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 dont know
Most consider significant sleep apnea to be
present with an REI > 15
15-25: Mild Apnea
26-40: Moderate Apnea
>40: Severe Apnea
Whos 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 Otolaryn 1990; 110: 136ff
7x 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 the number of MVA
ORL 1991; 53: 106-111
Laryngoscope 1995; 105: 657-61
Hows 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
Habits
Weight changes
Thyroid/Growth Hormone
abnormalities
GERD
sleep schedule
EtOH
PMH/Meds
Hypertension
Sedatives; Antihistamines
Physical Exam
Height and Weight (BMI)
BMI=[703.1 x weight(pounds)] / [Height (in)2]
neck 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 (p<0.01)
All: 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, its 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, Laryngoscope 99: 11-29, 1989
Monitor 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 non-interventional techniques
Weight loss, dental appliances
CPAP
Surgery
