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Sleep Disorders from Pediatrics
to Geriatrics
Sandra R. Coulson
MS, ST, Ed, COM
WAKE UP,
SNORING IS
DANGEROUS!
SLEEP DISORDERS…
• Insomnia: 32 million (unreliable estimate)
• Sleep Apnea: estimated 18 million Americans
(NHLBI)
• Obst...
Obstructive Sleep Apnea…
A Common Problem:
• Estimated prevalence: 40 MILLION Americans
who are undiagnosed (1 in 6)
• 50-...
CENTRAL SLEEP APNEA…
• The sleeper whose problem is central sleep
apnea periodically does not breathe at all, or
breathes ...
Risk Factors…
• Male gender
• Age
• Obesity
• Neck Circumference > 17.5 inches in men
16 inches in women
• Smoking
• Crani...
Risk Factors…
• High blood pressure.
• High blood pressure in lungs.
• Abnormal heart rhythm, heart
failure, coronary arte...
Symptoms of OSA in Children…
Restless Sleep
Headaches
Obesity
Large Tonsils
Noisy Breathing
Allergic Shiners
 Runny...
Symptoms of Sleep Apnea in Adults
and Children…

Daytime Symptoms:
• Excessive Daytime Sleepiness
• Depression / Anxiety /...
Symptoms of Sleep Apnea in Adults
and Children…
Nighttime Symptoms:
• Snoring
• Witnessed Breathing Pauses
• Frequent Awak...
Screening
Questionnaire…
•
•
•
•
•

Do you snore?
Are you sleepy during the daytime?
Do you have headaches or sore throats...
Is It a COLD or an ALLERGY?
• Cold:
• Runny nose and sneezing last 1-3 days; if cold symptoms persist for more
than a week...
• Allergy:
• Persistent watering of nose and eyes lasts anywhere from a few
weeks to several months, depending on the alle...
We Cannot See Adenoids and Septums
But We CAN See Tonsils and Tongues

Large Adenoids

Deviated Septum

Large tonsils

Wid...
Medical Conditions /Sinusitis…
•
•
•
•

Diabetes
Gastro esophageal reflux disease
Nasal polyps or septal deviation
Disorde...
Sleep Disorders Can
Cause Other Serious
Diseases:
DISEASES…
Type II Diabetes
• Almost 50% of type 2 diabetes patients have sleep
apnea;1 among obese type 2 diabetes patient...
Anyone you know???
The reason it is called “SleepDisordered Breathing…

Daytime…

Nighttime
If you suspect Sleep Apnea…

What do you look for?
Determine Etiological Factors which would
prevent the success of a therapy program
BY BEING PART OF A team!
1. Deviated Se...
Questions…
• Neck Size
• Morning headaches?
• Impaired memory/intellectual
performance
• Restless sleep?
• Nocturia? (Bedw...
Examine the Throat…
Medical History…

• Snores at night/naps
• Throat infections
• Ear infections
• Stops breathing
• Has halitosis
ALLERGIC SHINERS…
Long Uvula, Large Tongue=
Obstruction…
Neck Size…
Medical problems associated with
SLEEP DISORDERD BREATHING…
•
•
•
•
•
•
•
•
•

Obesity
Excessive sleepiness
Depression
Hyp...
CARDIOVASCULAR
LINKS…
• 5.7 million people in the US have heart failure
{American Heart Association Statistics}
• 76% of H...
Mortality Links…

• SDB is associated with a 3-fold
increase in mortality risk
• Severe sleep apnea raises
premature death...
Mood Disorder and Apnea…
• 54.1% of Bipolar patients were found to
be at risk for OSA
• Sleep apnea associated with major ...
Restless Legs Syndrome and
Periodic Limb Movements…
• Periodic Leg Movements (PLMD)
• Restless Legs Syndrome (RLS)
Movemen...
Cardiovascular Risk and RLS…
• 2 times greater risk of heart and
cardiovascular disease
• Women with RLS for 3 years are a...
Are pregnant women at
risk for sleep apnea?
Potential risk factors for SDB in pregnancy:
•
•
•
•
•
•

Nasal congestion and...
Consequences of Apnea for
Pregnant Women…
• Pregnancy associated with lower residual
volume and lower functional residual
...
Preeclampsia…

