Obstructive Sleep Apnea

Abdul Alraiyes MD
 Objectives

• OSA Definitions
• OSA Diagnostic criteria
• Epidemiology and genetics of OSA
• OSA Risk factors
• OSA pathophysiology and physiologic consequences
• OSA treatment
 Definitions

Apnea: 90 % or more decrease in the airflow for at least 10

seconds

Hypopnea: 50% decrease in the nasal pressure for at least

10 seconds with either:
-3% oxygen desaturation
-EEG arousal

OSA: Apnea Hypopnea Index > 5 events/hour

OSAS: OSA with physiologic and psychologic manifestation

 Apnea

At least 90% reduction in

the thermal sensor for at
least 10 seconds
 Hypopnea

50% reduction in the nasal

pressure for at least 10
seconds

with at least 3%
desaturation or
arousal
 AHI(Apnea Hypopnea index)

AHI = # of Apnea + # of Hypopnea X 60

Total Sleep time (in hours)
 OSA diagnosis criteria
Polysomnography:
Adults : AHI >5 events/hour
Pediatrics: AHI >1 event/hour

OSA Mild Moderate Severe

5 – 15 15 – 30 > 30
AHI events/ hour events/ hour events/ hour
 Differential diagnosis

1. Snoring
2. Central sleep apnea
3. Upper airway resistance syndrome
4. Insomnia
5. Cardiopulmonary disorders
 Epidemiology
A Random sample 602 employed men and women (30-60 years)
had polysomnography

AHI >5 in 9% of women and 24% of men

AHI >15 in 4% of women and 9% of men

AHI>5 and daytime hypersomnolence in

2% women
4% men
1 in 5 adults has at least mild sleep apnea
1 in 15 has at least moderate sleep apnea

Young, T., P.E. Peppard, and D.J. Gottlieb, Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med, 2002.
165(9): p. 1217-39
 Epidemiology

Young, T., P.E. Peppard, and D.J. Gottlieb, Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med, 2002.
165(9): p. 1217-39
 Genetics
Genetic factors:
Obesity
Craniofacial morphology
Connective tissue/muscle factors
Ventilatory control
Leptin

SDB and obesity have shared and unshared genetic

determinants
40% of the variance in the AHI may be explained by familial
factors Chromosome 2p
Also has linkage with BMI (LOD=3.08)
Biologically plausible candidate genes: acid phosphatase, POMC,
apolipoprotein, alpha-adrenergic receptor
Chromosome 19q13: Locus affecting AHI independently of BMI
Palmer, L.J., et al., A whole-genome scan for obstructive sleep apnea and obesity. Am J Hum Genet, 2003. 72(2): p. 340-50.
Palmer, L.J., et al., Whole genome scan for obstructive sleep apnea and obesity in African-American families. Am J Respir Crit Care Med, 2004.
169(12): p. 1314-21.
 Risk Factors(Non-modifiable)

1. Gender
2. Ethnicity / Race
3. Age
4. Pregnancy
5. Menopause
6. Genetics
7. Marfan’s, Down’s and Pierre Robin syndromes
.
Young, T., P.E. Peppard, and S. Taheri, Excess weight and sleep-disordered breathing. J Appl Physiol, 2005. 99(4): p. 1592-9
Palmer, L.J., et al., A whole-genome scan for obstructive sleep apnea and obesity. Am J Hum Genet, 2003. 72(2): p. 340-50.
Palmer, L.J., et al., Whole genome scan for obstructive sleep apnea and obesity in African-American families. Am J Respir Crit Care Med, 2004.
169(12): p. 1314-21.
.
 Risk Factors (Modifiable)

1. Obesity
2. ETOH
3. Sedatives
4. Neuromuscular disorders
5. Craniofacial abnormalities
6. Endocrine disorders
7. hormonal

.
•Young, T., P.E. Peppard, and S. Taheri, Excess weight and sleep-disordered breathing. J Appl Physiol, 2005. 99(4): p. 1592-9
•Nieto, F.J., P.E. Peppard, and T.B. Young, Sleep disordered breathing and metabolic syndrome. WMJ, 2009. 108(5): p. 263-5.
Risk Factors (Obesity)
 Risk Factors (Obesity)

•Sturm, R., Increases in morbid obesity in the USA: 2000-2005. Public Health, 2007. 121(7): p. 492-6.
 Risk Factors (Obesity)
According to Nieto et al,
the majority of subjects
with an AHI ≥ 5 are not
obese.
As the AHI increases, the
proportion of subjects with
sleep apnea who are obese
does increase.

