This document provides an overview of sleep disorders including sleep related breathing disorders, movement disorders, insomnias, parasomnias, hypersomnias, and circadian rhythm disorders. It discusses obstructive sleep apnea (OSA) in detail including its pathophysiology, risks of untreated OSA, diagnostic polysomnography, and treatment options like CPAP and surgery. It also covers other sleep-related issues in specialties like psychiatry, gastroenterology, dentistry, and pitfalls in diagnosing and treating sleep disorders.
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!
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!
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1. Sleep disorders – overview and pitfalls
Dr. Aditya Jindal
Interventional Pulmonologist & Intensivist, sleep specialist
Jindal Clinics
SCO 21, Sec 20D, Chandigarh
DM Pulmonary and Critical Care Medicine (PGI Chandigarh),
FCCP
2.
3.
4.
5.
6.
7.
8. Sleep disorders
1. Sleep related breathing disorders
2. Sleep related movement disorders
3. Insomnias
4. Parasomnias
5. Hypersomnias
6. Circadium rhythm sleep-wake disorders
9. Sleep related breathing disorder
• Central sleep apnea due to drug or substance
• Primary sleep apnea of infancy
• Obstructive sleep apnea
• Sleep-related nonobstructive alveolar
hypoventilation, idiopathic
• Primary central sleep apnea
• Central sleep apnea due to Cheyne Stokes
breathing pattern
• Central sleep apnea due to medical condition
not Cheyne Stokes
11. What is OSA?
OSA is a syndrome characterized by frequent
episodes of upper airway obstruction during
sleep, associated with recurrent arousals,
oxygen desaturation, and daytime symptoms
12. Pathophysiology of OSA
Interplay between three important factors
• Anatomic Structural narrowing of
airway
• Neurologic Inadequate upper airway
dilator muscle function
• Mechanical Altered upper airway
collapsibility
19. Sleep studies
• Count number of respiratory events and
divide by hours of sleep to generate AHI
Overnight polysomnography
is the ‘gold standard’ for
diagnosis of OSA
20. Sleep staging
Oronasal Flow
Snoring
Rate, rhythm
Respiratory
effort
Body position
Leg movement
SaO2
EEG
EOG
Flow sensor
EMG
Microphone
ECG
Thoracic
Abdominal
Position
EMG
Oximeter
29. Awake
Alpha rhythm-trains of sinusoidal 8-13 activity over occipital region ; attenuating
with eye opening
Eye blinks- conjugate vertical eye movementsat a frequency of .5-2hz
REM may be seen with initial deflection lasting < 500msec
Submental EMG - relatively high tone
30. NREM 1
slow eye movements: conjugate, regular , sinusoidal eye movement with
initial deflection >500 msec
vertex sharp waves
low amplitude 4-7 Hz/ mixed frequency activity
32. Sleep Spindles
• Sleep Spindle – 11-16 Hz
• .5 second spindles - 6-7
cycles
• Central - vertex region
• >.5 second in duration
33. K Complexes
• Sharp, slow waves, with a negative then
positive deflection
• No amplitude criteria
• >.5 second in duration
• Central in origin
34. NREM 3
•>20% Delta Activity ( .5-2 Hz with amplitude >75 uV)is
seen over frontal region
•no eye movements
•EOG leads will only pick up the EEG activity
•about thirty to forty five minutes after sleep onset
•far more difficult to awaken
35. Stage R
•Brain suddenly becomes much more active.
•REM-conjugate, irregular, sharply peaked eye movements with initial
deflection< 500 msec
•Low chin EMG activity
•Sawtooth waves- low amplitide sharply contoured or triangular (2-
6hz); over central head regions
46. Hypopnea This is an 18 second hypopneic event. The airflow
signal is reduced by approximately 50% during this event.
Airflow reduction
SAO2 desaturation
> effort with paradox Paradox ends
Inhale
Exhale
49. 5 Questions to Monitor CPAP
• Snoring despite CPAP?
• Weight change since CPAP started?
• When was equipment last checked?
• Still symptomatic?
• Problems?
50. CPAP Compliance
-Widely variable rates 50-70% overall
–-Probably need >4 hrs. nightly for
response
–-Compliance determined early on
51. CPAP Compliance
• Man or Machine?
– Man
• -Monitoring- Compliance feedback
• -Education/Reassurance/Reevaluation
• -Partner involvement
– Machine
• -Humidification- Warm Vs. Cold
• -Mask- Nasal Pillows, Full Face, Other
• -Blower- Bi-level, Auto-titration
• Berry RB. Sleep Med (1): 175; 2000
52. Practice points: Auto-Adjusting CPAP
• Auto-CPAP offers no benefit over fixed CPAP in terms of
efficacy on the AHI
• It has not been established that unattended auto-CPAP
titration is safe without a previous diagnostic PSG
• Some, but not all, studies indicate auto-CPAP results in a
lower cumulative CPAP level. However, the importance of the
amount of applied pressure on CPAP adherence is not
consistently demonstrated
• Auto-CPAP has variable effects on adherence
53. OSA Treatment: Surgery
• Laser-assisted uvulopalatoplasty (LAUP)
– AASM: not advised for OSA
• Uvulopalatopharyngoplasty (UPPP)
– 40% patients achieve AHI < 5
• Somnoplasty or Radiofrequency volumetric tissue
reduction (RFVTR)
– Role has yet to be fully defined
• Maxillofacial surgery
– Infrequently performed, but can be very effective
54. Radiofrequency Ablation
-Programmable levels of
radiofrequency energy delivered
by a proprietary disposable
device into upper airway
structures causing tissue necrosis
and fibrosis
-Less painful; ambulatory
procedure
-Unlikely to be singularly effective
for most OSA
-May be effective in combination
procedures
-Minimal peer-reviewed data
61. CSR
• If there is at least 3 consecutive cycles of cyclical crescendo
and decrescendo change in breathing amplitude
• + atleast one of the below :
1. 5 or more central apnea / hypopnea per hr of sleep.
2. The cyclic cresendo and decresendo change in breathing
amplitude has a duration of atleast 10 consecutive mins.
CSR has variable cycle length that is most commonly in the
range of 60 seconds.
74. Kapur et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep
apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep
Med. 2017
75.
76. Take home message
1. Have a high index of suspicion
2. In hospital/ clinic study (both diagnostic & titration)
is recommended
3. Use home sleep testing only if parameters are met
4. Be aware of sleep related non-respiratory disorders
5. Be ready to tackle problems!
