Obstructive sleep apnea (OSA) Presentation.pptx

Obstructive sleep apnea (OSA) Presesntation

1. Obesity related sleep disorders Presenter: dr yasra kiran (PGR pulmonology ) Facilitator: dr kashif sardar ( proff . Of pulmonology )

2. Case 2

3. Pt was in his usual state of health 7 yrs back when he started to have SOB exertional , walking distance of few meters at first , gradually progressive , now pt have walking distance of few steps before SOB onset. Pt is unable to perform daily life activities normally. SOB was associated with occasional dry cough and palpitations. Now SOB has worsen since one week and is associated with dry cough. No history of orthopnea ,PND ,feet swelling , chest pain Pt also have complaint of excessive day time sleepiness , frequent episodes of nodding , associated with night time loud intermittent snoring and restless sleep. Pt has complaint of apnea while sleeping No history of nocturia. Case 3

4. Case 4

5. Case 5

6. CLINICAL EXAMINATION 6

7. GPE Mild pedal edema RESPIRATORY SYSTOM: On inspection shape of chest is normal, no scar mark or visible pulsations, moving equally on both sides Trachea central in place Apex beat placed at 5 th ICS 1cm lateral to midclavicular line On auscultation, normal vesicular breathing with dec air entry with no added sounds CLINICAL EXAMINATION (cont’d) 7

8. CVS SYSTOM On inspection no chest deformity, scar or abnormal pulsations Apex beat is placed at 5 th IC space 1 cm lateral to mid clavicular line Both 1 st (normal intensity) and 2 nd heart sounds (loud P2) are audible No added sounds CLINICAL EXAMINATION (cont’d) ABDOMINAL SYSTOM EXAMINATION Shape of abdomen distended. Umbilicus central, No visible pulsations or scar marks present Soft, non tender. No mass palpable on deep palpation, no visceromegaly Shifting dullness or fluid thrill absent Bowel sounds audible 2-3 per minute, no bruit 8

9. CLINICAL EXAMINATION (cont’d) 9

10. HB 14.4 g/dl TLC 7,500 / cmm PLATELETS 155,000 / cmm UREA 41 mg/dl S.Cr 1.1 mg /dl RBS 180 mg/dl S. Na 137 mEq /L S. K 4.1 mEq /L ABGS: PH 7.393 PaCO2 51.3 mmHg PaO2 45 mmHg HCO3 30.6 mmol/L Lab Investigations CLINICAL EXAMINATION (cont’d) 10

11. OSA WITH ACUTE EXACERBATION DIAGNOSIS OBESITY BODY MASS INDEX ( BMI ): BMI   11

12. 12

13. OBSTRUCTIVE SLEEP APNOEA (OSA) 13

14. OSAS is defined as upper airway narrowing, provoked by sleep, causing sufficient sleep fragmentation to result in significant day time symptoms, usually excessive sleepiness 14

15. OSA is part of a spectrum ,with trivial snoring at one end and repetitive complete obstruction of airway throughout the night at the other end. OSA = Abnormal sleep studies OSA + presence of symptoms = obstructive sleep apnea syndrome (OSAS) OBSTRUCTIVE SLEEP APNOEA (OSA) 15

16. OSA is the third most common serious respiratory condition, after ASTHMA and COPD Prevalence is lower in women than men, due to their different fat distribution (upper body obesity or neck obesity is more of a male pattern) Almost 1 billion people affected globally, and with prevalence exceeding 50% in some countries EPIDEMIOLOGY 16

17. 17

18. PATHOPHYSIOLOGY Small pharyngeal size Excessive narrowing of the airway occurring with sleep onset Predisposing factors/conditions SMALL PHARYNGEAL SIZE WHEN AWAKE Fatty infiltration of pharyngeal tissues and external pressure from inc. neck fat or muscle mass Large tonsils Subtle abnormalities of craniofacial shape e.g. Minor micrognathia or retrognathia Extra submucosal tissue e.g. myxedema, mucopolysaccharidoses 18

19. EXCESSIVE NARROWING OF THE AIRWAY OCCURRING WITH SLEEP ONSET Obese or muscular neck mass may overwhelm the residual dilator action as well as starting size Neuromuscular diseases with pharyngeal involvement e.g. stroke, myotonic dystrophy, Duchene dystrophy, MND Drugs e.g. muscle relaxants, sedatives, alcohol Increasing age PREDISPOSING FACTORS/CONDITIONS Other predisposing conditions are: Acromegaly Hypothyroidism Other theories suggests years of damage to the mucosa from snoring , may reduce the protective reflex dilation of the pharynx in response to narrowing activated by surface receptors 19

