Sleep Apnea

We will be talking today about a disease that youll frequently face, and in
many times you will be the 1
st
persion to detect this disease , and if you
suspect a patient of yours having this problem its an ethical and legals
obligation that you refer him to a specialist to deal with this problem and
treat it , well , we will be talking about sleep apnea syndromes , and Ill let
you know why Im saying that you are very important part in detecting and
treating this disease .

In USA , they created American academy of dental sleep medicine
,because the importance of the dentist in the management with this disease .
You can look for AADSM and find useful information for you as a dentist
A small preview about whats sleep , and abnormalities that can occur in
sleep :
We usually sleep 1/3 of the night , ~ 8 hours , this the time required for an
adult to get a refresh sleep , so that he will not be sleepy or hypoactive or
having some concentration problems in the next day . However, some
people sleep less , some people sleep more .
When we sleep we go into stages, its not a uniform process ( light
superficial sleep and deep sleep ) .

Light sleep: occupies almost 75% - 85% of the sleep time. Collectively, we
call it Non REM sleep . But theres another stage we call it REM sleep, and
this is a distinct sleep stage , because during this stage we have ( in the
normal people ) complete muscle paralysis , but we have intense mental
activity . This is the stage we have dreams in, and this occupies almost of
the night.


The non REM sleep which occupies the rest of the night, we have stage 1
and stage 2 , the light sleep , the deep sleep or the delta sleep , we used to
call it (stage 3& 4) but now we in the new calcification they call it stage 3
,they added stage 4 to stage 3 because theres no clinical difference between
the two stages .

The function of each these 3 stages is very important :
* The light sleep facilitates you in the transition between sleep and
awakeness .
The deep sleep is the sleep which restore your body activities
The REM sleep , is responsible for rearranging your mental files in your
brain , so that you will have good mental activity in the next day .

Usually we need 7-10 mins in sleep , some people need longer ( normally ,
up to half an hour ) , but if you take more than 30 minutes, you usually
have a problem with sleep we call it insomnia , and this may be a
symptom of a sleep disorder , we usually inter the Non REM sleep and
then we go into the REM sleep , the REM periods occur initially for short
periods in the night , and at the end of the night ( at Down ), we usually
have the longest REM period which can be( 1-1.5) hours, thats why you
notice most of the dreams come at the end of the night , thats why you
may remember some of your dreams , and the REM and Non REM sleep
alternate during the night .








We call it sleep Histogram or hypnogram , people go from a weight
stage to light stages .

REM sleep , periods initially shorter but starts to be more prolonged by the
end of the night .
To study sleep we have something called sleep study , we do it in
the sleep lab , similar to any graphic study that we do for heart,
muscles and eyes. Its a collective of them , this is very important for
you to know , that the polysomnogram is none all of the night , when
the patient enters sleep lab , we give him 1-2 hours in order to take
the environment after that we
get him to sleep .
we connect 2 or 4 leeds for
EEG in cephalogram ,
occulograms leads for the
occulogram to detect the eye
movements , we put also
EMG on the chin for the chin
muscle to detect the muscle
activity .
we usually monitor Pulse
oximetry, cardiac rhythm by
EKG , and this will give us an
idea about the sleep stages .

Every night has different histogram and every person have different
histogram


But to detect the breathing disorders that occurs during the sleep and
this is the most important thing we need something to detect the
airflow, so we have nasal and oral detectors, to detect the flow of the
air and we have plethysmographs, (something like a band we put it
on the chest and abdomen to detect the chest and abdominal
movements.)
Some sleep labs , as the one we have in hospital have more
sophistications , we can have video monitoring for the patient to
detect which monitor he is sleeping in ( sopine , left side or right side)
and we have audio recording for the snoring .

Any patient we make sleep study we shold stop hypnotics at least 2 weeks
because this will affect sleep stages

Sleep Apnea
What we care about is the
upper airway , if its open
or not .
normal subject for normal
MRI for his upper airway ,
the opening is wide .
and this is a comic that
compares between the
blocked airways which is
the main pathology in obstructive sleep apnea .
In the past they used to study obstructive sleep apnea by during MRI during
sleep .


