What is Sleep Apnea and why does it matter? Noah S Siegel, MD Director of Sleep Medicine and Sleep Surgery Massachusetts Eye Ear Infirmary Harvard Medical School 7/31/2021 Classes of sleep disorders Sleep related breathing disorders Insomnias Parasomnias Circadian Rhythm disorders Hypersomnia Movement disorders Miscellaneous What is Sleep Medicine? SLEEP MEDICINE Otolaryngology Pediatric pulm, neuro, etc Pediatrics Internal Medicine Anesthesiology Family medicine Neurology Psychiatry Pulmonology/CCM Classes of sleep disorders Sleep related breathing disorders Insomnias Parasomnias Circadian Rhythm disorders Hypersomnia Movement disorders Miscellaneous
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Sleep related breathing disorders why does it matter?
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What is Sleep Apnea and why does it matter?
Noah S Siegel, MDDirector of Sleep Medicine and Sleep Surgery
Massachusetts Eye Ear InfirmaryHarvard Medical School
7/31/2021
Classes of sleep disordersSleep related breathing disorders
InsomniasParasomnias
Circadian Rhythm disordersHypersomnia
Movement disordersMiscellaneous
What is Sleep Medicine?
SLEEP MEDICINE
Otolaryngology
Pediatric pulm, neuro, etc
Pediatrics
Internal Medicine
Anesthesiology
Family medicine
Neurology
PsychiatryPulmonology/CCM
Classes of sleep disordersSleep related breathing disorders p g
InsomniasParasomnias
Circadian Rhythm disordersHypersomnia
Movement disordersMiscellaneous
Upper Airway Obstruction Upper Airway Obstruction
Upper Airway Obstruction Lower Airway Obstruction
Restrictive Airway Conditions Opioids
What is Obstructive Sleep Apnea?
• ↓airflow during sleep despite continued respiratory effort due to collapse of the pharyngeal airway• Hypoxemia, hypercapnia• Arousals with sympathetic surge
Marshall et al. Sleep 2008; 31:1079-1085Young et al. Sleep 2008; 31:1071-1078
Busselton, AustraliaWisconsin Cohort
RDI > 15
RDI < 5
RDI 5-15
YYears of follow-up
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Marin, Lancet 2005; 365: 1046-53
Non-fatal Cardiovascular Events
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AHI AHIQuartile
Coronary Coronary Heart Disease
Heart Heart Failure
StrokeQ
0Q
00-00-1.3 1.0 1.0 1.0
1.4.4-4-4.4 0.92 1.13 1.15
4.5.5-5-11.0 1.20 1.95 1.42
>11.0 1.27* 2.38* 1.58*
Shahar E et al. Am J Respir Crit Care Med 2001
Adjusted Relative Odds of Prevalent Coronary Heart Disease, Heart Failure, or Stroke, by Quartile of SDB
Sleep Heart Health Study:Cross-Sectional Analysis
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Wisconsin Sleep Cohort Study: Adjusted Odds Ratios for Hypertension at 4-year Follow-up Participants who were Normotensive at Baseline
0
0.5
1
1.5
2
2.5
3
3.5
0 0.1-4.9 5-14.9 >15
Odds Ratio
AHI
*OR adjusted for age, sex, ethnicity, BMI, neck & waist circumference, smoking and alcohol use
*
*
*
Peppard PE et al. N Eng J Med 2000 May 11; 342(19): 1378-84
Hypertension and OSA by AHI
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Sleep Apnea and Stroke
• Sleep apnea seen in 50%–80% of acute stroke and TIA patients.• OSA was the most common form• Central sleep apnea and Cheyne-stokes forms also reported • Sleep apnea improves in the subacute phase, primarily central and Cheyne-stokes
pattern, not OSA
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J Am Coll Cardiol. 2007.
P = 0.002
AF, n = 114
AF, n = 19
OSA and Atrial Fibrillation
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Gami et al, N Engl J Med. 2005 Mar 24;352(12):1206-14..
