During a flight from Honolulu to Hilo, air traffic controllers were unable to contact the pilots for 18 minutes. Since this incident, the airline captain was diagnosed with severe obstructive sleep apnea. Sleep apnea is a sleep disorder where breathing is interrupted during sleep by pauses or shallow breathing and affects 3.6% of people in North India. The gold standard test for diagnosing sleep apnea is an overnight sleep study called polysomnography. Positive airway pressure therapy using CPAP is very effective at reducing sleep apnea symptoms and improving quality of life.
This presentation gives some basic information regarding the definition , etiology and pathophysiology of " obstructive sleep apnea" which is a serious sleep disorder .Treatment methods are briefly reviewed with special emphasis on the role of the oral surgeon and orthodontist in the management of this medical condition .
This presentation gives some basic information regarding the definition , etiology and pathophysiology of " obstructive sleep apnea" which is a serious sleep disorder .Treatment methods are briefly reviewed with special emphasis on the role of the oral surgeon and orthodontist in the management of this medical condition .
OSA is an entity that is increasingly being managed by otolaryngologists...Hope this presentation helps to clear any doubts regarding its diagnosis and management!
What are the main sleeping disorders and what are the sleeping disorders related to respiratory system ? how to deal with it and how to diagnose and treat?
Obstructive sleep apnea (OSA)—also referred to as obstructive sleep apnea-hypopnea—is a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. It is the most common type of sleep-disordered breathing and is characterized by recurrent episodes of upper airway collapse during sleep. These episodes are associated with recurrent oxyhemoglobin desaturations and arousals from sleep.
BELL'S PALSY IS AN IDIOPATHIC LMN TYPE FACIAL PALSY..THE SEMINAR TELLS YOU OF COURSE OF NERVE..FACIAL MUSCLES THEIR ACTION..HOW TO EXAMINE..THE SEQUELAE OF FACIAL PALSY...LOOK AT IT..
Sleep and dreams are taken for granted by those not affected by obstructive sleep apnea. Unfortunately in around 10 million population around the world, sleep is a nightly battle which leaves it‟s victims and their bed partners fatigued, stressed and much less healthy.
Untreated sleep apnea is one of the major public health issues we face in common. The emergence of dental sleep medicine as a safe and effective treatment brings hope for the millions of patients looking for alternatives to CPAP treatment.
Oral appliances used to date constitute a relatively heterogeneous group of devices for the treatment of sleep apnea and non-apneic snoring.
As dental professionals, we have a significant role to play in the early diagnosis, management and care of patients suffering from sleep apnea. Oral appliances play a major role in the non surgical management of OSA and have become the first line of treatment in almost all patients suffering from OSA.
The interplay between anatomic, functional, and neural factors that influence the upper airway patency during wakefulness and sleep is still unclear. Although the role played by the prosthodontists is still in its infancy, there is much to learn and understand in the rapidly evolving field of sleep medicine.
The growing interest of prosthodontists in sleep medicine has contributed immensely toward effective prevention and treatment of OSA and sleep Bruxism for each patient based on his/her individual requirement
OSA is an entity that is increasingly being managed by otolaryngologists...Hope this presentation helps to clear any doubts regarding its diagnosis and management!
What are the main sleeping disorders and what are the sleeping disorders related to respiratory system ? how to deal with it and how to diagnose and treat?
Obstructive sleep apnea (OSA)—also referred to as obstructive sleep apnea-hypopnea—is a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort. It is the most common type of sleep-disordered breathing and is characterized by recurrent episodes of upper airway collapse during sleep. These episodes are associated with recurrent oxyhemoglobin desaturations and arousals from sleep.
BELL'S PALSY IS AN IDIOPATHIC LMN TYPE FACIAL PALSY..THE SEMINAR TELLS YOU OF COURSE OF NERVE..FACIAL MUSCLES THEIR ACTION..HOW TO EXAMINE..THE SEQUELAE OF FACIAL PALSY...LOOK AT IT..
