Obstructive Sleep Apnea
Brent A. Senior, MD
Associate Professor
Chief, Rhinology, Allergy, and Sinus Surgery
Otolaryngology/Head and Neck Surgery
University of North Carolina
What is OSA?
Disorder of obstructed breathing occurring
during sleep
 Apnea: cessation of breathing with
respiratory effort lasting greater than 10s
 Hypopnea:

 decreased
airflow of >70%
 Any decreased airflow with desaturation <90%

Total apneas and hypopneas per hour = AHI
or RDI or REI
What is Significant OSA?
Uh, I don’t know
 Most consider significant sleep apnea to be
present with an REI > 15

 15-25:
Mild Apnea
 26-40: Moderate Apnea
 >40: Severe Apnea
Who’s Got It?

NCSDR-1993
 40
million Americans with chronic sleep
disorder
 20 million with occasional sleep disorder

SDB (REI >5): 24% middle aged males
 9%

middle aged females
OSA >15/hr: 4% middle aged males
 2%
middle aged females
 NEJM
1993; 328: 1230-35
Why is it so Important?

Hypertension
 25%
of hypertensives have OSA (AI>5)
 Sleep Heart Health Study
 6000
patients corrected for bmi, neck, EtOH
• Nieto, et al. JAMA 283 (14): 1829-36, April 2000
 SDB
(including snoring) and Htn correlate
 1700
patients
• Bixler, et al Arch IM 160 (15): 2289-95, 2000
 Sleep
1980; 3: 221-4
 BMJ 1987; 294: 16-19
Health Impact

MI
 REI
>20 independent predictor of MI
 223
German males with angio confirmed CAD
• Schafer, et al. Cardiology 92(2): 79-84, 1999
 Increased
mortality in CAD patients
5
y study (Sweden)-62 patients; 19 with OSA (RDI
17)
• OSA mortality: 37.5%; Non-osa mortality: 9.3%
• Peker, et al. Am J Resp Crit Care 162 (1): 81-6, 7/2000
Health Impact

CVA
 REI
severity is independent predictor of Stroke
 128
patients (UM)- 75 stroke; 53 TIA
 62.5% with AHI >10 with stroke vs 12% controls
• Bassetti, C et al. Sleep 22(2): 217-23, 3/1999
Health Impact

Death
 AI<20,
at 8y follow-up: 4% mortality
 AI>20, at 8y follow-up: 37% mortality
 treatment with trach or CPAP: 0% mortality
 Chest

1988; 94: 9-14
NCSDR 1993
 38000
CV deaths related to OSA per year
Societal Impact
Societal Impact
75% of 75000 screened will be diagnosed
with OSA ($275 million)
 Fragmentation of sleep occurring with SDB

 increased
daytime sleepiness, decreased
intellect, behavioral and personality changes,
enuresis, sexual dysfunction
 Am
J Resp Crit Care Med 1996; 153: 1328-32
Societal Impact

Increased Traffic Accidents
 simulated
driving: SDB ~100x more likely to
drive off the road
 Acta
 7x
Otolaryn 1990; 110: 136ff
increased risk of auto accidents
 Clin
Chest Med 1992; 13: 427-34
Societal Impact

Reaction times
 with
OSA equivalent to a normal control who
was legally intoxicated (ABL >0.8)
 Powell
NB et al. Laryngoscope. 109(10):1648-54,
1999
 UPPP decreases
 ORL
the number of MVA
1991; 53: 106-111
 Laryngoscope 1995; 105: 657-61
How’s it Diagnosed?
History, Physical Examination, and Sleep
Study
 History

 Disrupted
sleep, restless sleep, awaken with
gasping and choking
 Loud snoring
 Tired, inappropriate falling asleep
 Witnessed apneas
History

Associated Complaints
 Weight
changes
 Thyroid/Growth
Hormone abnormalities
 GERD

