Sleep Apnea

Dr. Vishal Sharma

 History
• Lugaresis (1970): described OSAS

• Stanford University (1972): Polysomnography

• Sleep Latency Test devised in 1976

• Before 1980’s tracheostomy main treatment

• Ikematsu performed first UPPP in 1952

• Fujita popularized UPPP

• Kamami developed LAUP in late 1980s

Definitions
Sleep related breathing disorders
Synonym: sleep disordered breathing

Consists of:

A. Snoring

B. Obstructive sleep apnea

C. Obstructive sleep hypopnea

D. Upper airways resistance syndrome

Arousal: Abrupt change from deep stage to lighter
stage of NREM sleep, or from REM sleep to awakening
Arousal index: Number of arousals per hour of sleep

Apnea: Cessation of breathing for > 10 seconds

Apnea Index: Number of apneas per hour of sleep

Hypopnea: Decreased airflow (>50%) with oxygen

desaturation (> 4% ) for > 10 seconds

Snoring: breathing noise due to partial upper airway

obstruction
Obstructive sleep apnea: Cessation of airflow for > 10

seconds even with continued respiratory effort

Obstructive sleep hypopnea: Decreased airflow

(>50%) with oxygen desaturation (> 4% ) for > 10

seconds even with continued respiratory effort

Upper airway resistance syndrome (respiratory

effort related arousal): partial airway obstruction with

no apnea or hypnea, but arousal index > 15

Respiratory Distress Index:

Number of apneas + hypopneas + respiratory effort

related arousals per hour

Obstructive sleep apnea syndrome:

30 or more episodes of obstructive sleep apnea

during a 7- hour period of sleep

or apnea index > 5

or respiratory distress index > 15

 Types of sleep apnea

1. Obstructive: Normal respiratory chest wall

movement

2. Central: No respiratory chest wall movement

3. Mixed: Partial respiratory chest wall movement

 Grades of sleep apnea

American Sleep association grading:

1. Mild ------------ 5 - 20 apneas per hour

2. Moderate ----- 20 - 40 apneas per hour

3. Severe -------- more than 40 apneas per hour

Etiology of central
sleep apnea
• Cheyne-Stokes breathing-central sleep apnea
due to renal failure, heart failure, stroke
• Diabetes mellitus, Hypothyroidism, Acromegaly,
Parkinson disease, Myasthenia gravis, Idiopathic
cardiomyopathy, Muscular dystrophy
• Medullary tumor or infarction
• Arnold-Chiari malformation
• Cervical cordotomy
• High-altitude periodic breathing (at > 5000m)
• Use of opiates & other CNS depressants
Cheyne-Stokes crescendo-
decrescendo breathing
 Etiology of
obstructive sleep
apnea
Nose Pharynx

• Nasal polyps • Nasopharyngeal tumor

• DNS • Adenoids

 ed Turbinate  ed palatal / lingual tonsil

• Nasal packing • Enlarged lingual tonsils

Larynx • Retropharyngeal mass

• Tumors • Large tongue

• Edema • Micrognathia / Retrognathia

• Obesity
• Stenosis
Patho-physiology
 Increased compliance of pharyngeal tissues
+ Neuromuscular in-coordination & ed muscle tone
+ Anatomical abnormalities

Upper airway collapse  airway obstruction

Hypoxia + negative intra-thoracic pressure  Arousal

Increased tone of upper airway muscles + upper airway

obstruction clears

Patient goes to sleep

Upper airway collapses again causing arousal

Sequelae of sleep apnea
 Complications of sleep apnea
 Systemic hypertension  Coronary artery disease

 Pulmonary hypertension  Right heart failure

 Cardiac arrhythmias  Cerebro-vascular accident

 Polycythemia  Sleepiness accidents

 Depression  Impotence

 Vagal bradycardia  Sudden nocturnal death

Clinical Features
Snoring or sleep apnea?
 Symptoms of sleep apnea
Day- time
 Excessive sleepiness
 Morning headache
 Intellectual deterioration
 Personality change
 Depression
 Xerostomia
 Abnormal movements
Night- time
 Snoring
 Observed choking
 Arousal from sleep
 Repeated waking
 Nocturnal sweating
 Nocturnal enuresis
 Impotence
 Typical OSAS patient
• Synonym: Pickwickian syndrome

• Middle age or elderly male with hyper somnolence

• Obese with body mass index > 30

• Short neck with its circumference > 17 inches

• Hypertension & right heart failure

• Large bulky tongue, hypertrophied tonsils, bulky soft

palate, prominent posterior pharyngeal wall rugae
Mr. Pickwick & fat boy Joe
Throat in OSAS
 History from sleep partner
• Bed timings

• Body position

• Snoring

• Apnea (choking)

• Arousal from sleep

• Alcohol consumption

• Sedative use
Epworth daytime sleepiness scale

Score > 16 = moderate to severe sleep apnea

 Physical examination
General appearance, weight, body mass index

Blood pressure, cardiovascular examination

Cranio-facial: retrognathia, hypoplastic maxilla

Nasal: airway patency, DNS, turbinate hypertrophy

Tongue: macroglossia, lingual tonsil

Nasopharynx: adenoids, polyp, cyst, tumor

 Physical examination
Oropharynx: Soft palate, palatine tonsil, base of

tongue, posterior pharyngeal wall

Hypopharynx: tumor

Larynx: cyst, tumor, vocal cord mobility

Neck: short wide neck (circumference > 17 inches)