Sleep and dreams are taken for granted by those not affected by obstructive sleep apnea. Unfortunately in around 10 million population around the world, sleep is a nightly battle which leaves it‟s victims and their bed partners fatigued, stressed and much less healthy.
Untreated sleep apnea is one of the major public health issues we face in common. The emergence of dental sleep medicine as a safe and effective treatment brings hope for the millions of patients looking for alternatives to CPAP treatment.
Oral appliances used to date constitute a relatively heterogeneous group of devices for the treatment of sleep apnea and non-apneic snoring.
As dental professionals, we have a significant role to play in the early diagnosis, management and care of patients suffering from sleep apnea. Oral appliances play a major role in the non surgical management of OSA and have become the first line of treatment in almost all patients suffering from OSA.
The interplay between anatomic, functional, and neural factors that influence the upper airway patency during wakefulness and sleep is still unclear. Although the role played by the prosthodontists is still in its infancy, there is much to learn and understand in the rapidly evolving field of sleep medicine.
The growing interest of prosthodontists in sleep medicine has contributed immensely toward effective prevention and treatment of OSA and sleep Bruxism for each patient based on his/her individual requirement
Brief Report: OSA Evaluations for the Anaesthesiologist, Surgeon, Surgery Centresemualkaira
This short report presents a scope of the medical condition of Obstructive Sleep Apnea (OSA). Current methods for assessment and
diagnosis of OSA are presented. Complications and potential death
from untreated OSA places the anesthesiologist, surgeon and surgical center in a risk situation. Factors related to the risk factors
and points toward resolution are presented.
1. Sleep Apnea Prepared by: dr. Mohamad Ghazi 1
2. Outline: • Sleep Apnea definition • Epidemiology • Types of Sleep Apnea • Risk factors for Obstructive sleep apnea • Diagnosis • OSA can increase the risk of ? • Treatment Options for Sleep Apnea • Conclusion 2
3. Sleep Apnea is defined as the stopping of airflow during sleep and preventing air from entering the lungs caused by an obstruction.(1) What is Sleep Apnea? 1.British Snoring & Sleep Apnoea Association . 2. Orthodontics - Current Principles and Techniques - Graber 5th edition - 2011 Just as allergic disease significantly affects quality of life, obstructive sleep apnea, if it is untreated, may affect adversely the ability of adults and children to function adequately at work and at school.(2) 3
4. 4
5. Is Sleep Apnea Significant Health Issue ? 22 million Americans suffer from sleep apnea, with 80 percent of the cases of moderate and severe obstructive sleep apnea undiagnosed. (3) 3.American Sleep Apnea Association 4.Young et al 1993 5.Young et al 2002 15. Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012; 130: 576-84. EPIDEMIOLOGY: OSA present in 25-58% of Male and 10-37% of Female. (4)(5) According to a report by American Academy of Pediatrics, depends on the population studied, the prevalence of OSAS is in the range of 1% to 5% (15) 5
6. Types of Sleep Apnea: Obstructive sleep apnea is the most common type of sleep apnea. It occurs when the soft tissue in the back of your throat relaxes during sleep and blocks the airway, often causing you to snore loudly. 6
7. Central sleep apnea is a much less common type of sleep apnea that involves the central nervous system, occurring when the brain fails to signal the muscles that control breathing. People with central sleep apnea seldom snore. Complex sleep apnea is a combination of obstructive sleep apnea and central sleep apnea. A) Obstructive sleep apnea. Note continued chest and abdominal effort in the absence of airflow. B) Central sleep apnea. Note absence of chest and abdominal effort, as well as absence of airflow 7
8. You have a higher risk for obstructive sleep apnea if you are: Overweight ??? (Most Important Factor) 5.Young et al 2002 6.National Institutes of Health 14.Malhotra et al 2002 • About 70% of those with OSA are obese (14) • Higher BMI associated with higher prevalence – BMI>30: 26% with AHI>15, 60% with AHI>5 – BMI>40: 33% with AHI>15, 98% with AHI>5 Obese people have extrinsic narrowing of the area surrounding collapsible region of the pharynx and regional soft tissue enlargement. Increased fat deposits posteriolateral to oropharyngeal airspace at level of soft palate, in the soft palate, and in submental area. Risk factors for Obstructive sleep apnea(6) 8
9. • Sex : Male are more likely than Female to have sleep apnea. • Age : the risk increases as you get older. • A family history of sleep apnea.
