Obstructive sleep apnea (OSA) is a disorder where breathing is interrupted during sleep due to the airway becoming blocked or narrowed. It is characterized by pauses in breathing or instances of reduced breathing during sleep. A sleep study can be used to diagnose OSA by measuring the number of breathing pauses per hour. While weight loss and lifestyle changes are recommended, continuous positive airway pressure (CPAP) is the most effective treatment for OSA. Untreated OSA is associated with serious health risks like hypertension, cardiovascular disease, diabetes and stroke.

2. What is obstructive sleep apnea
(OSA)?
Disorder of obstructedDisorder of obstructed
breathing occurringbreathing occurring
during sleepduring sleep
Apnea: cessation ofApnea: cessation of
breathing withbreathing with
respiratory effortrespiratory effort
lasting greater thanlasting greater than
10s10s
Total apneas andTotal apneas and
hypopneas per hour =hypopneas per hour =
AHI or RDIAHI or RDI

4. History
Charles Dickens – the Pickwick PaperCharles Dickens – the Pickwick Paper
William Osler - Pickwickian SyndromeWilliam Osler - Pickwickian Syndrome
19181918
Guilleminault - OSAS - 1973Guilleminault - OSAS - 1973
Fujita - UPPP - 1981Fujita - UPPP - 1981
Sullivan - CPAP - 1981Sullivan - CPAP - 1981

5. Risk factors for OSA
Obesity & BMI greater than 25kg/m2Obesity & BMI greater than 25kg/m2
Cranial facial structureCranial facial structure
Alcohol consumptionAlcohol consumption
High and narrow hard palateHigh and narrow hard palate
Male gender ,Familial associationMale gender ,Familial association
Enlargement of tonsilsEnlargement of tonsils
Lesions of ANSLesions of ANS

6. Pathophysiology
snoringsnoring
tissue laxity andtissue laxity and
redundant mucosaredundant mucosa
anatomicanatomic
abnormalitiesabnormalities
decreased muscle tonedecreased muscle tone
with REM sleepwith REM sleep
airway collapseairway collapse

7. Pathophysiology
desaturationdesaturation
arousal with restoration of airwayarousal with restoration of airway
sleep fragmentation leading tosleep fragmentation leading to
hypersomnolencehypersomnolence

8. Consequences of OSA

9. Why is it so Important?
OSA causes HypertensionOSA causes Hypertension
25% of hypertensives have OSA (AI>5)25% of hypertensives have OSA (AI>5)
during the night, the apneas and hypopneas ofduring the night, the apneas and hypopneas of
OSA cause a transient rise in bloodOSA cause a transient rise in blood
pressure( 30 mm hg or more) and increasedpressure( 30 mm hg or more) and increased
activity of sympathetic nervous systemactivity of sympathetic nervous system

10. OSA causes Hypertension
Over time, the transient changes becomeOver time, the transient changes become
more sustained and are detectable duringmore sustained and are detectable during
the daytime, including evidence ofthe daytime, including evidence of
sympathetic overactivity ( Narkiewicz andsympathetic overactivity ( Narkiewicz and
Somers, 2003)Somers, 2003)
Studies have found that people with OSAStudies have found that people with OSA
(versus those with similar BP, but no OSA)(versus those with similar BP, but no OSA)
have faster HR, blunted heart ratehave faster HR, blunted heart rate
variabilityvariability

11. OSA causes Hypertension
,and increased blood pressure variability- all,and increased blood pressure variability- all
of which are markers of heightenedof which are markers of heightened
cardiovascular risk ( Caples et al., 2005)cardiovascular risk ( Caples et al., 2005)

12. OSA is associated with
cardiovascular disease and stroke
Epidemiological studies reveal anEpidemiological studies reveal an
association between OSA andassociation between OSA and
cardiovascular disease, includingcardiovascular disease, including
arrhythmias( Guilleminault et al.,1983);arrhythmias( Guilleminault et al.,1983);
CAD (Andreas et al.,1996) and specifically,CAD (Andreas et al.,1996) and specifically,
MI(Hung et al.,1990; Mooe et al.,1996;MI(Hung et al.,1990; Mooe et al.,1996;
Marin et al.,2005) and congestive heartMarin et al.,2005) and congestive heart
failure ( Javaheri et al.,1998).failure ( Javaheri et al.,1998).

13. OSA is associated with Impaired
glucose tolerance and Diabetes
 OSA contributes to the onset of diabetesOSA contributes to the onset of diabetes
through the development of glucosethrough the development of glucose
intolerance and insulin resistance, which areintolerance and insulin resistance, which are
established pathophysiological processes inestablished pathophysiological processes in
diabetes ( Martin et al.,1992)diabetes ( Martin et al.,1992)
 Recent data also indicate that diabetics withRecent data also indicate that diabetics with
OSA have poorer control of glucose levels,OSA have poorer control of glucose levels,
with improvement following treatment ofwith improvement following treatment of
OSA with CPAP(Babu et al.,2005)OSA with CPAP(Babu et al.,2005)

14. OSA is associated with Obesity
Data from the WisconsinData from the Wisconsin
Sleep Cohort also showSleep Cohort also show
that individuals with OSAthat individuals with OSA
have reduced level ofhave reduced level of
physical activity; OSAphysical activity; OSA
related sleepiness mayrelated sleepiness may
contribute to change incontribute to change in
activity and energyactivity and energy
expenditure, and thusexpenditure, and thus
contribute to weight gain.contribute to weight gain.