Thyroid enlargement, features of hypothyroidism

Investigations
 General Investigations
• Complete blood count: anemia, polycythemia

• Chest x-ray: cardiomegaly, pulmonary disorder

• Lung function: portable spirometry

flow volume loop  saw-tooth pattern

• Thyroid function tests: hypothyroidism

• Electro-cardiography: cardiac arrhythmias

• Arterial blood gas analysis

Portable spirometer
Investigations for confirmation
of sleep apnea

• Polysomnography

• Portable sleep monitoring

• Overnight pulse oximetry recording

• Multiple sleep latency test

Polysomnography parameters
1. Electro-encephalogram (EEG)

2. Electro-myogram (EMG): submental, anterior tibialis

3. Electro-oculogram (EOG) / Electro-nystagmogram

4. Electro-cardiogram (ECG)

5. Oxygen saturation 6. Nasal & oral airflow

7. Chest + abdominal movement detector

8. Sleeping position detector

9. Tracheal microphone 10. Esophageal manometer

Adult Polysomnography
Adult Polysomnography
Pediatric Polysomnography
Polysomnogram
Polysomnogram
Polysomnogram
Polysomnogram in arousal
Portable polysomnogram
Investigations to assess site
of airway obstruction
Awake patient Sleeping patient

Muller maneuver Flexible nasendoscopy

Lateral cephalometry Somno-fluoroscopy

C.T. scan of neck Cine C.T. scan

Pharyngeal manometry
Flexible endoscopy
Flexible endoscopy
 Muller’s maneuver
• After a forced expiration, pt attempts inspiration

with closed mouth & nose, whereby negative

pressure leads to collapse of airway

• Previously introduced flexible endoscope (via

nasal cavity) identifies weakened sections of

airway at levels of soft palate & tongue base,

during this maneuver

Muller’s maneuver in snoring
shows no airway narrowing

Before Muller After Muller

Muller’s maneuver in apnea
shows airway narrowing

Before Muller After Muller

Degree of airway obstruction
0 = no collapse
1+ = minimal collapse
2+ = collapse es cross-sectional area by 50%
3+ = collapse es cross-sectional area by 75%
4+ = collapse obliterates airway
3+ or 4+ score at soft palate level with 0 score at
tongue base level is ideal for UPPP
Score of > 2+ at tongue base level is not suitable for
Uvulo-palato-pharyngo-plasty (UPPP)
 Muller’s Oropharynx Hypopharynx
obstruction obstruction obstruction
types (soft palate) (tongue base)

I 3+, 4+ 0, 1+

II a 3+, 4+ 1+, 2+

II b 3+, 4+ 3+, 4+

III 0, 1+ 3+, 4+
Lateral cephalometry
Lateral cephalometry
 Lateral cephalometry

Measurements in obstructive sleep apnea:

• Posterior airway space (PAS) or narrowest width

of hypopharynx is < 5 mm

• Distance b/w mandibular plane to hyoid bone

(MP-H) is > 24 mm
 Somno-fluoroscopy
Sleeping pt observed with polysomnography &

during apneic episode visualized with fluoroscopy

for upper airway obstruction

• Type I = obstruction at soft palate level only

• Type II = obstruction at soft palate level followed

by obstruction at tongue base level

• Type III = obstruction at tongue base level

Cine C.T. scan:
• Rapid CT scanning of 8 cm of upper airway in 240

msec during apneic episode to study anatomical

changes during apneic episode. Research tool.

Pharyngeal manometry:
• Measurement of intra-luminal pressure at level of

soft palate, tongue base & hypopharynx

 D/D of excessive daytime
sleepiness (hyper somnolence)
 Sleep apnea syndrome  Narcolepsy

 Sleep deprivation  Hypoglycemia

 Hypothyroidism  Severe anemia

 Cerebral tumors  Depression

 Sedative drugs  Nocturnal myoclonus

 Idiopathic
 Non-surgical Tx for OSAS
• Lifestyle modifications

• Sleep hygiene

• Medications

• Nasal valve dilator

• Positioning device

• Nasal positive airway pressure device

 Lifestyle modifications
Weight reduction for obese patients

• Body mass index = weight in kg / (height in metres) 2

• Ideal BMI: male < 27.8; female < 27.3

Stop smoking

Stop alcohol consumption

Avoid sedative drugs

 Sleep hygiene
• Elevate head-end of bed by 300: decreases

pressure of abdominal contents on diaphragm

& improves upper airway patency

• Avoid lying supine: T-shirt with tennis ball at

back

• Avoid sleep deprivation

• Have regular sleep cycle

 Medications
• Amitriptyline & Protriptyline:

suppress REM sleep, respiratory stimulant,

increase pharyngeal muscle tone

• Nasal decongestant, antihistamine, steroid spray

• Fenfluramine to reduce obesity

• Thyroxin for hypothyroidism

 Nasal valve dilator

Adhesive strip placed over bridge of nose at bedtime

 Nasal valve dilator

Plastic spring ends inserted into nostrils

Nasal valve dilator
 Positioning devices

• Tongue retaining device

• Mandibular advancement device

• Optimized mandible retention

• Thornton adjustable positioner

Effect of positioning devices
Mandible advancement device
Tongue retaining device