20. 20

21. CLINICAL PRESENTATION 21

22. 22

23. COMMON Excessive sleepiness (ESS > 9) Loud snoring and apneic episodes Wakes up choking Poor concentration Waking unrefreshed Tiredness Nocturia R aised ANP levels from inc. central blood volume ,from sub atmospheric intrathoracic pressures during obstructed breathing Simply reflection of highly fragmented sleep ,preventing the normal reduction in urine flow associated with sleep LESS OFTEN Nocturnal sweating Reduced libido Oesophageal reflux ASSESSMENT FOR OSAS History Examination investigations 23

24. Evaluate sleepiness (ESS Score >9) Differentiate sleepiness (with tendency to nod off) from tiredness (without tendency to nod off) Snoring and apneas (form witness) Other OSAS symptoms e.g. Nocturia, restless sleep Weight gain over last 5-10 yrs Recent changes in neck size Any ENT surgery Past medical history e.g. for hypothyroidism, acromegaly, down syndrome CVS history e.g. AF, HTN Alcohol, smoking, addiction Occupation, shift working, driving issues history 24

25. 25

26. 26

27. Stop-bang score 27

28. 28

29. Depression Lifestyle issues Drugs (beta blockers, antidepressants, opiates, anxiolytics) Narcolepsy associated with cataplexy (sudden loss of muscle tone in response to excitement), sleep paralysis, prolific vivid dreaming Post severe head injury Post infectious (EBV) Idiopathic / hereditary Neurological disorders (Parkinson’s) d/d for excessive daytime sleepiness 29

30. Often unrewarding BMI (>30kgm2) Neck circumference (>17in) Undersized or set back mandible Upper airway size /oropharynx (boggy mucosa, enlarged tonsils), nasal patency Look for lower airway obstruction (wheeze) Signs of predisposing conditions (hypothyroidism, acromegaly, Cushing's, diabetes) Complications (HTN, HF, COR-PULMONALE, AF) Look for neuromuscular disorders examination 30

31. 31

32. Baseline investigations (CBC, RBS, RPM, S/E) ABGs Thyroid profile Fasting lipid profile FEV1/VC ratio ECHO Sleep studies investigations 32

33. Three types of sleep studies: Overnight oximetry alone , including HR Respiratory polysomnography / limited sleep studies: Oximetry with sounds , body movements, oronasal airflow, chest and abdominal movements, leg movements Full polysomnography (PSG): Respiratory PSG with EEG, EOG and EMG Full PSG is rarely indicated Respiratory PSG is usual routine investigation Abnormal oximetry mimicking OSA occurs with Cheyne-stokes breathing (HF, post-stroke) False negatives can occur in younger and thinner patients Sleep studies 33

34. Full psg 34

35. Apnea / hypopnea index 35

36. 36

37. 37

38. 38

39. 39

40. MANAGEMENT Not all patients need treatment Treatment depends on symptoms Lower the threshold when poorly controlled HTN, nocturnal angina, LVF or AF are present Early treatment improves EF in left heart failure SIMPLE APPROACHES Weight loss Reduce evening alcohol consumption Sleep decubitus, rather than supine, and with bed head elevated FOR SNORERS AND MILD OSA Mandibular advancement devices Adequate dentition Tonsillectomy if enlarged tonsils Pharyngeal surgery (last resort with poor outcomes), usually not recommended 40

41. 41

42. Worn in mouth at night Holds lower jaw forward (like jaw thrust in CPR) Adjustable or fixed forward displacement Side effects : excessive salivation, tooth pain, jaw ache or teeth alterations They are costly FOR SIGNIFICANT OSA CPAP therapy Bariatric surgery e.g. gastric band, gastric bypass Mandibular / maxillary advancement surgery (selected cases) Tracheostomy (rarely indicated) SEVERE OSA WITH CO2 RETENTION Non-invasive positive pressure ventilation (may require prior to CPAP) CPAP (for compensated CO2 retention) 42

43. New advances (mirtazapine :prevent loss of tone of pharyngeal dilators during sleep) No place of alerting agents (modafinil) Only reduce the perception of sleepiness than actual sleepiness 43

44. 44

45. 45

46. Somnoplasty Tonsillectomy / adenoidectomy Uvulopalatopharyngoplasty (UPPP) Jaw Surgery Septoplasty SURGERY 46

47. Hear damage and hear failure Arrhythmias Stroke Sudden cardia death Daytime drowsiness Dangerous complications of sleep apnea 47

48. thank you 48