Habits
 sleep
schedule
 EtOH

PMH/Meds
 Hypertension
 Sedatives;
Antihistamines
Physical Exam

Height and Weight (BMI)
 BMI=[703.1
 neck
x weight(pounds)] / [Height (in)2]
size
 Face-retrognathia
 Nose
 Oral cavity- palate, uvula, tonsils/pillars,
tongue, occlusion
Physical Examination
Physical Examination
Fiberoptic
Nasopharyngolaryngoscopy



Determines level of
obstruction
Provides estimate of degree
of obstruction
Technique
 supine
(i.e., in a sleeping
position)
 at FRC-point of maximal
relaxation
 snore maneuver
 Mueller maneuver- inspire
against a closed airway
Evaluation

Key Features of the History and Exam
 History
(105 patients)
 apnea
reported by bed partner (p<0.01)
 awakes with choking (p<0.005)
 hypertension: dias >95 (p<0.01)
 Exam
 BMI>30
 All:
(p<0.01)
sensitivity 92%; specificity 51%
 Am
Rev Resp Dis 1990; 142: 14-18
Objective Sleep Monitoring

Rationale: Difficulty
predicting OSA by
H&P with no EDS
 Loud
snoring and
witnessed apneas
identify OSA 54-64%
of the time

Sleep 1988; 11: 430-36
 H&P predict
OSA only
60% of the time

Sleep 1993; 16: 118-22
How To Treat?

Minimal intervention
 Drop
the Weight!
 Dental Appliances
 Variable
success rates,
though probably more
useful for mild apnea
 ?compliance

Interventional
 CPAP
 Surgery
CPAP

The “Gold Standard” in the treatment of
OSA
 Works
the best in the most people
 Positive pressure ventilation functions as a
pneumatic splint for the collapsing upper
airway

But... compliance is very poor
 159/214
(74%); mean 5.6 h/night; 77-89%
compliance (!)
 Krieger.
Sleep 15 (6 Suppl) S42-6, 1992
Surgery

Tracheotomy
 An
incision in the trachea
 Cures OSA nearly 100% of the time
 Prior to 1980, it’s all we had; still useful for
severe apneics
Remove TissueUvulopalatopharyngoplasty
(UPPP)

First successful alternative
to tracheotomy
 12
individuals
preop AI 54 +/- 28
 postop AI 28 +/- 28
 8/12 with post-op AI<20

• Fujita et al. Otolaryngol
HNS 1981; 89:923-34
Remove Tissue-Other Surgeries




Laser Midline
Glossectomy
Palatal Somnoplasty
LAUP
Radiofrequency tongue
base reduction
 Woodson,
et al, AAO
2000, Washington DC

18 patients completed
protocol, average 15,696 J
• REI decreased from 45.3
to 33.3
Enlarge the Bony SpaceOther Surgeries

Genioglossus Advancement/
Hyoid Repositioning
 Success
~80% (11-18mm)
 Less effective with RDI >60

Maxillo-mandibular
Advancement
 Particularly
useful in the
setting of hypopharyngeal
obstruction (Fujita 2 or 3)
 Best results when performed
following “Stage 1” surgery
Complication Avoidance
All OSA patients are at risk of Airway
Obstruction (even mild)
 Minimize risk:

 Expect
intubation disaster
 Pharyngeal procedure with nasal procedure
increases risk regardless of apnea severity
 Mickelson
and Hakim, Oto HNS 119: 352-6, 1998
 Amount
of intraoperative narcotic- worse with
greater apnea severity
 Esclamado,
 Monitor
Laryngoscope 99: 11-29, 1989
post-op with continuous oximetry
Summary
OSA is a potentially life-threatening
disorder that demands proper evaluation
 Components of that proper evaluation
include detailed sleep history, PE, and
endoscopic evaluation
 Objective sleep evaluation is required prior
to intervention

Summary

Treatments include
 Conservative
 Weight
 CPAP
 Surgery
non-interventional techniques
loss, dental appliances