A CPMC Regional CME Event
THE UNIFIED AIRWAY
- An Integrated Approach
Saturday October 1, 2011
SLEEP APNEA:
THE SILENT AIRWAY CONTRIBUTOR
Brandon Lu, M.D., M.S.
San Francisco Critical Care Medical Group
OBSTRUCTIVE SLEEP APNEA
• Repetitive upper airway closure during sleep
resulting in repeated reversible blood oxygen
desaturation and fragmented sleep1,2
• Severity measured by Apnea-Hypopnea Index
(AHI):
– Apnea: ≥ 90% decrease in airflow from baseline, for ≥
10 sec
– Hypopnea: ≥ 30% decrease in airflow from baseline, for
≥ 10 sec; accompanied by ≥ 4% desaturation from
baseline
1. Young et al., Am J Respir Crit Care Med 2002;165
2. Hiestand et al., Chest 2006;130
3. Iber et al., The AASM Manual for the Scoring of Sleep and Associated Events. 2007.
OSA: 2-MIN EPOCH OF SLEEP STUDY
OSA: SCOPE OF THE PROBLEM
• Estimated prevalence:
AHI > 5
AHI > 15
Men
Women
Men
Women
Wisconsin1
24
9
9
4
Pennsylvania2,4
17
-
7
2
SHHS3
46
18
• Up to 90% of people with OSA are
undiagnosed5
1.Young et al., N Engl J Med 1993;328 2.Bixler et al., Am J Respir Crit Care Med 2001;163
3.Nieto et al., JAMA 2000;283
4. Bixler et al., Am J Respir Crit Care Med 198;157
5. Young et al., Sleep 1997;20
OSA: ASSOCIATED MORBIDITIES
• Cardiovascular disease
• Hypertension, CAD, CHF, arrhythmias, stroke
• Metabolic syndrome, diabetes
• Daytime sleepiness, e.g. motor vehicle
accidents
• Dementia
• Mood disorder
• Mortality
SLEEP APNEA AND INTERMITTENT HYPOXEMIA
OSA AND THE SYMPATHETIC SYSTEM
Somers et al., J Clin Invest 1995;96
OSA: SYMPTOMS AND ASSOCIATED FINDINGS
•
•
•
•
•
•
•
•
•
Obese
Loud snoring
Witnessed apneas
Daytime sleepiness
Unrefreshing sleep
Males
Hypertension
DM
Memory and learning
impairments
•
•
•
•
Hypothyroidism
Acromegaly
Nasal obstruction
Craniofacial abnormalities
(i.e., Down’s syndrome,
Pierre-Robin syndrome)
PHYSICAL EXAMINATION
Mallampati classification
• Neck size greater than
17.5 inches (men)
• BMI greater than 30
• Pharynx - Thick side
walls
• Uvula - Long
• Soft palate - Low
• Tonsils - Large
• Nasal Obstruction
• Retrognathia
EPWORTH SLEEPINESS SCALE
• How likely are you to fall
asleep in the following
situations, in contrast to
feeling just tired?
•
•
•
•
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
•
>10 indicates daytime sleepiness
Johns, Sleep 1994
SITUATION
CHANCE OF DOZING
Sitting and Reading
____
Watching TV
____
Sitting inactive in a public place (e.g. in a
theater or a meeting)
____
As a passenger in a car without a break for an
hour
____
Lying down in the afternoon when
circumstances permit
____
Sitting and talking with someone
____
Sitting quietly after lunch without alcohol ____
In a car, while stopped for a few minutes in
traffic
____
WHEN TO REFER FOR SLEEP STUDY
•
•
•
•
Loud snoring, witnessed apneas, etc.
Daytime sleepiness
Physical exam, including obesity
Comorbidities (cardiovascular, metabolic, etc)
WHAT TO DO BEFORE SLEEP STUDY
• Treat nasal obstruction/congestion
• Startling Resistor: upstream obstruction leads to
suction force downstream
• Oral breathing vs. nasal breathing
• Oral breathing results in increased upper airway
resistance (12.4 vs. 5.2 cmH2O∙L-1∙s-1) and collapse
during sleep
Smith et al., J Appl Physiol. 1988 Meurice et al., Am J Respir Crit Care Med. 1996
Fitzpatrick et al., Eur Respir J. 2003.
