The Management of Snoring and Obstructive Sleep Apnea Rex Moulton-Barrett, MD Plastic and...

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Transcript of The Management of Snoring and Obstructive Sleep Apnea Rex Moulton-Barrett, MD Plastic and...

  • Slide 1
  • The Management of Snoring and Obstructive Sleep Apnea Rex Moulton-Barrett, MD Plastic and Reconstructive Surgery Otolaryngology & Head and Head Surgery Alameda Hospital June 2005
  • Slide 2
  • Spectrum of Sleep Disordered Breathing
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  • Slide 4
  • Definitions Upper Airway Resistance Syndrome ( UARS ) Definitions Upper Airway Resistance Syndrome ( UARS ) Daytime somnolence Daytime somnolence No significant apnea or O2 desaturation No significant apnea or O2 desaturation Habitual loud snoring (crescendo) Habitual loud snoring (crescendo) they wake from their own noise of snoring they wake from their own noise of snoring Guillaminault C, Stoohs R, Duncan S. Chest 99:40-48;1991 Guilleminault C, Stoohs R, Clerk A et al. Chest 104:781-787;1993
  • Slide 5
  • Definitions Definitions Hypopnoea: Chicago Criteria 1. Fall in average tidal volume by > 50% but < 10 second apnoea or < 50% tidal volume reduction and 2. at least 4% in oxyhemoglobin desaturation 3. EEG evidence of arousal
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  • Definitions Definitions Apnea Cessation of airflow for at least 10 seconds Obstructive / Central / Mixed based on presence or absence of respiratory movement
  • Slide 7
  • Prevalence of Sleep Apnea Prevalence of Sleep Apnea AHI= RDI = apnoea+hyponoea / hour >5 : 24% Males & 9% Females 4 - 6 times more common in men 20 million Americans Young T, Palta M, Dempsey J. N Engl J Med 328:1230-1235;1993 Young T, Palta M, Dempsey J. N Engl J Med 328:1230-1235;1993
  • Slide 8
  • Pathophysiology Scale Pathophysiology Scale RDI / AHI RDI / AHI UARS 40
  • Slide 9
  • A RDI of 15-20 events per hour is close to what adults seem to be able to tolerate with no clinical consequence. Hosselet JJ, Ayappa I, Norman RG et al. Classificatin of sleep-disordered breathing. Am J Respir Crit Care Med 163:398-405;2001 What is Significant RDI?
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  • 10x > risk, VAMV UCLA 2000
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  • Somnolence Induced MVAs Somnolence Induced MVAs 3 fold increase in motor vehicle accidents if RDI> 5
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  • Morbidity and Mortality Morbidity and Mortality Risk factor for cardiovascular disease Hypertension MI polycythemia, platelet aggregation Stroke Mortality AI>20 = 37% mortality over 8 yrs compared with 4% for AI 20 = 37% mortality over 8 yrs compared with 4% for AI
  • Diagnosis: Physical Exam Diagnosis: Physical Exam Upper body obesity / thick neck Upper body obesity / thick neck >17 males >16 females Airway abnormality Airway abnormality Nasal Oropharyngeal Hypopharyngeal
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  • Differential Diagnosis of OSAS Differential Diagnosis of OSAS Narcolepsy Narcolepsy REM sleep within 10 minutes Excessive daytime sleepiness associated with psychosocial and psychiatric disorders Excessive daytime sleepiness associated with psychosocial and psychiatric disorders Drug related syndromes Drug related syndromes Restless Legs / Periodic limb movement disorder Restless Legs / Periodic limb movement disorder Idiopathic hypersomnolence Idiopathic hypersomnolence
  • Slide 17
  • Evaluation of Upper Airway No consistent characteristic in OSA Quantitative measures depend on state Methods of Evaluation Cephalometric radiographs
  • Slide 18
  • Anatomic Factors in Airway Obstruction Increased nasal resistance. Excessive palatal length. Increased tongue size. Increased vertical airway length Enlarged tonsils. Mandibular retrusion.
