Know about Sleep Apnea and How to manage it.

1. Dr.Jitendra Patel,
ENT Specialist
ENT Sleep Well Clinic,
Noor Specialist Hospital,
MANAMA, BAHRAIN,
Phone : 00973-17242288

2. Introduction
One-half to one-third of life asleep
Obstructive sleep apnea is a commonly encountered
health problem and is usually overlooked.
the prevalence of OSA in people aged 30-60 years is
9-24 % for men and 4-9 % for women.
an individual with sleep apnea is rarely aware of
having difficulty in breathing !

3. Defination
Sleep apnoea is a sleep disorder characterized by
abnormal pauses in breathing or instances of
abnormally low breathing, during sleep. Each
pause in breathing, called an apnea, can last from
a few seconds to minutes, and may occur 5 to 30
times or more an hour. Similarly, each abnormally
low breathing event is called a hypopnea. Sleep
apnea is diagnosed with an overnight sleep test
called a polysomnogram, or "sleep study".

4. Classification
1. Central – 0.4 % - lack of respiratory effort
2. Obstructive – 84 % - breathing is interrupted by a
physical block to airflow despite respiratory effort,
and SNORING is common.
3. Mixed – 15 %

5. Symptoms
Symptoms Symptoms
1 Loud Snoring 7 Excessive day time
sleepiness
2 Frequent wake-up 8 Morning headache
3 Gasping during night 9 Morning tiredness
4 Low concentration 10 Non refreshing sleep
5 Poor Work Performance 11 Sexual Dysfunction
6 Poor Short term Memory
Sleep apnea affects not only adults but some children as well .

6. Epworth Scale

7. Health Related Outcomes
• Non-Cardiovascular •Cardiovascular
• Poor nocturnal sleep •Arrhythmias
• Daytime sleepiness, •Systemic Hypertension
vision problem •Pulmonary
Hypertension
• Motor vehicle accidents
•Coronary artery
• The part of the brain that disease
uses memory and learning •Stroke
is also affected
• Impaired quality of life
• central cyanosis
• sudden death

8. • The accident at the Chernobyl nuclear power
plant in the Ukraine is the worst nuclear
disaster in the history. The cause of the
disaster has been partially attributed to human
error caused by sleep apnea.

9. • Auto Accidents : According to the National
Highway Traffic Safety Administration
(NHTSA)- USA,
"drowsy driving" causes over 100,000 car
crashes each year.

10. Risk Factors
– Age (predominantly 40 - 70 years)
– Male gender
– Obesity
– Pharmacologic agents - alcohol, Sedatives , etc.
– Upper airway anatomical abnormalities
– Hypothyroidism
– Postmenopausal state

11. Signs
Throat:
Low Soft Palate

12. Other Throat Findings:
Enlarged Tonsils Long Uvula

13. Nose Findings:
Enlarged Turbinates Narrow Nasal Valve

14. Nasopharynx:
Enlarged Adenoid

15. Oropharynx:
Enlarged Base Tongue

16. Flexible nasopharyngoscopy with) 5
Müller Maneuver was done to detect
.the degree of collapse of soft palate

17. Full channel polysomnography
was performed for 8 hrs .The following
: parameters were studied
– Electromyogram (EMG)
– Electrocardiogram (ECG)
– Electro-oculogram (EOG)
– Electroencephalogram (EEG)
– Airflow
– Chest and Abdominal Wall Effort
– Body Position
– Oxyhemoglobin Saturation

18. .American Academy of Sleep Medicine
Diagnostic criteria ( A OR B + C)
A. Excessive daytime sleepiness that is not better
explained by other factors.
B. Two or more of the following that are not
explained by other factors:
- Choking or gasping during sleep.
- Recurrent awakening from sleep.
- Non-refreshing sleep.
- Impaired concentration
C. PSG shows 5 or more obstructed breathing
events per hr during sleep.

19. Polysomnographic signals
sheet ( 22 channels ).

20. Home based sleep study
Device

21. Home based sleep study
Placement of Device

22. Home based sleep study
Report

23. Severity of OSA
(According to Sleep Study Report)
 Mild: AHI : 5 to 15
Moderate: AHI : 15 to 30
Severe: AHI > 30

24. Clinically Significant OSA
AHI ≥15, or
AHI between 5 and 14 with any of the following associated
symptoms:
 Excessive daytime sleepiness
 Impaired cognition
 Mood disorders
 Insomnia
 Documented hypertension
 Ischemic heart disease
 History of stroke.

25. Take home message
1. Severity of OSA highly
predicted clinically & by AHI
2. Epworth Scale , BMI & Neck Circumference are
Highly sensitive parameters for OSA .

26. 3. AHI , O2 saturation can be easily done with Home
base sleep device.
4. Outcome of surgical intervention should be
predictable .
5. Severe OSA + high BMI +(NC > 17, Low O2 , high
ESS ) -----> poor out come.

27. 6. Diagnostic tool: Clinical + PSG
7. Treatment options : Multilevel surgery , CPAP ,
Sleep hygiene .
8. Sleep Medicine …Gray area !!

28. ENT Speicalist is the right
discipline to diagnose and
treat OSA and predict the out
come .

29. OSA in Children
 bedwetting
choking or drooling
excessive sweating at night
inward movement of the ribcage when
inhaling
learning and behavioral disorders
poor school performance
sluggishness or sleepiness (often misinterpreted as
laziness in the classroom)
snoring
teeth grinding
restlessness in bed
pauses or absence of breathing

30. Treatment Options

31. Non-Surgical Treatment
Life style Modifications
Weight reduction
Avoid CNS depressants (alcohol, sedatives)
Avoid smoking before sleeping.
Sleep on side w/ tennis ball on back
External nasal dilators/steroid spray
Oral Appliances
CPAP

32. Non-Surgical Treatment

33. Oral Devices
Compliance rate about 50%
May cause TMJ pain & damage to teeth
May be effective in patient with mild OSA

34. Oral Devices
Tongue retaining devices.
Mandibular advancing device.
Soft palate lifter.

35. Tongue Retaining Devices

36. Mandibular Advancement
Devices
Repositions and
stabilizes the
mandible & tongue
(sometimes soft
palate)

37. CPAP for Sleep Apnea

38. If you like it !!

39. CPAP Machine

40. Surgical Options
GOAL …..
Maintain unobstructed Airway

41. Surgical Treatment
Adenotonsillectomy - preferred treatment in children
Tonsillectomy , turbinoplasty , nasal valve surgery ,
septoplasty , FESS .
Uvulopalatopharyngoplasty (UPPP)

42. Coblation Tonsillectomy

43. Uvelopalatoplasty

44. Uvulopalatal Flap

45. Bariatric Surgery !!

46. Treatment Summary
Diagnosis of Non-Surgical Surgical
Obstructive Treatment Treatment
Sleep Apnea Options Options
Palate
CPAP
Nasal
OTC
Weight Loss
Remedies Oral
Sleep Position Oral Bariatric
Training Appliances

47. BMI !!
HOW to be controlled ??
Sleep well
Diet
Exercise
Bariatric surgery ??

48. Expected Benefits from The
treatment of OSA.
• Better blood pressure control
• Lower MI and CVA risk
• Fewer arrhythmias
• Lower mortality through less incidence of cvs
• Slow the progression of renal failure
• Improved diabetes control
• Better quality of life

49. THANK YOU