Diagnosis and Treatment

Sleep Apnea: Diagnosis and Treatment

Sleep Apnea

Sleep Apnea is Common Dangerous Easily recognized Treatable

Types of Sleep Disordered Breathing Apnea Cessation of airflow > 10 seconds Hypopnea Decreased airflow > 10 seconds associated with: Arousal Oxyhemoglobin desaturation

Sleep Apnea Risk Factors Obesity Increasing age Male gender Anatomic abnormalities of upper airway Family history Alcohol or sedative use Smoking Associated conditions

Diagnosis: History Snoring (loud, chronic) Nocturnal gasping and choking Ask bed partner (witnessed apneas) Automobile or work related accidents Personality changes or cognitive problems Risk factors Excessive daytime sleepiness Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95 3803.

Diagnosis: Assessing Daytime Sleepiness Often unrecognized by patient Ask family members Must ask specific questions Fatigue vs. sleepiness Auto crashes or near misses Sleep in inappropriate settings Work Social situations

Diagnosis: Physical Examination Upper body obesity / thick neck > 17 males > 16 females Hypertension Obvious airway abnormality

Why Get a Sleep Study? Signs and symptoms poorly predict disease severity Appropriate therapy dependent on severity Failure to treat leads to: Increased morbidity Motor vehicle crashes Mortality Other causes of daytime sleepiness

What Test Should be Used? In laboratory full night polysomnography Split night studies Home diagnostic systems Oximetry to full polysomnography

Polysomnography

Diagnostic Conclusions Signs and symptoms Excessive daytime sleepiness Hypertension and othercardiovascular sequelae Sleep study results Apnea / hypopnea frequency Sleep fragmentation Oxyhemoglobin desaturation

Treatment Objectives Reduce mortality and morbidity Decrease cardiovascular consequences Reduce sleepiness Improve quality of life

Behavioral Interventions Encourage patients to: Lose weight Avoid alcohol and sedatives Avoid sleep deprivation Avoid supine sleep position Stop smoking

Weight Loss Should be prescribed for all obese patients Can be curative but has low success rate Other treatment is required until optimal weight loss is achieved

Medical Interventions Positive airway pressure Continuous positive airway pressure (CPAP) Bi level positive airway pressure Oral appliances Other (limited role) Medications Oxygen 16

Positive Airway Pressure

Positive Airway Pressure

Laser Assisted Uvulopalatopharyngoplasty (LAUP) Indicated for snoring Preoperative evaluation

Uvulopalatopharyngoplasty (UPPP) Should include sleep study to rule out apnea Not a pain free procedure

Uvulopalatopharyngoplasty (UPPP) Usually eliminates snoring 41% chance of achieving AHI < 20 No accurate method to predict surgical success Follow up sleep study required

CPAP Compliance Patient report: 75% Objectively measured use > 4 hrs for > 5 nights / week: 46% Asthma medicine medicine compliance: 30%

CPAP Compliance entage day ys CPAP used Mean perc 70 60 50 40 30 20 10 1month 3 month 0 20 Minutes 4 Hours 7 hours Time CPAP used Adapted from Kribbs NB et al. Am Rev Respir Dis 1993;147.

Strategies to Improve Compliance Machine patient interfaces Masks Nasal pillows Chin straps Humidifiers Ramp Desensitization Bi level pressure

CPAP Masks

Sleep Apnea Dangerous Common Easily recognized Treatable

Sleep Apnea