat

• Snoring is typically worse when lying on the back due to gravity effects

What else contributes?What else contributes?

• Dryness in the nose and throat slows down airflow and prevents re-opening of the throat–Medicines that dry out the mucus membranes–Dry air in the winter–Mechanical blockage in the nose (polyps,

deviated nasal septum)–Allergies, colds, or sinusitis–Tobacco abuse dries out mucosal surfaces

What else contributes?What else contributes?

• Muscle collapse or weakness–Alcohol–Sleeping pills–Sedatives or muscle relaxants–Weight gain –Deeper sleep, with more relaxed muscles

• Sleep apnea is a chronic respiratory sleep disorder characterized by recurrent episodes of partial or complete upper airway obstruction during sleep (apneas, hypopneas) and are associated with repeated disruption of sleep resulting in excessive daytime somnolence and other medical co-morbidities.

Sleep Disordered Breathing

• Apnea: complete cessation of airflow lasting 10 seconds or more

• Hypopnea: reduced airflow to about 50% lasting 10 seconds or more

• Arousal: a change in sleep state• UARS: Respiratory event related arousals

during sleep associated with excessive daytime sleepiness. No apneas or hypopneas

• AHI: number of apneas/hypopneas per hour of sleep. Used to grade severity of the Respiratory disturbance in sleep.

• Prevalence increases with increasing age and body mass index (>28), family history(54% offspring), african american, asian and hispanic,

• Neck circumference >17 inches in men and >16 inches in women is risk factor

• Other conditions predispose i.e hypothyroidism, rhinosinusitis

• Males affected twice as much as premenopausal women

• Certain syndromes affecting anatomy of upper airway are associated with SDB in the young(Treacher Collins, Pierre-Robin, Marfans, Alperts, trisomy 21 etc)

• Drugs: Alcohol, sedatives, tobacco smoke

Classification of SDB

• Intermittent snoring-nuisance, no health sequelae

• UARS-upper airway resistance syndrome

• Mild OSA- AHI 5-15

• Moderate OSA- AHI 15-30

• Severe OSA- AHI >30

• CSA-central sleep apnea

Central Sleep Apnea

• Apneas occurring during sleep due to disordered control of breathing rather than obstruction to airflow. As opposed to obstructive apnea respiratory effort also ceases during the episode of apnea

Cheyne stokes respiration is the most common and occurs commonly in heart failure

It is treated with CPAP

Other conditions with CSA are neuromuscular diseases, pontine stroke etc

What is the impact of SDB

• Road traffic accidents- mortality• Lower productivity at school and work• Morbidity-Impaired immune function,

HTN, insulin resistance, stroke,pulm HTN, poor asthma control, ventricular arrythmias and sudden death

• Neurocognitive and mood dysfunction• Reduced quality of life

Neurocognitive effects of sleep deprivation

• Impaired mood, reduced vigilance, impaired concentration and reduced memory

• Impaired performance in surgical skills, anesthesia administration, intubation and EKG interpretation (Weinger MB JAMA 2002)

Cardiovascular effects

• Associated nocturnal desaturations result in increases in C-reactive protein levels, neuropeptide Y, IL-6, IL-8 suggest predisposition to CVD risk

• Increased carotid artery atherosclerosis• Increased incidence of HTN independent of obesity• Increased odds for stroke in next 4 yrs with AHI>20

in cross sectional studies• Ventricular ectopy-sudden cardiac death usually

seen in pts with co-existing heart failure

Metabolic effects

• Increased insulin and glucose levels during GTTs in people with BMI>29 and AHI>25 probably due to increased catecholamines, cortisol and growth hormone

Pulmonary effects of Sleep apnea

• Decreased responses to changes in CO2 when awake

• Vagal stimulation leads to nocturnal exacerbation of asthma symptoms

• Complications of anesthesia with perioperative morbidity

• Pulmonary HTN can occur with AHI>70 and desaturations and/or coexistent obstructive lung disease, hypoxemia and hypercapnia

When is snoring a problem?When is snoring a problem?

• Snoring can be a symptom of Obstructive Sleep Apnea (OSA). Other symptoms include:–Daytime tiredness and overall fatigue–Restless sleep–Waking up choking or gasping–Morning headaches, dry mouth, or sore

throat–Trouble thinking clearly or remembering

things

When is snoring a problem?When is snoring a problem?

• Snoring can be a symptom of Obstructive Sleep Apnea (OSA). Some medical problems caused by OSA include:–Elevated blood pressure–Cardiac arrhythmias–Pulmonary hypertension–Automobile accidents–Social problems like divorce and spousal

arguments, diminished job performance, lack of concentration and memory

How do I tell the difference?How do I tell the difference?

• Snoring, when accompanied by these other symptoms, prompts medical evaluation–Epworth Sleepiness Scale–Sleep study (polysomnogram)–At-home sleep study

Integral part of a general medical evaluation

• Ask about sleep habits including day naps• Performance at work/school• Interference with daily tasks• Energy level• Daytime sleepiness• Snoring, choking, gasping, breathholding• Refreshed upon awakening• Drug use

Physical exam features

• Nasal passages

• Oropharyngeal passage

• TMJ function

• Body weight

• BP

Polysomnogram (PSG)

• Electroencephalogram• EOG-oculogram• Electromyogram-genioglossus and anterior

tibialis• Respiration• Abdomen and chest wall motion• Body position• EKG• O2 saturation• Snoring

What can help me?What can help me?

