Transcript Sleep Disordered Breathing Mark Howell, MD, FACS Ear,Nose and Throat Associates Johnson city ,Tennessee.

Sleep Disordered Breathing
Mark Howell, MD, FACS
Ear,Nose and Throat Associates
Johnson city ,Tennessee
ZZZZZZZZZZZZZZZZZZZZZ
• Snoring is the act of breathing with a
grunting or snorting sound while asleep
• Snoring is involuntary, and can be
disruptive to your own sleep or to bed
partner’s sleep
• Snoring can be embarrassing and a
source of friction between partners
• Snoring can be a sign of worrisome
medical problems.
Problems with Snoring
• Snoring is caused by obstructed airflow
through the nose and throat.
• It is often intermittent throughout the night
and can be as noisy as loud conversation
• Problems include lack of sleep by yourself
or your bed partner, but many snorers do
not know that they snore
Who Snores?
• British survey: ~40% of
population surveyed snored;
Male:female was 2:1
• US study: 44% of males and
28% females; ages 30-60 yrs old
General points
• 70 million people suffer from sleep disorders.
• 70% are primary sleep disorders
• Up to 50% of these are related to Sleep
disordered breathing
• It costs millions of dollars in health care per
year
• At least 2300 sleep studies/ 100000
people/year needed to adequately address
the demand for diagnosis and treatment.
• <14% of medical interns questioned patients
about sleep. (Haponik 1996)
Airflow obstruction
• Noisiness in snoring is related to
obstruction of the airflow at one or more
locations:
–The nose
–The soft palate and uvula
–The base, or back part, of the tongue
–The tissues on the sidewalls of the throat
• Snoring is typically worse when lying on
the back due to gravity effects
What else contributes?
• Dryness in the nose and throat slows
down airflow and prevents re-opening of
the throat
–Medicines that dry out the mucus membranes
–Dry air in the winter
–Mechanical blockage in the nose (polyps,
deviated nasal septum)
–Allergies, colds, or sinusitis
–Tobacco abuse dries out mucosal surfaces
What else contributes?
• Muscle collapse or weakness
–Alcohol
–Sleeping pills
–Sedatives or muscle relaxants
–Weight gain
–Deeper sleep, with more relaxed muscles
• Sleep apnea is a chronic respiratory
sleep disorder characterized by
recurrent episodes of partial or
complete upper airway obstruction
during sleep (apneas, hypopneas) and
are associated with repeated disruption
of sleep resulting in excessive daytime
somnolence and other medical comorbidities.
Sleep Disordered Breathing
• Apnea: complete cessation of airflow lasting
10 seconds or more
• Hypopnea: reduced airflow to about 50%
lasting 10 seconds or more
• Arousal: a change in sleep state
• UARS: Respiratory event related arousals
during sleep associated with excessive
daytime sleepiness. No apneas or
hypopneas
• AHI: number of apneas/hypopneas per hour
of sleep. Used to grade severity of the
Respiratory disturbance in sleep.
• Prevalence increases with increasing age and body
mass index (>28), family history(54% offspring), african
american, asian and hispanic,
• Neck circumference >17 inches in men and >16 inches
in women is risk factor
• Other conditions predispose i.e hypothyroidism,
rhinosinusitis
• Males affected twice as much as premenopausal
women
• Certain syndromes affecting anatomy of upper airway
are associated with SDB in the young(Treacher
Collins, Pierre-Robin, Marfans, Alperts, trisomy 21 etc)
• Drugs: Alcohol, sedatives, tobacco smoke
Classification of SDB
• Intermittent snoring-nuisance, no health
sequelae
• UARS-upper airway resistance
syndrome
• Mild OSA- AHI 5-15
• Moderate OSA- AHI 15-30
• Severe OSA- AHI >30
• CSA-central sleep apnea
Central Sleep Apnea
• Apneas occurring during sleep due to disordered
control of breathing rather than obstruction to airflow.