Sudden death during night more likely in those with OSA
OSA and Sudden Cardiac Death
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Consequences: Diabetes • Severe OSA patients with sleepiness are at ↑ risk for diabetes (83% of
patients diabetes have unrecognized OSA)*
• Insulin sensitivity improves after CPAP therapy
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*Pamidi et al, Front Neurology 2012; 3, 126
Consequences: Gastroesophageal Reflux Disease
• 54-76% of OSA patients have (GERD) • Risk factors: obesity, male sex, and alcohol use• OSA may trigger GERD due to decreased intrathoracic pressure
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sleepiness and cognition• Reduced alertness & vigilance
• Increased motor vehicle crashes
• Increased work-related accidents
• Poor job/school performance
• Difficulty concentrating & reduced productivity
• Falling asleep inappropriate social circumstances
• Daytime symptoms:• Somnolence, fatigue, nonrefreshing sleep regardless of TST• Poor concentration, morning HA, diff driving
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BMI and OSA• ~60-70% of OSA is attributable to obesity• 10% weight gain = 6x increase risk of mod-sev
OSA, 32% increase in AHI• 10% weight loss = 26% reduction in AHI
• Bottom line: higher BMI, higher likelihood of OSA
Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. Journal of applied physiology (Bethesda, Md : 1985) 2005; 99:1592-1599.Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA 2000; 284:3015-3021.
Nasal exam: external• Nasal bones, upper and lower lateral
• 12 healthy volunteers, no nasal complaints• Randomized, single blinded, cross-over• Airflow resistance measured by SG pressure• No difference during wakefulness• UAR during sleep: oral 12.4 cmH2O (4.5-40.2) vs nasal 5.2 cmH2O (1.7-10.8),
Fitzpatrick MF, McLean H, Urton AM, Tan A, O'Donnell D, Driver HS. Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J 2003; 22:827-832.
Friedman tongue position (modified Mallampati)
Friedman M et al. Staging of Obstructive Sleep Apnea/Hypopnea Syndrome: A Guide to Appropriate Treatment. Laryngoscope. 114:454-459, 2004.
Brodsky and Friedman tonsil size
Friedman M et al. Staging of Obstructive Sleep Apnea/Hypopnea Syndrome: A Guide to Appropriate Treatment. Laryngoscope. 114:454-459, 2004.
position implies a longer (and therefore more collapsible tongue base)• Airway rotates anteriorly
(note epiglottis)
Dental findings
Maxillomandibular insufficiency/hypoplasiaPHYSICAL EXAMThere were no vitals filed for this visit.
BMI 30.4 kg/m2General: no distress, awake, no central obesity, not overtly sleepy todayPsych: responds appropriate to questioningNeuro: A&Ox3, CN II-XII grossly intactMusculoskeletal: normal movement of all four extremitiesPulmonary: breathing comfortably on room air, no stridor/stertorCardiovascular: good peripheral perfusionEars: external ears normal bilaterallyNormal EAC, TM and MES bilaterallyNose: no external nasal deformityCaudal septum midline, nasal mucosa healthyInferior turbinates normalCraniofacial structure: good maxillary projectionClass 1 occlusion, good dentition, no overjetNo mandibular insufficiencyHard palate good width and not high archedIntermolar distance 5cmOral cavity: + tongue scalloping, large for oral cavityOropharynx: tonsils 1+Modified Mallampati 3Good retropalatal space, soft palate and uvula not thick or elongated, no posterior pillar webbingNeck: thick/muscular, supple, hyoid in good positionNo lymphadenopathyTrachea midline thyroid normal to palpation
Sleep medicine PE:
“Crowded pharynx”
STOP-BANG
• Validated screening tool for obstructive sleep apnea• Score of ≥ 3 has >90% sensitivity to
detect moderate to severe OSA• High positive predictive value (85%)
Gender male≥ 3 points indicates significant risk for OSA
*There are multiple versions and scoring systems for STOP-BANG
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Diagnostic Approach
• Clinical suspicion and evaluation
• Sleep testing• Home sleep apnea test• Polysomnography
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Types of Sleep testing devices
• Type I - Attended with full sleep staging • EEG, EOG, ECG, Limb EMG, Chin EMG, respiratory effort at chest and abdomen, airflow monitors, pulse oximetry
• Type II – Unattended with at least 7 channels• EEG, EOG, ECG, EMG, Airflow, Respiratory effort, Oxygen saturation
• Type III – Unattended with at least 4 channels• 2 respiratory /airflow,1 Cardiac (ECG), oxygen saturation
• Type IV – Unattended with at least 3 channels• Channels to calculate AHI or RDI by airflow or thoraco-abdominal movement
• Other – Peripheral arterial tonometry
Polysomnography channels
• EOG – Electrooculogram• EEG - Electroencephalogram• EMG - Electromyogram• EKG - Electrocardiogram• Nasal and oral airflow• Thoracic and abdominal respiratory effort• Pulse oximetry• Body Position
• False negatives• Limited to respiratory disorders• No sleep architecture• Bad data • No CPAP titration studies• Not approved for diagnosis of
central sleep apnea
Definitions
1. Apneaa. > 90% drop airflow excursion from baseline lasting >10
seconds2. Hypopnea
a. 30% drop in airflow from baseline lasting > 10 seconds and:
b. Associated with > 3% oxygen desaturation or arousal3. RERA:
a. ≥ 10 seconds increased respiratory effort or flattening of inspiratory waveform leading to an arousal. Does not meet criteria for apnea or hypopnea.
