Obstructive Sleep Apnea

in Adults
 SLEEP APNEA
Outline

Definition
Epidemiology
Diagnosis
Pathophysiology
Clinical Consequences
Treatment options
OBSTRUCTIVE SLEEP APNEA (OSA)

It is the intermittent cessation of breathing

during sleep due to the collapse of the
pharyngeal airway
 EPIDEMIOLOGY

• The estimated prevalence is approximately 15 % in

males and 5 % in females
• The prevalence of OSA in the USA appears to be
increasing due to rising rates of obesity.
• The prevalence of OSA also varies by race and ethnicity.

J Clin Sleep Med. 2009;5(3):263. Physiol Rev. 47:)1(90;2010

. Jan;155(1):186-92.
Am J Respir Crit Care Med. 1997
 IN SAUDI ARASBIA
Estimated “Clinically Significant” OSAS :

7.45% (M: 11.2%, F: 4.0%)

PSAISA STUDY
 Prevalence of Sleep Apnea
Percent of Population

Adapted from Young T et al. N Engl J Med 1993;328.

OBSTRUCTIVE SLEEP APNEA:

DIAGNOSIS
 Diagnosis: History

• Snoring (loud, chronic)

• Excessive daytime sleepiness
• Nocturnal gasping and choking
• Ask bed partner (witnessed apneas)
• Personality changes or cognitive problems
• Nocturia, night sweating, impotence

Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.

 Diagnosis: History
• Risk factors :
–Gender
–Obesity
–Hypertensive
–Hypothyrodism
–Ethnic factors
–Familial/genetic
–Alcohol
–Smoking Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.
 SLEEP APNEA
CLINICAL FEATURES
 SLEEP APNEA
CLINICAL FEATURES
 Diagnosis: Physical Examination

• Obese / thick neck

> 17” males

> 16” females

• Hypertension

• Obvious upper airway abnormality

 Exam: Oropharynx

Class I Class II

The
Mallampati
Class III classification Class IV
 SLEEP APNEA
CLINICAL FEATURES
 SLEEP APNEA
CLINICAL FEATURES
LABARATORY INVESTIGATION
OF
OBSTRUCTIVE SLEEP APNEA
 SLEEP APNEA
DIAGNOSIS
INITIAL LABORATORY EVALUATION

• Routine laboratory data are not helpful.

• Screen for hypothyroidism in older patients

• Polycythemia is an uncommon finding.

• An ABG if OHS is suspected.

 DIAGNOSIS

Polysomnography (PSG)
• Full polysomnography is the recommended
method of assessing patients with suspected
sleep disorders.

• It is considered the gold standard

Flemons et al. NEJM 2002;347:498

Malhotra et al. Lancet 2002;360:237
 Polysomnogram: Variables monitored
• Neurological (Sleep Stages)
 EEG (Electroencephalogram)
 EOG (Elecrooculogram)
 EMG (Electromyogram)
• Submental
• Anterior tibial
• Respiratory (Sleep disordered breathing)
 Airflow
 Respiratory effort
 Oxygen saturation
 Upper airway sounds
• Cardiac (Sleep cardiac disrhythmias)
 ECG (Electrocardiogram)
 Derived Measures From
Full Polysomnography

Apnea: A drop in the flow by > 90%  10 sec.

Hypopnea:
 A reduction in airflow (>30%) for  10 sec

 with either >3% desaturation or EEG

arousal

AASM SCORING MANUAL, Version 2.0

apnea
hypopneas
 90 Second-long Obstructive Apnea

Flow

93 %

53 %

30 Sec. 30 Sec. 30 Sec.

 SLEEP APNEA
DIAGNOSIS

OSA is confirmed on PSG if :

 AH1  5 with symptoms or signs of

disturbed sleep

 AH1  15 regardless of symptoms

American Academy of Sleep Medicine. International classification of sleep disorders, 2nd ed:
Diagnostic and coding manual, American Academy of Sleep Medicine, Westchester, IL 2005.
 SLEEP APNEA
Severity of OSAS

1. Mild (AHI of 5-15)

2. Moderate (AHI of 15-30)

3. Severe (AHI of >30)

American Academy of Sleep Medicine. International classification of sleep disorders, 2nd ed:
Diagnostic and coding manual, American Academy of Sleep Medicine, Westchester, IL 2005.
 THE STOP-BANG QUESTIONNAIRE
Anesthesiology 108, 812-821. 2008.

