osa

1. OBSTRUCTIVE SLEEP
APNOEA

2. • Apnoea means no breathing at all. There is no movement of air at the level of
nose and mouth.
• It is of three types.

3. SLEEP APNOEA (CONTD)
• 1. OBSTRUCTIVE: There is collapse of the upper airway resulting in cessation of
airflow. Other factors may be obstructive conditions of nose, nasopharynx, oral
cavity and oropharynx, base of tongue or larynx.
• 2. CENTRAL: Airways are patent but brain fails to signal the muscles to breathe.
• 3. MIXED: It is combination of both types.

4. PHYSIOLOGY OF SLEEP
• A normal healthy adult sleeps for 7–8 h. Sleep occurs in two phases: non-rem
and REM. The two phases occur in semiregular cycles, each cycle lasting for 90–
120 min. There are thus three or four cycles of sleep

5. NON-REM SLEEP
It forms 75–80% of sleep and occurs in four stages
1. Stage I. Transition from wakefulness to sleep. It constitutes 2–5% of sleep. EEG
shows decrease of alpha and increase of theta waves. Muscle tone is less.
Person can be easily aroused from this stage
2. Stage II. Characterized by sleep spindles or ‘K’ complexes and decrease in
muscle tone. It constitutes 45– 55% of sleep
3. Stage III. Forms 3–8% of sleep, characterized by delta waves. It is deep sleep
4. Stage IV. Forms 10–15% of sleep, characterized by delta waves. It is deep,
most restful sleep.

6. REM SLEEP
• Forms 20–25% of total sleep, characterized by
• Rapid eye movements
• Increased autonomic activity with erratic cardiac and respiratory movements.
Dreaming occurs in this stage but muscular activity is decreased so that dreams
are not enacted.

7. DIFFERENCES BETWEEN NON-REM AND REM
SLEEP

8. 0 = never dozing off
1 = slight chance of dozing off
2 = moderate chance of dozing off
3 = high chance of dozing off.

9. PATHOPHYSIOLOGY OF OSA
Apnoea during sleep causes hypoxia and retention of carbon dioxide which leads
to pulmonary constriction leading to
• Congestive heart failure
• Bradycardia
• Cardiac hypoxia leading to left heart failure
• Cardiac arrhythmias sometimes leading to sudden death.
There are frequent arousals which cause sleep fragmentation, daytime sleepiness
and other manifestations.

10. PATHOPHYSIOLOGY OF OSA

12. CLINICAL FEATURES
History patient’s bed partner gives more reliable information than the patient himself because latter
does not know what happened during sleep
SYMPTOMS
• Snoring and obstructive episodes
• Excessive day time sleiness
• Morning headache
• Intellectual deterioration and personality changes
• Abnormal body movements
• Nocturnal enuresis and impotence
• Obesity

13. SIGNS
• Snoring
• Features of airway obstruction in children due to adenoid hypertrophy, kissing
tonsil, etc
• Obese patient with short neck, bulky tongue, micrognathia with hypoplasia of
mandible, craniofacial abnormalities, excessive bulky soft palate with redundant
mucosa, large tongue

14. PHYSICAL EXAMINATION risk factors include male gender, obesity and age above
40 years.
• BODY MASS INDEX. it is calculated by dividing body weight in kilograms by
height in metres squared. normal bmi, 18.5–24.9; overweight, 25–29%; and
obesity, 30–34.9. obese patients need to reduce weight.
• COLLAR SIZE. neck circumference at the level of cricohyroid membrane is
measured. collar size should not exceed 42 cm in males and 37.5 cm in
females.

15. • COMPLETE HEAD AND NECK EXAMINATION. look for tonsillar hypertrophy, retrognathia,
macroglossia, elongated soft palate and uvula, base of tongue tumours, septal deviation,
nasal polyps, turbinate hypertrophy and nasal valve collapse.
MULLER’S MANOEUVRE.
• A flexible endoscope is passed through the nose and the patient asked to inspire vigorously
with nose and mouth completely closed
• Look for collapse of the soft tissues at the level of base of tongue and just above the soft
palate. level of pharyngeal obstruction can be found.
SYSTEMIC examination is done to look for hypertension, congestive heart failure, pedal oedema,
truncal obesity and any sign of hypothyroidism

16. • CEPHALOMETRIC RADIOGRAPHS are taken for craniofacial anomalies and tongue
base obstruction.
• POLYSOMNOGRAPHY. it is the “gold standard” for diagnosis of sleep apnoea and
records various parameters which include:
• EEG (electroencephalography)—to look for non-rem or rem sleep and stages of
non-rem sleep.
• ECG (electrocardiography)—for heart rate and rhythm.
• EOM (electroculogram)—for rolling eye movements.
• EMG (electromyography)—recorded from submental and tibialis anterior
muscle.