• There are many different snoring aids for sale because none work for all people

• Primarily they can benefit based on the area of obstruction

• Things that don’t work (long term)–Holding partner’s nose–Elbow to the ribs–Pillow over partner’s face–Waking them up to tell them they are snoring

• Chinstraps–“Sleep Angel” closes

the mouth so you are forced to breathe through the nose

• Special pillows–Reposition the head to

open the airway more

• Snore spray–Lubricates the mucus

membranes

• Feedback alarms–Wake you slightly

when you snore• Ear plugs

–Allow bed partner to ignore problem

• Separate rooms–Bed partner physically

moves to avoid noise• Breathe right

–Helps nasal breathing

Treatment

• Weight loss• Avoidance of drug and alcohol use• Smoking cessation• Postural training• Nasal patency• Dental appliances• CPAP/BiPAP• Surgery

How do you treat OSA?How do you treat OSA?

• Weight loss• Continuous Positive Airway Pressure

(CPAP)–The “mask” for breathing at night–Gold standard: it works every hour that you use

it–Compliance can be poor

• Oral appliance–Repositions the jaw to move the tongue

forward, decreasing obstruction

Snoring treatments - medicalSnoring treatments - medical

• Oral appliance – moves the teeth forward to help bring the jaw forward

• Throat strengthening exercises – to try to help the muscles of the throat prevent collapse due to better tone

• Weight loss – help from physician with diet and exercise program

• Improving moisture with humidifier, nasal saline

• Change sleeping position

CPAP

• Splints open airway during sleep• Reduces blood pressure• Improves heart function (in pts with CSA)• Do not always need titration study

Needs to be used atleast 6 hrs nightlyMedicare guidelines: AHI>15 for 2 hr sleep

test or AHI>5 with sleepiness, impaired cognition, HTN, IHD or h/o CVA

CPAP

• Compliance poor in >40% of pts but best when significant daytime sleepiness present

• Side effects that decrease tolerance of CPAP are nasal and sinus congestion, conjunctivitis, noise, claustrophobia, mouth leak etc

• Humidification and regular follow up, help compliance

ORAL APPLIANCES

How do you treat OSA?How do you treat OSA?

• Surgery to correct the airway obstruction–Septoplasty/turbinoplasty–Tonsillectomy–Uvulopalatopharyngoplasty–Tongue base surgery–Genioglossus advancement–Tracheotomy–Maxillary-mandibular advancement

• Not all surgeries are for everyone. Some only work on certain types of obstruction

• More invasive surgeries have been more effective

Snoring treatments - surgicalSnoring treatments - surgical

• Nasal surgery – improves nasal airflow

• LAUP – shrinks and scars the uvula and soft palate

• Uvulectomy – removes the uvula

• “Snoreplasty” – injection to shrink the uvula

• Pillar implants – small synthetic implants in the palate to stiffen it

Surgery

• UPPP- 50% success rate in reducing AHI by 50%

• Tongue advancement• Hyoid elevation• Mandibular osteotomy (lower jaw)• Maxillomandibular osteotomy and

advancement (both jaws)• Radiofrequency ablation

Radiofrequency ablationMultiple procedures and poor for obese patients

Tongue base suspensionSame

Midline or Central tongue reductionComplex, risk of paralysis, loss of function

SMILE (Submucosal minimal lingual excision)Significant learning curve and complications

Genioglossus bone advancementFracture risk, nerve injury, long term results?

Maxillomandibular advancement

Maxillary-mandibular advancement

TORS Tongue Base Reduction Study

• Italilian study by Vicini et al ( June 2009)• 10 Patient retrospective review• AHI pre 38.3 and post 20.6• Large SD• Only one obese patient• Multiple different procedures performed• Patients had tracheotomy at time of surgery• Reasonable and safe surgical option

Hypoglossal Neurovascular Bundle Anatomy

• Inferolateral in tongue base

• Midway between midline and lateral tongue margin

• Stays close to superior margin of hyoid (0.9cm)

• 2.7 cm inferior and 1.6cm lateral to foramen cecum

• Allows for aggressive tongue base reduction

TORS Tongue Base Reduction

• Excellent visualization

• Articulating instruments

• Effective

TORS Tongue Base Reduction

• Radiographic improvement

• Both axial and sagittal

Snoring – Sleep Apnea?Snoring – Sleep Apnea?

• Snoring is a problem, both for the snorer and for their bed partner

• There are solutions for snoring, but there is no single common solution

• Snoring can be the symptom of a true medical problem, Obstructive Sleep Apnea

• Please contact your physician if you or your loved one has these symptoms

2340 Knob Creek Road2340 Knob Creek Road

Any Questions?Any Questions?

• Ear, Nose & Throat Associates–Mark Howell, MD,FACS–2340 Knob Creek Rd, Suite 704–Johnson City, TN 37604–423-929-9101 phone–423-434-2032 fax–www.entjc.com

Resources

• www.sleepfoundation.org

• www.asaa.org