Categories
Otolaryngeal system (ENT)

Obstructive sleep apnea (OSA)

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)
Risk factors for obstructive sleep apnea (OSA)
Risk factors for obstructive sleep apnea (OSA) | Motamedi, K. K., McClary, A. C., & Amedee, R. G. (2009). Obstructive sleep apnea: a growing problem. The Ochsner Journal, 9(3), 149–153. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/21603432

Craniofacial and oropharyngeal features:

  • Large neck circumference
  • Retro- /micrognazia
  • Nasal obstruction
  • Enlarged tonsils/adenoids
  • Macroglossia
  • Low-lying soft palate
osa
The Calgary Guide | http://calgaryguide.ucalgary.ca/

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
NocturnalDiurnal
SnoringExcessive sleepiness
Witnessed apnoeasMorning headaches
Choking at nightDepression/irritability
NocturiaMemory loss
InsomniaDecreased libido

Case study:


Complications

Cardiovascular involvement

  • Drug-resistant systemic hypertension (>50% cases)
  • Ischemic heart disease
  • Cardiac arrhythmias 
  • Stroke
Pathological relationship between sleep apnea and cardiovascular disease
Pathological relationship between sleep apnea and cardiovascular disease | Kasai T, Floras JS, Bradley TD. Sleep apnea and cardiovascular disease: a bidirectional relationship. Circulation 2012;126:1495-510

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):

Indications for the management of obstructive sleep apnoea based on the apnoea hypopnoea index (AHI)
Indications for the management of obstructive sleep apnoea based on the apnoea hypopnoea index (AHI): Continuous positive airway pressure (CPAP) should be considered as the first choice of treatment, whereas positional treatment is indicated only when positional apnoeas have been documented. | Spicuzza, L., Caruso, D., & Di Maria, G. (2015). Obstructive sleep apnoea syndrome and its management. Therapeutic Advances in Chronic Disease, 6(5), 273–285. https://doi.org/10.1177/2040622315590318

Weight loss:

  • Bariatric surgery indicated if BMI > 40
1200px-cpapanwender
Person using a CPAP mask, covering only nose | Michael Symonds – Eigenanfertigung (Aufnahme ist übrigens nicht gestellt.), CC BY-SA 2.0 de, https://commons.wikimedia.org/w/index.php?curid=6078536

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).
10.1177_2040622315590318-fig4
Treatment options for obstructive sleep apnoea. | Bloch K. (2006) Alternatives to CPAP in the treatment of the obstructive sleep apnea syndrome. Swiss Med Wkly 136: 261–267.

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
    • SubtypesConventional 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
uppp-_4_figures
Uvulopalatopharyngoplasty. A) pre-operative, B) original UPPP, C) modified UPPP, and D) minimal UPPP. | By Drcamachoent – Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=38852585

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