OSA OSA Pathogenesis, Co-Pathogenesis, Co-

morbidities and Outcomesmorbidities and OutcomesJohn Reid, MD FRCP(C)John Reid, MD FRCP(C)

RMGIM Conference, BanffRMGIM Conference, Banff

November 24, 2012November 24, 2012

DisclosuresDisclosures

I have no conflicts of interest to I have no conflicts of interest to declare, financial or otherwisedeclare, financial or otherwise

ObjectivesObjectives

Brief discussion of OSABrief discussion of OSA Epidemiology Epidemiology PathogenesisPathogenesis Co-morbiditiesCo-morbidities Treatment outcomesTreatment outcomes

Discuss controversies or clinical Discuss controversies or clinical dilemmasdilemmas

Question/ DiscussionQuestion/ Discussion

OSA - PrevalenceOSA - Prevalence

OSA Syndrome: OSA + Daytime OSA Syndrome: OSA + Daytime SleepinessSleepiness

4% of adult males4% of adult males 2% of adult females2% of adult females

AHI > 5AHI > 5 24% of adults males 24% of adults males 9% of adult females9% of adult females

<<50% of cardiac patients may have 50% of cardiac patients may have Sleep ApneaSleep Apnea

OSAOSA

Other associated complaints Other associated complaints include:include: Sleep fragmentation Sleep fragmentation

Insomnia of sleep maintenanceInsomnia of sleep maintenance Un-refreshing sleepUn-refreshing sleep Morning headachesMorning headaches Tiredness / fatigueTiredness / fatigue Memory / mood problemsMemory / mood problems

OSA - ImplicationsOSA - Implications Poor quality sleep, EDSPoor quality sleep, EDS HTN (1-3 X ↑)HTN (1-3 X ↑) CAD (30 – 40% ↑)CAD (30 – 40% ↑) Stroke (50% ↑)Stroke (50% ↑) DM ?DM ? Neuropsychological morbidityNeuropsychological morbidity Pulmonary HTN, Right heart failurePulmonary HTN, Right heart failure Motor vehicle and other accidents (3-10 X)Motor vehicle and other accidents (3-10 X) Estimated increase risk of death of 1%/yr vs Estimated increase risk of death of 1%/yr vs

treated OSA (treated OSA (Sassani A, et al. Sleep. 2004: 27;453-8)Sassani A, et al. Sleep. 2004: 27;453-8)

OSA: Co-morbiditiesOSA: Co-morbidities

ChildrenChildren ADHDADHD Growth RestrictionGrowth Restriction Poor school performancePoor school performance

Academic achievementAcademic achievement Long-lasting consequences?Long-lasting consequences?

OSA - ImplicationsOSA - Implications

Symptoms Symptoms generallygenerally more severe in more severe in patients with more severe diseasepatients with more severe disease

However, symptoms do not always However, symptoms do not always correlate with AHI (eg UARS)correlate with AHI (eg UARS)

AHI does not always correlate with AHI does not always correlate with hypoxemiahypoxemia

OSA PathogenesisOSA Pathogenesis

Repetitive collapse of upper airway Repetitive collapse of upper airway during sleep, resulting in arousals during sleep, resulting in arousals and/or hypoxemiaand/or hypoxemia

Excessive Daytime sleepiness often Excessive Daytime sleepiness often arises from sleep loss/fragmentationarises from sleep loss/fragmentation

Cardiovascular consequences of Cardiovascular consequences of repetitive arousals, hypoxemia, repetitive arousals, hypoxemia, catecholamines & cortisol & catecholamines & cortisol & inflammatory cytokinesinflammatory cytokines

OSA PathogenesisOSA Pathogenesis

OSA- Area of CollapseOSA- Area of Collapse

OSA - DefinitionsOSA - Definitions

Apnea Apnea Absence (<20% of baseline) of airflow for 10 sAbsence (<20% of baseline) of airflow for 10 s

HypopneaHypopnea Reduction in airflow (30%, 50%?) from Reduction in airflow (30%, 50%?) from

baseline for 10 s AND followed by an EEG baseline for 10 s AND followed by an EEG arousal or desaturationarousal or desaturation