Surgical procedures for the treatment ofBhagwat Kapse
Apnea” is the Greek word for “without breath.”
Obstructive sleep apnea (OSA) was
( 1837) First Charles Dickens term “Pickwickian syndrome”
described a similar presentation of a typical OSA patient; obese, somnolent, and with an excessive appetite.
This is an undergraduate presentation on Snoring and Obstructive Sleep Apnoea in ENT.
It includes Overview, Types, Severity, Symptoms, Risk Factors, Diagnosis and Treatment options(Management), Differences between children and adults, Key points etc.
https://orcid.org/0000-0001-9306-2267
Pamudith Karunaratne
"Breath Easy: The Role of Orthodontics in Managing Obstructive Sleep Apnea"safabasiouny1
obstructive sleep apnea and orthodontics including diagnosis and treatment
Sleep disruption caused by breathing disorders are potentially life-threatening and therefore an important global health issue.
Sleep disorders, particularly untreated obstructive sleep apnea (OSA) has been known as a risk and possible causative factor in
1.
development of systemic hypertension,
2.
depression,
3.
stroke, angina
4.
cardiac dysrhythmias.
5.
can be associated with motor vehicle accidents,
6.
poor work performance and therefore, also makes a person prone to occupational accidents and reduced quality of life.
7.
adversely affects patients on their personal, social and professional levels.
Obstructive sleep apnea (OSA)
Definition: cessation of airflow for more than 10 seconds and hypopnoea is 50% reduction in air flow
It is Classified as central, obstructive and mixed and can be graded as mild, moderate and severe
Numerous studies have shown that women have an increased susceptibility to chronic respiratory conditions.This presentation explores briefly into the epidemiology, the gender differences in disease presentation and its wider healthcare implications.
It is very important to refer proper patient at proper time for infertility treatment. This presentation explores briefly the different criteria to refer the patient and the follow-up after.
Safe iv cannulation (prevention of iv thrombophlebitis)Chaithanya Malalur
A basic introduction to applying an intravenous canula. A note on commonly accessible veins, purpose of IV cannulation, materials & procedure, after care, complications & management
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
Hospital acquired infections: The different common sources of infection, their routes of spread and the growing antimicrobial resistance. Also includes a discussion on hospital Infection prevention and control guidelines and the universal and standard precautions.
An overview of the respiratory tract infections, microbiology and the implications of antibiotic resistance. Summarizing the antibiotic recommendations in pneumonia.
Over 1.4 million people each year worldwide suffer from hospital acquired infections. We can follow simple steps and protocols to prevent many of these cases.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
2. During this time air traffic controllers were frantically radioing the flight
from Honolulu to Hilo for 18 minutes but receiving no response from the
pilots. Since this incident the airline captain has been diagnosed with
severe obstructive sleep apnea.
Shelley Perlman; BCMJ, Vol. 56, No. 2, March 2014, page(s) 94-96 WorkSafeBC
4. What is sleep apnea?
▪ Sleep apnea, is a sleep disorder characterized by
pauses in breathing or periods of shallow
breathing during sleep.
▪ Each pause can last for a few seconds to a few
minutes and they happen many times a night.
▪ In the most common form, this follows loud
snoring.
▪ There may be a choking or snorting sound as
breathing resumes.
