Types of sleep apnea and its management.pptx

Sleep Apnea, various types, Diagnostic tools and managament

1. SLEEP APNEA Smrithi Rajeev MSc RT Moderated by – miss Lavanya Faculty of respiratory therapy

2. INTRODUCTION Sleep related breathing disorders are characterized by abnormal breathing patterns during sleep, and include (1) obstructive sleep apnea (OSA) syndrome (2) central sleep apnea syndrome (3) mixed sleep apnea, and (4) sleep related hypoventilation/hypoxemia syndromes.

3. Apneas: The cessation of airflow for at least 10 seconds in adults. Apneas can be associated with arousals from sleep, increased arterial carbon dioxide, and decreased oxygen levels .

4. Hypopneas: Is present when the following three criteria are present: Airflow decreased ≥30% from baseline The decreased airflow lasts ≥10 seconds The decreased airflow is accompanied by ≥3% SpO 2 desaturation from pre-event baseline or an arousal.

5. OBSTRUCTIVE SLEEP APNEA Obstructive sleep apnea is a sleep disorder which is very common in obese individuals. Obstructive sleep apnea constitutes a major part of sleep disordered breathing. Sleep apnea is characterized by repetitive pauses in breathing during sleep, despite the effort to breathe, and is usually associated with a reduction in blood oxygen saturation.

6. Cardinal features include obstructive apneas, hypopneas, and respiratory effort-related arousals (RERAs), which are caused by recurring collapse of the upper airway during sleep. A large number of patients with OSA demonstrate what is commonly called the Pickwickian syndrome

7. Symptoms of OSA Excessive daytime sleepiness Loud snoring Dry mouth and sore throat Morning headache Difficulty concentrating during the day High blood pressure

8. RISK FACTORS FOR OSA Male gender Older age Genetics Greater BMI and neck circumference Smoking, alcohol intake, sedative use Heart diseases Ethnicity - Indian and Chinese ethnicity are related to a high risk for OSA.

9. CENTRAL SLEEP APNEA Central sleep apnea (CSA) is a disorder characterized by the repetitive stopping or reduction of both airflow and ventilatory effort during sleep. CSA can be classified as primary CSA (idiopathic or unknown cause) or secondary CSA.

10. Examples of conditions associated with secondary CSA include Cheyne -Stokes breathing (congestive heart failure), medical conditions (e.g., encephalitis, brain stem neoplasm, brain stem infarction, spinal surgery, hypothyroidism, drug or substance abuse), and high-altitude periodic breathing. CSA is further categorized as either (1) hyperventilation-related CSA or (2) hypoventilation-related CSA. Hyperventilation-related CSA is the most common.

11. Hyperventilation-related CSA includes Primary CSA and CSA associated with Cheyne -Stokes breathing, and medical conditions such as congestive heart failure or high-altitude periodic breathing. Patients with hyperventilation-related CSA develop alternating cycles of apnea—or hypopneas—with hyperpnea during sleep.

12. Hypoventilation-related CSA is usually a secondary problem related to an underlying condition, such as a central nervous system disease, central nervous system-suppressing drugs or substances, neuromuscular disorders, or severe diseases of pulmonary mechanics

13. During sleep, the patient no longer has the wakefulness stimulus to breathe and, as a result, alveolar hypoventilation and central apnea occur. The patient’s breathing is restored during arousal from sleep, but again decreases when sleep resumes—resulting in cyclic periods of normal ventilation, hypoventilation, and apnea.

14. MIXED SLEEP APNEA Mixed sleep apnea is a combination of obstructive and central sleep apnea. It usually begins as central apnea followed by the onset of ventilatory effort without airflow. Clinically, patients with predominantly mixed apnea are classified (and treated) as having OSA.

15. Sleep related hypoventilation disorder Sleep-related hypoventilation disorders involve elevated blood levels of carbon dioxide during sleep that result from a lack of air moving in and out of the lungs. This insufficient breathing is commonly tied to other health problems. Often, people with sleep-related hypoventilation disorders have lung conditions like chronic obstructive pulmonary disease (COPD) or pulmonary hypertension. Disorders that affect the nervous system and some types of medications can also affect breathing and trigger hypoventilation.

16. A specific type of sleep-related hypoventilation disorder is called obesity hypoventilation syndrome (OHS). This condition can occur in obese patients and normally co-occurs with obstructive sleep apnea. It is frequently associated with poor sleep and can lead to detrimental effects on the cardiovascular system. Many people with sleep-related hypoventilation disorders struggle to breathe properly when they are awake, but the problem normally intensifies during sleep. As with central sleep apnea, treatment for sleep-related hypoventilation disorders is often directed at managing an underlying illness contributing to breathing problems.

17. Sleep related hypoxemia syndrome Hypoxemia is a low level of oxygen in the blood. Sleep-related hypoxemia disorder is when oxygen concentrations drop, but the levels of carbon dioxide don’t rise high enough to cross the threshold for diagnosis as a sleep-related hypoventilation disorder. Sleep-related hypoxemia disorder occurs mostly as the result of another health problem that affects breathing, including a number of types of lung conditions, and addressing hypoxemia frequently involves a focus on that underlying issue.