Prevents falling back of tongue

Optimized mandible retention
Thornton adjustable positioner
Positive airway pressure devices
• Gold standard treatment

• Prevents apneas in 99-100% patients

• C.P.A.P.: Continuous positive airway pressure

• Bi.P.A.P.: Bi-level positive airway pressure (less

pressure given during expiration)

• A.P.A.P.: Automatic positive airway pressure

(adjusts pressure breath by breath)
Continuous positive airway pressure
Continuous positive airway pressure
Continuous positive airway pressure
Continuous positive airway pressure
Continuous positive airway pressure
Continuous positive airway pressure
Continuous positive airway pressure
Polysomnogram before CPAP
Polysomnogram after CPAP
 Surgical Tx of OSAS
1. Nasal surgery

2. Palatal surgery

3. Tongue base surgery

4. Maxillo-facial surgery

5. Tracheostomy: last resort, 100% cure; relieves

all levels of airway obstruction

Nasal & nasopharyngeal surgery
More effective for snoring than sleep apnea

1. Septo-turbinoplasty

2. Radio-frequency turbinate somnoplasty

3. Nasal polypectomy

4. Nasal valve reconstruction

5. Nasal mass excision

6. Adeno-tonsillectomy
 Somnoplasty
• Small probe delivers radiofrequency energy into

tissue bulk, causing coagulative lesions which

shrink on healing

• Body absorbs these lesions over 4-8 weeks

leading to tissue volume reduction

• Used for enlarged base of tongue / soft palate /

turbinates causing snoring / sleep apnea

Turbinate Somnoplasty
 Palatal Surgery
Relieve palato-pharyngeal level obstruction

1. Uvulo-palato-pharyngo-plasty (UPPP)

2. Laser-assisted Uvulo Palato-plasty (LAUP)

3. Radio-frequency uvulo-palato-plasty (RFUP)

4. Uvulo-palatal flap

5. Lateral pharyngoplasty

6. Palatal stiffening operations

Uvulo Palato Pharyngo Plasty
Uvulo Palato Pharyngo Plasty
• Remove palatine tonsils

• Trim tonsillar pillars (optional)

• Remove uvula & variable amount of soft palate

• Suture posterior tonsillar pillar to anterior

tonsillar pillar

• Suture posterior soft palate mucosa to anterior

soft palate mucosa
Uvulo-palato-pharyngo-plasty
Uvulo-palato-pharyngo-plasty
Post excision & suturing
Structures removed in UPPP
Uvulo-palato-pharyngo-plasty
Post-UPPP healing
Laser-assisted uvulopalatoplasty
Laser-assisted uvulopalatoplasty
Soft palate Somnoplasty
Soft palate Somnoplasty
Soft palate Somnoplasty
Uvulo-palatal flap
Lateral Pharyngoplasty
Lateral Pharyngoplasty
 Palatal stiffening surgery
Done primarily for snoring

• Injection of sclerosing agents into soft palate

• Laser-assisted palatal stiffening operation:

longitudinal strip of palatal mucosa removed

lesion heals by scarring

• Cautery-assisted palatal stiffening operation

• Pillar procedure
Pillar procedure
Pillar procedure
 Tongue base surgery
1. Radiofrequency tongue base somnoplasty

2. Submucosal Minimally Invasive Lingual Excision

or Coblation tongue base ablation

3. Laser–assisted tongue base ablation

4. Lingual tonsillectomy

5. Linguloplasty

6. Tongue base suspension

Tongue base Somnoplasty
Coblation partial glossectomy
Coblation partial glossectomy
Coblation lingual tonsillectomy
Linguloplasty
Tongue base suspension
Tongue base suspension
Tongue base suspension
 Maxillofacial Procedures
Relieve tongue base level obstruction

1. Maxillo-mandibular osteotomy & advancement

2. Genioglossus advancement

3. Maxillary expansion

4. Mandibular expansion

5. Infra-hyoid myotomy & superior suspension

6. Supra-hyoid myotomy & anterior advancement

Mandibular advancement
Maxillo-mandibular advancement
Genioglossus advancement
Genioglossus advancement
Maxillary expansion
Mandibular expansion
Infra-hyoid myotomy + superior
suspension to mandible
Supra-hyoid myotomy & anterior
advancement to thyroid cartilage
Tracheostomy
Treatment of central sleep apnea
• Acetazolamide: induces metabolic acidosis &

increases baseline ventilation

• Theophylline: respiratory stimulant

• Zolpidem: sedative hypnotic, consolidates sleep

• Continuous positive airway pressure

• Adaptive servo ventilation: provides a fixed CPAP

of 5 cm water. Better than nasal CPAP.

Thank You