41. "Sleep Apnea: What Is Sleep Apnea?". NHLBI: Health Information for the Public. U.S. Department of Health and Human Services. July 10, 2012.
2. "What Are the Signs and Symptoms of Sleep Apnea?". NHLBI. July 10, 2012.
5. Obstructive sleep apnea (OSA)
▪ OSA is a disorder that is characterized by
obstructive apneas and hypopneas due to
repetitive collapse of the upper airway during
sleep.
Untreated OSA has many potential consequences
and adverse clinical associations:
excessive daytime sleepiness
impaired daytime function
metabolic dysfunction
and an increased risk of cardiovascular disease and mortality
5
6. Obstructive sleep apnea (OSA)
Cardinal features in adults:
▪ Obstructive apneas, hypopneas, or respiratory effort
related arousals
▪ Daytime symptoms attributable to disrupted sleep, such
as sleepiness, fatigue, or poor concentration
▪ Signs of disturbed sleep, such as snoring, restlessness,
or resuscitative snorts
6
7. Prevalence in India
▪ In 2006, a population-based survey from north
India had estimated the prevalence of OSAS at
3.6% (males and females being 4.9 and 2.1%
respectively)
▪ In a hospital-based study of urban men between
35 and 65 yr from western India, the prevalence
of OSA was 19.5% and of OSAS was 7.5%
7
1. Sharma SK, Kumpawat S, Banga A, Goel A. Prevalence and risk factors of obstructive sleep apnoea syndrome in a population of Delhi, India. Chest 2006;
130 :149-56.
2. Udwadia ZF, Doshi AV, Lonkar SG, Singh CI. Prevalence of sleep disordered breathing and sleep apnoea in middle-aged urban Indian men. Am J Respir
Crit Care Med 2004; 169 : 168-73.
8. Risk factors
Advancing age: prevalence of OSA increases from
young adulthood through the 6th to 7th decade
Male gender: OSA is approximately 2 to 3 times more
common in males than females
Obesity: prevalence of OSA progressively increases as
the BMI and associated markers (eg, neck
circumference, waist-to-hip ratio) increase
Craniofacial or upper airway soft tissue abnormalities:
abnormal maxillary or short mandibular size, a wide
craniofacial base, tonsillar hypertrophy, and adenoid
hypertrophy, adeno-tonsillar hypertrophy in children 8
9. Additional risk factors
▪ Additional risk factors identified in some studies
include smoking, nasal congestion, menopause,
and family history.
▪ Rates of OSA are also increased in association
with certain medical conditions, such as
pregnancy, end-stage renal disease, congestive
heart failure, chronic lung disease, stroke.
9
10. Pathophysiology
of OSA
▪ OSA is characterized by recurrent,
functional collapse during sleep of
the velopharyngeal and/or
oropharyngeal airway, causing
substantially reduced or complete
cessation of airflow despite ongoing
breathing efforts.
▪ This leads to intermittent
disturbances in gas exchange (eg,
hypercapnia and hypoxemia) and
fragmented sleep.
10
14. Good Practice Statements
▪ Diagnostic testing for OSA should be performed
in conjunction with a comprehensive sleep
evaluation and adequate follow-up.
▪ Polysomnography is the standard diagnostic test
for the diagnosis of OSA in adult patients in
whom there is a concern for OSA based on a
comprehensive sleep evaluation.
Kapur, V.K., Auckley, D.H., Chowdhuri, S., Kuhlmann, D.C., Mehra, R., Ramar, K. and Harrod, C.G., 2017. Clinical practice guideline for diagnostic testing for
adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med, 13(3), pp.479-504.