1. Snoring
Do you snore loudly (louder than talking or loud enough to be heard
through closed doors)?
Yes No
2. Tired
Do you often feel tired, fatigued or sleepy during the daytime?
Yes No
3. Observed
Have you been observed to stop breathing while asleep?
Yes No
4. Blood pressure
Do you have or are you being treated for high blood pressure?
Yes No
 THE STOP-BANG QUESTIONNAIRE
Anesthesiology 108, 812-821. 2008.

5. BMI -
BMI more than 35kg/m2?
Yes No
6. Age -
age over 50 years?
Yes No
7. Neck cimrcumferce
- neck circumference greater than 40 cm?
Yes No
8. Gender
– gender – male?
Yes No
THE STOP-BANG QUESTIONNAIRE
Anesthesiology 108, 812-821. 2008.

• High risk of OSA –’ yes’ to three or more

items.

• Low risk of OSA – ‘yes’ to less than three

items
 SLEEP APNEA
PATHOPHYSIOLOGY

The Pharynx is smaller and more

compliant
 SLEEP APNEA
PATHOPHYSIOLOGY

• When breathing in, the intra-luminal

pressure becomes negative and so the
pharyngeal walls are sucked in
• When awake, this is overcome by the action
of the opening (dilating) forces
 SLEEP APNEA
PATHOPHYSIOLOGY
During sleep:
Muscle tone throughout the body decreases,
including dilator muscles

Collapsing Forces > Dilating Forces

Pharyngeal Narrowing
Douglas et al. Lancet 1994;344:653
White et al. Lancet 2002;360:237
 Pathophysiological Effects

↓ Airway
Sleep Apnea
Tone
Hypoxia
Oxygenation

Plural
Re-

Pressure
swings

Ventilation
Re-establish Arousal
Airway Tone Sympathetic
Activation
 Clinical Consequences
OSA

Sleep fragmentation,
Hypoxia / Hypercapnia

Excessive daytime Cardiovascular

sleepiness Complications

Morbidity
Mortality
 Clinical Consequences
OSA

Sleep fragmentation

Excessive daytime Cardiovascular

sleepiness Complications

Morbidity
Mortality
 OSA Consequences:
Excessive Daytime Sleepiness

• Increased motor vehicle crashes

• Increased work-related accidents
• Depression
• Family discord
• Decreased quality of life
 Sleep Disordered Breathing with Excessive
Daytime Sleepiness is a Risk Factor for Mortality
in Older Adults

Sleep. 2011 April 1; 34(4): 435–442.

 Clinical Consequences
OSA

Sleep fragmentation,
Hypoxia / Hypercapnia

Excessive daytime Cardiovascular

sleepiness Complications

Morbidity
Mortality
 Intermediary Mechanisms Associated with OSA
that Potentially Contribute to Risk of CVD
Risk of Cardiovascular
Intermediary Diseases
Mechanisms
Obstructive Sleep
Apnea Sympathetic Activation Hypertension
Increased Catecholamines
Vasoconstriction
Congestive Heart Failure
Hypoxemia
Tachycardia
Reoxygenation Impaired Cardiovascular Cardiac Arrhythmia
Hypercapnia Variability
Intrathoracic Endothelial Dysfunction Cardiac Ischemia
Pressure Changes Vascular Oxidative Stress Cerebrovascular Disease
Arousals
Inflammation

Shamsuzzaman, A. S. M. et al. JAMA 2003;290:1906-1914.

