Innovations and Upgrades in

the Diagnosis and Management of OSAS

Magne Tvinnereim, MD.,Ph.D. Specialist in ENT- & Sleep- Medicine. CEO, Spiro Medical AS & EuroSleep AS

Disclosure: Company Interest

The Philippines

How many are the patients ?

> 15 % of Population affected from OSASPopulation – 100 Million

Gives ; > 15 million sufferers

3

Obstructive Sleep Apnea

▲ A relatively newly discovered disease▲ Intitally belived to be a sleep disorder. ▲ Diagnosed with EEG and PolySomnoGraphy▲ Cumbersome, time consuming, inaccurate

and expensive, usually in-hospital procedures

Diagnostic Upgrade – 2013, American Academy of Sleep Medicine

Upper Airway narrowing generates increased Respiratory Effort for the Lungs to supply blood oxygen.

In 2013 (AASM) : Respiratory Effort is the most important parameter, measured by the Gold Reference Standard the Oesophageal Pressure

Obstructive Apnoea

Either, A , Symptoms and related conditions,

1. The patient complains of sleepiness, nonrestorative sleep, fatigue, or insomnia. 2. The patient wakes with breath holding, gasping, or choking.3. The bed partner or other observer reports habitual snoring, breathing interruptions,

or both during the patient’s sleep.4. The patient has been diagnosed with hypertension, a mood disorder, cognitive

dysfunction, coronary artery disease, stroke, congestive heart failure, atrial fibrillation, or type 2 diabetes mellitus.

and B , Polysomnography (PSG) or OCST demonstrates:5 or more predominantly obstructive respiratory events.

or C,PSG or OCST demonstrates(pr. sleep hr. or pr.hr. recording)15 or more predominantly obstructive respiratory events.

satisfy the criteria

AASM; Esophageal Manometry is the Gold Standard for Respiratory Effort determination.

Diagnosis - ICSD-3, 2014 - Criterias.

Demands (AASM; 2007 / 2013):

OSA = RERA + AHI = RDI RERA = Respiratory Effort Related Arousals

= Arousals during increased Lung work. OSA = Obstructive Sleep Apnea = AHI + RERA.

(Apnoeas, Hypopneas, Asleep/Awake.) RDI = Obstructive Respiratory Distress Index.

These parameters give the Complete Diagnosis.

Diagnosing OSAS

1. Increased Respiratory Effort (RE)lasting for more than 10 seconds….

2. Ending with an Arousal……. .

Comprises; Respiratory Effort Related Arousal (RERA).

AASM News – 2013:

Obstructive Respiratory Events

are considered harmful if:

Increased Respiratory Effort (RE)

Decrease in Airflow Increase in Respiratory Effort

Sympathetic n. activity

HypertonyIncreased Pulse Rate

Left Ventricualr-Workload

Arousal

Respiratory Effort & Arousal

Diagnosis Established

OSAS = AHI + RERA = RDI.

5 < RDI < 15 ; Mild.15 < RDI < 30 ; Moderate.30 < RDI ; Serious.

Which TREATMENT to choose ?

Non Surgical Approaches Nasal / Oral Appliances POSA – Treatment.

CPAP

Surgical Approaches

Site of Phase I Phase II Obstruction ? Upper Lower

Phase III Nose

Multi- Soft Tissue

Level Skeletal Bariatric Surgery

Phase I :Upper obstruction

• The highest pressure gradient is above the soft palate

P2, below soft palate

P0, in oesophagus

Lower obstruction Tonsil Hypertrophy - tonsillectomy

Macroglossia - excision- implants

Lingual Tonsils - excision

Maxillo-Mandibular surgery

Surgical Level Strategy.

Upper: Nasal Surgery Soft tissue Pharyngeal surgery

Lower: Soft tissue Pharyngeal / BOT surgery, Implants.Multilevel: Lateral collapse – mostly Oropharyngeal

To be excluded by ENT-exam or DISE.Then consider;Multilevel Soft Tissue Surgery/BOT-excision.Implants ; ReVent, InspireSkeletal, max/mandib. – genioglossus etc. …

Diagnostic Upgrades.AHI – Diagnosis : Oesophageal Pressure is the Gold Reference Standard

for measuring the Respiratory Effort

Respiratory Effort Related Arousals, RERA : Incorporated in the Diagnosis.

Preoperative Evaluation : By multiplePharyngeal Pressure Sensors

Frequent Comorbities has to be investigated and taken into the Diagnostic Considerations.

Innovation : ApneaGraph® Spiro

OSA : Complete Automated Diagnosis - Level of Obstruction

- Level of Snoring - Gold Reference Standard

Safe – Tolerable – Cost Effective – Covers all AASM - 2013 Criteria.

Questions?