15. Recommendations
1. We recommend that clinical tools, questionnaires and prediction
algorithms not be used to diagnose OSA in adults, in the absence of
polysomnography or home sleep apnea testing. (STRONG)
2. We recommend that polysomnography, or home sleep apnea testing
with a technically adequate device, be used for the diagnosis of OSA in
uncomplicated adult patients presenting with signs and symptoms that
indicate an increased risk of moderate to severe OSA. (STRONG)
3. We recommend that if a single home sleep apnea test is negative,
inconclusive, or technically inadequate, polysomnography be performed
for the diagnosis of OSA. (STRONG) 15
16. Recommendations (contd…)
4. We recommend that polysomnography, rather than home sleep apnea testing, be
used for the diagnosis of OSA in patients with significant cardiorespiratory
disease, potential respiratory muscle weakness due to neuromuscular condition,
awake hypoventilation or suspicion of sleep related hypoventilation, chronic
opioid medication use, history of stroke or severe insomnia. (STRONG)
5. We suggest that, if clinically appropriate, a split-night diagnostic protocol, rather
than a full-night diagnostic protocol for polysomnography be used for the
diagnosis of OSA. (WEAK)
6. We suggest that when the initial polysomnogram is negative and clinical
suspicion for OSA remains, a second polysomnogram be considered for the
diagnosis of OSA. (WEAK)
16
18. Clinical algorithm for implementation of
clinical practice guidelines (contd…)
18Kapur, V.K., Auckley, D.H., Chowdhuri, S., Kuhlmann, D.C., Mehra, R., Ramar, K. and Harrod, C.G., 2017. Clinical practice guideline for diagnostic testing for
adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med, 13(3), pp.479-504.
19. Polysomnography
▪ Polysomnography, a type of sleep
study, is a multi-parametric test
used in the study of sleep and as
a diagnostic tool in sleep
medicine.
▪ Nocturnal, laboratory-based
polysomnography (PSG) is the
most commonly used test in the
diagnosis of obstructive sleep
apnea syndrome (OSAS)
19
21. Management of OSA
▪ OSA is a chronic disease that requires long-term,
multidisciplinary management.
▪ The goals of therapy are to: reduce or eliminate
apneas, hypopneas, and oxyhemoglobin
desaturation during sleep and thereby improve
sleep quality and daytime function.
21
22. Management of OSA
Several international organizations have published
clinical practice guidelines for the management of
OSA in adults, including:
o American Academy of Sleep Medicine (AASM),
o American Thoracic Society (ATS)
o American College of Physicians (ACP)
o International Geriatric Sleep Medicine Force
The recommendations discussed below are generally
consistent with these guidelines.
22
24. Management of OSA
Patient education:
▪ Management begins with patient education.
▪ Importantly, patients should be warned about the
increased risk of motor vehicle accidents
associated with untreated OSA and the potential
consequences of driving while sleepy.
24
25. Management of OSA
Patient education:
▪ Importantly, all patients should be warned about the
increased risk of motor vehicle accidents associated
with untreated OSA and the potential consequences of
driving or operating other dangerous equipment while
sleepy.
▪ Patients should also be counseled to avoid activities
that require vigilance and alertness if sleepy.
25Strohl KP, Brown DB, Collop N, et al. An official American Thoracic Society Clinical Practice Guideline: sleep apnea, sleepiness, and driving risk in
noncommercial drivers. An update of a 1994 Statement. Am J Respir Crit Care Med 2013; 187:1259.
26. Management of OSA
Behavior modification:
▪ Behavior modification is indicated for most
patients who have OSA.
This includes:
losing weight & exercising
changing the sleep position (if OSA is positional),
abstaining from alcohol
avoiding certain medications (benzodiazepines, barbiturates,
antiepileptic drugs, sedating antidepressants, antihistamines, and
opiates) 26
27. Management of OSA
Behavior modification:
▪ Weight loss & exercise recommended to all patients
with OSA who are overweight or obese
▪ Weight loss (including bariatric surgery), has been
shown to improve overall health and metabolic
parameters, decrease the AHI, reduce blood pressure,
improve quality of life, and probably decrease daytime
sleepiness
27AHI: apnea-hypopnea index (the number of apneas and hypopneas per hour of sleep)
Randerath WJ, Verbraecken J, Andreas S, et al. Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J 2011; 37:1000.