PEC is an important cause of:
•
•
•
•
•

Infant prematurity
Neonatal morbidity
Maternal morbidity and morta...
Consequences of Apnea on Fetus:
• Concern for fetal wellbeing with recurrent
desaturations and possible hypoventilation
(D...
Gestational Diabetes…
Diabetes occurring during pregnancy
• 30-50% of women with GDM end up
developing DM later in life
• ...
Reflux - Another Issue…
• In a study presented at the 70th Annual
Scientific Meeting of the American College of
Gastroente...
Is this a chicken or an egg?
Childhood Obstructive Sleep Apnea

OSA
Airway Examination
• CT Scan
• Lateral Cephalometric Exam
When you see…
• A Narrow, under-developed maxillary arch
Grade 4 Tonsils…
• If the tonsils are not treated or
removed, it is certain to be an
Orthodontic nightmare and a
total relapse case.
Short Lingual Frenulum…
Tongue Thrust = Abnormal
Swallow…

Anterior Bite Closed But needs
•Sleep Studies…
Looks like fun!!!
• Are they accurate?
Sleep Study…
•
•
•
•

Typical result…
Time in bed: 9 hours 47 minutes
Time asleep: 6 hours 46 minutes
AWAKE: 3 hours due t...
Treatment

Modalities
Tonsillectomy/Adenoidectomy…
• Chronic or recurrent tonsil infections—Tonsillectomy
may reduce the number, but will not co...
Uvulopalatopharyngoplasty…
Laser-Assisted Uvulopalatoplasty…
• Conservative resection and re-contouring of
the soft palate and uvula
• Outpatient pro...
Somnoplasty…
• Radio-frequency generator is used to cause
internal scarring and shrinkage of the soft
palate and uvula
• L...
Uvulopalatopharyngoplasty…

Success: Low
Maxillofacial SURGERY…
• Inferior Sagittal Osteotomy with HYOID
suspension
• Ramus osteotomy
• Mandibular sub apical osteo...
Devices…
•
•
•
•

Mandibular Repositioners
Tongue Controllers
Nasal/Intra-oral Positive Pressure Devices
Drugstore Applian...
Issues with Medications…
• Benzodiazepines, hypnotics, narcotics
may relax the airway more in patients
who have sleep apne...
A GREAT TEAM…
Dentist
Orthodontist
Pediatric Dentist
Pediatrician
Physician
Breathing Specialist
Osteopath
Cranio-Sachral ...
CPAP…
• CPAP is still considered the
“Gold Standard” by most physicians.

Compliance: Low
Myofunctional Therapy with
a TEAM APPROACH


Helps to minimize snoring by training the
tongue to rest in a normal posture...
APP for Patient’s Monitoring
Their OWN Snoring…

SNORELAB.COM
for IPHONES

Snoreclock.com
for DROIDS
SNORELAB.COM…
• This woman snored so loudly that her whole
family wore ear plugs to sleep!
• She started the exercise prog...
One Week after Starting therapy…

exercises
FACIAL SHAPE CHANGES…
PROFILE CHANGE…
He Stopped Snoring within one week
Airway Examination…
• CT Scan
• Lateral Cephalometric Head Film
Summary…
• Successful treatment of snoring and
sleep apnea is totally dependent
upon an accurate diagnosis of the
region o...
Sleep…
“[Sleep is] the golden chain that ties
health and our bodies together.”
Thomas Dekker (1572-1632)
Sandy Coulson Sleep Disorder Spreecast
Sandy Coulson Sleep Disorder Spreecast
Sandy Coulson Sleep Disorder Spreecast
Sandy Coulson Sleep Disorder Spreecast
Sandy Coulson Sleep Disorder Spreecast
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Sandy Coulson Sleep Disorder Spreecast

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Sandra Coulson, COM, discusses the etiology of sleep disordered breathing.

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Transcript of "Sandy Coulson Sleep Disorder Spreecast"

