Obstructive Sleep Apnea 2016 Diagnosis and...
Transcript of Obstructive Sleep Apnea 2016 Diagnosis and...
![Page 1: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/1.jpg)
Obstructive Sleep Apnea 2016 Diagnosis and Treatment
Grand Rounds BRRH
May 17th 2016
Presented by
Natalio J. Chediak MD
![Page 2: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/2.jpg)
Understand the pathophysiology of Obstructive Sleep Apnea ( OSA ).
Recognized the Symptoms of OSAS.
Determine the appropriate Sleep Testing.
Treatment options for OSA.
When to refer to a Sleep Specialist.
Objectives
![Page 3: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/3.jpg)
Decrease ventilatory motor neuron output leading to decease in tidal volume and minute ventilation
Upper airway dilatory muscles relaxation leading to reduced luminal caliper and increasing resistance.
Increase in Paco2 and decreasing in Pao2. **breathing becomes more dependant on central
chemoresponsiveness.
Ventilation during NREM Sleep
![Page 4: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/4.jpg)
Anatomy of the upper airway
![Page 5: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/5.jpg)
Reduced muscle activity of upper airway dilators.
Reduced upper-airway caliber.
Increase airway resistance.
Increase pharyngeal collapsibility.
LEADING TO REDUCED TIDAL VOLUME & HYPOVENTILATION
Upper-Airway Changes During Sleep
![Page 6: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/6.jpg)
Upper-airway resistance increases during sleep.
Hypoventilation is a universal finding during sleep caused by upper-airway resistance and decrease central ventilatory motor output.
Ventilation during NREM sleep is critically dependent on chemical stimuli-PaCO2/PaO2.
In summary
![Page 7: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/7.jpg)
Obstructive (80%)
OSA
UARS
Central (10-15%)
Hypocapnic
CSR-CSA, high altitude
Hypercapnic
Pontine lesions, RCB
Types of sleep disordered breathing syndromes
![Page 8: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/8.jpg)
Repetitive episodes of complete (apnea) or partial (hypopnea) upper airway obstruction occurring during sleep lasting 10 seconds or longer.
Events often result in
Decrease SaO2
Termination of event with arousal
Obstructive sleep apnea, Adult
![Page 9: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/9.jpg)
Apnea Patterns
Obstructive Mixed Central
Airflow
Respiratory
effort
![Page 10: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/10.jpg)
Epidemiology of OSA
OSA = AHI ≥5 24% men
9% women
OSA=AHI ≥5 and EDS 4% men
2% women
Higher prevalence in Asians and Afro-American’s
![Page 11: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/11.jpg)
Upper airway size in OSA
Schwab, R. Clinics in Chest Medicine 1998
![Page 12: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/12.jpg)
Control of Dilator Muscles Effects On Pharyngeal Muscle Activity
Normal
Subject
Awake
OSA
Patient
NREM
Genioglossus EMG
Tensor Palatini
EMG
Airflow
Genioglossus EMG
Tensor Palatini
EMG
Airflow
![Page 13: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/13.jpg)
![Page 14: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/14.jpg)
Pathophysiology of Sleep Apnea Awake: Small airway + neuromuscular compensation
Loss of neuromuscular
compensation
+ Decreased pharyngeal
muscle activity
Sleep Onset
Hyperventilate: correct
hypoxia & hypercapnia
Airway opens
Airway collapses
Pharyngeal muscle
activity restored
Apnea Arousal from sleep
Hypoxia &
Hypercapnia
Increased ventilatory
effort
![Page 15: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/15.jpg)
Clinical Consequences
Cardiovascular
Complications
Morbidity
Mortality
Sleep Fragmentation
Hypoxia/ Hypercapnia
Excessive Daytime
Sleepiness
Sleep Apnea
![Page 16: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/16.jpg)
Increased motor vehicle crashes
Increased work-related accidents
Poor job performance
Depression
Family discord
Decreased quality of life
Consequences: Excessive Daytime Sleepiness
![Page 17: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/17.jpg)
Systemic hypertension
Cardiac arrhythmias
Myocardial ischemia
Cerebrovascular disease
Pulmonary hypertension / cor pulmonale
Consequences: Cardiovascular
![Page 18: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/18.jpg)
Arousals and/or hypoxemia Sympathetic hyperactivity
Increased catecholamine's
Increased adhesion molecule activity
Endothelial injury
Suppressed circulating nitric oxide
Exaggerated pressor responses
Insulin resistance
All improved by treatment of OSA
Mechanisms of CV dysfunction in OSA
![Page 19: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/19.jpg)
Arrhythmia and OSA
Diurnal arrhythmia is not common
Nocturnal arrhythmias are common
Usually occur during the apneas
Sinus bradycardia most common
75% of all OSA
High grade AV blocks in 4% to 8%
Pacemaker?
