obstructive sleep apnoea

1. OSAH
(Obstructive sleep
apnoea/hypopnoea)
ADITYA GHOSH ROY
PGT 3
NRSMCH

2. Respiratory Sleep Disorders include 4
1. OSAH (Obstructive sleep
apnoea/hypopnoea)
2. Central Sleep Apnoea/hypopnoea
3. Cheyne Stokes breathing
4. Sleep hypoventilation

4. DEFINATION
 Defined as 5 or more respiratory events (apnoeas /
hypopnoeas / RERAs) per hour of sleep lasting
≥10seconds in association with excessive day time
somnolence, waking with gasping, choking, or breath
holding spells or witnessed spells of apnoeas, snoring
or both,
 Usually accompanied by reduction in blood oxygen
saturations of at least 3% – 4% and is terminated by
brief, unconscious arousals from sleep.

5. PATHOGENESIS
 Upper airway dilating muscle----
Hyoid position– geniohyoid
Tongue position– genioglossus
Palate position– tensor palatini
 Negative airway pressure
 Nasal and laryngeal muscle stimulated
 Stimulation of upper airway muscle

6. Features of upper airway in patients of
OSAH
 Upper airway muscle are more hyper trophic
 Contract more powefully during wakefullness
 Delay between Upper airway muscle activity and
diaphragm muscle activity
 Posterior displacement of tongue and mandible
 Oval shaped airway

8. Chronic vascular over perfusion
Upper airway oedema
Snoring and recurrent upper airway obstruction
Mechanical trauma
Decreased airway size
Decreased Upper airway muscle dilating activity
obstruction

9. APNOEA
AROUSAL
Loud snort and compensatory phase of
hyperventilation
sleep
Hypoxaemia
Hypercapnia
Neg pressure
Stimulus to resp and
reticular
Increased resp effort
Vasocostriction
Tachycardia
Inc BP

11. SYMPTOMS
 Night Time Symptoms
 Loud, habitual snoring
 Witnessed apnoeas
 Nocturnal awakenings
 Gasping and choking
episodes during sleep
 Nocturia
 Abnormal body
movements
o Day time symptoms
o Unrefreshing sleep
o Daytime headaches
o Excessive daytime sleepiness
o Lack of concentration, poor
memory, irritability
o May lead to automobile or work
related accidents
o Decreased libido

12. DIAGNOSIS

13. HISTORY

15. PHYSICAL
EXAMINATION

16. INVESTIGATIONS
 Overnight oximetry
 Home multi channel testing
 Overnight
polysomnography
 Fibroptic nasopharngoscopy
 Drug induced sleep
endoscopy
 Esophageal manometry
 MRI
 3D CT
 Cephalometry
 Nasal spray test

17. OVERNIGHT OXIMETRY
Measurement oxygen saturation
Oxygen dips
ODI ( OXYGEN DESATURATION INDEX )
ODI > 15 THEN OSA

18. HOME MULTI CHANNEL TESTING
 Nasal flow
 Chest movements
 Abdominal movements
 Pulse oximetry
 Advantages
 disadvantages

19. OVERNIGHT POLYSOMNOGRAPHY
 Done under supervision
 Hospital admission
 Complex assessment
 Gold standard

20. APNOEA HYPOPNOEA INDEX
AHI OSA
<5 NO OSA
5 – 15 MILD OSA
15 – 30 MODERATE OSA
> 30 SEVERE OSA

23. FIBROPTIC
NASOPHARYNGOSCOPY
Nasal
Retro palatal
Retro lingual
Awake asleep positions
Mullers maneuver

24. DRUG INDUCED SLEEP ENDOSCOPY
 Commonly performed
 Propofol
 Target controlled propofol infusion
 Anaesthetist
 All monitors
 Saturation to be maintained

25. SLEEP NASAL ENDOSCOPY GRADING

26. OESOPHAGEAL MANOMETRY
Diagnose apnoes , hypopnoea
GERD
Localization of upper airway obstruction

27. MRI
 Localization of site of obstruction
 Quantify the amount of surgical tissue volume
reduction necessary to resolve snoring
 High cost
 Time factor

28. 3D CT
 Evaluation of upper airway obstruction
 Retropalatal space

29. CEPHALOMETRY
CEPHALOMETRY
(relation between
various soft tissue and
bony landmarks based
on carefully taken
lateral X rays.)

