Pulmonology Book

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Obstructive Sleep Apnea

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  1. See Also
    1. Obstructive Sleep Apnea in Children
    2. Sleep Apnea
    3. Central Sleep Apnea
  2. Epidemiology
    1. Incidence: Apneas and Hypopneas (AHI) >5/hour in ages 30 to 60 years of age
      1. Without daytime somnolence: 24% of men and 9% of women
      2. With daytime somnolence: 4% of men and 2% of women
  3. Causes
    1. Adults
      1. Narrow airway (key factor)
        1. Narrows most in the hypopharynx (below Tongue)
        2. Can narrow to pencil diameter in some patients
      2. Obesity and short neck
      3. Hypognathia
      4. Jaw deformities
      5. Large Tongue and uvula
      6. Neurologic deficits (central or peripheral)
    2. Children (occurs in 1-3% of children)
      1. See Obstructive Sleep Apnea in Children
  4. Provocative Factors
    1. Sleep deprivation
    2. Alcohol use
    3. Tobacco abuse
    4. CNS Depressant medications
    5. Chronic nasal congestion
  5. Symptoms: Adults
    1. Excessive daytime Sleepiness
      1. Falling asleep at wheel or in conversation
      2. May also present with alternative terminology
        1. Fatigue
        2. Tiredness
        3. Lack of energy
    2. Loud snoring
    3. Gasping or Choking during sleep
    4. Nocturnal Hypertension and arrhythmias
    5. Morning Headache
    6. Nocturia
    7. Nocturnal confusion
    8. Intellectual deterioration
  6. Symptoms: Children
    1. Minimal Hypersomnolence if any
    2. Nocturnal Enuresis
    3. Excessing nighttime sweating
    4. Developmental delay
    5. Learning difficulties (e.g. ADHD)
  7. Signs
    1. General appearance
      1. Short neck
      2. Overweight (Obesity in 70% of cases)
    2. Nasopharynx
      1. Nasal Polyps
      2. Severe septal deviation
      3. Large residual adenoid tissue
    3. Oropharynx
      1. Macroglossia
      2. Large tonsils
      3. High arched palate
      4. Micrognathia and Retrognathia
      5. Mallampati Score 3 or 4
        1. Disproven: Does not predict Sleep Apnea risk
    4. Larynx and trachea
      1. Large obstructive lesions
    5. Neck circumference (best predictor of Sleep Apnea)
      1. Men: >17 inch neck circumference
      2. Women: >16 inch neck circumference
  8. Differential Diagnosis
    1. See Sleepiness
    2. Central Sleep Apnea
  9. Complications
    1. See Sleep Apnea
    2. Increased mortality risk and stroke risk
      1. Yaggi (2005) :
    3. Hypertension is closely associated with Sleep Apnea
      1. Risk of developing Hypertension with mild to moderate OSA: Odds Ratio 2-3
      2. Peppard (2000) :
  10. Diagnostics
    1. See Polysomnogram (Sleep Study)
  11. Management: Non-surgical
    1. See Sleep Hygiene
    2. Airway Management Measures
      1. See Nasal Continuous Positive Airway Pressure (CPAP)
        1. Do not use without Sleep Study (will worsen Central Sleep Apnea)
      2. Bilevel Pap (BIPAP)
    3. Weight loss
      1. Sleep Apnea significantly improved with 9-14 kg loss
      2. Snoring in 19 asymptomatic obese male snorers
        1. Only mild decrease with interventions
          1. Oxymetazoline Nasal Decongestant
          2. Foam wedge support to sleep on side
        2. Marked decrease with weight loss
          1. Three kilogram weight loss
            1. Snores cut in half (176/hour)
          2. Six kilogram weight loss
            1. Snoring nearly eliminated
      3. Reference
        1. Braver (1995) Chest 107:1283
    4. Avoid supine body position during sleep
      1. Sew a tennis ball in the back of a night shirt
      2. Makes sleeping on back too uncomfortable
    5. Oral appliance
      1. See Mandibular Advancement Device
    6. Potentially helpful Medications
      1. Intranasal Corticosteroids
        1. Chronic Rhinitis
        2. Nasal Polyps
        3. Septal deviation
      2. Tricyclic Antidepressants
      3. Avoid CNS depressant medications
    7. Hospitalized patients with undiagnosed OSA
      1. Elevate head of bed
      2. Provide Supplemental Oxygen while sleeping
      3. Schedule outpatient Sleep Study
      4. Do not use empiric CPAP (worsens central apnea)
        1. BIPAP is safer if empiric treatment is used
  12. Management: Surgery
    1. Uvulopalatopharyngoplasty (UPPP)
      1. No longer recommended due to low efficacy
      2. Laser or excision of redundant posterior pharynx
      3. Only effective in 30-50% of patients
        1. Airway narrows below level where surgery occurs
      4. Modified procedures
        1. Laser-assisted uvulopalatoplasty
        2. Radiofrequency ablation
    2. Maxillomandibular advancement
      1. Indicated for receding chin and jaw
    3. Tracheotomy
      1. Measure of last resort only
  13. References
    1. Bower (2000) Otolaryngol Clin North Am 33(1):49
    2. Flemons (2002) N Engl J Med 347:498
    3. Gozal (1998) Pediatrics 102:616
    4. Owens (1998) Pediatrics 102:1178
    5. Piccinillo (2000) JAMA 284:1492
    6. Sliverberg (2002) Am Fam Physician 65(2):229
    7. Victor (1999) Am Fam Physician 60(8):2279

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