18. DIAGNOSIS The diagnosis of sleep apnea begins with a comprehensive sleep evaluation, which includes a history from the patient and spouse. History should include details about snoring, sleep fragmentation, periods of apnea during sleep, non-refreshing sleep, and persistent daytime sleepiness. The Epworth Sleepiness scale is routinely used as a validated measure of daytime sleepiness .

19. Abnormalities in the posterior pharynx include a large uvula, enlarged tonsils, a long soft palate, redundant lateral pharyngeal walls, macroglossia (enlarged tongue), and the presence of an overbite of the upper teeth with a posterior placement of the mandible. The Mallampati classification score is frequently used in physician notes to describe abnormalities of the soft palate and uvula

20. The second step is to take a careful examination of the upper airways and at times a PFT to determine whether upper airway obstruction is present.

21. The Mallampati classification score is frequently used in physician notes to describe abnormalities of the soft palate and uvula

22. POLYSOMNOGRAPHY Polysomnography is a specialized sleep test that monitors and records a number of physiologic parameters that occur during sleep. The PSG may be administered as either (1) a full-night, attended, in-laboratory polysomnograph or (2) a split-night, attended, in-laboratory polysomnograph . In-home, unattended, portable monitoring can be used as a reasonable alternative for patients who have a high likelihood of either moderate or severe OSA.

23. In a split-night, attended, in-laboratory PSG, the diagnosis of OSA is established during the first portion of the study, followed by a form of positive airway pressure (CPAP, BPAP, VPAP) treatment—called a CPAP (or BPAP or VPAP) titration polysomnogram. The positive airway pressure is applied to prevent upper airway obstruction or central apneas during sleep for the remaining time. This test is both diagnostic and therapeutic. Because of the perceived cost-effectiveness, there is a growing trend to perform split-night studies, if the patient’s total sleep time allows.

24. A sleep disorder specialist (SDS) setting up scalp electrodes on a patient to be studied. While the patient sleeps, the SDS (1) monitors brain waves, eye movements, muscle activity, multiple breathing patterns, and blood oxygen levels using specialized recording equipment, (2) interprets the recordings as they happen and responds appropriately to any emergencies, (3) instructs the patient in recording and maintaining a sleep diary of wake/sleep cycles, and (4) provides support services related to the treatment of sleep-related problems—including helping the patient use various treatment devices for breathing problems during sleep.

25. Apnea Index: The total number of apneas per hour of sleep. Apnea Hypopnea Index (AHI): The total number of apneas and hypopneas calculated per hour of total sleep. Respiratory Disturbance Index (RDI): The total number of events (e.g., apneas, hypopneas, and RERAs) per hour of sleep. Oxygen Desaturation Index (ODI): The total time that the oxygen saturation falls by more than 3 percentage points per hour of sleep, or of total recording time.

26. AHI: AHI < 5 normal AHI 5 – 15 mild AHI 15 – 30 moderate AHI > 30 severe

27. Diagnosis of CSA CSA is diagnosed when the majority of the respiratory events are central apnea or hypopneas. On the PSG, there is an absence of nasal or oral airflow and thoracoabdominal movements. Patients diagnosed with CSA are evaluated carefully for the presence of cardiac disease and lesions involving the cerebral cortex and the brain stem. Atrial fibrillation is also associated with CSA. The treatment for CSA depends on its specific cause

28. MANAGEMENT OF OSA BEHAVIORAL MODIFICATION : For patients who have OSA and modifiable risk factors – weight reduction, sleeping to a side, exercise, abstain from alcohol, medications etc. POSITIVE AIRWAY PRESSURE : Positive airway pressure therapy is considered the first-line therapy for OSA. the cause of many cases of OSA is related to (1) an anatomic misconfiguration of the pharynx and (2) the decreased muscle tone that normally develops in the pharynx during REM sleep.

29. Positive airway pressure is useful in preventing the collapse of the hypotonic and obstructed airway and is the standard treatment for most cases of OSA. Positive airway pressure can be delivered as continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) ORAL APPLIANCES : a mandibular-repositioning device or a tongue-retaining device. SURGERY : Surgery is most effective in non obese patients who have OSA due to a severe, surgically correctable, obstructing lesion. Examples: tonsillectomy, uvulopalatopharyngoplasty (UPPP), etc.

30. Implantable upper airway stimulator Recently, studies have shown the effectiveness of an implantable device that stimulates the hypoglossal nerve (XII), which in turn activates the genioglossal muscle (the tongue) to contract and increase the patency of the upper airway.

31. references Terry Des Jardins; Clinical manifestations and Assessments of Respiratory diseases; Chapter no. 31; Page no ; 420 Sleep Related Breathing Disorders- Sleep Apnea Robert M, James K, Albert J; Egan’s Fundamentals Of Respiratory Care 10 th Edition, Chapter 30, Page no. 662 Disorders of Sleep