28. ▪ 72 overweight patients (mean BMI 32 kg/m2) with mild
OSA (mean AHI 10 events per hour of sleep)
The patients were randomly assigned to receive:
A. a single session of general nutrition and exercise advice
B. or a more intensive program that included a low calorie
diet for three months plus nutrition and exercise
counseling for one year
Patients in group (B) had:
significantly greater weight loss (11 vs 2 kg)
reduction in the AHI (mean change from baseline, -4 vs 0.3
events per hour)
improvement in quality of life compared with the control group 28
29. CONCLUSIONS:
▪ VLCD combined with active lifestyle counseling
resulting in marked weight reduction is a feasible and
effective treatment for the majority of patients with mild
OSA, and the achieved beneficial outcomes are
maintained at 1-year follow-up.
29
VLCD: very low calorie diet
30. In a 2014 meta-analysis that included five small
randomized trials, a supervised exercise program
was associated with significantly improved:
AHI (mean change, -6 events/hour)
sleep efficiency
subjective sleepiness
cardiorespiratory fitness with minimal change in body
weight
30
31. Management of OSA
Behavior modification: sleep position
▪ During the diagnostic sleep study, some patients will be
observed to have OSA that develops or worsens during
sleep in the supine position.
Sleeping in a non-supine position (eg, lateral recumbent)
may correct or improve OSA in such patients and should
be encouraged but not generally relied upon as the sole
therapy
31
1. Jokic R, Klimaszewski A, Crossley M, et al. Positional treatment vs continuous positive airway pressure in patients with positional obstructive sleep apnea
syndrome. Chest 1999; 115:771.
2. Benoist L, de Ruiter M, de Lange J, de Vries N. A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent
sleep apnea. Sleep Med 2017; 34:109.
32. Management of OSA
Behavior modification: alcohol avoidance
▪ All patients with untreated OSA should avoid alcohol,
as it can depress the CNS, exacerbate OSA, worsen
sleepiness, and promote weight gain.
▪ In patients who snore but do not have OSA at baseline,
alcohol consumption can prompt frank OSA.
32
Issa FG, Sullivan CE. Alcohol, snoring and sleep apnea. J Neurol Neurosurg Psychiatry 1982; 45:353
33. Continuous positive
airway pressure
(CPAP)
▪ CPAP therapy is the
mainstay of therapy for
adults with OSA.
▪ The mechanism of CPAP
involves maintenance of a
positive pharyngeal
transmural pressure so that
the intraluminal pressure
exceeds the surrounding
pressure
33
34. Continuous positive
airway pressure
(CPAP)
▪ CPAP also stabilizes the
upper airway through
increased end-expiratory
lung volume.
▪ As a result, respiratory
events due to upper airway
collapse (eg, apneas,
hypopneas) are prevented.
34
35. Management of OSA
Positive airway pressure therapy:
▪ For patients with severe OSA (AHI ≥30 events per
hour) → positive airway pressure as initial
therapy
▪ For patients with mild to moderate OSA →
positive airway pressure as initial therapy rather
than an oral appliance (Grade 2B).
35
36. Management of OSA
Positive airway pressure therapy:
▪ For patients who anticipate problems with positive
airway pressure therapy adherence, an oral appliance
(eg, mandibular advancement devices, tongue retaining devices) is a
reasonable alternative as first-line therapy.
36
37. In a meta-analysis of 35
randomized trials,
CPAP compared with sham resulted in significant
reduction in:
AHI (mean difference -33.8 events/hour)
improved daytime sleepiness as assessed by the Epworth
Sleepiness Scale (mean difference -2 points),
systolic and diastolic blood pressure
sleep-related quality of life.
▪ No appreciable effect on mortality was reported.