17. • PULSE OXIMETRY—to assess oxygen saturation of blood to know lowest spo2
during sleep.
Nasal and oral airflow—for episodes of apnoea and hypopnoea.
• SLEEP POSITION—helps to know whether apnoea/hypopnoea episodes occur in
supine or lateral recumbent position.
• BLOOD PRESSURE.
• OESOPHAGEAL PRESSURE - negative oesophageal pressure helps to know
degree of breathing efforts made by the patient.

18. SPLIT-NIGHT POLYSOMNOGRAPHY
• In this study, the first part of night is used in usual polysomnography while the second part of
night is used in titration of pressures for continuous positive airway pressure (cpap)
• It is not recommended because episodes of sleep apnoea occur more often in the second half of
night and are thus missed
• Titration of pressures for cpap should ideally be done on a second night
• Polysomnography can differentiate between primary snoring, pure osa and central sleep apnoea

19. TREATMENT (NONSURGICAL)
1. Change in lifestyle. those with mild disease and minimal symptoms can be treated with weight
loss and dietary changes but those with cor pulmonale as a result of severe osa may require surgery.
(a) use of alcohol in the evening aggravates osa. sedatives/hypnotics taken at night also have the
same effect.
(b) smoking should be avoided
(c) reduction of weight is helpful.
2. Positional therapy. patient should sleep on the side, as supine position may
cause obstructive apnoea. a rubber ball can be fixed to the back of shirt to
prevent adopting supine position.

20. 3. Intraoral devices. they alter the position of mandible or tongue to open the
retropalatal airway and relieve snoring and sleep apnoea.
Mandible advancement device (mad) keeps the mandible forward while tongue-
retaining device (trd) keeps tongue in anterior position during sleep.
They help improve or abolish snoring. mad is also useful in retrognathic patients

21. 4. Continuous positive airway pressure (cpap).
It provides pneumatic splint to airway and increases its calibre. optimum airway
pressure for device to open the airway is determined during sleep study and is
usually kept at 5–20 cm h2o. about 40% of patients find the use of cpap device
cumbersome and difficult to carry with them when travelling and thus stop using
it.
when cpap is not tolerated, a bipap (bilevel positive airway pressure) device is
used. it delivers positive pressure at two fixed levels—a higher inspiratory and a
lower expiratory pressure
Now an autotitrating pap (apap) is also available which continuously adjusts the
pressure. their disadvantages are same as those of cpap

22. SURGERY. it is indicated for failed or noncompliant medical therapy. permanent
tracheostomy is the “gold standard” of treatment but it is not accepted socially and
has complications of its own. it is usually not a preferred option by patients.
NASAL SURGERY. nasal obstruction may be the primary or the aggravating factor for
osa
• Septoplasty to correct deviated nasal septum
• Removal of nasal polyps and reduction of turbinate size help to relieve nasal
obstruction
• Sometimes nasal surgery is also indicated for efficient use of cpap.
.

23. OROPHARYNGEAL SURGERY. UVULOPALATOPLASTY (UPP) is the most common procedure performed
for snoring and osa. it is 80% effective in snoring but osa is relieved only in 50%. some patients of osa
are known to relapse in long-term studies because of another site becoming active in the cause of
obstruction (e.g. base of tongue). upp can be laser or radiofrequency assisted
TONSILLECTOMY AND/OR ADENOIDECTOMY. surgical treatment is tailored to the level of obstruction
a) nose and nasopharynx (level i).
b) (b) soft palate and tonsils (level ii).
c) (c) tongue base and pharynx (level iii).
sometimes more than one level is involved.

24. ADVANCEMENT GENIOPLASTY WITH HYOID SUSPENSION.
• It is done in patients where base of tongue also contributes to osa.
• Patients with retrognathia and micrognathia are also the candidates
• Procedure involves resection of a rectangular portion of the mandible including
genial tubercles and the attached genioglossi muscles, its rotation by 90° and
fixation by plates
• It helps to pull the base of tongue anteriorly
• Along with this procedure, the hyoid bone is freed from its inferior musculature
and suspended from lower border of mandible by wires.
• This also helps to pull the base of tongue anteriorly

25. TONGUE BASE RADIOFREQUENCY.
Radiofrequency (rf) is used in five to six sittings to reduce the size of tongue.
rf needle is inserted submucosally. it coagulates tissue and causes scarring thus
reducing the size of tissue.
MAXILLOMANDIBULAR ADVANCEMENT OSTEOTOMY.
osteotomies are performed on mandibular ramus and maxilla. osteotomy of the
maxilla is like a le fort i procedure. these osteotomies are then fixed in anterior
position with plates and screws. this surgical procedure is effective in selected cases
but has the disadvantage of causing aesthetic facial changes.

26. SUMMARY OF MANAGEMENT OF OSA