Apnea: :
cessation breathing of (airflow) lasting greater then ten seconds .
"Cessation of breathing that lasts less than 10 secs is not apnea, it
might occur in normal individual"

If the amplitude of the tide is going down this is a Hypopnea , but to be
significant , this amplitude has to be decreased by 50% , or if its not
decreased by 50 % , to be associated with a decrease in the oxygen
saturation by about 3% .
Reduction in the amplitude of breathing flow >50% Or < 50% Reduction of
flow + 3% Reduction in SpO2 ]
e all can have apneas and hypopnea during their sleep , but the number of
these apneas is the most important factor , if you have less than 5 apnea or
hypopnea per hour , this is normal , and we do not consider any problem.
But if you have more that 5 apneas , then you have sleep apnea syndrome ,

We divide sleep apnea to :
Obstructive and Central
Obstructive apnea ( we dentist deal mostly with this )
Cessation of airflow by the nose & mouth despite continuous respiratory
effort.
The problem is in upper airway , the brain is functioning well , thers no
problem , the CNS has no problems , it is ( CNS ) giving signals fro the Chest
and abdominals muscles to move , but the airways are blocked , chest and
abdominals will keep moving and actually this movement may be sometimes
vigorous , if the obstructions prolonged .


Central apnea ( due to medical disorder as heart faitlure , strokes ,
neurological problems)
Cessation of airflow @ the nose & mouth with no respiratory effort .
everything is not working , the abdominal movenet are relaxed , no chest
wall movement , no air flow .

Mixed apnea:
starts as central apnea followed by an obstructive apnea or the opposite

Mallampati Score :
This is something you will face because your life is facing this picture , you
ll keep facing the patients opening their mouth , and theres a score , we call it
mallampati score, they use it in anesthesia ,to know how to incubate patients.
But they found that this mallampati score is also associated with the risk for
obstructive sleep apnea, and since youre the person who tell people to open
their mouth , so that you will deal with their teeth , you will have the chance
to detect people who may have higher risk for obstructive sleep apnea .



So in class 1 , mallampati score, the whole tonsils are visible , the soft and hard
palate are seen and you see the tonsils
In class 2 , half of the tonsils are seen
Class 3 , you cannot see the tonsils but you see the hard and soft palate and you
see the uvula
Class 4 , part of the hard palate is seen
And whenever you see class 3 and class 4 , you may ask the patient few
questions and if hes fitting the profile for obstructive apnea , you need to
refer him to a specialist . (( Refer to the picture above ))

A student asked a question : the problem is that we see the hard palate , not
when see the tonsils ??
Answer : No , the thing that , people who obstructive sleep apnea have low
palate , the lower the palate the opening is smaller , so will not be
seeing the tonsils , so if you ask him to open his mouth you can see the
hard palate obstructing the view, so when you open the mouth and you
tell the patient you use a tongue depressor to depress his tongue and you
cannot see the tonsils ( you can see only the hard palate ) , this is a severe
mallampati score .

Those who are going to maxillofacial surgery also this score is very important
to them when they are dealing to there patients .

Obesity is strongly correlated with obstructive
sleep apnea. However, they found that some
people who are not obese may have
obstructive sleep apnea , about 10-15% of
patients of obstructive sleep apnea are not
obese . However, obesity and other anatomical
abnormalities play an important role if the
patient is predisposed to obstructive sleep
apnea, there are some functional abnormalities
that people with obstructive sleep apnea who die and you do autopsy for the
pharyngeal muscle, you will not have any histological problems. However,
they function in an abnormal way , they collapse quickly , they relax quickly
and they predispose the airway to be closed .

When we sleep , all our
muscles relax , so if you look
at the diameter of the upper
air way , normally , the
dilator pharyngeal muscle
keeps the upper airway
open , will also relax , and
the diameter will be narrow
. However , we dont need
much oxygen during sleep ,
so this diameter as adequate for our activities during sleep . However, people
who have obstructive sleep apnea this excessive relaxation whether its
aggravated by anatomical abnormalities or not , will lead to a critical narrow ,
this will make the patient snore . so patients usually they snore , and with the
proverition of this explosure the air way is completely closed , so the patient
will have apnea , the patient will not suffocate .
There is a strong association
between Mallampati score &
obstructive sleep apnea .. but
this doesn't mean that all
patients who scored 4 in this
system have obstructive sleep
apnea ,, they just have higher
risk than patients who scored 1
or 2.