 Cardiovascular Consequences:
Hypertension
Prospective Study of Association Between OSA
and Hypertension over 4 years
(700 patients) Adjusted
3 for age,
2.5 sex, BMI,
2 neck
Odds 1.5 circ.,
Ratio 1 cigs.,
0.5 ETOH,
0 baseline
0 0.1 - 4.9 5 - 14.9 > 15 Htn
Apnea / Hypopnea Index (AHI)
Adapted from Peppard PE et al. N Engl J Med 2000;342.
 Hazard Ratios for Incident CHF
1.8
Men
1.6

• A prospective
1.4
cohort study of
1.2 1927 men and
Women 2495 women
1 without baseline
heart failure
0.8
• Followed for a
0.6 median of 8.7
years after
0.4
baseline PSG
0.2

0 AHI Gottlieb et al. Circulation 2010, 122:352-360:

 OSA is a Risk Factor for CHF

CONCLUSION
Among men, OSA appeared to be associated
with an increased risk of developing heart
failure, even after adjustment for potential
confounders.
Association of Nocturnal Arrhythmias with
Sleep-disordered Breathing
The Sleep Heart Health Study

Am J Respir Crit Care Med. 2006 April 15; 173(8): 910–916.

 Incident CAD and OSA

12 year
follow-up

Treated with CPAP All Men

No CPAP

N=1651

Marin, Lancet 2005

 OSA and Heart Attacks

Conclusion
OSA increases the risk of fatal and non-
fatal cardiovascular events and CPAP
treatment may reduce this risk
Mortality Risk With Untreated Sleep-
Disordered Breathing (n=1396)

Young et al, Sleep. 2008; 31(8): 1071–1078

Sleep Apnea as an Independent Risk
Factor for All-Cause Mortality
The Busselton Health Study

Sleep. 2008; 31(8): 1079–1085

 Sleep Apnea and All-Cause Mortality in
SHHS
1.0
Survival Probability

0.9

Apnea-hypopnea index
0.8
(events/hr)
< 5.0
5.0 – 14.9
15.0 – 29.9
> 30.0
0.7
0 1 2 3 4 5 6 7 8 9 10
Years
Numbers at risk: 6294 6205 6110 6001 5868 5732 5566 5411 4756 2357 300
Total Deaths: 0 59 143 241 359 478 616 757 875 989 1046
Punjabi et al, PLOS Med 2009
Frequency of Sleep Apnea in Stroke and
TIA Patients: A Meta-analysis

CONCLUSIONS
- SDB is very common in stroke patients.
- Sleep studies should be considered in all
stroke and TIA patients.

J Clin Sleep Med 2010;6(2):131-137.

Obstructive Sleep Apnea–Hypopnea and Incident Stroke

The Sleep Heart Health Study

Sleep Apnea and Stroke in Men

Covariate Unadjusted Fully-Adjusted
Quartile of OAHI

IV: 19.13 – 164.5 3.91 (1.55 – 9.86) 2.86 (1.10 – 7.39)

III: 9.50 – 19.12 2.35 (0.89 – 6.20 ) 1.86 (0.71 – 4.95)

II: 4.05 – 9.49 1.96 (0.71 – 5.40) 1.86 (0.67 – 5.12)

I: 0.00 – 4.04 1.00 1.00

Am J Respir Crit Care Med 2010 Jul 15;182(2):269-77

Obstructive Sleep Apnea–Hypopnea and Incident Stroke

The Sleep Heart Health Study

Sleep Apnea and Stroke in Women

Covariate Unadjusted Fully-Adjusted
Quartile of OAHI
IV: 19.13 – 164.5 3.91 (1.55 – 9.86) 1.21 (0.65 – 2.24)
III: 9.50 – 19.12 2.35 (0.89 – 6.20 ) 1.20 (0.67 – 2.16)
II: 4.05 – 9.49 1.96 (0.71 – 5.40) 1.34 (0.76 – 2.36)
I: 0.00 – 4.04 1.00 1.00
Association of incident obstructive sleep apnoea
with outcomes in a large cohort of US veterans

