Sle e p Apne a T he No t so Sile nt Kille r Dominic A. Munafo, - PowerPoint PPT Presentation

Sle e p Apne a… T he No t so Sile nt Kille r Dominic A. Munafo, Jr., M.D., F.ABSM Chief Medical Officer

T oday’s Goals  Wha t is o b struc tive sle e p a pne a (OSA)  Unde rsta nd dia g no sis a nd tre a tme nt  Unde rsta nd the b a sic pa tho physio lo g y  K no w thre e c o nditio ns hig hly a sso c ia te d with OSA

What is Obstr uc tive Sle e p Apne a (OSA) I nsidio us c o nditio n o f re pe titive pa rtia l o r c o mple te a irwa y c o lla pse during sle e p F re que ntly a ssoc ia te d with: o b e sity • dia b e te s • he a rt dise a se •

T he Obstr uc te d Air way

um o f Dise a se Spe c tr • Sno ring • Uppe r Airwa y Re sista nc e Syndro me - (UARS) • Sle e p Apne a – Ob struc tive – Ce ntra l • Ob e sity Hypo ve ntila tio n Syndro me - (OHS)

Pulmo na ry Dise a se a nd Obe sity Obesity Simple Obesity Obesity Hypoventilation Eucapnic Exercise intolerance Hypercapnic Frequent OSA Dyspnea on exertion Frequent OSA Likely increased Increased post-op risk Abnormal respiratory drive 1. pneumonia respiratory drive 2. atelectasis

Sc ope o f the Pro b le m • 20 - 30 millio n Ame ric a ns • Wisc o nsin sle e p c o ho rt study – 626 sub je c ts a g e 30-60 – AHI > 5 in 9% o f wo me n – AHI > 5 in 24% o f me n Yo ung T , N E ng l J Me d 1993;328

Sc ope o f the Pro b le m • OSA Pr e vale nc e in othe r dise ase state s – Ob e sity – 75% – T ype I I DM – 72% (mo de ra te & se ve re – 66%) – Hype rte nsio n – 50 to 75% – CAD & A. F ib . – 50% – CHF – 50 to 75% – De pre ssio n – 40 to 45%

Obstr uc tive Sle e p Apne a • Most c ommon symptoms – L o ud sno ring – Witne sse d a pne a – E xc e ssive da ytime sle e pine ss – Wa king up c ho king & g a sping – Co g nitive impa irme nt

Obstr uc tive Sle e p Apne a Most c ommon signs • – Ob e sity – Ne c k size ≥ 17 men ≥ 16 women – Na so pha ryng e a l na rro wing – Ma xillo -ma ndib ula r a no ma lie s – Hype rte nsio n – Stro ke – He a rt fa ilure

How to Diagnose Ob struc tive Sle e p Apne a Clinic a l suspic io n • Co nsiste nt sig ns a nd sympto ms • Ove rnig ht sle e p study lo o king • fo r re spira to ry e ve nts (HST o r PSG)

Wha t a re Re spir ator y E ve nts Apne a – no a irflo w ≥ 10 seconds Hypopne a – reduced airflow ≥ 10 se c o nds, usua lly a sso c ia te d with o xyg e n de sa tura tio n o r e vide nc e o f a ro usa l

Diagnosing OSA

Co nse q ue nc e s o f Untre a te d OSA Wo lk, R. e t a l. Circ ula tio n 2003;108:9-12

Co nse q ue nc e s o f Untre a te d OSA L e ung , e t a l. Am J Re spirCrit Ca re Me d 2001;164:2147-65

Co nse q ue nc e s o f Untre a te d OSA 0 - 50 0 150 200 150 Baseline Phenylephrine OSA Calculation of LV transmural pressures 150 - 0 = 150 200 - 0 = 200 150 - (- 50) = 200

Co nse q ue nc e s o f Untre a te d OSA 0 - 50 + 10 150 200 150 Phenylephrine – α 1 agonist CPAP = 10 OSA Calculation of LV transmural pressures 150 - 10 = 140 200 - 0 = 200 150 - (- 50) = 200

E ffe c ts o f the Supine Position • V/ Q misma tc h • Shunting • L ung b a se s we ll pe rfuse d b ut po o rly ve ntila te d • Re duc e d lung vo lume s

E ffe c ts o f the Supine Position Pra c tic a l c o nse q ue nc e • during g e ne ra l a ne sthe sia – Mo re ra pid de c line in o xyg e n sa tura tio n during a pne a , < 2 minute s vs. 6 minute s whe n b re a thing 100% o xyg e n

ity Sc ale o f OSA Se ve r • Apne a Hypopne a Inde x - (AHI) – Mild sle e p a pne a - 5 – 15 e ve nts / ho ur – Mo de ra te sle e p a pne a - 16 – 30 e ve nts / ho ur – Se ve re sle e p a pne a - > 30 e ve nts / ho ur • Who to T re a t ? – AHI ≥ 30 5 - 29 ⇒ if sympto ma tic o r if c o -mo rb iditie s pre se nt – AHI

Co nse q ue nc e s o f Untre a te d OSA OSA is assoc iate d with: No c turna l b lo o d pre ssure e le va tio n • • I nde pe nde nt risk fa c to r fo r hype rte nsio n Cha ng e s in L V g e o me try a nd func tio n • Me ta b o lic Syndro me •

Ultima te Conse que nc e s I nc re a sing pre va le nc e o f c hildho o d o b e sity a nd it’ s c o mplic a tio ns c o uld a c tua lly re sult in the c urre nt g e ne ra tio ns o f c hildre n living le ss we ll and fo r a time tha n pre vio us g e ne ra tio ns sho r te r * Da nie ls, F uture Child. 2006 Spring ;16(1):47-67

e atme nt Options fo r OSA T r • Pe rma ne nt we ig ht lo ss • Co ntinuo us po sitive a irwa y pre ssure (CPAP) • Ora l a pplia nc e s • Ora l a nd/ o r ma xillo -fa c ia l surg e rie s • T ra c he o sto my

CPAP T he r apy for OSA Applie d via na sa l ma sk • Ac ts a s pne uma tic splint • Co mplia nc e limits utility • Ma sk fit c ruc ia l •

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