Patients with obstructive sleep apnea do not dying during sleep , unless they
have some other problems .
A student asked a question ,but unfortunately I didnt hear !
Answer : The problem is not in the bronchi , the problem is in the upper airway
, in the pharynx .
When the apnea happens , God created a mechanism in your brain that causes
something we call it arousal , this arousal is restoration of EEG that you have
during awakening , and your brain will stimulate the muscle to contract again
and open the upper airway ,and the apnea will be terminated , but this arousal(
in most people ) will not reach the level of complete awakening , however some
people complain that they have awakening , so the cycle will be repeated , and
according to the severity of the disorder, this will be repeated according to the
number of times that the patient is having this phenomena .
Now , this is if the patient is not under the effect of anything that suppresses
the brain activity , so its dangerous to
people who are having obstructive
sleep apnea , or suspected to have
obstructive sleep apnea to be under the
effect of alcohol , drugs , narcotics ,
anesthetics and any CNS depressants .
Certain anatomical abnormalities are
associated with obstructive sleep apnea
here are examples of them :
1- Nasal problems like people who
have allergic rhinitis with
hypertrophy of the nasal mucosa
, they can have similar picture ,
presence of nasal polyps ,
deviated nasal septum .

2- in the children , the most common cause of obstructive sleep apnea is
tonsilar hypertrophy , and those kids when you do adeonotonsilectomy
most of them you cure them from obstructive sleep apnea .
3- If you have hypertrophy of any structure in the upper airway, nasal soft
palate , uvula .
4- facial malformations : as micrognathia .
5- the whole anatomy is distorted as acromegaly patiens : they have large
tongue , large structures that may cause narrowing of the airway . also ,
marphans syndrome. Down syndrome also well known to have
obstructive sleep apnea.
Neurological disorders that are associated with obstructive sleep
apnea , Parkinson disease , muscular dystrophy , strokes , motor
neuron disease, poliomyelitis, parkinsonism .
6- endocrine abnormalities: Acromegaly, hypothyroidism


This patient is having a massive uvula as
shown in the picture :
When uvula is large it can obstruct the
airway during sleep .



Massive tonsils , we see it in children more
than old people, sometimes due to recurrent
tonsillitis . ( kissing tonsils )
This is taken when the patient is awake
(small space) , you can imagine what space
will be left when he is asleep !
(very small )


People with acromegaly or other causes of macroglossia , you see the intents of
the teeth over the edges of the
tongue .
A patient may come to a doctor
has some specific presentation
like EDS (excessive daytime
sleepiness), snoring and
witnessed apnea , on the other
side, he may came with many
non-specific presentation :
1- morning headache
2- 2-cannot control his blood
pressure
3- depression
4- Anxiety
5- tempermental behavior ) )
6- poor job performance
7- impotence(sexual problems )
8- mouth breathing .


Sleep deprivation is the most common cause of excessive daytime sleepiness.
This tongue is enlarged & the
irregular surfaches at both
sides represent the teeth
markings
[[Teeth marks on tongue ]]
mean macroglossia ]]

Some patients have medical disorders that prevent them from sleep as cancer
patients , toothache patients , sleep derivation from any source medical
disorder , neurologic disorder , life style problem they all have EDS .

Many scales to assess the degree of sleepiness (severity ) , the most common
one is Epworth sleepiness scale .

* One of the most important things that are not included in the reports or
the sleeping skills reports or may be Included indirectly is to ask the
patient whom you suspect has excessive sleepiness or obstructive sleep
apnea that if he\she has ever slept while driving and had a car accident.
Maybe they dont check here in Jordan but in the US you are not allowed
to drive if you have obstructive sleep apnea, even if you havent caused
an accident, as well as epileptics until you get well after detected
S Si it tu ua at ti io on n C Ch ha an nc ce e O Of f D Do oz zi in ng g
-Sitting and reading
-Watching TV
-Sitting inactive in a public place (e.g a theater or a
meeting)
-As a passenger in a car for an hour without a
break
-Lying down to rest in the afternoon when
circumstances permit
-Sitting and talking to someone
-Sitting quietly after a lunch without alcohol
-In a car, while stopped for a few minutes in traffic

0 = no chance of
dozing
1 = slight chance
of dozing
2 = moderate
chance of dozing
3 = high chance
of dozing

examinations (epileptics 3-5 years), (obstructive sleep apnea maybe 1
month).
There was a magazine called (AL-Arabi) that had a topic titled laugh
and the world laughs with you which mentioned that for the people
who got obstructive sleep apnea (snore and you sleep alone) :S were
involved in many divorce cases due to the snoring .
In children: the prognosis is similar but instead of having hypoactivity and
sleepiness they will be in a state of hyperactive attention, nocturnal
enuresis (bed wetting), they will have nightmares and night terrors etc.

