Repetitive episodes of nocturnal breathing cessation due to upper airway collapse for ≥10 sec during sleep.
- 90-95% of all sleep apnoea cases
- 2–4% of the adult population
Etiopathogenesis
Risk factors:
- Snoring
- Male gender, middle-age
- Menopause (women)
- Obesity (70% cases)
Craniofacial and oropharyngeal features:
- Large neck circumference
- Retro- /micrognazia
- Nasal obstruction
- Enlarged tonsils/adenoids
- Macroglossia
- Low-lying soft palate
Presentation
Sleep deprivation:
- Excessive daytime somnolence (>80% cases) → impaired performance at work and major work-related and road accidents
- Nicturia (excessive need to urinate at night + stress-induced insomnia)
- Poor concentration
- Headaches
- Fatigue
| Nocturnal | Diurnal |
|---|---|
| Snoring | Excessive sleepiness |
| Witnessed apnoeas | Morning headaches |
| Choking at night | Depression/irritability |
| Nocturia | Memory loss |
| Insomnia | Decreased libido |
Case study:
Complications
Cardiovascular involvement
- Drug-resistant systemic hypertension (>50% cases)
- Ischemic heart disease
- Cardiac arrhythmias
- Stroke
Low-grade systemic inflammation:
- May contribute to initiate/accelerate atherogenesis
Other morbidities:
- Metabolic impairment (independent of body weight)
- Diabetes mellitus type II
- Altered serum lipid profile
Diagnosis
Polysomnography: :
Multi-parametric test which includes the following:
- EEG
- Eye movements (EOG)
- Skeletal muscle activation (EMG)
- ECG
- Respiratory airflow and respiratory effort indicators
- Peripheral pulse oximetry
- Sleep latency
- Sleep efficiency
- Arousal index
Management
Apnea-hypopnea index (AHI):
Weight loss:
- Bariatric surgery indicated if BMI > 40
Continuous positive airway pressure (CPAP):
- Indicated in:
- All patients with AHI > 15, independently from the presence of comorbidities, type of work and severity of symptoms
- AHI 5-15 in the presence of symptoms (i.e. sleepiness, impaired cognition, mood disorders) or hypertension, coronary artery disease or previous cerebrovascular accidents
- Generally administered through the nose: nCPAP (TREATMENT OF CHOICE)
- Long-term complication: Complex sleep apnoea (complex SA)
- Primarily OSA/mixed apnoeas who develop central apnoeas on positive airway pressure (PAP) treatment (treatment-emergent central apnoeas) or have significant persistent central apnoeas on PAP treatment (treatment-persistent CSAs).
Sleep surgery:
- Uvulo-palatopharyngoplasty (UPPP) (if CPAP fails)
- Resection of uvula, part of the soft palate and tissue excess in the oropharynx, and is usually performed with simultaneous tonsillectomy
- Subtypes: Conventional or laser-assisted (LAPP)
- Long-term complications:
- Velopharyngeal insufficiency (M/C, ⅓ cases)
- Dry throat
- Swallowing difficulty
- Maxillomandibular advancement (MMA) (for craniofacial malformations)
- Osteotomy of the maxilla and mandibular. The advancement of the skeleton structures passively induces an anterior displacement of the soft palate and the tongue with a simultaneous widening of the pharyngeal space.
- Tracheotomy (M/effective)
- Last resort: Reserved for severe OSA whose life is at risk and for whom all other treatment approaches have failed