The AASM Manual for the Scoring of Sleep and Associated Events, Version 2.5
Obstructive Hypopnea
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The AASM Manual for the Scoring of Sleep and Associated Events, Version 2.5
Obstructive Apnea Respiratory Effort Related Arousal (RERA)
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Measures of Sleep Apnea Frequency
• Apnea / Hypopnea Index (AHI)• # apneas + hypopneas per hour of sleep
• Respiratory Disturbance Index (RDI)• # apneas + hypopneas + RERAs per hour of sleep
• Respiratory Event Index (REI)• # respiratory events per hour of monitoring time on Home
Sleep Apnea Testing (HSAT)
The AASM Manual for the Scoring of Sleep and Associated Events, Version 2.5
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IICSD-3 Diagnostic Criteria for OSA
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≥ 15 obstructive respiratory events/hour
≥ 5 obstructive respiratory events/hour
and:
Snoring, witnessed apneas, fatigue, somnolence, mood/cognitive disorder, hypertension, type 2 diabetes, stroke or cardiac disease
• Most commonly recommended Rx for OSA• Extensive long term data• Approx. 50% compliance @ 1 year
PPositive Pressure Devices
•CPAP•BiPAP•APAP (auto-adjusting or auto-titrating)•Adaptive Servoventilation (ASV)
OSA – CPAP Decreases CV Events
AHI Number of Patients
Treatment Non-fatal CV events/100 person years
Fatal CV Events/100 person years
Healthy N/A 264 None 0.45 0.30
Simple Snorers <5/hour 377 None 0.58 0.34
Mild to Moderate OSA
5-30/hour 403 None 0.89 0.55
Severe OSA >30/hour 235 None 2.13 1.06
Long-Term CV Outcomes in Men with OSA-Hypopnea with or without Treatment with CPAP: an observational Study. Marin JM, Carrizo SJ, et al. Lancet 2005; 365: 1046-53.
OSA – CPAP Decreases CV Events
AHI Number of Patients
Treatment Non-fatal CV events/100 person years
Fatal CV Events/100 person years
Healthy N/A 264 None 0.45 0.30
Simple Snorers <5/hour 377 None 0.58 0.34
Severe OSA >30/hour 373 CPAP 0.64 0.35
Mild to Moderate OSA
5-30/hour 403 None 0.89 0.55
Severe OSA >30/hour 235 None 2.13 1.06
Long-Term CV Outcomes in Men with OSA-Hypopnea with or without Treatment with CPAP: an observational Study. Marin JM, Carrizo SJ, et al. Lancet 2005; 365: 1046-53.
Oral appliance therapy
Surgery for OSA
• General comments• Nasal surgery• Soft Tissue Surgery• Oropharynx (UPPP)• Base of tongue/hypopharynx
• Skeletal Surgery• Upper Airway Stimulation Surgery• Bariatric surgery
Surgical Considerations• CPAP Compliance• Severity of apnea• Anatomy/level of obstruction
Kezirian EJ, Hohenhorst W, de Vries N (2011) Drug-induced sleep endoscopy: the VOTE classification. Eur Arch Otorhinolaryngol 268:1233–1236. doi:10.1007/s00405-011-1633-8
Oropharyngeal Collapse ccc
Tongue base collapse
Tongue Base Collapse1:30 Epiglottis Patterns
Anterior Posterior
Lateral collapse
1:30
• Meta-analysis of papers on surgical modifications of the upper aerodigestive tract in patients with obstructive sleep apnea
Efficacy of Surgery
• “Analysis of the uvulopalatopharyngoplasty papers revealed that this procedure is, at best, effective in treating less than 50% of patients with obstructive sleep apnea syndrome.”
Efficacy of Surgery
UPPP Response Rates Based on Level of Obstructionn=168 patients (9 papers)