•Nieto, F.J., et al., Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health
Study. JAMA, 2000. 283(14): p. 1829-36.
 Alcohol
•Acute increase in nasal and pharyngeal resistance in awake
subjects
•Reduction of genioglossus activity
•Increased number and duration of hypopneas and apneas

•Issa, F.G. and C.E. Sullivan, Alcohol, snoring and sleep apnea. J Neurol Neurosurg Psychiatry, 1982. 45(4): p. 353-9.
 Risk Factors (Anatomic physical findings)

1. Increased laryngeal length

2. Increased tissue elasticity
3. Increased soft tissue
I. Intraluminal (tonsils)
II. Extraluminal ( retropharyngeal fat ) Neck size > 17 in
4. Macroglossia
5. Micrognathia

•Young, T., J. Skatrud, and P.E. Peppard, Risk factors for obstructive sleep apnea in adults. JAMA, 2004. 291(16): p. 2013-6.
•Schellenberg, J.B., G. Maislin, and R.J. Schwab, Physical findings and the risk for obstructive sleep apnea. The importance of oropharyngeal
structures. Am J Respir Crit Care Med, 2000. 162(2 Pt 1): p. 740-8.
 Signs and Symptoms
Nocturnal: Daytime
Restlessness (90%) Excessive daytime somnolence
Snoring (78%) Fatigue
Witnessed apnea (50-60%) Morning headaches (50%)
Choking/Dyspnea (18-31%) Poor concentration
Nocturia (28%) Decreased libido (33%)
Diaphoresis (~25%) Decreased attention
Reflux (~25%) Depression
Drooling (36%) Personality changes
Dry mouth (74%) Insomnia
Bed partner sleep disruption

Young, T., J. Skatrud, and P.E. Peppard, Risk factors for obstructive sleep apnea in adults. JAMA, 2004. 291(16): p. 2013-6.
Normal Breathing
Pathophysiology
Pathophysiology
Leung, R.S. and T.D. Bradley, Sleep apnea and cardiovascular disease. Am J Respir Crit Care Med, 2001. 164(12): p. 2147-65.
 Physiologic consequences
Sleep apnea

Enhanced SNS activity, Hypoxia, Hypercapnia, Intrathoracic

Pressure Swings

Oxidative Stress Increased inflammation

Increased coagulation HTN
Endothelial dysfunction
Platelet Aggregation Insulin resistance
CHD
CVA
Arrhythmias
DEATH
Leung, R.S. and T.D. Bradley, Sleep apnea and cardiovascular disease. Am J Respir Crit Care Med, 2001. 164(12): p. 2147-65.
 Epworth Sleepiness Scale
0 - WOULD NEVER DOZE
1- SLIGHT CHANCE OF DOZING
2- MODERATE CHANCE OF DOZING
3- HIGH CHANCE OF DOZING

Sitting reading
Watching TV
Sitting inactive in public
Passenger in a car for 1 hour
Lying down in the afternoon when circumstances permit
Sitting and talking
Sitting quietly after lunch
In a car, while stopped for a few minutes in traffic

•Issa, F.G. and C.E. Sullivan, Alcohol, snoring and sleep apnea. J Neurol Neurosurg Psychiatry, 1982. 45(4): p. 353-9.
 Drowsy Driving

Sleep apnea association with MVA is independent of sleepiness.

