OBSTRUCTIVE SLEEP APNEA

ANUSHA K.S. II M.D.S.

CLASSIFICATION

Dyssomnias A. Intrinsic Sleep Disorders B. Extrinsic Sleep Disorders C. Circadian Rhythm Sleep Disorders 2. Parasomnias A. Arousal Disorders B. Sleep-Wake Transition Disorders C. Parasomnias Usually Associated with REM Sleep D. Other Parasomnias 3. Sleep Disorders Associated with Mental, Neurologic, or Other Medical Disorders A. Associated with Mental Disorders B. Associated with Neurologic Disorders C. Associated with Other medical disorders 4.Proposed sleep disorders American academy of sleep medicine

INTRINSIC SLEEP DISORDER

The intrinsic sleep disorders are primarily sleep disorders that either originate or develop within the body or that arise from causes within the body Obstructive sleep apnea is classified under this catergory

DEFINITION

Obstruction of the upper airway Repetitive pauses in breath during sleep due to reduction in blood oxygen saturation Duration-20-40 seconds

SIGNS AND SYMPTOMS

Daytime sleepiness Restless sleep Irritability,anxiety,depression,forgetfulness, increased heart rate and blood pressure,unexplained weight gain,increased urination,gastroesoophageal reflux disease and heart burns

ADULTS

Daytime sleepiness Hippocampal atrophy due to apnea observed during neuro imaging

HIPPOCAMPUS

Originates from greek work hippo meaning horse and kampos meaning sea monster It belongs to the limbic system and plays important roles in the consolidation of information from short-term memory to longterm memory and spatial navigation

HIPPOCAMPUS

Changes in brain morphology associated with obstructive sleep apnea

Obstructive sleep apnea (OSA) causes hypoxemia and fragmented sleep, which lead to neurocognitive deficits.The study hypothesised that focal loss of cortical gray matter generally within areas associated with memory processing and learning and specifically within the hippocampus would occur in OSA Methods Voxel-based morphometry, an automated processing technique for magnetic resonance images, was used to characterise structural changes in gray matter between apneic and non-apneic patients Results The analysis revealed a significantly lower gray matter concentration within the left hippocampus .No further significant focal gray matter differences were seen in the right hippocampus and in other brain regions Conclusion This preliminary report indicates changes in brain morphology in OSA, in the hippocampus, a key area for cognitive processing Journal of sleep medicine 4(2003)451-454

CHILDREN

Hyposomnolence occurs in children Overtired or hyperactive Cause of obstructive sleep apneatonsillectomy and adenoidectomy Excessive weight

RISK FACTORS

Old age-muscular and neurological loss of the upper airway Decreased muscle tone is temporary due chemical depressants,alcoholic drinks,and sedative medications

Permanent is due to traumatic brain injury,neuromuscular disorders or poor adherance to chemical and speech therapy disorders Individuals with decreased muscle tone,increased soft tissue around the airway and narrowed muscle tone

Men-increased mass in the torso and neck have increased risk of obstructive sleep apnea Women-less risk due to physiology and progesterone and increased risk during pregnancy

Causes

Tonsilitis Old age(natural or premature) Brain injury(temporary or permanent) Decreased muscle tone due alcohol,medications and smoking Nasal infection by epstein barr virus during acute infection of infectious mononucleosis

Craniofacial syndromes

Down syndrome-large tongue,decreased muscle tone and narrow nasopharynx,obesity ,enlarged tonsils and adenoids Cleft palate-open palate with a narrow passage.Closure due to surgery or an appliance results in osa Treacher collins syndrome Pierre robin syndrome

PIERRE ROBIN SYNDROME

cleft palate, micrognathia (a small jaw) and glossoptosis (airway obstruction caused by backwards displacement of the tongue base) Treatment Mandibular distracrtion and advancement devices

PIERRE ROBIN SYNDROME

TREACHER COLLINS SYNDROME

Downward slanting eyes, micrognathia (a small lower jaw), conductive hearing loss, underdeveloped zygoma, drooping part of the lateral lower eyelids, and malformed or absent ears,cleft palate Also known as mandibulofacial dysostosis Treatment-tracheostomy and gastrostomy to increase the caloric intake

TREACHER COLLINS SYNDROME

POST OPERATIVE COMPLICATIONS

Velopalatal insufficiency-involves tailoring the tissue from the back of the throat and using it to purposefully cause partial obstruction of the opening of the nasopharynx and causes osa Velopharyngeal insufficiency-depending on size and position, the flap itself may have an "obturator" or obstructive effect within the pharynx during sleep, blocking ports of airflow and hindering effective respiration