PVC more often when SaO2 < 60%
Therapy aimed at eliminating OSA
![Page 20: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/20.jpg)
Consequences: Pulmonary hypertension
Prevalence10-30% if pulmonary function is normal73% if airflow obstruction present
PathogenisisMechanical factorsHypoxia
Improves with NCPAP and tracheostomy, not with O2
![Page 21: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/21.jpg)
Mortality and OSA
0 1 2 3 4 5 6 7 8 9
Interval (years)
0.5
0.6
0.7
0.8
0.9
1
1.1
Untreated (He et al) n=104
NCPAP n=42
UPPP n=73
Keenan, S.P. et al. Chest 1994;105:155-159
![Page 22: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/22.jpg)
Obesity
Increasing age
Male gender
Anatomic abnormalities of upper airway
Family history
Alcohol or sedative use
Smoking
Associated conditions
Sleep Apnea Risk Factors
![Page 23: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/23.jpg)
Hypothyroidism
Acromegaly
Amyloidosis
Vocal cord paralysis
Marfan syndrome
Down syndrome
Neuromuscular disorders
Risk Factor: Associated Conditions
![Page 24: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/24.jpg)
Snoring (loud, chronic)
Nocturnal gasping and choking Ask bed partner (witnessed apneas)
Automobile or work related accidents
Personality changes or cognitive problems
Risk factors
Excessive daytime sleepiness
Diagnosis: History
Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.
![Page 25: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/25.jpg)
Often unrecognized by patient
Ask family members
Must ask specific questions
Fatigue vs. sleepiness
Auto crashes or near misses
Sleep in inappropriate settings
Work
Social situations
Diagnosis: Assessing Daytime Sleepiness
![Page 26: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/26.jpg)
Upper body obesity / thick neck
> 17-18” males
> 16” females
Hypertension
Obvious airway abnormality
Diagnosis: Physical Examination
![Page 27: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/27.jpg)
Septal Deviation causing Nasal Resistance
![Page 28: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/28.jpg)
Tonsillar hypertrophy in OSA
Normal Patient
![Page 29: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/29.jpg)
Palatomegaly in OSA
Schellenberg, J ARRCCM 2000;162:740-748
![Page 30: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/30.jpg)
Tongue size in OSA
Schellenberg, J ARRCCM 2000;162:740-748
![Page 31: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/31.jpg)
Retrognathia in OSA
Schellenberg, J ARRCCM 2000;162:740-748
![Page 32: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/32.jpg)
In-laboratory full night polysomnography
Split night studies
Home diagnostic systems
Oximetry to full polysomnography
What Test Should be Used?
![Page 33: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/33.jpg)
Signs and symptoms
Excessive daytime sleepiness
Hypertension and other cardiovascular outcomes.
Sleep study results
Apnea / hypopnea frequency
Sleep fragmentation
Oxyhemoglobin desaturation
Diagnostic Conclusions
![Page 34: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/34.jpg)
![Page 35: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/35.jpg)
![Page 36: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/36.jpg)
![Page 37: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/37.jpg)
Signs and symptoms
Excessive daytime sleepiness
Hypertension and other cardiovascular outcomes.
