Lecture on Sleep Apnea
Abimbola Farinde,PhD
11/15/15
1
Objectives
 Define and understand sleep apnea
 Provide assessments and diagnosis for sleep
apnea
 Discuss the treatment options available for sleep
apnea
 Discuss a patient case presentation on sleep
apnea
2
Background/Origin
 Definition:

Apnea: cessation of airflow at the nose
and mouth lasting at least 10 seconds

Classifications: obstructive or central apnea
Obstructive-episodic upper airway obstruction
during sleep
• Complete or partial obstruction
• Causation: obesity, polyps, enlarged tonsils)
• Varying degree of O2 desaturation, hypercarbia,
and sleep fragmentation
Central-repeated episodes of apnea causes by
temporary loss of respiratory effort during
somnolence
• >10% of all apnea with numerous idiopathic
presentations
3
Sleep Physiology
 Circadian rhythm
Controlled by 2 oscillators with different period lengths
•
•
•
1st oscillator: biologic clock (suprahiasmic
nucleus)
2nd oscillator: neurobiologic mechanism
Involvement of delta-sleep-inducing peptide
and factor S
 Synchronization of sleep-wake cycle
•
Last 25 hours with 24-hour cycle imposed by earth’s
rotation
4
Pathophysiology Of OSA &
CSA
OSA
 Disordered breathing during sleep
 Respiratory efforts with no airflow (upper airway
obstruction)
CSA
 Interruption of both airflow /breathing efforts
Note: Mixed apneas can have both central and
obstructive components.
1st central apnea followed by 1 or more
obstructed breaths
5
Epidemiology
 12 million Americans
 OSA affects approximately 4% men and 2%
women in U.S
 Prevalence in U.S children: 2%
 Male-to-Female ratio:
Children: 1:1
Adulthood: 2:1 or more
 African Americans and Hispanics >Whites
 African Americas are 3.5 times for likely to develop
OSA
6
DSM-IV Classification of Sleep
Disorders
 Primary Sleep Disorders
Dyssomnias
Primary Insomnia
Primary hyersomnia
Breathing-related sleep disorders
Narcolepsy
Circadian rhythm sleep disorder
Delayed sleep phase type
Jet lag type
Unspecified type
Dyssomnias not otherwise specified
 Parasomnias
Nightmare disorder
Sleep terror disorder
Sleepwalking disorder
7
DSM-IV Classification of Sleep
Disorders (cont’d)
Parasomnias not otherwise specified
 Sleep disorders Related to Another Mental
Disorder
Insomnia related to another mental disorder
Hypersomnia related to another mental disorder
 Other Sleep Disorder
Sleep disorder due to a general medical condition
Substance-induced sleep disorder
8
Risk Factors
Morbidly obese (esp. neck size >17in)
 Anatomical disproportion (e.g. small
jaw, large tongue)
 Men >40 years of age
Postmenopausal women
Family history of sleep apnea
Smoking/Alcohol use
Abnormalities in structure of upper
airway
9
Signs and Symptoms of OSA
 Airway occlusion lightened depth of sleep,







arousal from sleep
Repetitive bouts of hypoxia
Heightened peripheral vascular constriction
Tachycardic-bradycardic events during sleep
Daytime symptoms (morning headache, poor
memory, and irritability)
High blood pressure and other cardiovascular
complications
Feelings of depression
Reflux/Nocturia/Impotence
10
Diagnostic Tests
 Polysomnography (standard for diagnosis)
o
o
Overnight and during usual bedtime
Gauge severity of OSA
Inclusion in polysomnography:
o
o
o
o
o
o
Electroculography
Chin and leg surface electromyography
Two EEG channels
Breathing assessments (nasal/oral airflow sensor or pulse
oximetry)
1 ECG channel (heart rate and rhythm)
Others: seizure activity, esophageal ph measurements
 Daytime nap studies (specific not sensitive)
 Imaging Studies
o
o
Anteroposterior and lateral neck radiography
CINE MRI during sleep
11
Diagnostic Tests
Other tests
o
CBC, multiple sleep latency test, MRI of brain
and brainstem
12
Treatments for Sleep Apnea
Medical Care
 Positional therapy (1.e., avoidance of sleeping on back)
Encourage sleep in prone position
 Weight loss
 Oral appliances (aid with bringing lower jaw and tongue
forward during sleep) improvement of OSA
 Surgery: tonsillectomy and adenoidectomy (common in
pediatric patients
 Continuous positive airway pressure (CPAP)
Amount of CPAP
Mainstay of therapy in most adults
 Over-the-counter disposable adhesive covered nasal strips
13
Treatments for Sleep Apnea
Surgical Care
 Adenotonsillectomy
o Curative in some instances
o Demonstrates improvement in neurocognitive
function
Uvulopalatopharyngoplasty (UPPP)
o removal of uvula, posterior margins of the soft
palate, and lateral pharyngeal wall mucosa via
scalpel or laser ablation
o Likely to resolve OSA is obstruction is localized
to soft palate
o Successful reduction of apnea in 50% of patients
and snoring in 90%
 Tongue reduction procedures
(midline partial glossectomy)
 Trachectomy
o
Effective
for life-threatening obstructive apnea
14
Treatments for Sleep Apnea
Pharmacological Interventions
 OSA
o
o
o
o
o
Avoidance of CNS depressants (i.e., alcohol,
anxiolytics, hypnotics, narcotics)
Protriptyline (mild OSA without hypercapnia)
-Dose: 10-30mg/day
-Anticholinergic side effects
Fluoxetine
-Dose:20mg/day
-Reduction of apnea in some patients
Respiratory stimulants: theophylline and
clonidine(males)
Medroxyprogesterone
-Dose: 60mg
-Improvement of sleep apnea and obesityhypoventilation
15
Treatments for Sleep Apnea
Pharmacological Interventions (cont’d)
 CSA
o
o
Hypercapnic CSA:
-Ventillatory support with O2 and CPAP
-Acetazolamide, theophylline, and
medroxyprogesterone
Non-hypercapnic CSA
- Benzodiazepines (triazolam or temazepam)
- Acetazolamide, CPAP, and O2
16
Patient Case: History of Present
Illness
 CC: “complaints of snoring, apneic episodes
during sleep, disturbed sleep at night, daytime
hypersomnolence and fatigue”
 RB is a 79 year old African American male who
currently admitted to 3J who received work-up for
“spells” from an inpatient sleep consult. Patient
has had complaints for last few years but recently
got worse.
17
Past Medical History
 Coronary
artery disease
 Hypothyroidism
 Colonic Polyps
 Hematochezia
 Hypertension
 Hyperlipidemia
18
Social/Occupational/Military
History
 Part time horse rancher
 >80 pack year history of smoking
 Rarely smokes presently
 Lives with wife
 3 children
 Vietnam Veteran
19
Review of Systems
 Vital Signs
Temp: 96.7oF BP: 123/66 R:16 P:95 Ht: 70in
Wt:74.5KG(163.8lbs)