OSA- OSA+, CPAP-

OSA+, CPAP+
Molnar MZ, et al. Thorax 2015;70:888-895. doi:10.1136/thoraxjnl-2015-206970
Obstructive Sleep Apnea:
Treatment
 SLEEP APNEA
TREATMENT OPTIONS

• Behavioral
• Mechanical
• Surgical
 SLEEP APNEA
TREATMENT OPTIONS

BEHAVIORAL:
• Weight loss
• Body positioning
• Avoidance of CNS Depressants
• Avoidance of upper airway irritants
 SLEEP APNEA
TREATMENT OPTIONS

BEHAVIORAL:
• Weight loss
• Body positioning
• Avoidance of CNS Depressants
• Avoidance of upper airway irritants
 SLEEP APNEA
TREATMENT OPTIONS
BEHAVIORAL:WEIGHT LOSS
• The cornerstone of treatment in every
overweight patient
• Can be curative
• A 10-15% reduction in weight can be
associated with a 50% reduction in number
of apnea.
• Decreases upper airway collapsibility.
 SLEEP APNEA
TREATMENT OPTIONS
BEHAVIORAL:WEIGHT LOSS

• Unfortunately weight loss is difficult to

achieve and maintained
• Apnea may recur in spite of maintained
weight loss on long-term follow-up
 SLEEP APNEA
TREATMENT OPTIONS

BEHAVIORAL:
• Weight loss
• Body positioning
• Avoidance of CNS Depressants
• Avoidance of upper airway irritants
SLEEP-POSITION
TRAINING
 SLEEP APNEA
TREATMENT OPTIONS

BEHAVIORAL:
• Weight loss
• Body positioning
• Avoidance of CNS Depressants
• Avoidance of upper airway irritants
 SLEEP APNEA
TREATMENT OPTIONS

BEHAVIORAL:
• Weight loss
• Body positioning
• Avoidance of CNS Depressants
• Avoidance of upper airway irritants
 SLEEP APNEA
TREATMENT OPTIONS
BEHAVIORAL:
AVOIDANCE OF CNS DEPRESSANTS
 Alcohol
 Sedative hypnotics

 Narcotics

 Anesthetics

 Sedative antihistamines
 SLEEP APNEA
TREATMENT OPTIONS

BEHAVIORAL:

• Weight loss
• Body positioning
• Avoidance of CNS Depressants
• Avoidance of upper airway irritants
 SLEEP APNEA
TREATMENT OPTIONS
MECHANICAL

• Continuous Positive Airway Pressure

(CPAP)

• Dental Appliances
 SLEEP APNEA
TREATMENT OPTIONS
MECHANICAL: CPAP

Mechanism of Action:
• Acts as a pneumatic splint to prevent
airway collapse
 SLEEP APNEA
TREATMENT OPTIONS
MECHANICAL: CPAP
• Initial treatment of choice in patients with
moderate to severe obstructive sleep apnea.
• Required pressure must be individually
determined.
• Long-term compliance is 60-70%.
Wali and Kryger. Cur opin Pulm Med 1995;1:498
 BENEFITS OF CPAP:
PERFORMANCE

35

30

25

20

15

10

0
Before CPAP After CPAP No Apnea

Adapted from Findley L et al. Clin Chest Med 1992;13.

