This document provides an overview of obstructive sleep apnea (OSA). It discusses the definition, signs and symptoms, epidemiology, diagnosis using polysomnography, and treatment options including continuous positive airway pressure therapy and upper airway surgery. The key points are that OSA involves recurrent collapse of the upper airway during sleep, leading to pauses in breathing and oxygen level drops. Diagnosis is via an overnight sleep study, and treatment focuses on eliminating airway obstructions through devices, weight loss, or surgery.

1. พญ.สุภลักษณ์ ตันติทวีโชค
แพทย์ประจำบ้ำนเวชศำสตร์ครอบครัว ชั้นปีที่3
ENT Topic presentation:
Obstructive Sleep Apnea

2.  Obstructive sleep apnea (OSA)
Obstructive sleep apnea-hypopnea (OSAH)
 a sleep disorder that involves cessation or significant decrease in
airflow in the presence of breathing effort.
 most common type of sleep-disordered breathing(SDB)
Obstructive sleep apnea

3. No disease Disease

5. characterized
 recurrent episodes of upper airway collapse during sleep.
 recurrent oxyhemoglobin desaturations
 arousals from sleep
excessive daytime sleepiness (EDS)
* OSA + excessive daytime sleepiness
=obstructive sleep apnea syndrome (OSAS)
=obstructive sleep apnea-hypopnea syndrome (OSAHS)

6. Signs and symptoms
Nocturnal symptoms
Snoring
Witnessed apneas
Gasping and choking
Apneas
Nocturia
Insomnia
Daytime symptoms
Morning headache
Dry / sore throat
Excessive daytime
sleepiness
Daytime fatigue/tiredness
Cognitive deficits
Personality/mood changes
Sexual dysfunction

7. The cardinal symptoms
3 S :
 S noring
 S leepiness
 S ignificant-other report of sleep apnea episodes

8. The clinical presentation of a child with obstructive sleep apnea is
nonspecific and requires increased awareness by the primary care
physician.
OSA symptoms in children can include the following:
Obstructive sleep apnea in children
the typical pediatricOSA patient was one with adenotonsillar hypertrophy
Abnormal breathing during sleep
Frequent awakenings or restlessness
Frequent nightmares
Enuresis
Difficulty awakening
Excessive daytime sleepiness
Hyperactivity/behavior problems
Daytime mouth breathing

9.  Naresh M. Punjabi,et al.The Epidemiology of Adult Obstructive Sleep Apnea. Proc Am Thorac Soc. 2008
Feb 15; 5(2): 136–143. pubmed
3.2%
The prevalence of SDB (AHI > or = 5) was 27% and 16% in men and women
The prevalence of OSAS (AHI > or = 5 + excessive daytime sleepiness) was 4.5% in men and 3.2% in
women

10.  healthy children younger than 8 years, the prevalence of obstructive sleep
apnea is estimated to be 1-3%.
 Habitual snoring is common during childhood and affects approximately
10% of children aged 2-8 years
 the frequency of habitual snoring decreases after age 9-10 years.
 Obesity confers 4-fold to 5-fold added risk for sleep-disordered breathing.
Epidemiology of OSA in children

11.  Most children with obstructive sleep apnea are aged 2-10 years
(coinciding with adenotonsillar lymphatic tissue growth).
 Children with severe obstructive apnea are likely to present
when aged 3-5 years.

12. The etiology of OSA involves
Structural factors
nonstructural factors
Etiology

13. Structural factors related to craniofacial bony anatomy that
predispose to pharyngeal collapse during sleep
 Retrognathia and micrognathia
 Inferior displacement of the hyoid
 Adenotonsillar hypertrophy
 High, arched palate
 Pierre Robin syndrome
 Down syndrome
 Prader-Willi syndrome
Structural factors

14. Retrognathia micrognathia

15. • Micrognathia
• glossoptosis
• Horsehoe-shaped
cleft palate
• Autosomal
dominant
• new (de novo)
genetic changes

18.  Obesity
 Age
 Supine sleep position
 Hypothyroidism
 Stroke
Nonstructural factors

19.  Apnea
 Hypopnea
 Respiratory effort–related arousal (RERA)
Definitions of respiratory events

20. Apnea
defined by the American Academy of Sleep Medicine (AASM) as
 the cessation of airflow for 10 seconds

21. Hypopnea
 a recognizable transient reduction (but not complete
of breathing 10 seconds
 a decrease of greater than 30% in the amplitude of a
measure of breathing,
 or a reduction in amplitude of less than 30%
+with oxygen desaturation of 4% or more

22. Respiratory effort–related arousal (RERA)
 an event characterized by increasing respiratory effort for 10
seconds or longer
 an arousal from sleep but one that does not fulfill the criteria
for a hypopnea or apnea.
 The criterion standard to measure RERAs is esophageal
manometry, as the AASM recommends. but impractical

23.  The overnight polysomnography(PSG) is the standard diagnosis
 It involves simultaneous recordings of multiple physiologic signals
during sleep, including
 Electroencephalogram (EEG)
 Electrooculogram (EOG)
 Electromyogram (EMG)
 Electrocardiogram (ECG)
 oronasal airflow
 oxyhemoglobin saturation.
 chest wall effort
 body position
 snore microphone
Diagnosis
Polysomnogram = gold-standard diagnosis