  • Slide 19
  • Impact of nose on snoring and OSAS Impact of nose on snoring and OSAS Obstruction increases airway resistance Obstruction increases airway resistance Anterior rhinomanometric volume has an inverse relationship with RDI p
  • SNAP Testing SNAP Testing PSG: polysomnograpghy considered gold standard PSG: polysomnograpghy considered gold standard inherant variability, inherant variability, problems of reproducibility problems of reproducibility SNAP testing: out-patient, localizes site of obstruction, inexpensive SNAP testing: out-patient, localizes site of obstruction, inexpensive Direct and solid correlation between both for measurement of RDI Direct and solid correlation between both for measurement of RDI For RDI >= 5 : 95% positive predictive value, For RDI >= 5 : 95% positive predictive value, 96% specificity 96% specificity 75% sensitivity 75% sensitivity Allan, P, Chaney, J, Mair, E. Otolaryngol HNSurg, 2004 Allan, P, Chaney, J, Mair, E. Otolaryngol HNSurg, 2004
  • Slide 35
  • SNAP Testing Acoustic Analysis of Oro-Nasal Respiration Sound & Airflow Detection Sound & Airflow Detection Pulse Oximetry & Pulse rate Pulse Oximetry & Pulse rate Apnea & Hypopnea Indices Apnea & Hypopnea Indices Snoring Analysis Snoring Analysis 6 hours+ continuous recording 6 hours+ continuous recording
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  • SNAP Data Collection Cannula
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  • Effort & Movement Transducer
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  • Why SNAP ? Why SNAP ? Patient Selection OSA detection Snoring Localization & Quantification Outcome Monitoring
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  • SNAP - Apnea
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  • SNAP - Oximetry
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  • SNAP - Snoring
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  • Slide 44
  • OSA in Children OSA in Children History Shyness Developmental Delay Aggressive Behavior Symptoms of ADD Witnessed apneas: positive predictive value of 86% T&A are usual source of obstruction Several studies show improvement in behavior and school performance after T+A
  • Slide 45
  • Treatment for OSA Treatment for OSA Medical Reduction of Risk factors CPAP - Most common treatment Drugs Airway appliances Surgical
  • Slide 46
  • Reduction of Risk Factors Reduction of Risk Factors Obesity Sleep hygiene Nasal obstruction Body position Sedative and alcohol use
  • Slide 47
  • Drugs Drugs Oxygen - most widely used ProtriptylineTheophylineProgesteroneNicotine Serotonin antagonists Modafinil (Provigil)
  • Slide 48
  • Modafinil in obstructive sleep apnea-hypopnea syndrome: a pilot study in 6 patients by Arnulf I, Homeyer P, Garma L, Whitelaw WA, Derenne JP. Service de Pneumologie et Laboratoire du Sommeil, Hopital Pitie-Salpetriere, Paris, France. Respiration 1997; 64(2):159-61 ABSTRACT We studied the effects of modafinil, a vigilance-enhancing drug, on excessive daytime sleepiness, memory, night sleep and respiration in 6 patients with obstructive sleep apnea- hypopnea syndrome (OSAHS) using a double-blind random cross-over design with 24-hour polysomnography, verbal memory test and a 5-week sleep-wake diary kept by the patients. There were two 2-week treatment periods in which either modafinil or placebo was used; they were separated by a 1-week wash-out period. Our results show that modafinil reduces daytime sleep duration, lengthens the duration of subjective daytime vigilance and improves long-term memory in patients with OSAHS without modifying night sleep and respiration events. Pharmacologic Treatment
  • Slide 49
  • CPAP Splints the Upper Airway Collapsing forces Tissue pressure and mass Constrictor muscle tone Negative inspiratory pressure Dilating forces Dilating muscle tone Tissue pressures that stabilize the airway n CPAP augments dilating forces
  • Slide 50
  • CPAP Has Poor Compliance CPAP Has Poor Compliance CPAP is effective Not a cure Pattern of use established early Drop out rate > 25% 50% effective use
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  • Bi-level Applied Pressure Bi-level Applied Pressure CPAP forces patients to produce high expiratory pressures uncomfortable CPAP forces patients to produce high expiratory pressures uncomfortable Collapsing pressures are increased during inspiration Collapsing pressures are increased during inspiration Bi-level pressure applies lower pressures during expiration and higher levels during inspiration Bi-level pressure applies lower pressures during expiration and higher levels during inspiration Increased initial patient acceptance Increased compliance?
  • Slide 52
  • Side Effects of CPAP Side Effects of CPAP Dry nose and mouth (65%) Mask discomfort (50%) Sneezing and rhinitis (25-35%) Claustrophobia Social impediment Alleviating side effects increases compliance Warmed humidity Eliminating air leaks More comfortable masks
  • Slide 53
  • Airway Appliances Airway Appliances Nasal Appliances Breath Rite Strips Oral appliances Mandible repositioning Some devices reduce RDI Some devices reduce RDI Patient compliance Patient compliance TMJ and teeth problems TMJ and teeth problems Tongue repositioning Patient selection Follow up PSG to test efficacy
  • Slide 54
  • Surgical Treatment of Snoring & OSAS Types of procedures Prevent obstruction Bypass obstruction Key to success is to localize site of obstruction
  • Slide 55
  • Nasal Surgery Nasal airway resistance Increased nasal airway resistance leads to increased negative inspiratory pressures Addition of nasal surgery may improve surgical success and increase CPAP use Rarely definitive treatment for OSAS alone
  • Slide 56
  • Pillar Procedure Pillar Procedure 3 p