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![Sleep…
“[Sleep is] the golden chain that ties
health and our bodies together.”
Thomas Dekker (1572-1632)](https://image.slidesharecdn.com/sleepdisordersfrompediatricstogeriatricsspreecast332014-140303183549-phpapp02/85/Sandy-Coulson-Sleep-Disorder-Spreecast-75-320.jpg)
Uploaded byThe Raphael Center for Integrative Education
Sandy Coulson Sleep Disorder Spreecast
This document discusses various sleep disorders from pediatrics to geriatrics. It provides statistics on common sleep disorders like insomnia, sleep apnea, and narcolepsy. It describes risk factors, symptoms, and potential health consequences of obstructive sleep apnea, including increased risks of diabetes, heart disease, and stroke. The document also discusses screening questionnaires, medical conditions that can contribute to sleep disorders, and various treatment options like tonsillectomy, uvulopalatopharyngoplasty, and somnoplasty procedures.
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Sandy Coulson Sleep Disorder Spreecast
- 2. Sleep Disorders fromPediatrics to Geriatrics Sandra R. Coulson MS, ST, Ed, COM
- 3.
- 4. SLEEP DISORDERS… • Insomnia:32 million (unreliable estimate) • Sleep Apnea: estimated 18 million Americans (NHLBI) • Obstructive sleep apnea: 12 million Americans Narcolepsy: 200,000 Americans (NHLBI estimate); 50,000 diagnosed. • Chronic Fatigue Syndrome: 500,000 Americans (CDC/NIAID) • 2011 Health Grades Inc.
- 5. Obstructive Sleep Apnea… ACommon Problem: • Estimated prevalence: 40 MILLION Americans who are undiagnosed (1 in 6) • 50-90% diagnosed are referred for a sleep evaluation. Most do not follow through. Myers et al, JAMA, 2013
- 6. CENTRAL SLEEP APNEA… •The sleeper whose problem is central sleep apnea periodically does not breathe at all, or breathes so shallowly that oxygen intake is ineffectual. The brain just seems to shut down. In either type of sleep apnea, obstructive or CENTRAL, the lack of oxygen usually causes the patient to wake, at least briefly. (Hypopneas)
- 7. Risk Factors… • Malegender • Age • Obesity • Neck Circumference > 17.5 inches in men 16 inches in women • Smoking • Craniofacial structures • Smoking • Family History
- 8. Risk Factors… • Highblood pressure. • High blood pressure in lungs. • Abnormal heart rhythm, heart failure, coronary artery disease (CAD), or stroke. • Depression. • Diabetes.
- 9. Symptoms of OSAin Children… Restless Sleep Headaches Obesity Large Tonsils Noisy Breathing Allergic Shiners Runny Nose Frequent Upper Airway Infections Earaches Bedwetting
- 10. Symptoms of SleepApnea in Adults and Children… Daytime Symptoms: • Excessive Daytime Sleepiness • Depression / Anxiety / ADHD • Morning Headache • Dry, Irritated Throat & Raspy Voice • Social and Workplace Issues • Short Attention Span, Hot Temper, Impulsive, Memory Problems
- 11. Symptoms of SleepApnea in Adults and Children… Nighttime Symptoms: • Snoring • Witnessed Breathing Pauses • Frequent Awakenings • Frequent episodes of Bedwetting • Insomnia
- 12. Screening Questionnaire… • • • • • Do you snore? Areyou sleepy during the daytime? Do you have headaches or sore throats in the AM? Has anyone witnessed apneas or respiratory gasps? Do you not get ‘enough sleep’ despite adequate time in bed? • If they answer any affirmatively, use the “EPWORTH SLEEPINESS SCALE” TO ASSES SEVERITY. We give this to everyone!
