Obstructive Sleep Apnea
and
Upper Airway Resistance Syndrome
Dragos Manta, MD
Assistant Professor of Medicine
Division of Pulmonary, Critical Care and Sleep
Medicine
Sleep Architecture
What is Obstructive Sleep
Apnea (OSA) ?
• Intermittent partial or complete
airway collapse during sleep
• Leading to
– Frequent night-time arousals
– Sleep Fragmentation
– Decreased oxygen levels
– Non-restorative sleep
Daytime Consequences
• Causes excessive daytime fatigue
(EDF) and sleepiness (EDS)
– Increased risk of motor vehicle
accidents
– Decreased work productivity
Other Daytime
Consequences
• Increased risk of complications following
sedation/anesthesia for
procedures/surgery
• Tell your anesthesiologist if you have
OSA
• Bring you machine for procedures/surgery
Long Term Consequences
• Increased cardio-vascular risk
– Hypertension and diabetes
– Myocardial infarction/ Coronary
artery disease
– Atrial fibrillation recurrence after
cardioversion/ ablation
– Strokes
– Dementia
– Erectile dysfunction
Who Is At Risk?
•
•
•
•
•
Obese
Men over 40
Women post-menopausal
Non-Caucasian race
Elderly (more than 40% of people
over 65 have OSA)
• Children
– enlarged tonsils/adenoids
Symptoms of OSA
• Snoring
• Apneic episodes
observed by bed
partner
• Unexplained nighttime arousals
• Agitated sleep
• Insomnia
• Nocturia
• Non-restorative
sleep
• Morning headaches
• Drowsiness
• Excessive daytime
sleepiness
• Need to take naps
• Excessive caffeine
usage
Signs of OSA
• Narrow airway
• Thick neck (usually over 16 inches in
women and 17 inches in men)
• Swelling of the lower extremities
Other Signs of OSA
•
•
•
•
Difficult to control blood pressure
Difficult to control blood sugars
Recurrent atrial fibrillation
Fluid retention
Testing for OSA
• In-lab sleep study
• Ambulatory monitoring or portable studies
– in patients with high risk for OSA and no other
medical problems
– Caveat: does not rule it out
2 min of Sleep in OSA
Upper Airway Resistance
Syndrome (UARS)
UARS-Definition
• Increased upper airway resistance
during sleep that leads to arousals
and sleep fragmentation
• Without causing partial or
complete airway collapse
OSA
R. G. Norman, D M. Rapoport et al. Sleep 1997
UARS
R. G. Norman, D M. Rapoport et al. Sleep 1997
Why UARS?
• Associated with functional somatic
syndromes
– Fibromyagia
– Chronic fatigue syndrome
– Migraine headaches
– Irritable bowel syndrome
• Associated with insomnia
Demographics of UARS
• Tend to be younger than typical OSA
patients
• BMI can be normal or lower than of
patients with OSA
• Women and men equally affected
Symptoms UARS
•
•
•
•
Snoring is not universal
Have a lot of nighttime arousals
Tend to have superficial sleep
Patients are sleepy like most OSA
patients
• Fatigue rather than sleepiness in some
patients
Fatigue vs Sleepiness
• Characterized by
• Sleepiness means the
physical exhaustion
propensity of falling
asleep
• Worse in the
morning and
• Worse in the
evenings
afternoon
Insomnia and OSA/UARS
Wickwire, Emerson; Collop, Nancy. Chest. 137(6):1449-1463,
June 2010
Treatment of OSA/UARS
•
•
•
•
•
PAP (positive airway pressure)
Oral Appliances
Surgery
Adjunctive therapies
Emerging therapies
CPAP – GOLD Standard
CPAP
• Most efficacious
option
• Most commonly
prescribed
• Acts as a
“pneumatic splint”
splinting the upper
airway and
preventing airway
collapse during
sleep.
