Non PAP treatments Flashcards
Lifestyle advice for all severities of OSAHS
- stop smoking interventions and services
Nicotine is a stimulant and can therefore have negative effects on the ability to get to sleep and stay asleep. It can also contribute to upper airway dysfunction. - preventing excess weight gain
- obesity; identification, assessment and management
- A patient with a BMI over 25 is considered overweight, and over 30 is considered obese. There are limitations to BMI and its reflection of a patient’s weight and health but it is used clinically as a ball park figure.
- Obesity and in particular central deposition of the fat are risk factors for OSA
- Males tend to have predominantly central fat deposition around the neck and trunk, and abdominal visceral fat which is why OSA is more predominant in males and post menopausal females (who will tend to get a more male fat deposition post menopause).
Bidirectional relationship
CPAP doesn’t cause with loss, so lifestyle factors need to be controlled
- alcohol use disorders; prevention
Alcohol is a central nervous system depressant that causes brain activity to slow down. Alcohol has sedative effects that can induce feelings of relaxation and sleepiness, but the consumption of alcohol – especially in excess – has been linked to poor sleep quality and duration. It has a biphasic effect on sleep, meaning the effect is different in the first and second half of the night. It suppresses the first cycle of REM in the first half of the night but then causes REM rebound in the second half, leading to worsening OSA and mores sleep disruption.
MAD
To be used for mild OSAHS and symptoms that affect usual daytime activities or unable to tolerate or declines CPAP - customisable therapy
MADs work by pulling the lower jaw forwarded and creating a wider space in the airway. They can be particularly helpful in retrognathic individuals. They likely have limited benefit in those with very severe OSA or those with high levels of parapharyngeal fat.
MAD contraindications
- seizures
- few or no teeth
- active periodontal disease or untreated dental decay
- crooked, crowded or turned teeth
- deep bites
- underbite
Positives of MRD
- conceptually simple
- less intrusive
- patients may find easier than CPAP
Side effects of MRDs
- dry mouth
- excess salivation
- pain in muscles of face and jaw
-gum irritation
-gagging - tenderness of teeth
- minor orthodontic movement of teeth
Glossopharyngeal nerve stimulation
- mild OSA and/ or primary snoring
- low frequency neuromuscular electrical stimulation via 4 electrodes resting directly on tongue
Most of the evidence for this device has come from industry sponsored clinical trials. It is likely to work in select individuals where the tongue falling back is the main cause of the OSA and has only been tested in quite mild OSA/snorers. In comparison to CPAP the device is a similar price but the part that goes into the mouth has to be replaced every 3 months (the device stops working if this has not been replaced regardless of level of usage) which would be similar to replacing a CPAP mask 2-3 times per year.
Surgery
- uvulopalatopharyngoplasty: attempts to widen the airway behind the tongue by removing excess tissue from sides of the throat behind tongue, shortening soft palate and removing uvula. UPPP is rarely used these days. There is poor evidence for its long term effectiveness and although it may sound like minor surgery it is not.
- nasal surgery : removal of polyps and septoplasty
Mouth breathing can promote airway collapse. Therefore if someone is mouth breathing due to nasal polyps or a deviated septum, if this is corrected and the individual goes on to nasal breathing successfully this can reduce or sometimes reverse OSA. It is unlikely to be successful in reversing OSA in the obese individual with severe OSA, but may result in improvements and the ability to use a nasal mask which is more effective than an oronasal mask in treating OSA.
Maxillomandibular advancement surgery (MMA) can be an effective treatment for obstructive sleep apnea (OSA). In MMA, the bones of the upper and lower jaw are repositioned to relieve airway obstruction. The procedure also suspends the attached pharyngeal airway muscles in an anterior position and simultaneously increases pharyngeal soft tissue tension. Most common in mandibular retrognathia
Hypoglossal nerve stimulation : electrodes placed on hypoglossal nerve, and controls movement of tongue
Non PAP treatments
Non invasive
- lifestyle intervention
- MRDS / MADS
- Glossopharyngeal nerve stimulation
Surgical
-uvulopalatopharyngoplasty
- maxillomandibular advancement surgery
- nasal surgery
-hypoglossal nerve stimulation
What is upper airways resistance syndrome?
UARS is defined by the occurrence of excessive daytime sleepiness unexplained by another cause and associated with more than 50% of respiratory events that are non-apnoeic and non-hypopnoeic (i.e. RERAs). RERAs are characterized by a progressive increase in respiratory effort. This may be assessed by direct measurement of oesophageal pressure or by another marker of respiratory effort such as the changes in pulse transit time. RERAs may induce both cortical and autonomic arousals and potentially lead to cardiovascular activation. Respiratory flow, when using nasal cannula or a pneumotachograph, exhibits only qualitative change named inspiratory flow limitation.
- patients are slimmer than OSA - may be normal weight
- craniofacial abnormalities
- increased females
The cycle of obstructive sleep disordered breathing
Open airway
Sleep
Increased UA resistance/ UA muscle relaxation/ reduced UA reflexes
Narrowed airway + obstructive factors
Partially or fully closed away
Hypoxia/ hypercapnia
Increased ventilatory effort
Arousal
What are some obstructive factors that can cause partially or fully closed airways
Think of some obstructive factors:
* Excess neck fat
* Large tonsils
* Crowded oropharynx
* Jaw falling back
* Tongue falling back