- 13. Is It aCOLD or an ALLERGY? • Cold: • Runny nose and sneezing last 1-3 days; if cold symptoms persist for more than a week, see a doctor - you may have complications such • as bronchitis or sinusitis • • Sore throat and / or coughing • • General malaise -fever, muscle aches, chills, sweats, loss of appetite, fatigue -which indicate an infection • • Burning sensation in nose, often accompanied by nasal/sinus tenderness • • Mucus can become yellow, green, thick, foul-smelling or bloody
- 14. • Allergy: • Persistentwatering of nose and eyes lasts anywhere from a few weeks to several months, depending on the allergen • Itchiness of the nose, eyes and roof of the mouth or back of throat • General feeling of well-being, except for areas experiencing allergic symptoms; appetite usually is not diminished • In most cases, sinuses are not painful or tender • Mucus is watery and clear
- 15. We Cannot SeeAdenoids and Septums But We CAN See Tonsils and Tongues Large Adenoids Deviated Septum Large tonsils Wide tongue/Long Uvula
- 16. Medical Conditions /Sinusitis… • • • • Diabetes Gastroesophageal reflux disease Nasal polyps or septal deviation Disorders of the immune system (fungal infections are especially risky) • Oral or intravenous steroid treatment • Hypothyroidism -- causes congestion that often clears up when the condition is treated • Cystic fibrosis -- a genetic disorder in which the mucus is very thick and builds up
- 17. Sleep Disorders Can CauseOther Serious Diseases:
- 18. DISEASES… Type II Diabetes •Almost 50% of type 2 diabetes patients have sleep apnea;1 among obese type 2 diabetes patients, the prevalence of sleep apnea has been estimated at 86%. AM J RESPIR CRIT CARE MED.2010 Mar 1;181(5):507-13. doi: 10.1164/rccm.200909-1423OC. Epub 2009 Dec 17. • 76% Congestive Heart Failure Javaheri S. Sleep-related breathing disorders in heart failure. In: Heart Failure, A Companion to Braunwald’s Heart Disease, edited by Douglas L. Mann. WB Saunders, Philadelphia 2010; 471-487 • 70% Stroke/TIA http://sleepdisorders.about.com/od/sleepandgeneralhealth/f/Sleep_Apnea_Stroke_Risk.htm Mar 4, 2013 ...
- 19.
- 20. The reason itis called “SleepDisordered Breathing… Daytime… Nighttime
- 21. If you suspectSleep Apnea… What do you look for?
- 22. Determine Etiological Factorswhich would prevent the success of a therapy program BY BEING PART OF A team! 1. Deviated Septum 2. Enlarged Turbinates 3. Polyps 4. Enlarged Adenoids and / or Tonsils 5. Allergic Rhinitis and / or Sinusitis 6. Vaulted -Narrow Palatal Arch Formation REFER! Ask Questions
- 23. Questions… • Neck Size •Morning headaches? • Impaired memory/intellectual performance • Restless sleep? • Nocturia? (Bedwetting)
- 24.
- 25. Medical History… • Snoresat night/naps • Throat infections • Ear infections • Stops breathing • Has halitosis
- 26.
- 27. Long Uvula, LargeTongue= Obstruction…
- 28.
- 29. Medical problems associatedwith SLEEP DISORDERD BREATHING… • • • • • • • • • Obesity Excessive sleepiness Depression Hypertension Cardiovascular disease Diabetes Stroke Cognitive impairment Cerebrovascular disease
- 30. CARDIOVASCULAR LINKS… • 5.7 millionpeople in the US have heart failure {American Heart Association Statistics} • 76% of Heart Failure Patients have SDB • Heart Failure is the MOST expensive disorder to treat • Obstructive Sleep Apnea is noted in 49% of atrial fibrillation patients and 30% of cardiovascular patients • OSA presents in 70% of heart attack patients
- 31. Mortality Links… • SDBis associated with a 3-fold increase in mortality risk • Severe sleep apnea raises premature death risk by 46%
- 32. Mood Disorder andApnea… • 54.1% of Bipolar patients were found to be at risk for OSA • Sleep apnea associated with major depression (2.4% in men, 5.4% in women) • Treatment of OSA ameliorates symptoms in the short and long term Soreca, Bipolar Disord, 2012 Wheaton, Sleep, 2012 Scjwartz, J Clin Sleep Med, 2007
- 33. Restless Legs Syndromeand Periodic Limb Movements… • Periodic Leg Movements (PLMD) • Restless Legs Syndrome (RLS) Movement disorder (Rest increases symptoms) • Sensory Motor Syndrome
- 34. Cardiovascular Risk andRLS… • 2 times greater risk of heart and cardiovascular disease • Women with RLS for 3 years are at greater risk for heart disease • Older Men with RLS are 67% times more likely to have a stroke than those without Li,RCircuLlatioSn,2013
- 35. Are pregnant womenat risk for sleep apnea? Potential risk factors for SDB in pregnancy: • • • • • • Nasal congestion and gestational rhinitis (1) Increased Mallampati scores (2) Reduction in size of upper airway (3,4) Weight gain Reduction in FRC (5) and airway collapsibility (6) Vacuum effect related to increased ventilator drive (7) • • • • • • • 1-Young T. J All Clin Immunol 1997; 99: S757-62. 2- Pilkington S. Br J Anesth 1995; 74:638-42 3- Iczi B. ERJ 2006; 27:321-7 4- Iczi B. AJRCCM 2003; 167:137-40 5- Crapo R. Clin Obstet Gynecol 1995; 39:3-16 6- White DP. AJRCCM 2005; 172:1363-70 7- Edwards N. Thorax 2002; 57:555-8
- 36. Consequences of Apneafor Pregnant Women… • Pregnancy associated with lower residual volume and lower functional residual capacity (FRC) • Lower oxygen reserve because of lower FRC and higher oxygen consumption
- 37. Preeclampsia… PEC is animportant cause of: • • • • • Infant prematurity Neonatal morbidity Maternal morbidity and mortality Maternal ICU admissions Precursor of cardiovascular disease
- 38. Consequences of Apneaon Fetus: • Concern for fetal wellbeing with recurrent desaturations and possible hypoventilation (Data from high altitude residents strongly suggests risk of growth restriction and PEC with chronic hypoxia) (Doctors in Denver are very aware of the risks!)