37Jonas DE, Amick HR, Feltner C, et al. Screening for Obstructive Sleep Apnea in Adults: Evidence Report and Systematic Review for the US Preventive
Services Task Force. JAMA 2017; 317:415.
38. In a meta-analysis of 22
randomized trials (1160 patients)
▪ Compared nocturnal CPAP with a control (sham
CPAP, placebo tablets, or conservative
management)
Nocturnal CPAP significantly improved both
subjective and objective sleepiness, quality of life,
cognitive function, and depression
38Giles TL, Lasserson TJ, Smith BJ, et al. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006;
:CD001106.
39. Network meta-analysis of 80
randomized controlled trials
Objective:
▪ To synthesize evidence from available studies on the
relative efficacies of CPAP, mandibular advancement
device (MAD), supervised aerobic exercise training and
dietary weight loss in patients with OSA.
Results:
▪ CPAP decreased AHI the most [by 25.27 events/hour
(22.03 to 28.52)] followed by exercise training, MADs
and dietary weight loss.
39Iftikhar IH, Bittencourt L, Youngstedt SD, et al. Comparative efficacy of CPAP, MADs, exercise-training, and dietary weight loss for sleep apnea: a network
meta-analysis. Sleep Med 2017; 30:7.
40. Network meta-analysis of 80
randomized controlled trials
Conclusion and highlights of the study:
1. CPAP is the most efficacious in complete resolution of
sleep apnea.
2. Exercise training can significantly improve daytime
sleepiness.
3. Exercise training can be a useful adjunct to CPAP and
MADs.
40Iftikhar IH, Bittencourt L, Youngstedt SD, et al. Comparative efficacy of CPAP, MADs, exercise-training, and dietary weight loss for sleep apnea: a network
meta-analysis. Sleep Med 2017; 30:7.
41. Apnea-hypopnea index (AHI)
▪ AHI is calculated by dividing the number of apnea
events by the number of hours of sleep.
The AHI values for adults are categorized as:
41
Category AHI
Normal <5
Mild sleep apnea 5 to 14
Moderate sleep apnea 15 to 29
Severe sleep apnea >30
42. Patient selection for therapy
1. Patients with an AHI >5 events per hour of sleep
plus one or more clinical or physiologic sequelae
attributable to OSA.
2. Patients with an AHI ≥15 events per hour of
sleep, even in the absence of symptoms.
3. Patients with an increased number of RERAs (eg,
≥10 per hour) and excessive daytime sleepiness,
even if the AHI is ≤5 events per hour.
42
RERA: Respiratory-effort related arousal
43. Patient selection for therapy
4. Patients who perform mission critical work (eg,
airline pilots, air traffic controllers, locomotive engineers, bus
and truck drivers) and have an AHI 5 to 15, even if
there are no clinical or physiological symptoms
attributable to OSA.
The decision to initiate therapy therefore requires some
clinician judgement as well as recognition that the
driver may be poorly motivated to report symptoms.
43
44. Modes of positive airway pressure
therapy: CPAP
▪ CPAP delivers positive airway pressure at a level that
remains constant throughout the respiratory cycle.
▪ It is used most often because it is the simplest, the most
extensively studied, and associated with the most
clinical experience.
▪ A pressure relief setting (ie, lowers the positive airway
pressure at the onset of exhalation) is sometimes used
to improve comfort and tolerance of the device.
44
45. Modes of positive airway pressure
therapy: BPAP
Bilevel positive airway pressure
▪ (BPAP) delivers a preset inspiratory positive airway
pressure (IPAP) and expiratory positive airway pressure
(EPAP).
▪ The degree of pressure support and consequently tidal
volume is related to the difference between the IPAP
and EPAP.
There is no proven advantage to using BPAP instead of
CPAP for the routine management of OSA
45
46. Modes of positive airway pressure
therapy: APAP
Automatic positive airway pressure
▪ (APAP) increases or decreases the level of positive
airway pressure in response to a change in airflow, a
change in circuit pressure, or a vibratory snore (signs
that generally indicate that upper airway resistance has
changed).