•Issa, F.G. and C.E. Sullivan, Alcohol, snoring and sleep apnea. J Neurol Neurosurg Psychiatry, 1982. 45(4): p. 353-9.
Physical exam
 Airway narrowing

lateral pharyngeal walls (OR = 2.5; 95% CI, 1.6-3.9)

•Schellenberg, J.B., G. Maislin, and R.J. Schwab, Physical findings and the risk for obstructive sleep apnea. The importance of
oropharyngeal structures. Am J Respir Crit Care Med, 2000. 162(2 Pt 1): p. 740-8.
 tonsillar enlargement

tonsillar enlargement (OR = 2.0; 95% CI, 1.0-3.8)

•Schellenberg, J.B., G. Maislin, and R.J. Schwab, Physical findings and the risk for obstructive sleep apnea. The importance of
oropharyngeal structures. Am J Respir Crit Care Med, 2000. 162(2 Pt 1): p. 740-8.
 Notched-edges tongue

Tongue enlargement (OR = 1.8; 95% CI, 1.0-3.1)

•Schellenberg, J.B., G. Maislin, and R.J. Schwab, Physical findings and the risk for obstructive sleep apnea. The importance of
oropharyngeal structures. Am J Respir Crit Care Med, 2000. 162(2 Pt 1): p. 740-8.
 Overjet

•Schellenberg, J.B., G. Maislin, and R.J. Schwab, Physical findings and the risk for obstructive sleep apnea. The importance of
oropharyngeal structures. Am J Respir Crit Care Med, 2000. 162(2 Pt 1): p. 740-8.
 Micrognathia

•Schellenberg, J.B., G. Maislin, and R.J. Schwab, Physical findings and the risk for obstructive sleep apnea. The importance of
oropharyngeal structures. Am J Respir Crit Care Med, 2000. 162(2 Pt 1): p. 740-8.
 Neck size > 17 in

•Schellenberg, J.B., G. Maislin, and R.J. Schwab, Physical findings and the risk for obstructive sleep apnea. The importance of
oropharyngeal structures. Am J Respir Crit Care Med, 2000. 162(2 Pt 1): p. 740-8.
Mallampati
Nasal turbinates
 Treatment
1. Weight loss
2. Avoidance of alcohol and sedatives
3. Underlying etiology
4. Continuous Positive Pressure Ventilation
5. Surgery
6. Dental appliances
 Treatment (CPAP)

Hypopharyngeal Retropalatal
Retroglossal
CPAP Treatment
Thickening of Lateral Pharyngeal Walls in Patient with
Sleep Apnea

Schwab, R.J., et al., Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing. Significance of
the lateral pharyngeal walls. Am J Respir Crit Care Med, 1995. 152(5 Pt 1): p. 1673-89.
Thickening of Lateral Pharyngeal Walls in
Patient with Sleep Apnea

Schwab, R.J., et al., Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing. Significance of
the lateral pharyngeal walls. Am J Respir Crit Care Med, 1995. 152(5 Pt 1): p. 1673-89.
CPAP Treatment
 Treatment (CPAP)

Nasal Pillows Nasal Mask Full Face Mask

 Treatment (CPAP)
Medicare Coverage:

1.Coverage of CPAP is initially limited to a 12 week period for beneficiaries

diagnosed with OSA

2.CPAP for adults is covered when diagnosed using a clinical evaluation and a
positive polysomnography (PSG) performed in a sleep laboratory;

3.A positive test for OSA is established if either of the following criterion using the
Apnea-Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) are met:

•AHI or RDI greater than or equal to 15 events per hour, or

•AHI or RDI greater than or equal to 5 and less than or equal to 14 events per
hour with documented symptoms of excessive daytime sleepiness, impaired
cognition, mood disorders or insomnia, or documented hypertension,
ischemic heart disease, or history of stroke.
Normal Hypnogram
OSA Hypnogram
OSA Hypnogram
Treatment (CPAP)
Treatment (CPAP)
CPAP Troubleshooting
 CPAP Troubleshooting

1. Pressure intolerance
2. Mask discomfort
3. Excessive leak
4. Dry nose and mouth
5. Insomnia
6. Excessive daytime sleepiness
despite adequate use
7. Noise
 CPAP Troubleshooting

1. Expiratory pressure relief

2. Bi-level ventilation
3. Ramp
4. CPAP desensitization sessions
5. Proper mask fitting
6. Nasal steroids
7. Heated humidification
8. Re-titration
9. Stimulant medication
 Treatment (Surgery)

Hypopharyngeal Retropalatal
Retroglossal
 Treatment (Surgery)

Tonsillectomy and adenoidectomy

 Treatment (Surgery)

Uvulopalatopharyngoplasty
 Treatment (Surgery)

Maxillary – Mandibular advancement surgery

 Treatment (Dental appliances)

Mild OSA
Snoring
Questions?
Thank You