As opposed to obstructive apnea respiratory effort
also ceases during the episode of apnea
Cheyne stokes respiration is the most common and
occurs commonly in heart failure
It is treated with CPAP
Other conditions with CSA are neuromuscular
diseases, pontine stroke etc
What is the impact of SDB
• Road traffic accidents- mortality
• Lower productivity at school and work
• Morbidity-Impaired immune function,
HTN, insulin resistance, stroke,pulm
HTN, poor asthma control, ventricular
arrythmias and sudden death
• Neurocognitive and mood dysfunction
• Reduced quality of life
Neurocognitive effects of sleep
deprivation
• Impaired mood, reduced vigilance,
impaired concentration and reduced
memory
• Impaired performance in surgical skills,
anesthesia administration, intubation
and EKG interpretation (Weinger MB JAMA
2002)
Cardiovascular effects
• Associated nocturnal desaturations result in
increases in C-reactive protein levels, neuropeptide
Y, IL-6, IL-8 suggest predisposition to CVD risk
• Increased carotid artery atherosclerosis
• Increased incidence of HTN independent of obesity
• Increased odds for stroke in next 4 yrs with AHI>20
in cross sectional studies
• Ventricular ectopy-sudden cardiac death usually
seen in pts with co-existing heart failure
Metabolic effects
• Increased insulin and glucose levels
during GTTs in people with BMI>29 and
AHI>25 probably due to increased
catecholamines, cortisol and growth
hormone
Pulmonary effects of Sleep apnea
• Decreased responses to changes in CO2
when awake
• Vagal stimulation leads to nocturnal
exacerbation of asthma symptoms
• Complications of anesthesia with
perioperative morbidity
• Pulmonary HTN can occur with AHI>70 and
desaturations and/or coexistent obstructive
lung disease, hypoxemia and hypercapnia
When is snoring a problem?
• Snoring can be a symptom of
Obstructive Sleep Apnea (OSA). Other
symptoms include:
–Daytime tiredness and overall fatigue
–Restless sleep
–Waking up choking or gasping
–Morning headaches, dry mouth, or sore
throat
–Trouble thinking clearly or remembering
things
When is snoring a problem?
• Snoring can be a symptom of Obstructive
Sleep Apnea (OSA). Some medical
problems caused by OSA include:
–Elevated blood pressure
–Cardiac arrhythmias
–Pulmonary hypertension
–Automobile accidents
–Social problems like divorce and spousal
arguments, diminished job performance, lack
of concentration and memory
How do I tell the difference?
• Snoring, when accompanied by these
other symptoms, prompts medical
evaluation
–Epworth Sleepiness Scale
–Sleep study (polysomnogram)
–At-home sleep study
Integral part of a general medical
evaluation
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Ask about sleep habits including day naps
Performance at work/school
Interference with daily tasks
Energy level
Daytime sleepiness
Snoring, choking, gasping, breathholding
Refreshed upon awakening
Drug use
Physical exam features
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Nasal passages
Oropharyngeal passage
TMJ function
Body weight
BP
Polysomnogram (PSG)
• Electroencephalogram
• EOG-oculogram
• Electromyogram-genioglossus and anterior
tibialis
• Respiration
• Abdomen and chest wall motion
• Body position
• EKG
• O2 saturation
• Snoring
What can help me?
• There are many different snoring aids
for sale because none work for all
people
• Primarily they can benefit based on the
area of obstruction
• Things that don’t work (long term)
– Holding partner’s nose
– Elbow to the ribs
– Pillow over partner’s face
– Waking them up to tell them they are snoring
• Chinstraps
– “Sleep Angel” closes
the mouth so you are
forced to breathe
through the nose
• Special pillows
• Feedback alarms
– Wake you slightly
when you snore
• Ear plugs
– Allow bed partner to
ignore problem
– Reposition the head to • Separate rooms
– Bed partner physically
open the airway more
moves to avoid noise
• Snore spray
– Lubricates the mucus
membranes
• Breathe right
– Helps nasal breathing
Treatment
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Weight loss
Avoidance of drug and alcohol use
Smoking cessation
Postural training
Nasal patency
Dental appliances
CPAP/BiPAP
Surgery
How do you treat OSA?