Pathophysiology

Rapid and Non-rapid eye movement

NREM sleep is further divided into Stages 1, 2 and 3 NREM sleep The deepest stage (stage 3 of NREM) is required for the physically restorative effects of sleep, and in preadolescents this is the period of release of human growth hormone NREM stage 2 and REM, which combined are 70% of an average person's total sleep time, are more associated with mental recovery and maintenance

During REM sleep in particular, muscle tone of the throat and neck, as well as the vast majority of all skeletal muscles, is almost completely attenuated, allowing the tongue and soft palate/oropharynx to relax, and in the case of sleep apnea In the cases where airflow is reduced to a degree where blood oxygen levels fall, or the physical exertion to breathe is too great, neurological mechanisms trigger a sudden interruption of sleep, called a neurological arousal

In significant cases of OSA, one consequence is sleep deprivation due to the repetitive disruption and recovery of sleep activity This sleep interruption in stage 3 (also called slow-wave sleep), and in REM sleep, can interfere with normal growth patterns, healing, and immune response, especially in children and young adults

PHYSIOLOGY OF SLEEP APNEA

NAKAMURA AND LUND HYPOTHESIS

Parafunctional activities lead to changes in rem sleep which leads arousal mechanism due to neurological response It eventually leads to disturbance in sleep in the Nrem stage 3 which is deep sleep This leads to obstruction of breath and it leads to osa

Diagnosis

Polysomnography Home oximetry

DIAGNOSTIC CRITERIA

The patient has a complaint of excessive sleepiness or insomnia. Occasionally,the patient may be unaware of clinical features that are observed by others. Frequent episodes of obstructed breathing occur during sleep. Associated features include: 1. Loud snoring 2. Morning headaches 3. A dry mouth upon awakening 4. Chest retraction during sleep in young children

Polysomnographic monitoring demonstrates: 1. More than five obstructive apneas, greater than 10 seconds in duration,per hour of sleep and one or more of the following: a. Frequent arousals from sleep associated with the apneas b. Bradytachycardia c. Arterial oxygen desaturation in association with the apneic episodes 2. MSLT may or may not demonstrate a mean sleep latency of less than 10minutes. The symptoms can be associated with other medical disorders (e.g., tonsil-lar enlargement). Other sleep disorders can be present

Mild: Associated with mild sleepiness or mild insomnia.Most of the habitual sleep period is free of respiratory disturbance. The apneic episodes are associated with mild oxygen desaturation or benign cardiac arrhythmias. Moderate: Associated with moderate sleepiness or mild insomnia.The apneic episodes can be associated with moderate oxygen desaturation or mild cardiac arrhythmias Severe: Associated with severe sleepiness.. Most of the habitual sleep period is associated with respiratory disturbance, with severe oxygen desaturation or moderate to severe cardiac arrhythmias. There can be evidence of associated cardiac or pulmonary failure.

DURATION

Acute: 2 weeks or less Subacute: More than 2 weeks but less than 6 months Chronic: 6 months or longer

Polysomnography

Grade the severity of sleep apnea, the number of events per hour is reported as the apnea-hypopnea index (AHI) An AHI of less than 5 is considered normal An AHI of 5-15 is mild; 15-30 is moderate and more than 30 events per hour characterizes severe sleep apnea

HOME OXIMETRY

Non invasive method of monitoring blood oxygenation High probability patients were identified by an Epworth Sleepiness Scale (ESS) score of 10 or greater and a Sleep Apnea Clinical Score (SACS) of 15 or greater.[18] Home oximetry, However, does not measure apneic events or respiratory event-related arousals and thus does not produce an AHI value.

Treatment

Weight loss Continuous positive airway pressure Mandibular advancement devices

Physical intervention

Continuous positive airway pressure Variable positive airway pressure Automatic positive airway pressure

Mandibular advancement devices

Herbst appliance Thorton appliance

THORNTON APPLIANCE

MANDIBULAR ADVANCEMENT DEVICES-

HERBST APPLIANCE

Tongue positioning devices

CONTINUOUS POSITIVE AIRWAY PRESSURE

Medications

Fluoxetine,paroxetine,acetazolamide, trytophan

Surgery

Nasal surgery including turbinectomy Tonsillectomy Uvulopharyngoplasty Radiofrequency abalation of the tongue Genioglossus advancement Hyoid suspension Maxillomandibular advancement

RESEARCH

Neurostimulation is used currently in the treatment of obstructive sleep apnea Didgeridoo is used to relax the muscles around the mouth and throat Didgeridoo is an instrument of australian origin which is used in research for treatment of obstructive sleep apnea

DIDGERIDOO

REFERENCES

MAXILLOFACIAL PROSTHETICS-TAYLOR MAXILLOFACIAL PROSTHETICS-CHALION AMERICAN ACADEMY OFSLEEP MEDICINE-2001 PG 52-9 JOURNAL OF SLEEP MEDICINE 4(2003)451-454

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