27.  Apneic episodes occur in the presence of respiratory muscle effort.
 Apneic episodes lasting 10 seconds or longer
 Apneic episodes are most prevalent during REM sleep.
 Patients may have a combination of apneas and hypopneas
 Mixed apneas may occur.
 Sleep disruption due to arousals is usually seen at the termination of an
episode of apnea.
PSG findings characteristic of OSA

28. Polysomnographic Criteria for OSA

29. The AHI is the number apnea and hypopnea of recorded during the
study per hour of sleep.
AHI = ( Apneas + Hypopneas)
the severity of OSA is classified as follows:
 None/Minimal: AHI < 5 per hour
 Mild: AHI ≥ 5, but < 15 per hour
 Moderate: AHI ≥ 15, but < 30 per hour
 Severe: AHI ≥ 30 per hour
Apnea Hypopnea Index (AHI)
Children
Normal AHI< 1 per hour
Very mild AHI 1,< 5 per hour
Mild AHI  5,<10 per hour
Moderate AHI  10,< 20 per hour
Severely AHI  20 per hour

30. the average number of episodes of apnea, hypopnea, and
respiratory event-related arousal per hour of sleep
 RDI = (RERAs + Hypopneas + apneas)
The respiratory disturbance index (RDI)

31. Epworth Sleepiness Scale(ESS)
> 10 = ESD
Score >10 is reported to have
93.5% sensitivity
100% specificity

32. The multiple sleep latency test (MSLT)
• Is tests for excessive daytime sleepiness by measuring how quickly
you fall asleep in a quiet environment during the day.
• Also known as a daytime nap study.

33. Cardiovascular comorbidities
 The most severe cardiovascular consequence of OSA is pulmonary
hypertension, and the resultant cor pulmonale

34. OSA and inflammation
 There is emerging evidence that OSA is a disease with chronic
grade systemic inflammation and increased oxidative stress
likely lead to the end organ morbidities
 Systemically, the pro-inflammatory cytokines, TNF-α, IL-6, IL-8
and C-reactive protein have been found to be elevated in the
serum of OSA patients.
 Levels of regulatory cytokines such as IL-10 are decreased
Consequences of OSA

35. Metabolic comorbidities
 Elevations in low density lipoprotein (LDL) cholesterol
 reduced levels in high density lipoprotein (HDL) cholesterol

36.  Mild apnea have a wider variety of options,
 Moderate-to-severe apnea should be treated with nasal
continuous positive airway pressure (CPAP).
Treatment

37. Behavior modification
 Weight loss and exercise
 Sleep position :Sleeping in a non-supine position (eg, lateral
recumbent) may correct or improve OSA
 Alcohol avoidance
 Medications avoidance
 Sedative effect medication: benzodiazepine receptor agonists, barbiturates,
other antiepileptic drugs, sedating antidepressants, antihistamines, and opiates
 Weight gain side effect :Antidepressants that cause weight gain
(eg, mirtazapine )
conservative nonsurgical treatment

38.  The mechanism of continuous positive airway pressure (CPAP) involves
maintenance of a positive pharyngeal transmural pressure
 In a meta-analysis of 35 randomized trials, CPAP compared with sham resulted in
a significant reduction in the apnea-hypopnea index
-AHI; mean difference -33.8 events/hour
-improved daytime sleepiness as assessed by the Epworth Sleepiness
Scale (mean difference -2 points)
-reduce systolic and diastolic blood pressure
-imorove sleep-related quality of life
POSITIVE AIRWAY PRESSURE THERAPY

40. Indications for treatment of CPAP
 The American Academy of Sleep Medicine (AASM) recommends offering positive
airway pressure therapy to all patients who have been diagnosed OSA by
 respiratory disturbance index (RDI) ≥15 events per hour with or without symptoms
 RDI between 5 and 14 events per hour that is accompanied by any of the following:
- sleepiness, nonrestorative sleep, fatigue
- insomnia symptoms; waking up with breath holding, gasping, or choking
- habitual snoring and/or breathing interruptions
- hypertension
- mood disorder
- cognitive dysfunction
- coronary artery disease
- stroke
- congestive heart failure
- atrial fibrillation
- type 2 diabetes

41. Oral appliances
 mandibular advancement devices
 tongue retaining devices)
ALTERNATIVE THERAPIES

42. Oropharyngeal :Structure tonsillar hypertrophy, adenoid hypertrophy
craniofacial abnormalities
 Tonsillectomy ± adenoidectomy
 Uvulopalatopharyngoplasty (UPPP)
 maxillomandibular advancement surgery
 Hyoid Suspension
Upper airway surgery

46. maxillomandibular advancement

48.  http://www.atsjournals.org/doi/full/10.1513/pats.200708-118MG
 http://emedicine.medscape.com/article/295807-overview
 http://rcot.org/datafile/_file/_doctor/3b03465492591d3f97333cec47ce490a.pdf
 http://www.rcot.org/pdf/MR!RC9M9!C9%20(Snoring)%20%20aEP@RGPKBX4KRBc(_3P9M9
KEQ_%20(Obstructive%20Sleep%20Apnea).pdf
 http://rcot.org/datafile/_file/_doctor/67e4c100dd2a9cc4051a5c9112eea741.pdf
 http://slideplayer.com/slide/6109008/
 http://advan.physiology.org/content/32/3/196
 http://reference.medscape.com/medline/abstract/8464434
Reference