2. Definition: Sleep Disordered Breathing
• A disorder of breathing during sleep only, or
significantly affected by sleep. In general, the
patient has little or no problem breathing
while awake.
• Not a true sleep disorder
3. Categories
• Mechanical : The inappropriate collapse of the
pharynx during sleep
– Snoring
– Inspiratory Flow Limitation
– Obstructive sleep apnea
• Chemical : Central Sleep Apnea
• Neuromuscular : paralysis of involuntary
muscle (diaphragm) or lack of adequate tidal
volume requiring ventilation at night
4. Continuum of Sleep Disordered
Breathing
Least
Mechanical
Severity
Chemical
Most
Neuromuscular
5. Continuum of Sleep Disordered
Breathing:
Treatment
Least
Severity
Most
Mechanical
Chemical
Neuromuscular
Oral Appliances
CPAP
Combination
Surgery
Tracheostomy
Cpap
Vpap
Oral Appliances
Combination
Oxygen
Ventilator
Tracheotomy
Combination
6. Continuum of Sleep Disordered
Breathing:
Treatment Success
Severity
Least
Mechanical
Chemical
CPAP <50%
?
OA’s >50%
TAP-PAP > 95%
Tracheotomy 100% ?
Most
Neuromuscular
Ventilator +
Tracheotomy = 100%?
TAP-PAP = 100%?
33. Patient History
• Loud snoring, excessive fatigue, several wrecks
• Uncontrolled hypertension, 5 different
medications per day
• Morning blood pressure on medication 175/120
• Stroke 5 years previous
• Four psg’s, no osa, no diagnosis, tried and failed
cpap
• HST: RDI 3, significant upper airway resistance
40. Immediate TAP CS
• Moved screw forward to compensate for
maxillary hypoplasia
• Opened vertical 15 mm to accommodate
tongue
• Patient titrated himself 5mm beyond
maximum protrusion in first week
• Blood pressure on awakening 145/90
• No snoring, head aches, fatigue
45. Neuromuscular Patients
• Generally need ventilatory assistance during
the day
• Paralysis of diaphragm
• Intercostal muscle deterioration
• Limited function of limbs
• Adequate dentition for retention
47. Neuromuscular Patients:
History
45 yo, post polio
Paralyzed from neck down
Mask developed by DRI using
“bite block”
Pressure: 45 cmw
Volume ventilator
Could use intercostals during
day
Inserted by biting into trays
61. Family and Social Hx
• Divorced and remarried
• Father died at age 51 of HA
– Professional football player with very large neck
• Son and grandchild have osa by symptoms
• Orthodontist
– Focused on treating non-extraction and
developing airways
– Very knowledgeable in tmd and occlusion
62. Treatment Hx
• No initial sleep study or consultation with
physician
• Numerous oral appliances tried over 1 yr
– Herbst
– Silencer
– Snore guard
– Silent Knight
• Failure of all appliances
• Appliances still fit