  1. 1. Sleep Disorders from Pediatrics to Geriatrics Sandra R. Coulson MS, ST, Ed, COM
  2. 2. WAKE UP, SNORING IS DANGEROUS!
  3. 3. SLEEP DISORDERS… • Insomnia: 32 million (unreliable estimate) • Sleep Apnea: estimated 18 million Americans (NHLBI) • Obstructive sleep apnea: 12 million Americans Narcolepsy: 200,000 Americans (NHLBI estimate); 50,000 diagnosed. • Chronic Fatigue Syndrome: 500,000 Americans (CDC/NIAID) • 2011 Health Grades Inc.
  4. 4. Obstructive Sleep Apnea… A Common Problem: • Estimated prevalence: 40 MILLION Americans who are undiagnosed (1 in 6) • 50-90% diagnosed are referred for a sleep evaluation. Most do not follow through. Myers et al, JAMA, 2013
  5. 5. CENTRAL SLEEP APNEA… • The sleeper whose problem is central sleep apnea periodically does not breathe at all, or breathes so shallowly that oxygen intake is ineffectual. The brain just seems to shut down. In either type of sleep apnea, obstructive or CENTRAL, the lack of oxygen usually causes the patient to wake, at least briefly. (Hypopneas)
  6. 6. Risk Factors… • Male gender • Age • Obesity • Neck Circumference > 17.5 inches in men 16 inches in women • Smoking • Craniofacial structures • Smoking • Family History
  7. 7. Risk Factors… • High blood pressure. • High blood pressure in lungs. • Abnormal heart rhythm, heart failure, coronary artery disease (CAD), or stroke. • Depression. • Diabetes.
  8. 8. Symptoms of OSA in Children… Restless Sleep Headaches Obesity Large Tonsils Noisy Breathing Allergic Shiners  Runny Nose Frequent Upper Airway Infections Earaches Bedwetting
  9. 9. Symptoms of Sleep Apnea in Adults and Children… Daytime Symptoms: • Excessive Daytime Sleepiness • Depression / Anxiety / ADHD • Morning Headache • Dry, Irritated Throat & Raspy Voice • Social and Workplace Issues • Short Attention Span, Hot Temper, Impulsive, Memory Problems
  10. 10. Symptoms of Sleep Apnea in Adults and Children… Nighttime Symptoms: • Snoring • Witnessed Breathing Pauses • Frequent Awakenings • Frequent episodes of Bedwetting • Insomnia
  11. 11. Screening Questionnaire… • • • • • Do you snore? Are you sleepy during the daytime? Do you have headaches or sore throats in the AM? Has anyone witnessed apneas or respiratory gasps? Do you not get ‘enough sleep’ despite adequate time in bed? • If they answer any affirmatively, use the “EPWORTH SLEEPINESS SCALE” TO ASSES SEVERITY. We give this to everyone!
  12. 12. Is It a COLD or an ALLERGY? • Cold: • Runny nose and sneezing last 1-3 days; if cold symptoms persist for more than a week, see a doctor - you may have complications such • as bronchitis or sinusitis • • Sore throat and / or coughing • • General malaise -fever, muscle aches, chills, sweats, loss of appetite, fatigue -which indicate an infection • • Burning sensation in nose, often accompanied by nasal/sinus tenderness • • Mucus can become yellow, green, thick, foul-smelling or bloody
  13. 13. • Allergy: • Persistent watering of nose and eyes lasts anywhere from a few weeks to several months, depending on the allergen • Itchiness of the nose, eyes and roof of the mouth or back of throat • General feeling of well-being, except for areas experiencing allergic symptoms; appetite usually is not diminished • In most cases, sinuses are not painful or tender • Mucus is watery and clear
  14. 14. We Cannot See Adenoids and Septums But We CAN See Tonsils and Tongues Large Adenoids Deviated Septum Large tonsils Wide tongue/Long Uvula
  15. 15. Medical Conditions /Sinusitis… • • • • Diabetes Gastro esophageal reflux disease Nasal polyps or septal deviation Disorders of the immune system (fungal infections are especially risky) • Oral or intravenous steroid treatment • Hypothyroidism -- causes congestion that often clears up when the condition is treated • Cystic fibrosis -- a genetic disorder in which the mucus is very thick and builds up
  16. 16. Sleep Disorders Can Cause Other Serious Diseases:
  17. 17. DISEASES… Type II Diabetes • Almost 50% of type 2 diabetes patients have sleep apnea;1 among obese type 2 diabetes patients, the prevalence of sleep apnea has been estimated at 86%. AM J RESPIR CRIT CARE MED.2010 Mar 1;181(5):507-13. doi: 10.1164/rccm.200909-1423OC. Epub 2009 Dec 17. • 76% Congestive Heart Failure Javaheri S. Sleep-related breathing disorders in heart failure. In: Heart Failure, A Companion to Braunwald’s Heart Disease, edited by Douglas L. Mann. WB Saunders, Philadelphia 2010; 471-487 • 70% Stroke/TIA http://sleepdisorders.about.com/od/sleepandgeneralhealth/f/Sleep_Apnea_Stroke_Risk.htm Mar 4, 2013 ...
  18. 18. Anyone you know???
  19. 19. The reason it is called “SleepDisordered Breathing… Daytime… Nighttime
  20. 20. If you suspect Sleep Apnea… What do you look for?
  21. 21. Determine Etiological Factors which would prevent the success of a therapy program BY BEING PART OF A team! 1. Deviated Septum 2. Enlarged Turbinates 3. Polyps 4. Enlarged Adenoids and / or Tonsils 5. Allergic Rhinitis and / or Sinusitis 6. Vaulted -Narrow Palatal Arch Formation REFER! Ask Questions
  22. 22. Questions… • Neck Size • Morning headaches? • Impaired memory/intellectual performance • Restless sleep? • Nocturia? (Bedwetting)
  23. 23. Examine the Throat…
  24. 24. Medical History… • Snores at night/naps • Throat infections • Ear infections • Stops breathing • Has halitosis
  25. 25. ALLERGIC SHINERS…
  26. 26. Long Uvula, Large Tongue= Obstruction…
  27. 27. Neck Size…
  28. 28. Medical problems associated with SLEEP DISORDERD BREATHING… • • • • • • • • • Obesity Excessive sleepiness Depression Hypertension Cardiovascular disease Diabetes Stroke Cognitive impairment Cerebrovascular disease
  29. 29. CARDIOVASCULAR LINKS… • 5.7 million people in the US have heart failure {American Heart Association Statistics} • 76% of Heart Failure Patients have SDB • Heart Failure is the MOST expensive disorder to treat • Obstructive Sleep Apnea is noted in 49% of atrial fibrillation patients and 30% of cardiovascular patients • OSA presents in 70% of heart attack patients
  30. 30. Mortality Links… • SDB is associated with a 3-fold increase in mortality risk • Severe sleep apnea raises premature death risk by 46%
  31. 31. Mood Disorder and Apnea… • 54.1% of Bipolar patients were found to be at risk for OSA • Sleep apnea associated with major depression (2.4% in men, 5.4% in women) • Treatment of OSA ameliorates symptoms in the short and long term Soreca, Bipolar Disord, 2012 Wheaton, Sleep, 2012 Scjwartz, J Clin Sleep Med, 2007
  32. 32. Restless Legs Syndrome and Periodic Limb Movements… • Periodic Leg Movements (PLMD) • Restless Legs Syndrome (RLS) Movement disorder (Rest increases symptoms) • Sensory Motor Syndrome
  33. 33. Cardiovascular Risk and RLS… • 2 times greater risk of heart and cardiovascular disease • Women with RLS for 3 years are at greater risk for heart disease • Older Men with RLS are 67% times more likely to have a stroke than those without Li,RCircuLlatioSn,2013
  34. 34. Are pregnant women at risk for sleep apnea? Potential risk factors for SDB in pregnancy: • • • • • • Nasal congestion and gestational rhinitis (1) Increased Mallampati scores (2) Reduction in size of upper airway (3,4) Weight gain Reduction in FRC (5) and airway collapsibility (6) Vacuum effect related to increased ventilator drive (7) • • • • • • • 1-Young T. J All Clin Immunol 1997; 99: S757-62. 2- Pilkington S. Br J Anesth 1995; 74:638-42 3- Iczi B. ERJ 2006; 27:321-7 4- Iczi B. AJRCCM 2003; 167:137-40 5- Crapo R. Clin Obstet Gynecol 1995; 39:3-16 6- White DP. AJRCCM 2005; 172:1363-70 7- Edwards N. Thorax 2002; 57:555-8
  35. 35. Consequences of Apnea for Pregnant Women… • Pregnancy associated with lower residual volume and lower functional residual capacity (FRC) • Lower oxygen reserve because of lower FRC and higher oxygen consumption
  36. 36. Preeclampsia… PEC is an important cause of: • • • • • Infant prematurity Neonatal morbidity Maternal morbidity and mortality Maternal ICU admissions Precursor of cardiovascular disease
  37. 37. Consequences of Apnea on Fetus: • Concern for fetal wellbeing with recurrent desaturations and possible hypoventilation (Data from high altitude residents strongly suggests risk of growth restriction and PEC with chronic hypoxia) (Doctors in Denver are very aware of the risks!)
  38. 38. Gestational Diabetes… Diabetes occurring during pregnancy • 30-50% of women with GDM end up developing DM later in life • GDM is cause for infant morbidity • Other complications
