Obstructive Sleep Apnea Syndrome

1
Obstructive Sleep Apnea Syndrome

• Robert H. Stroud, M.D.
• Francis B. Quinn, M.D.
• February 4, 1998

2
History

• Charles Dickens - The Pickwick Papers
• William Osler - Pickwickian Syndrome 1918
• Guilleminault - OSAS - 1973
• Fujita - UPPP - 1981
• Sullivan - CPAP - 1981

3
Epidemiology

• 85 men
• Prevalence - 2 in women, 4 in men
• two thirds are obese
• elderly
• African-American

4
Pathophysiology

• Bernoulli principle and Venturi effect
• snoring
• tissue laxity and redundant mucosa
• anatomic abnormalities
• decreased muscle tone with REM sleep
• airway collapse

5
Pathophysiology

• desaturation
• arousal with restoration of airway
• sleep fragmentation leading to hypersomnolence

6
Pathophysiology - complications

• desaturation with compensatory polycythemia
• hypercapnia with pulmonary hypertension
• systemic hypertension
• arrythmias

7
Evaluation

• complete HP
• snoring - characteristics
• daytime sleepiness

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Evaluation - history

• restless sleep
• personality change
• impaired cognitive skills
• weight gain

• morning headache
• nocturia/enuresis
• sexual dysfunction
• sedative use

9
Evaluation - history

• adenotonsillar hypertrophy
• nasal obstruction
• hypothyroidism
• acromegaly
• Down syndrome

• micrognathia
• retrognathia
• obesity
• vocal cord paralysis
• HN masses

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Evaluation - physical exam

• retrognathia
• mouth-breathing
• tired appearance

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Evaluation - physical exam

• Nasal obstruction - turbinate hypertrophy,
  polyposis, septal deviation
• oral cavity and oropharynx
• redundant mucosa
• beefy red
• elongated uvula
• macroglossia
• AT hypertrophy

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Evaluation - physical exam

• fiberoptic examination
• Muellers maneuver
• examine in supine position
• usually difficult to localize one site of
  obstruction

13
Evaluation

• Polysomnography
• EEG
• EOG
• submental EMG
• nasal and oral airflow
• respiratory muscle effort

• oxygen saturation
• ECG
• anterior tibialis EMG
• sleep position

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Evaluation - polysomnography

• central, obstructive, mixed apneas
• apnea - cessation of flow for 10 secs
• hyponea - 50 decrease in flow or EEG arousal

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Evaluation - polysomnography

• respiratory disturbance index (RDI) - apneas
  hyponeas per hour
• apnea duration
• degree of desaturation
• sleep disturbance index - arousals per hour

16
Evaluation - radiography

• lateral neck film in children
• CT and MRI of limited benefit
• somnofluoroscopy
• cephalometrics

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Evaluation - other studies

• thyroid function tests
• arterial blood gas
• complete blood count
• audio tape
• rhinomanometry
• multi sleep latency test (MSLT)

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Treatment

• raise intra-pharyngeal pressure
• decrease pharyngeal closing pressure
• increase muscular activity

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Treatment

• weight loss
• avoid sedatives
• pharmacotherapy
• orthodontic devices
• continuous positive airway pressure

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Treatment - CPAP

• 100 effective
• titrate pressure
• poor compliance - 50-80

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Treatment - surgical

• adenotonsillectomy - preferred treatment in
  children
• tracheostomy - cure for OSAS
• used for failure of more conservative treatment
• life threatening cardiopulmonary complications
• alternative techniques to lessen complications

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Treatment - surgical

• Uvulopalatopharyngoplasty (UPPP)
• excise excess tissue from free margin of soft
  palate
• /- tracheostomy
• variable response - approximately 50
• /- nasal surgery

23
Treatment - surgical

• laser midline glossectomy
• mandibular advancement
• maxillary advancement - LeFort I osteotomy
• hyoid suspension and inferior sagittal mandibular
  osteotomy
• hyoid expansion

24
Treatment - complications

• failure to achieve relief
• difficult airway, anesthetic risk
• decreased respiratory drive
• bleeding, infection, pain
• velopharyngeal incompetence
• nasopharyngeal stenosis
• post-obstructive pulmonary edema

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Conclusion

• life threatening complications
• suboptimal treatment either due to poor response
  or limited compliance
• good patient selection and long-term follow- up