30. NASAL SPAY TEST
 Nasal decongestant
 Alternate nights
 Severity of snoring

31. TREATMENT

32. Specific Medical therapies
 Positional therapy – (LATERAL POSITION)
 Positive Airway pressure
 CPAP – mainstay of treatment, acts as pneumatic
splint(prevents collapse of airway and avoids OSA)
 Bi-level systems
 Auto CPAP
 Oral Appliances
 Tongue retaining devices
 Mandibular advancing devices
 Snore guard
 Palatal Lifting devices
 NAPA (Nocturnal Airway Patency Device)

33. CPAP(CONTINOUS POSITIVE
AIRWAY PRESSURE )
 Acts as pneumatic splint
 whereby blowing air via a tube and mask through
the nasal and/or oral passageway
 support the pharyngeal and palatal walls
 preventing collapse of the airway.

34. METHOD OF TITRATION
 Admit a patient for overnight diagnostic Polysomnography,
and halfway through the night, when the severity and the
diagnosis of OSA have been confirmed, to commence CPAP
for the second half of the night. This is referred to as a
SPLIT NIGHT.
 CPAP titration technique – The starting pressure is usually
approximately 4 cm H20 and the pressure is increased
quickly until all apnoeas and hypopnoeas are eliminated.
 Another technique increasingly used is to send the subject
home with an autoCPAP machine. Most autoCPAP machines
will collect data on compliance, leaks and pressure profile.

35. CPAP

36. SIDE EFFECTS
 Claustrophobia
 Nasal Stuffiness
 Skin abrasions and leaks
 Ulceration of bridge of nose
 Air swallowing
 Pulmonary barotrauma

37. ORAL
APPLIANCES
Tongue retaining devices
Mandibular advancing
devices
Snore guard
Palatal Lifting devices
NAPA (Nocturnal Airway
Patency Device)

39. UVULOPALATOPHARYNGOPLASTY
 Where obstruction is at upper pharyngeal or velopharyngeal
level
Remove tonsils, trimming faucial pillars, removal of
uvula and variable amount of soft palate mucosa
then suturing anterior and posterior faucial pillars
and anterior and posterior soft palate mucosa
Stiffen soft palate by scarring
Increase space behind soft palate
Reduction in obstruction

40. UVULOPALATOPHARYNGOPLASTY

41. SUCCESS OF UPPP
 Friedman staging for success of
UPPP
 Palate position
 BMI
 Tonsil size
 Friedman staging for success
of UPPP
 Stage 1 80%
 Stage 2 40%
 Stage 3 8%

42. PALATAL IMPLANTS
 Placement of three woven
implants which stiffen the
palate
 Fibrotic bands within capsule
which stiffens palate further

43. RADIOFREQUENCY TISSUE
VOLUME REDUCTION
 Submucosal application of the
radiofrequency energy to the midline soft
palate.
 Initial treatment directed at a point
approximately midway between the hard
and soft palate junction and the base of the
muscular uvulae.
 Carried out as a day care or OPD procedure
 Less complications

44. LASER MIDLINE GLOSSECTOMY
Approximately 2.5 x 5cm
midline tongue tissue is
excised.
 Might also require lingual
tonsillectomy, reduction of
aryepiglottic folds and
partial epiglottectomy.
 Usually combined with
tracheostomy for airway
protection.

45. LINGUAL TONSILLECTOMY
 Radiofrequency ablation
of lingual tonsil

46. HYPOGLOSSAL NERVE
STIMULATION

47. GENIOGLOSSAL ADVANCEMENT
 anterior attachment of
genioglossus
 genial tubercle of mandible
 Mobilized by osteotomy
 Segment advanced
 Fixed in inferior aspect of
osteotomy
 Increases retro lingual space

48. GENIOGLOSSAL ADVANCEMENT

49. HYOID MYOTOMY AND
SUSPENSION
 Hyoid mobilized by inferior
myotomy and fixed anteriorly
and inferiorly to thyroid
cartilage
 Advances the hyoid and
epiglottis anteriorly
 Increases retro lingual space

50. Maxillomandibular Advancement
 Maxillomandibular
Advancement
 Le fort 1 maxillary
osteotomy and advancing
maxilla forwards.
 move maxilla and
mandible as far forwad
as possible

51. Increases the retropalatal and
retrolingual space

52. Complications
 Malocclusion
 Relapse
 Nerve paresthesia
 Nonunion , malunion
 TM joint dysfunction
 Bleeding
 Subsequent dental work

54. COMPLICATIONS
 Pain
 Hemorrhage
 Airway problem
 Palatal incompetence
 Wound infection
 Wound dehiscence
 dysphagia
 Dry throat
 Inc pharyngeal secretion
 Dysphagia
 Loss of taste
 Globus symptoms
 Voice changes
 Velopharyngeal stenosis
 Velopharyngeal fistula