  39. 39. Reflux - Another Issue… • In a study presented at the 70th Annual Scientific Meeting of the American College of Gastroenterology, 81 patients with documented sleep complaints at least three nights per week underwent polysomnographic sleep evaluations. 26 percent had acid reflux. Of those who suffered with reflux, 94 percent of the recorded reflux events were associated with arousal from sleep or awakening.
  40. 40. Is this a chicken or an egg?
  41. 41. Childhood Obstructive Sleep Apnea OSA
  42. 42. Airway Examination • CT Scan • Lateral Cephalometric Exam
  43. 43. When you see… • A Narrow, under-developed maxillary arch
  44. 44. Grade 4 Tonsils…
  45. 45. • If the tonsils are not treated or removed, it is certain to be an Orthodontic nightmare and a total relapse case.
  46. 46. Short Lingual Frenulum…
  47. 47. Tongue Thrust = Abnormal Swallow… Anterior Bite Closed But needs
  48. 48. •Sleep Studies…
  49. 49. Looks like fun!!! • Are they accurate?
  50. 50. Sleep Study… • • • • Typical result… Time in bed: 9 hours 47 minutes Time asleep: 6 hours 46 minutes AWAKE: 3 hours due to Arousals ( I did one just to find out what happens. I do not have OSA, but I did not sleep well!)
  51. 51. Treatment Modalities
  52. 52. Tonsillectomy/Adenoidectomy… • Chronic or recurrent tonsil infections—Tonsillectomy may reduce the number, but will not completely eliminate, these infections. • Peri-tonsillar abscess (pocket of infection spreading outside the tonsil) • Enlarged tonsils causing obstruction of the throat • Adenoids blocking the nasal airway
  53. 53. Uvulopalatopharyngoplasty…
  54. 54. Laser-Assisted Uvulopalatoplasty… • Conservative resection and re-contouring of the soft palate and uvula • Outpatient procedure • Low morbidity • Success rate: LOW
  55. 55. Somnoplasty… • Radio-frequency generator is used to cause internal scarring and shrinkage of the soft palate and uvula • Local Anesthetic • Outpatient • Success: LOW
  56. 56. Uvulopalatopharyngoplasty… Success: Low
  57. 57. Maxillofacial SURGERY… • Inferior Sagittal Osteotomy with HYOID suspension • Ramus osteotomy • Mandibular sub apical osteotomy • Maxillary-mandibular advancement • Tracheostomy Success Rate: Moderate…Very Costly…Often not covered by insurance
  58. 58. Devices… • • • • Mandibular Repositioners Tongue Controllers Nasal/Intra-oral Positive Pressure Devices Drugstore Appliances (Doctor’s Snore Guard)
  59. 59. Issues with Medications… • Benzodiazepines, hypnotics, narcotics may relax the airway more in patients who have sleep apnea. • Narcotics can contribute to central sleep apnea.
  60. 60. A GREAT TEAM… Dentist Orthodontist Pediatric Dentist Pediatrician Physician Breathing Specialist Osteopath Cranio-Sachral Therapist Myofunctional Therapist
  61. 61. CPAP… • CPAP is still considered the “Gold Standard” by most physicians. Compliance: Low
  62. 62. Myofunctional Therapy with a TEAM APPROACH  Helps to minimize snoring by training the tongue to rest in a normal posture Changes head and neck posture which opens the airway Allows for better nasal breathing (noses are ‘use them or lose them’) Changes sleep behavior with better sleep rejuvenation Changes facial esthetics CHANGES LIVES!
  63. 63. APP for Patient’s Monitoring Their OWN Snoring… SNORELAB.COM for IPHONES Snoreclock.com for DROIDS
  64. 64. SNORELAB.COM… • This woman snored so loudly that her whole family wore ear plugs to sleep! • She started the exercise program and went to Seattle to care for her elderly mother. • She has sent a “SNORE REPORT” every day!
  65. 65. One Week after Starting therapy… exercises
  66. 66. FACIAL SHAPE CHANGES…
  67. 67. PROFILE CHANGE…
  68. 68. He Stopped Snoring within one week
  69. 69. Airway Examination… • CT Scan • Lateral Cephalometric Head Film
  70. 70. Summary… • Successful treatment of snoring and sleep apnea is totally dependent upon an accurate diagnosis of the region of obstruction and treatment that is directed at the ETIOLOGY!
  71. 71. Sleep… “[Sleep is] the golden chain that ties health and our bodies together.” Thomas Dekker (1572-1632)
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