15. Societal Impact
Fragmentation of sleepFragmentation of sleep
occurring with SDBoccurring with SDB
increased daytimeincreased daytime
sleepiness, decreasedsleepiness, decreased
intellect, behavioral andintellect, behavioral and
personality changes,personality changes,
enuresis, sexual dysfunctionenuresis, sexual dysfunction
Increased traffic accidentsIncreased traffic accidents

16. How’s it Diagnosed?
SymptomsSymptoms
Physical examinationPhysical examination
AHIAHI
Sleep study- polysomnography (PSG)Sleep study- polysomnography (PSG)

18. Physical Exam
Height and Weight (BMI)Height and Weight (BMI)
BMI=[703.1 x weight(pounds)] / [Height (in)BMI=[703.1 x weight(pounds)] / [Height (in)22
]]
neck sizeneck size
Face-retrognathiaFace-retrognathia
NoseNose
Oral cavity- palate, uvula, tonsils/pillars,Oral cavity- palate, uvula, tonsils/pillars,
tongue, occlusiontongue, occlusion

19. What is Significant OSA?
Uh, I don’t knowUh, I don’t know
Most considerMost consider
significant sleepsignificant sleep
apnea to be presentapnea to be present
with an AHI > 15with an AHI > 15
15-25: Mild Apnea15-25: Mild Apnea
26-40: Moderate26-40: Moderate
ApneaApnea
>40: Severe Apnea>40: Severe Apnea

20. Fiberoptic
Nasopharyngolaryngoscopy
Determines level ofDetermines level of
obstructionobstruction
Provides estimate of degreeProvides estimate of degree
of obstructionof obstruction
TechniqueTechnique
supine (i.e., in a sleepingsupine (i.e., in a sleeping
position)position)
at FRC-point of maximalat FRC-point of maximal
relaxationrelaxation
snore maneuversnore maneuver
Mueller maneuver- inspireMueller maneuver- inspire
against a closed airwayagainst a closed airway

21. TREATMENT
NON SURGICALNON SURGICAL
• CPAPCPAP
• APAPAPAP
• ORAL PRESSUREORAL PRESSURE
THERAPYTHERAPY
• BPAPBPAP
• ORAL APPLIANCESORAL APPLIANCES
SURGICALSURGICAL
• UPPPUPPP
• LAUPLAUP
• Palatal somnoplastyPalatal somnoplasty
• Laser midlineLaser midline
glossectomyglossectomy

22. CPAP
The “Gold Standard” in the treatment ofThe “Gold Standard” in the treatment of
OSAOSA
Works the best in the most peopleWorks the best in the most people
Positive pressure ventilation functions as aPositive pressure ventilation functions as a
pneumatic splint for the collapsing upperpneumatic splint for the collapsing upper
airwayairway
But... compliance is very poorBut... compliance is very poor

24. Oral Appliances
 Mandibular repositioning appliancesMandibular repositioning appliances
(MRAs)(MRAs)
Lower the tongue position , reduce theLower the tongue position , reduce the
mandibular plane-to- hyoid distance,mandibular plane-to- hyoid distance,
advance the mandible and widen the upperadvance the mandible and widen the upper
oropharynx (retropalatal & retroglossal) inoropharynx (retropalatal & retroglossal) in
some patients.some patients.

25. Oral Appliances
Contraindication : TMJ disorder, bruxismContraindication : TMJ disorder, bruxism
 Tongue – retaining devices (TRD)Tongue – retaining devices (TRD)
used in pts. Contraindicated to MRAsused in pts. Contraindicated to MRAs
hold the tongue forward and affecthold the tongue forward and affect
genioglossus muscle activitygenioglossus muscle activity

28. Surgery
TracheotomyTracheotomy
An incision in the tracheaAn incision in the trachea
Cures OSA nearly 100% of the timeCures OSA nearly 100% of the time
Prior to 1980, it’s all we had; still useful forPrior to 1980, it’s all we had; still useful for
severe apneicssevere apneics

29. Remove Tissue-
Uvulopalatopharyngoplasty
(UPPP)
First successful alternativeFirst successful alternative
to tracheotomyto tracheotomy
Increase area of the retro –Increase area of the retro –
palatal airwaypalatal airway
Success of UPPP isSuccess of UPPP is
variablevariable

31. Remove Tissue-Other Surgeries
Laser MidlineLaser Midline
GlossectomyGlossectomy
Palatal SomnoplastyPalatal Somnoplasty
LAUPLAUP
Radiofrequency tongueRadiofrequency tongue
base reductionbase reduction

32. Enlarge the Bony Space-
Other Surgeries
Genioglossus Advancement/Genioglossus Advancement/
Hyoid RepositioningHyoid Repositioning
Success ~80% (11-18mm)Success ~80% (11-18mm)
Less effective with RDI >60Less effective with RDI >60
Maxillo-mandibularMaxillo-mandibular
AdvancementAdvancement
Particularly useful in theParticularly useful in the
setting of hypopharyngealsetting of hypopharyngeal
obstructionobstruction

33. CONCLUSION
OSA is a potentially life-threateningOSA is a potentially life-threatening
disorder that demands proper evaluation.disorder that demands proper evaluation.
Components of that proper evaluationComponents of that proper evaluation
include detailed sleep history, PSG, andinclude detailed sleep history, PSG, and
endoscopic evaluation. Most cases are notendoscopic evaluation. Most cases are not
recorded as peoples are not aware of it, andrecorded as peoples are not aware of it, and
they suffer some serious consequences. Sothey suffer some serious consequences. So
it is better to prevent the disease than curingit is better to prevent the disease than curing
it.it.

34. THANK YOU