TYPES OF SLEEP STUDY
•
•
•
•
Diagnostic study
Split night study
CPAP titration study
Home study
WHEN TO REFER TO A SLEEP PHYSICIAN
• No guideline
• Troubleshoot
- Mask, pressure, alternate therapeutic options
• Follow-up
- Medicare guideline requires documentation within 90
days of CPAP initiation:
•
•
Face-to-face evaluation documenting benefit
Objective evidence of adherence reviewed by treating
physician (>4 hr use on 70% of nights)
• Critical mass
POSITIVE AIRWAY PRESSURE
Types of Home Nocturnal Positive Airway Pressure Devices
Type of Device
Continuous Pressure
Pressure Delivery
Unchanged through
the night
Indication
OSA
Mechanism
Prevents upper airway
obstruction
Bilevel Pressure
Separate inspiratory
and expiratory
pressure
1) OSA
2) Ventilatory Failure
In OSA may increase
patient comfort and
compliance
Auto Pressure
Delivered pressure
changes breath to
breath
1) Estimating CPAP
requirements in OSA
2) Improving OSA
patient comfort and
compliance
Measurement of
changes in flow are
compensated for by
increased pressure
delivered on a breath
to breath basis
COMFORT FEATURES OF CPAP:
C-FLEX / EPR
• PEF sensing allows a reduction in flow during
exhalation
• Comfort mode
• Not for ventilation, only for maintenance of a
patent upper airway
10
Pressure
5
0
I
E
I
E
I
SURGICAL OPTIONS FOR OSA
Uvulopalatopharyngoplasty (UPPP)
Shortens uvula, trims soft palate, and
sutures back the anterior and posterior
pharyngeal pillars; tonsillectomy is
performed if indicated.
Won et al., Proc Am Thorac Soc. 2008
Genioglossus advancement
Enlarges the hypopharyngeal space by
pulling forward the tongue base at the
geniotubercle through a mandibular
osteotomy
SURGICAL OPTIONS FOR OSA
Maxillomandibular advancement
osteotomy
Advances the maxilla and mandible to
enlarge the retrolingual and retropalatal
spaces
Won et al., Proc Am Thorac Soc. 2008
Adenotonsillectomy
First-line therapy for obstructive sleep
apnea in children; both adenoid and
tonsillar tissue are removed, and the
lateral pharyngeal walls are sutured to
prevent collapse
PALATAL IMPLANTS
http://www.snoring911.com/treatments.php
SURGICAL OPTIONS FOR OSA
• Tracheostomy: effective; last resort
• MMA: severe OSA who can’t use CPAP and OA not an option
• UPPP: does not reliably normalize AHI in mod/sev OSA; try
CPAP or OA first
• Multi-level or stepwise surgery: acceptable in patients with
narrowing of multiple sites in the upper airway
• LAUP: not routinely recommended (standard)
• RFA: can be considered in mild/mod OSA who can’t use
CPAP or OA
• Palatal implants: may be effective in mild OSA who can’t use
CPAP or OA
Practice Parameters for the Surgical Modifications of the Upper Airway for
Obstructive Sleep Apnea in Adults. AASM 2010
ORAL APPLIANCES
“Oral appliances are indicated for use in
patients with mild to moderate OSA who
prefer them to CPAP therapy, or who do not
respond to, are not appropriate candidates
for, or who fail treatment attempts with
CPAP…Follow-up polysomnography or an
attended cardiorespiratory (Type 3) sleep
study is needed to verify efficacy…” AASM,
SLEEP, 2006.
OSA AND COUGH
• 108 consecutive referrals for suspected OSA: 33%
of OSA pts reported chronic cough (>2 mos.) predominantly females (61% vs. 17%), more
nocturnal heartburn (28% vs. 5%) and rhinitis
(44% vs. 14%) compared to those without SDB.
• 75 chronic cough pts without pulmonary
pathology; 35/38 (92%) who underwent sleep
study had OSA; 93% given CPAP and had
improvement in cough
Chan et al., Eur Respir J. 2010
Sundar et al., Cough 2010
OSA AND GERD
• 1116 patients with PSG-diagnosed OSA and 1999
participants in a general health survey:
- Weekly nocturnal reflux symptoms present in 10.2%
OSA pts vs. 5.5% general population (p<0.001) and
13.9% severe versus 5.1% mild OSA
- Frequent nocturnal reflux symptoms were associated
with severity of OSA (OR 3.0, severe versus mild OSA,
P<0.001) after correcting for multiple factors
• Nocturnal reflux associated with transient lower
esophageal sphincter relaxation (TLESR) but not
by negative intra-esophageal pressure during OSA
Shepherd et al., J Sleep Res 2011
Kuribiyashi et al., Neurogastroenterol Motil 2010
OSA AND GERD
• Patient with OSA and GER showed decreased 24-hr
acid contact time after treatment with CPAP
Tawk et al., Chest 2006