- 39. Gestational Diabetes… Diabetes occurringduring pregnancy • 30-50% of women with GDM end up developing DM later in life • GDM is cause for infant morbidity • Other complications
- 40. Reflux - AnotherIssue… • In a study presented at the 70th Annual Scientific Meeting of the American College of Gastroenterology, 81 patients with documented sleep complaints at least three nights per week underwent polysomnographic sleep evaluations. 26 percent had acid reflux. Of those who suffered with reflux, 94 percent of the recorded reflux events were associated with arousal from sleep or awakening.
- 41. Is this achicken or an egg?
- 42. Childhood Obstructive SleepApnea OSA
- 43. Airway Examination • CTScan • Lateral Cephalometric Exam
- 44. When you see… •A Narrow, under-developed maxillary arch
- 46.
- 47. • If thetonsils are not treated or removed, it is certain to be an Orthodontic nightmare and a total relapse case.
- 48.
- 49. Tongue Thrust =Abnormal Swallow… Anterior Bite Closed But needs
- 50.
- 52. Looks like fun!!! •Are they accurate?
- 53. Sleep Study… • • • • Typical result… Timein bed: 9 hours 47 minutes Time asleep: 6 hours 46 minutes AWAKE: 3 hours due to Arousals ( I did one just to find out what happens. I do not have OSA, but I did not sleep well!)
- 54.
- 55. Tonsillectomy/Adenoidectomy… • Chronic orrecurrent tonsil infections—Tonsillectomy may reduce the number, but will not completely eliminate, these infections. • Peri-tonsillar abscess (pocket of infection spreading outside the tonsil) • Enlarged tonsils causing obstruction of the throat • Adenoids blocking the nasal airway
- 56.
- 57. Laser-Assisted Uvulopalatoplasty… • Conservativeresection and re-contouring of the soft palate and uvula • Outpatient procedure • Low morbidity • Success rate: LOW
- 58. Somnoplasty… • Radio-frequency generatoris used to cause internal scarring and shrinkage of the soft palate and uvula • Local Anesthetic • Outpatient • Success: LOW
- 59.
- 60. Maxillofacial SURGERY… • InferiorSagittal Osteotomy with HYOID suspension • Ramus osteotomy • Mandibular sub apical osteotomy • Maxillary-mandibular advancement • Tracheostomy Success Rate: Moderate…Very Costly…Often not covered by insurance
- 61. Devices… • • • • Mandibular Repositioners Tongue Controllers Nasal/Intra-oralPositive Pressure Devices Drugstore Appliances (Doctor’s Snore Guard)
- 62. Issues with Medications… •Benzodiazepines, hypnotics, narcotics may relax the airway more in patients who have sleep apnea. • Narcotics can contribute to central sleep apnea.
- 63. A GREAT TEAM… Dentist Orthodontist PediatricDentist Pediatrician Physician Breathing Specialist Osteopath Cranio-Sachral Therapist Myofunctional Therapist
- 64. CPAP… • CPAP isstill considered the “Gold Standard” by most physicians. Compliance: Low
- 65. Myofunctional Therapy with aTEAM APPROACH Helps to minimize snoring by training the tongue to rest in a normal posture Changes head and neck posture which opens the airway Allows for better nasal breathing (noses are ‘use them or lose them’) Changes sleep behavior with better sleep rejuvenation Changes facial esthetics CHANGES LIVES!
- 66. APP for Patient’sMonitoring Their OWN Snoring… SNORELAB.COM for IPHONES Snoreclock.com for DROIDS
- 67. SNORELAB.COM… • This womansnored so loudly that her whole family wore ear plugs to sleep! • She started the exercise program and went to Seattle to care for her elderly mother. • She has sent a “SNORE REPORT” every day!
- 68. One Week afterStarting therapy… exercises
- 69.
- 70.
- 71. He Stopped Snoringwithin one week
- 73. Airway Examination… • CTScan • Lateral Cephalometric Head Film
- 74. Summary… • Successful treatmentof snoring and sleep apnea is totally dependent upon an accurate diagnosis of the region of obstruction and treatment that is directed at the ETIOLOGY!
- 75. Sleep… “[Sleep is] thegolden chain that ties health and our bodies together.” Thomas Dekker (1572-1632)