RERARERA No reduction in airflow, but evidence of No reduction in airflow, but evidence of

progressively increasing respiratory effort, progressively increasing respiratory effort, followed by an EEG arousalfollowed by an EEG arousal

OSAOSA

Normal Normal < 5 per hour (AHI, RDI)< 5 per hour (AHI, RDI)

Mild Mild 5 - 155 - 15

ModerateModerate 15 - 3015 - 30

SevereSevere > 30> 30

Partial Sleep ReportPartial Sleep Report

OximetryOximetry

Oximetry - Severe OSAOximetry - Severe OSA

Apneas – Mild Apneas – Mild DesaturationDesaturation

Respiratory Event Related Respiratory Event Related Arousal (RERA)Arousal (RERA)

OSA - TreatmentOSA - Treatment

Conservative TherapyConservative Therapy Weight loss, positional therapy, avoidance of Weight loss, positional therapy, avoidance of

alcohol, stop smoking, treat nasal congestionalcohol, stop smoking, treat nasal congestion Specific TherapySpecific Therapy

CPAPCPAP Dental ApplianceDental Appliance Oropharyngeal SurgeryOropharyngeal Surgery Pillar® ProcedurePillar® Procedure Nasal EPAP (Provent®)Nasal EPAP (Provent®) Hypoglossal Nerve StimulationHypoglossal Nerve Stimulation

CPAP TherapyCPAP Therapy

Improves neurophysiologic Improves neurophysiologic symptoms, including EDS, in symptoms, including EDS, in patients with severe OSApatients with severe OSA

Data inconclusive in patients with Data inconclusive in patients with mild to moderate OSA – significant mild to moderate OSA – significant variabilityvariability

Modest benefit shown in patients Modest benefit shown in patients with moderate OSAwith moderate OSA

Dental AppliancesDental Appliances

Recommended for mild - moderate Recommended for mild - moderate patients and those who cannot patients and those who cannot tolerate CPAPtolerate CPAP

Improves OSA and hypoxemia in mild-Improves OSA and hypoxemia in mild-moderate patientsmoderate patients

Not as effective as CPAPNot as effective as CPAP Not as extensively studied as CPAPNot as extensively studied as CPAP 1/3 of all patients may have clinical 1/3 of all patients may have clinical

or structural contraindicationsor structural contraindications

Dental AppliancesDental Appliances

Oropharyngeal SurgeryOropharyngeal Surgery

Tonsillectemy & AdenoidectemyTonsillectemy & Adenoidectemy Uvulapalatopharyngeoplasty (UPPP)Uvulapalatopharyngeoplasty (UPPP) Rhinoplasty and Nasal septalsurgeryRhinoplasty and Nasal septalsurgery Maxillo-mandibular (Bimaxillary) Maxillo-mandibular (Bimaxillary)

advancementadvancement

SurgerySurgery

T&A - first line for childrenT&A - first line for children UPPP - a consideration for carefully UPPP - a consideration for carefully

selected patients - less effective selected patients - less effective than CPAPthan CPAP

LAUP - for primary snoring only, LAUP - for primary snoring only, not not a treatment of OSAa treatment of OSA

Pillar ProcedurePillar Procedure

Nasal EPAP – Provent®Nasal EPAP – Provent®

SummarySummary

OSA is very common and increasing OSA is very common and increasing in prevalencein prevalence

Caused by repetitive collapse of the Caused by repetitive collapse of the upper airway during sleepupper airway during sleep

Significant health consequencesSignificant health consequences Oximetry has limitations as Oximetry has limitations as

screening tool, screening tool, notnot sensitive enough sensitive enough to to rule outrule out OSA OSA

SummarySummary

TreatmentTreatment Most often CPAPMost often CPAP Consider dental applianceConsider dental appliance Maybe consider surgeryMaybe consider surgery Pillar ®, Provent®?Pillar ®, Provent®? Always include conservative measuresAlways include conservative measures

Discussion PointsDiscussion Points

CPAP alternativesCPAP alternatives What to do about non-sleepy OSA What to do about non-sleepy OSA

patientspatients Peri-operative managementPeri-operative management RetestingRetesting License regulationLicense regulation Your questions?Your questions?