* Obstructive sleep apnea incidence:
- adults > children (>40 years) apart of children have adenotonsillectomy .
- males (4%) > females (2%)
- obese (high risk)

Plysomnogram:
We account for the number of apnea per night, so if the patient slept for 6
hours wed take the number of apnea and then divided that
by 6 to get the number of apnea or
hypopnea per hour (Apnea/Hypopnea
Index (AHI) ) or (Respiratory Disturbance
Index (RDI) ) so both AHI or RDI have the
same meaning which is the # of apnea
hypopnea per hour. There are some differences but they arent important.


Some theories suggest that
OSA in elderly should be
diagnosed when Apnea-
hypopnea index is more than 6.


Apnea Hypopnea Index (AHI):
Normal: less than 5 events per hour
Mild: 5-15 events per hour
Moderate: 16-30 events per hour
Moderately Severe: 31-39 events per hour
Severe: over 40 events per hour


The most significant amount for severe cases is between 50s and 60s.

Q/ why do we care about the apnea and obstructive sleep apnea and their
numbers when they dont cause death?
A/ people with OSA have higher mortality rate (so the severity is directly
proportional to the mortality rate)

-as you can see in the figure above the blue line (squares) represents the
amount of apnea/hypopnea that is lower than 20 which is less morality in
comparison to the red line (triangles) which is higher than 20.



*the mortality usually occurs due to 2 reasons:
1- road traffic accidents (sleep) but now its decreased.
2- Cardiovascular events (strokes): the patients with obstructive sleep
apnea will get with the apnea hypoxemia, reoxygenation, temporally
hypercapnia, intrathoracic pressure changes because of vigorous breathing
and the arousals of the brain.
All these primary mechanisms will stimulate intermediary mechanisms
(all sympathetic pathways, coagulation, endothelial function, inflammatory
pathways, cytokines and insulin) and all of these will stimulate and will
lead to cardiovascular diseases.

Cardiovascular disease include cardiac arrhythmias, hypertension, heart
failure, coronary artery disease, cardiac ischemia, more myocardial
infarction(MI) or heart attacks , strokes and pulmonary hypertension (not
mentioned in the slide) which will lead to the right side heart failure.
(see slide #33)
If we get a patient with no obstructive sleep apnea and we admit him
into the sleep lab and we recorded snoring and we checked the breathing
flow which was normal and everything else was normal except that he was
only snoring it will be fine, as to no indications of a sleeping problem.

In patients with central sleep apnea:
1- breathing flow is absent 3- the chest not moving
2- the abdomen is not moving as well. what we see there is just peristalsis.
In central apnea: no airflow, no chest & abdominal effort
The small waves in this abdominal plethysmograph are artifacts caused
by intestinal movement..



Q/someone asked about the duration of apnea?
A/ Dr. answered: it should be at least 10secs no less if its less we dont
consider it as an apnea or hypopnea.

In the obstructive sleep apnea there isnt any flow. However there is
movement but its abnormal (the patient tries his best to move the chest and the
abdomen walls but the effort is not consistent).

Treatment of OSA:
CNonsurgical Reaction :
OWeight Loss: 80-85% are obese , it has been documented in multiple
studies that weight loss will result in decreasing the apnea\hypopnea
index , and we have to targets in treatment of obstructive sleep apnea :
A- Decrease the apnea\hypopnea index , (immediate target).
B- Turn the index to normal .
Weight loss has been documented in multiple studies to decrease
apnea\hypopnea index so , Decrease the risk from obstructive sleep apnea.
The aim of Treatment is to reduce Apnea-hypopnea index as mortality &
morbidity of obstructive sleep apnea are associated with high index..
In obstructive sleep apnea: Minimal or very low airflow, chest &
abdominal efforts are present despite being irregular..