▪ The degree of improvement of major outcomes
conferred by APAP and CPAP is similar
46
47. Selecting PAP
▪ For most patients with OSA, CPAP as the initial mode of
PAP is ideal (Grade 2C).
▪ Auto-titrating CPAP is a reasonable alternative in
patients with uncomplicated OSA who are diagnosed by
home sleep apnea testing, particularly if access to a
sleep laboratory is limited
▪ For patients who do not tolerate fixed CPAP, a trial of
an alternative mode of PAP before abandoning positive
pressure therapy (Grade 2C). BPAP and auto-titrating
CPAP are acceptable options. 47
48. Selecting PAP
BPAP may be preferred initial therapy in certain subgroups
of patients with OSA, like:
patients with coexisting OSA and chronic hypercapnic
respiratory failure
patients with coexisting OSA and significant central
sleep apnea.
48
49. Selecting PAP
▪ The appropriate amount of PAP is determined by
titration.
▪ This is performed during a sleep study, in order to
confirm that the amount of PAP to be prescribed
effectively eliminates respiratory events and snoring.
49
50. Pt compliance with PAP
Contributing factors include:
Patient education
Close follow-up
Treatment of complications
Comfort of the patient-device interface
Subjective success of the patient's first night using PAP
at home
Support of the patient's bed partner
50
51. Management of OSA
Pharmacological approach:
▪ A variety of pharmacologic agents have been
investigated in randomized trials as primary therapeutic
agents for the management of sleep-disordered
breathing on OSA.
▪ This includes drugs that might act to stimulate
respiratory drive directly (eg, theophylline) or indirectly
(eg, acetazolamide) or drugs that reduce upper airway
collapsibility (eg, desipramine)
51Taranto-Montemurro L, Sands SA, Edwards BA, et al. Desipramine improves upper airway collapsibility and reduces OSA severity in patients with minimal
muscle compensation. Eur Respir J 2016; 48:1340.
52. Management of OSA
Surgical management:
▪ Surgical therapy is generally reserved for selected
patients in whom positive airway pressure or an oral
appliance was either declined, not an option, or
ineffective.
▪ Examples of surgically correctable lesions that may
obstruct the upper airway include tonsillar hypertrophy,
adenoid hypertrophy, or craniofacial abnormalities
52
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Sleep Med 2009; 5:263.
2. Randerath WJ, Verbraecken J, Andreas S, et al. Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J 2011; 37:1000.
3. Senchak AJ, McKinlay AJ, Acevedo J, et al. The effect of tonsillectomy alone in adult obstructive sleep apnea. Otolaryngol Head Neck Surg 2015;
152:969.
53. Management of OSA
Surgical management:
▪ Hypoglossal nerve stimulation via an implantable
neurostimulator device is a novel treatment strategy
that may have a role in selected patients with moderate
to severe OSA who decline or fail to adhere to positive
airway pressure therapy
53
1. Eastwood PR, Barnes M, Walsh JH, et al. Treating obstructive sleep apnea with hypoglossal nerve stimulation. Sleep 2011; 34:1479.
2. Goding GS Jr, Tesfayesus W, Kezirian EJ. Hypoglossal nerve stimulation and airway changes under fluoroscopy. Otolaryngol Head Neck Surg 2012;
146:1017.
3. Schwartz AR, Barnes M, Hillman D, et al. Acute upper airway responses to hypoglossal nerve stimulation during sleep in obstructive sleep apnea. Am J
Respir Crit Care Med 2012; 185:420.
54. Conclusion:
Potential benefits of successful treatment of OSA
include:
improved quality of life
improved systemic blood pressure control
reduced healthcare utilization and costs
possibly decreased cardiovascular morbidity and
mortality
54