Sleep study results
Apnea / hypopnea frequency
Sleep fragmentation
Oxyhemoglobin desaturation
Diagnostic Conclusions
![Page 38: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/38.jpg)
Improve bed partners sleep
Improve patients sleep
Alleviate daytime sleepiness
Reverse cognitive impairment
Improve diurnal blood pressure
Minimize cardiovascular risk
Reverse pulmonary hypertension and/or hypercapnia
Why treat OSA?
![Page 39: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/39.jpg)
Risk counseling Motor vehicle crashes
Job-related hazards
Judgment impairment
OSA and comorbidity treatment Behavioral
Medical
Surgical
Therapeutic Approach
![Page 40: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/40.jpg)
Behavioral Weight loss
Postural therapy
Avoid ethanol and tobacco
Mechanical Positive airway pressure
Oral appliance
Surgical
Treatment of obstructive sleep disordered breathing
![Page 41: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/41.jpg)
Positive airway pressure
Continuous positive airway pressure (CPAP)
Bi-level positive airway pressure (BiPAP or Bi-level PAP)
Self adjusting positive airway pressure
Expiratory pressure release
Oral appliances
Other (limited role)
Medications
Oxygen
Medical Interventions
![Page 42: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/42.jpg)
RDI 30 regardless of symptoms
RDI 5-30
EDS
Impaired cognition
Mood disorder
Insomnia
ASCVD
Consensus Statment in Chest 1999;115:863-866
Indications for positive airway pressure therapy
![Page 43: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/43.jpg)
Positive Airway Pressure
![Page 44: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/44.jpg)
Patient report: 75%
Objectively measured use
> 4 hrs for > 5 nights / week: 46%
Asthma-medicine compliance: 30%
CPAP Compliance
![Page 45: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/45.jpg)
Machine-patient interfaces Masks Nasal pillows Chin straps
Humidifiers Ramp Desensitization Pressure modification strategies
Strategies to Improve Compliance
![Page 46: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/46.jpg)
Oral Appliances
Indications
Snoring and apnea (not severe)
Efficacy
Variable
Side effects
TMJ discomfort, dental misalignment, and salivation
![Page 47: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/47.jpg)
![Page 48: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/48.jpg)
Staging of Surgical Procedures
Diagnosis of Sleep Apnea
Upper Airway Evaluation
Phase I Surgery
Post Operative Polysomnogram (+ Sleep Apnea)
Phase II Surgery - MMA
Adapted from Riley RW et al. Otolaryngol Head Neck Surg 1993;108.
Type I
UPPP
Type II
UPPP + GA
Type III
GA
![Page 49: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/49.jpg)
Sites of Airway Narrowing
Collapse at softpalate only
Multiple sites ofcollapse
Adapted from Morrison DL et al. Am Rev Respir Dis 1993;148.
18%
82%
![Page 50: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/50.jpg)
Uvulopalatopharyngoplasty (UPPP)
![Page 51: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/51.jpg)
UPPP success in OSA
Author Reported Adjusted
Borowiecki 46% 43%
Wetmore 63% 40%
Katsantonis 33% 9%
Caldarelli 50% 29%
Gislason 65% 57%
Total n=126 37%
![Page 52: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/52.jpg)
Staged Surgical Procedures
![Page 53: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/53.jpg)
Improve bed partners sleep
Improve patients sleep
Alleviate daytime sleepiness
Reverse cognitive impairment
Improve diurnal blood pressure
Minimize cardiovascular risk
Reverse pulmonary hypertension and/or hypercapnia
Why treat OSA?
![Page 54: Obstructive Sleep Apnea 2016 Diagnosis and Treatmentweb.brrh.com/msl/GrandRounds/2016/GrandRounds_05-17... · Obstructive sleep apnea, Adult . Apnea Patterns Obstructive Mixed Central](https://reader036.fdocuments.net/reader036/viewer/2022081402/5f1bac0ea648795436651c0d/html5/thumbnails/54.jpg)
When the case does not respond to therapy or intolerante to treatment.
Complex Sleep History- OSA plus RLS,RBD, Insomnia.
When to refer to a Sleep Specialist