Slides prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal , for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology.
A clear and concise explanation of the basic concepts in the subject matter concerned.
He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students
2. • Sleep
–Reversible behavioral state of perceptual
disengagement and unresponsiveness to
surrounding
• 2 Stages
•REM ( 20 % ) - Alert Mind, Relaxed body
•NREM ( 80 % ) - Relaxed Mind, Active
body
3. • Apnea : Cessation of breathing from nose and mouth
for >10 sec
– Obstructive : Chest wall moves
– Central : Chest wall doesn’t move
– Mixed : Chest wall partly moves
• Hypopnea : Decreased airflow (<50% from baseline)
with > 4% Hb O2 desaturation and arousal
4.
5. • The Apnea–Hypopnea Index (AHI)
– Used to indicate the severity of sleep apnea
– Represented by the number of apnea and
hypopnea events per hour of sleep
• OSAS is defined as AHI > 5
• Grades:
– Mild : 5-14
– Moderate : 15-29
– Severe : >30
6. Pathophysiology
• Incompletely Understood !
• Hypothesis
– During REM sleep : Collapse occurs in upper airway
‘pharynx’ (due to defect in pharyngeal dilator
muscles activity and anatomical abnormalities)
Hypoxia arousal Upper airway collapse
improves and patient sleeps again
– During sleep, airway again collapses leading to
hypoxia and arousal
7. • Multiple arousals result in poor quality of sleep
and day - time sleepiness
• Chronic repeated hypoxia causes hemodynamic
complications like
–Pulmonary HTN ,Systemic HTN
–CAD, CVA, CHF
11. Typical Syndromic Patient
• Old Age
• Male
• Obese - BMI > 30
• Thick / Short Neck >17″
• Hypertension/Thyromegaly
• Large Bulky tongue/Tonsils
• Nasal Obstruction
• Pitting Edema
• Disproportionate Anatomy
12. Approach to management
• Detailed History /Involve
Bed-partner
• Sleep history
– Bed time
– Alcohol / Sedative use
– Body position/Snoring
– Arousals/Apneas
• Assess Day time
sleepiness
– Epworth Sleepiness
Scale
– Stanford Sleepiness
Scale
14. • Flexible Nasopharyngoscopy : Mueller’s Maneuver, assess
airway collapse
Normal Airway Bulky Base of Tongue
Before Mueller’s Maneuver After Mueller’s Maneuver
After a forced expiration, an
attempt at inspiration is
made with closed mouth and
nose (reverse Valsalva)
15. Investigations
• Polysomnography
– Gold Standard Investigation
– Done in a “SLEEP LAB”
– Measures:
•EEG/EOG/ EMG
•ECG / B.P
•Position of Patient / Movements of Chest and abdomen
•Airflow /O2 Saturation
•Esophageal Pressure
16. • Cephalometry
– Enlarged tongue and soft palate
– Inferiorly displaced hyoid bone
– Inferior displacement of the
mandibular body
– Reduced oropharyngeal and
hypopharyngeal airway
17. • Anatomical Risk assessment
– X-Ray /CT Scan /MRI /Fluoroscopy /Acoustic Reflex
• Multiple Sleep Latency Test
– Document daytime sleepiness
– Subject asked to sleep 4-5 times in day every 2
hours
• TFT/ECHO
19. General Treratment
• Weight Reduction
• Sleep Hygiene
– Elevate head end of bed
– Avoid alcohol, sedatives
– Avoid lying supine (T- shirt with tennis ball at back )
• Positive Airway Pressure (PAP) Device
– CPAP (Continuous) / Bi–PAP(Biphasic) /APAP(Automated)
• Positioning Devices
– Mandibular Advancement Device
– Tongue Retaining Device
20. •Nasal CPAP is first line treatment with ~100%
Efficacy (Gold standard medical Rx )
•Pressure must be individually titrated
•A/E : Noise, Mask discomfort, Claustrophobia
•Compliance low ~ 50%
21.
22. Surgical Treatment
1. Nasal Surgery
2. Palatal Surgery
3. Tongue Base Surgery
4. Maxillo -facial Surgery
5. Tracheostomy