HEAD: PERRLA, EOMI
MOUTH: no lesions
NECK: supple no lymph nodes palpable
LUNGS: course breath sounds
HEART: no murmurs
ABDOMEN: soft mildly tender diffusely, no bowel sounds,
nondistended
 EXTREMITIES: great toe with patchy heterogeneous flat
multicolored dark lesion
 NEUROLOGICAL: delayed tendon reflex
20
Medications





Clopidogrel 75mg daily to prevent blood clots
Dilitiazem 240mg daily for blood pressure
Etodolac 300mg at bedtime
Levothyroxine 0.137mg daily for hypothyroidism
Lisinopril 20mg/HCTZ 25MG every morning for
blood pressure
 Metoprolol tartrate 25mg twice a day for blood
pressure
 Simvastatin 20mg at bedtime for cholesterol
 Fluticasone nasal inh once daily in both nostrils for
allergies
21
Pertinent Laboratory Values
Glucose
102H
40H
Anion gap
1.6H
136
T.Protein
Potassium
4.4
ALT
21
Chloride
104
29.0
T. Bilirubin
0.8
40
3.7
WBC
6.9
RBC
4.63L
11.9L
BUN
Creatinine
Sodium
CO2
Albumin
TSH
Calcium
9.8
Alkphos
AST
Urea
Nitrogen
HGB
9
69
6.7
25
22
Cholesterol
157
HCT
36.4L
Pertinent Laboratory Values
(cont’d)
BUN
40H
HgA1C
5.7
Plts
234
LDL
96
HDL
35L
TG
130
23
INR-R/PT
1.02/13.7
Assessment/Plan
Assessment: clinical features
suggestive of obstructive sleep apnea
syndrome. Episodes of “spells” need
not be secondary to sleep-related
breathing disorder. History is
indicative of central sleep apnea
24
Assessment/Plan (cont’d)
Plan:
 Perform ECHO and full PFT
 Overnight sleep study and CPAP titration
 Advised patient to keep ideal body weight and
avoid driving when sleepy
 Advised patient to follow sleep hygiene measures
 Avoid driving and operating dangerous equipment
until elimination of daytime sleepiness
 Cautioned patient about exacerbations of sleeprelated breathing problems: alcohol, sedatives,
and hypnotics
 Scheduled for follow-up visit
25
Results of Pulmonary Function Test
FVC = 3.13L or 75% predicted.
FEV1 = 2.14L or 81% predicted.
FEV1/FVC ratio 68
FEF 25-75% = 1.56L/sec or 69%
predicted.
TLC = 10.00L or 146% predicted.
26
Results of Sleep Study
 Sleep efficiency (total sleep time/recording time):48% (normal
>85%)
 Sleep onset latency: 62 minutes (normal 3-30
minutes)
 REM sleep latency: 108 minutes (normal 60-120 minutes)
 101 obstructive apneas and 24 hypopneas)
apnea-hyponea index of 41 events/hr (normal <5)
 Minimum o2 saturation by pulse oximetry: 92% and baseline
oxygen saturation : 96%
 Mild Snoring during sleep study
 No EEG or EKG abnormalities
Final Impression: Obstructive Sleep Apnea Syndrome
27
References
 Dipiro, JT et al. Pharmacotherapy: A Pathophysiologic
Approach. 5TH edition. New York: The McGraw-Hill
Companies, Inc; 2005. p.1327-1328.
 Colin, Wayne & Duval, Susan. Surgical treatment of
obstructive sleep apnea. AORN journal. Sept. 25, 2005.
 Steffan, Michael. Sleep Apnea. E-medicine from the
WebMD. 2006
 Guilleminault, C. et al. Maxillomandibular expansion for
the treatment of sleep-disordered breathing: preliminary
result. Laryngoscope. 2004;114(5):893-6.
 Young, T, Peppard, PE, Gottlieb, DJ. Epidemiology of
obstructive sleep apnea: a population health
perspective. Am J Respir Crit Care Med.
2002;165(9):1217-39.
 Paje, Dama T. & Kremer, Michael. The Perioperative
Implications of Obstructive Sleep Apnea. Orthopaedic
28
Nursing. 2006;25(5):291-297.