• Immediate improves
sleep
• Improves quality of
life, daytime
sleepiness
• Improves
hypertension control
• Improves glycemic
control in patients
with diabetes
CPAP Prescription
• A fixed pressure is prescribed after
– Titration during monitored overnight
PSG
– Auto-CPAP trial
CPAP pressure
•
•
•
•
Severity of OSA
Body position
Weight
Sleep stage ( N2 and REM sleep
require highest pressures)
Auto-CPAP or APAP
• For high pressure intolerance
• For OSA concentrated by
– sleep stage (N2, REM)
– position (supine)
Morgenthaler TI et al. Practice parameters for the use of autotitrating
continuous positive airway pressure devices for titrating pressures and
treating adult patients with obstructive sleep apnea syndrome: an update for
2007. An American Academy of Sleep Medicine report. Sleep.
2008;31(1):141-147.
• Certain APAP devices may be
initiated and used in the selfadjusting mode for unattended
treatment of patients with moderate
to severe OSA without significant
comorbidities (Option)
BIPAP
• Offers no significant advantage over
CPAP for OSA patients (Gay PC et al. Sleep.
2003;26(7):864-869)
• For patients that require high pressures
of CPAP > 15 cm H2O
• For patients intolerant to CPAP due to
perceived difficulties with exhalation
• For patients with OSA and OHS or
COPD
Masks Interfaces
• Nasal masks are the standard of
care
• Nasal inserts (“pillows”) are popular
• Nasal-oral (full face) masks
Follow Up after Initiation of
CPAP
• Office visit
• Data Download
– Compliance
– Residual apneic episodes
– Mask Leaks
Oral Appliance (OA)
Therapy
• Mandibular
Advancement
Devices (MADs)
Effectiveness of MADs
• No significant difference
between OAs and CPAP
in the percentage of mild
OSA patients achieving
their target AHI/RDI.
• For moderate to severe
OSA, however, the odds
of achieving the target
AHI were significantly
greater with CPAP than
with OAs.
Summary of Recommendations
AASM 2015
• OAs are recommended for
– primary snoring after OSA is ruled out by
sleep physician
– Patients with OSA who are intolerant of
CPAP therapy or prefer alternate therapy
• Qualified dentist use a custom,
titratable appliance over non-custom
oral devices
• Sleep physicians and qualified dentists
provide follow up
Summary of Recommendations
AASM 2015
• Sleep physicians conduct follow-up
sleep testing
–
–
–
–
To document or improve treatment efficacy
If patients develop recurrent symptoms
If substantial weight gain
With diagnoses of comorbidities relevant to
OSA
• Impact of OAs on resistant HTN or long
term consequences of OSA not well
studied
Surgical Treatment
• Apart from tracheostomy, surgery is
less predictable and effective
• Counseling about alternative therapies,
success rates and complications
• Can be considered for selected
patients that failed or not willing to
consider PAP and OA therapy
• Further research is needed to clarify
patient selection, safety and efficacy of
surgical approaches for OSA
Adjunctive Therapies
• Weight loss should be advised for all
obese patients with OSA
– Caveat: the magnitude of correlation of OSA
severity and weight is greater with weight gain
rather than weight loss
• Bariatric surgery related weight loss
provides either resolution of OSA (around
40%) or major improvements of AHI, sleep
architecture, CPAP requirements and
daytime sleepiness
Adjunctive Therapies
• Exercise
– Sedentary lifestyle associated with OSA
• Avoidance of alcohol or sedatives
before bedtime
Positional Therapy
• For purely supine apnea
• Tennis ball sawn in a back pajama pocket
• Commercially available devices that
prevents rolling to supine position
• Objectively document effectiveness with
position monitor
3 New FDA-Approved
Therapies
• Nasal expiratory PAP devices (Nasal
EPAP)
• Oral pressure therapy (OPT)
• Electrical Stimulation (ES)
Nasal Expiratory PAP Devices
• Unidirectional
flow resistance
valves
• Expiratory flow
resistance
without any
inspiratory
resistance
• For Mild OSA
Oral Pressure Therapy
(OPT)
• Gentle oral suction
sufficient to
displace the soft
palate and the
tongue anterior and
superior
• For mild OSA
Electrical Stimulation (ES)
Electrical Stimulation (ES)
• Promising for moderate and severe
OSA in non-obese patients
• Adherence was improved
• For selected patients
• ?Long term efficacy and side effects
Thank You!
Questions?