• Weight loss
• Continuous Positive Airway Pressure
(CPAP)
–The “mask” for breathing at night
–Gold standard: it works every hour that you use
it
–Compliance can be poor
• Oral appliance
–Repositions the jaw to move the tongue forward,
decreasing obstruction
Snoring treatments - medical
• Oral appliance – moves the teeth forward to
help bring the jaw forward
• Throat strengthening exercises – to try to
help the muscles of the throat prevent
collapse due to better tone
• Weight loss – help from physician with diet
and exercise program
• Improving moisture with humidifier, nasal
saline
• Change sleeping position
CPAP
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Splints open airway during sleep
Reduces blood pressure
Improves heart function (in pts with CSA)
Do not always need titration study
Needs to be used atleast 6 hrs nightly
Medicare guidelines: AHI>15 for 2 hr sleep
test or AHI>5 with sleepiness, impaired
cognition, HTN, IHD or h/o CVA
CPAP
• Compliance poor in >40% of pts but best
when significant daytime sleepiness present
• Side effects that decrease tolerance of CPAP
are nasal and sinus congestion,
conjunctivitis, noise, claustrophobia, mouth
leak etc
• Humidification and regular follow up, help
compliance
ORAL APPLIANCES
How do you treat OSA?
• Surgery to correct the airway obstruction
– Septoplasty/turbinoplasty
– Tonsillectomy
– Uvulopalatopharyngoplasty
– Tongue base surgery
– Genioglossus advancement
– Tracheotomy
– Maxillary-mandibular advancement
• Not all surgeries are for everyone. Some
only work on certain types of obstruction
• More invasive surgeries have been more
effective
Snoring treatments - surgical
• Nasal surgery – improves nasal airflow
• LAUP – shrinks and scars the uvula and
soft palate
• Uvulectomy – removes the uvula
• “Snoreplasty” – injection to shrink the
uvula
• Pillar implants – small synthetic implants
in the palate to stiffen it
Surgery
• UPPP- 50% success rate in reducing
AHI by 50%
• Tongue advancement
• Hyoid elevation
• Mandibular osteotomy (lower jaw)
• Maxillomandibular osteotomy and
advancement (both jaws)
• Radiofrequency ablation
Radiofrequency
ablation
Multiple procedures and poor for obese
patients
Tongue base suspension
Same
Midline or Central tongue reduction
Complex, risk of paralysis, loss of function
SMILE (Submucosal minimal lingual excision)
Significant learning curve and complications
Genioglossus
Fracture
bone advancement
risk, nerve injury, long term results?
Maxillomandibular
advancement
Maxillary-mandibular advancement
TORS Tongue Base Reduction Study
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Italilian study by Vicini et al ( June 2009)
10 Patient retrospective review
AHI pre 38.3 and post 20.6
Large SD
Only one obese patient
Multiple different procedures performed
Patients had tracheotomy at time of surgery
Reasonable and safe surgical option
Hypoglossal Neurovascular Bundle Anatomy
• Inferolateral in tongue
base
• Midway between
midline and lateral
tongue margin
• Stays close to superior
margin of hyoid (0.9cm)
• 2.7 cm inferior and
1.6cm lateral to
foramen cecum
• Allows for aggressive
tongue base reduction
TORS Tongue Base Reduction
• Excellent
visualization
• Articulating
instruments
• Effective
TORS Tongue Base Reduction
• Radiographic
improvement
• Both axial and
sagittal
Snoring – Sleep Apnea?
• Snoring is a problem, both for the snorer
and for their bed partner
• There are solutions for snoring, but there
is no single common solution
• Snoring can be the symptom of a true
medical problem, Obstructive Sleep
Apnea
• Please contact your physician if you or
your loved one has these symptoms
2340 Knob Creek Road
Any Questions?
• Ear, Nose & Throat Associates
–Mark Howell, MD,FACS
–2340 Knob Creek Rd, Suite 704
–Johnson City, TN 37604
–423-929-9101 phone
–423-434-2032 fax
–www.entjc.com
Resources
• www.sleepfoundation.org
• www.asaa.org