Obstructive Sleep Apnoea

Burwell coined the term PICKWICKIAN syndrome Obesity + Hypersomnolence + Pulmonary

Hypoventilation + Cor Pulmonale.
Ideal Night sleep is 7.5 to 8.5 hrs
Sleep is a reversible behavioural state of perceptual disengagement from and unresponsiveness to
the environment.
REM and Non REM sleep effects respiratory drive, stability and ventilator mechanisms (decreased).

IMPACT OF SLEEP ON RESPIRATION

REM NREM stage 1 and 2 NREM stage 3 and 4

Irregular breathing Periodic Stable
Diaphragm active but Ribcage
and upper airway muscles All diaphragm, ribcage and upper airway muscles active
inactive
Apnoea Short, central Short central Rare
Decreased as compared to Less than stage 1,2 but better
Least chemoresponsiveness
wakefulness than REM
Arousability to respiratory
Arousability to respiratory stimuli Low Thresholds
stimuli High threshold

Arousal requires immediate cortical and reticular activation via increased respiratory drive, level of
ventilation, activation of cough reflex, activation of upper airway dilator and abductor muscles.
REM – 20 % whereas NREM is 80 %
APNOEA >10 sec cessation of respiration during sleep leading to arousal.
HYPOPNEIC EVENT Decrease in airflow in asso with Oxyhaemoglobin desaturation.
APNOEA INDEX No of apneas occurring per hr of sleep.
RDI = Respiratory Disturbance Index aka Apnoea/Hypopnoea index i.e. no of both apneas and
hypopnoeas occurring per Hr of sleep.
RERA Absence of apnoea / hypopnoea with a 10 sec or more of progressive negative esophageal
pressure (Pes), culminating in arousal.

Sleep Disorders
Respiratory and Non respiratory sleep disorders.
Respiratory Sleep Disorders include 4 Syndromes
1. OSAH (Obstructive sleep apnoea/hypopnoea)
2. Central Sleep Apnoea/hypopnoea
3. Cheyne Stokes breathing
4. Sleep hypoventilation
Obstructive Sleep Apnoea is constituent of Sleep Apnoea Syndrome (Obstructive, Central & Mixed)
 Sleep Apnoea syndrome is defined as 30 or more apnoeic episodes during a 7 hour period of
sleep or an apnoea index equal to or greater than 5.
3 types of Sleep apnoea syndrome :
Mild Apnoea index 5 to 20/hr
Moderate 20 – 40/hr
Severe > 40/hr
OBSTRUCTIVE SLEEP APNOEA defined as 5 or more respiratory events (apnoeas /
hypopnoeas / RERAs) per hour of sleep lasting ≥10seconds in association with excessive day time
somnolence, waking with gasping, choking, or breath holding spells or witnessed spells of apnoeas,
snoring or both,
Usually accompanied by reduction in blood oxygen saturations of atleast 3% – 4% and is terminated
by brief, unconscious arousals from sleep.
Can occur in association with other syndromes (pickwickian syndrome , central sleep apnoea, upper
airway resistance syndrome) or independently.
Pickwickian syndrome with OSA Arterial hypoxemia during wakefulness, Hypersomnolence,
pulmonary HTN, with chronic right heart failure and nocturnal hypoventilation.
Diagnosis is confirmed by demonstration of increase in PaCO2 of greater than 10mmHg during
sleep.
Snoring is usually the first manifestation of sleep disordered breathing.

EPIDEMIOLOGY AND RISK FACTORS :

Prevalence = 5%
M:F = 2:1
Obesity >120% of ideal body weight
Fat in neck plays largest role
30% of snoring males with collar size >17 have sleep apnoea.

Anatomical Abnormalities :

Obstruction due to
Nose – DNS, polyps, HIT etc
Oral cavity, Oropharynx – Elongated soft palate and uvula, tonsillitis, macroglossia, retrognathia
Hypopharynx, Larynx – Laryngeal tumours, Omega epiglottis, Laryngotracheal stenosis

IN CHIDREN :

Congenital
Acquired
Others
CONGENITAL
• Nasal Obstruction – Choanal atresia, complete
nasal agenesis, neonatal rhinitis, congenital cysts
of nasal cavity, dentigerous cysts etc