As u can see in the graph below, by losing weight some pts have resolved
completely & other pts improved & got a lower Apnea hypopnea index.
Gastric bypass surgery for Patients who failed to lose weight by diet
resulted in significant decrease in body mass index and Apnea-hypopnea
index, so they advice anybody who is extremely obese and failing weight
reduction by diet to having obstructive sleep apnea .

O nCPAP (nasal Continuous Positive Airway
Pressure)
very beneficial for those who can't lose weight.
by dietary measures & are not candidates for
gastric bypass surgery.
CPAP works as a pneumatic splint & keeps
the airway open during sleep .

0
20
40
60
80
100
120
140
pre wt loss post wt loss
D
B
E
/

h
r

T
S
T



Components:
PAP machine (provides the airflow) & is
connected by a hose to the interface
The Interface: nasal or full face mask (oro-nasal)
or nasal pillows, provides the connection to the
user's airway..

Side Effects
You have to know that this mask is not without side effects, it
may cause severe problems as fracture in nasal bridge or simulitis in
the face , acne in the face . However , The most common problem is
difficulty in tolerating forced air.
nCPAP gives continuous pressure of the same level during
inspiration & expiration; When the patient inspires air that would be
in the same direction of CPAP pressure, but when he expires air it
would be against the machine pressure .
To overcome this problem:
Ramp feature was added to the machine. This feature allows
patients to start with low air pressure, followed by an automatic,
gradual increase in the pressure to the patients' prescribed setting as
they fall asleep.
The pressure is detected by a sleep study , we make polysomnogram
with CPAP treatment to know what pressure needed to eliminate the
apnea , CPAP titration study , we make it after diagnosis .



Some patients suffer from obesity , sever snoring ,witness apnea and
hypertension , you should not make polysomnogram at one night ,
and the sleep titration study at another night . you should make Split
night study .In the 1
st
third of the night you polysomnogram (
without CPAP ) , then I wake him up , put the CPAP .

O Positional changes:
Some patients cant tolerate CPAP, we can advice them
positional changes if the sleep study suggest that most of the apneas
occur in the sopine position , theses patients have to sleep at the right
or left side , HOW ??
The tennis ball trick: by attaching a tennis ball to the back of a
pajama top, patient can sew a sock to the back of the pajama top,
&put a tennis ball in it. The tennis ball is uncomfortable when patient
lies on his back, and he will respond by turning on his side

In most patients sleep apnea increases in supine position,, that's
why some patients benefit from sleeping on their sides

OOrthodontic appliances: (Patients fail in nasal CPAP , or cannot
tolerate CPAP)
Tongue equalizer & Tongue retaining devices , (performed by
dentists) , mandibular repositioning devices .
but they are only effective in mild & moderate cases..

O Nasopharyngeal Tube


C Surgical Rx: ( from slides )
1) Uvulopalatopharyngoplasty (UPPP)
2) Tracheostomy ( final option ) we should not use it unless we
were in the emergency ( breathlessness ) because it has many
complications .
3) Mandibular Advancement
4) Hyoid bone suspension
5) Tonsillectomy & adenoidectomy
6) Thyroidectomy
7) Nasal septal deviation repair
8) Genio-Glossus Advancement
9) Somnoplasty


Pre Surgical Warning:
OSA pts shouldn't undergo operations that
needs general anesthesia but if they have to like
if a pt. has appendicitis & has to do
appendectomy urgently.. he must tell his dr. that
he has OSA.. why? The critical period here is
the post-operative period because the patient is
still under the effect of anesthesia that's why
the endotracheal tube shouldn't be removed
after operation or it should be replaced by nasal
CPAP until hes fully awake .
We prefer not to remove the tube .

For more information visit arabicmedical.net & read the essay
of "sleep Apnea" by Dr. Sulaiman Almomany.

Done by : Majd M. Hidmi & Mohammed Al-Esayi
Forgot us for any mistake , Good luck
WARNING
OSA pts must Avoid
Alcohol or any other CNS
depressants (valium ,
diazepam , lorazepam,
hypnotics, anxiolytics,
etc..) within 4 to 6 hours
of sleep.
because these drugs
abolish the protective
arousals leading to
persistent hypoxia which
insults the brain in a way
similar to multi-infarct
dementia , strokes , brain
ischemia .