 EFFECT OF CPAP ON
HYPERTENSION

• Effective treatment of OSA with nasal

CPAP for 9 weeks lowered nocturnal
and daytime systolic and diastolic BP
by approx.10 mmHg

Becker et al, Circulation 2003;107

 EFFECT OF CPAP ON
HYPERTENSION

A Standard of practice paper of American

Academy of Sleep Medicine recommends:

CPAP as an adjunctive treatment for

Hypertension in patients with Obstructive
Sleep Apnea
Sleep 2006;29,375
CPAP Reduces Fatal &
non-Fatal CV Events

Lancet 2005; 365: 1046-53

 SLEEP APNEA
TREATMENT OPTIONS
MECHANICAL: ORAL APPLIANCES
• These are devices designed to improve upper
airway patency during sleep.
• Enlarge pharyngeal airway and prevent
collapse.
• Some protrude the mandible forward.
• Others hold the tongue in a more anterior
position.
ORAL APPLIANCES
 SLEEP APNEA
TREATMENT OPTIONS
ORAL APPLIANCES

Side Effects
 Expensive
 Temporomandibular joint pain
 SLEEP APNEA
TREATMENT OPTIONS
MECHANICAL: ORAL APPLIANCES

Efficacy:
Trials revealed that it is effectiveness in mild-
moderate OSA

Thorax 1997; 52:362

Chest 2002;121:739
 SLEEP APNEA
TREATMENT EFFICACY
NASAL CPAP Oral Appliances
RCT less RCT
AHI   
Sleepiness  
Quality of life  
Driving Ability  X
Cognition  X
Depression  X
Blood Pressure  X
Blood Glucose  X
Mortality X X
 SLEEP APNEA
TREATMENT EFFICACY
The American Academy of Sleep
Medicine recommends offering positive
airway pressure therapy to all patients
who have been diagnosed with OSA.

J Clin Sleep Med. 2009;5(3):263.

 POLYSOMNOGRAPHY
Who should be
treated ?
AHI <5 AHI 5 -14 AHI >15

Symptoms A Trial of
No Treatment or Sequellae CPAP

Mission Critical NO YES

Worker?

A Trial of A Trial of
NO Treatment
CPAP CPAP

International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014
 SLEEP APNEA
TREATMENT OPTIONS

Who should receive non-CPAP treatments?

 Individuals with mild OSA

 Oral Appliances or Conservative Measures

 Individuals who refuse or failed PAP treatment

 Oral Appliances or Surgery

 Individuals with reversible causes
 Surgery Malhotra and White. Lancet 2002;360:237
 Upper Airway Surgery

• Most effective in OSA due to a severe, surgically

correctable, obstructing lesion.

• There is no consensus regarding the role of

surgery.

• No optimal screening or imaging procedures.

• Surgical therapy is considered when PAP or an oral

appliance is declined or ineffective
 Surgical Options

• Tracheostomy
• Maxillomandibular advancement
• Uvulopalatopharyngoplasty –
• Multi-level or stepwise surgery
• Laser assisted uvulopalatoplasty
• Radiofrequency ablation
This device was approved by the US Food
and Drug Administration in April 2014.
 SLEEP APNEA
CLINICAL PEARLS

• OSAS is a common disorder and should be

part of the systemic review
• OSAS should be suspected in a patient
who is obese, hypertensive, snorer, and
sleepy
• PSG is the recommended diagnostic
method
 SLEEP APNEA
CLINICAL PEARLS
Untreated sleep apnea is associated with:
• Car accidents.
• Increased prevalent and incident of
hypertension.
• Increased incident of CAD & CHF.
• Cardiac arrhythmia and sudden death.
• Stroke.
• All cause mortality.
 SLEEP APNEA
CLINICAL PEARLS

• CPAP is the treatment of choice

• Oral appliances are reasonable alternatives

 SLEEP APNEA
CLINICAL PEARLS

• Surgical therapy is generally reserved for

selected patients in whom:

 PAP or an oral appliance was either

declined, not an option, or ineffective.
 SLEEP APNEA
CLINICAL PEARLS

• A notable exception is patients whose OSA

is due to a surgically correctable
obstructing lesion.
Thank You