Obstructive sleep apnea Flashcards
Miloro 2015
What defines Obstructive Sleep Apnea syndrome?
Complete or partial upper airway obstruction causing apneas or hyponeas during sleep.
“>10 apneas or hypopneas per hour”
Hyponea= reduction in airflow>10 secs (50% decrease of desaturation of 3%) Apnea= cessation of airflow >10 seconds
Snoring is OSA?
No - but it can progress to OSA
Pickwickian Syndrome
Charles Dickens “joe the Fat Boy”
= obesity with hypoventilation
OSA prevalence
8:1 , M:F until menopause when women catch up
What are 3 types of OSA?
Central = CNS problem usually tumor or infarct of brainstem
tx with drugs or phrenic nerve pacemakers
Obstructive = Upper airway obstruction at level of pharynx = Most common
dx- with polysolmogram
Mixed
Patients with OSAS usually have all the following except:
a. snoring
b. excessive daytime sleepiness
c. lack of REM sleep
d. obesity
d. Obesity
Predisposing Factors
Male, Age >50, Smoking, Obesity, Max/Mand deficiency, Hypothyroidsm
Think STOP BANG
What are common comorbidities?
CAD, HTN, AFIB,CHF, STROKE, COPD, OBESITY, GERD, Renal disease
AHI
Apnea hyponea Index= (# apneas + hypopneas)/ total sleep time
<5 = normal 5-15 = mild 15-30 = moderate >30 = severe
An RDI of 30 indicates:
a. normal
b. mild OSA
c. moderate OSA
d. severe OSA
C. moderate OSA
RDI = (# apneas + hypopneas + respiratory event related arousals) x 60 / total sleep time
Mild OSA =5-20
Moderate 20-40
Severe >40
Sher success Criteria?
Successful treatment is AHI <20 or 50% reduction in AHI preop
Cure = AHI <5
Which can be used to classify an airway in the Fujita system?
a. Epworth Sleep Scale
b. Polysomnography
c. Bed partner interview
D. Nasopharygoscopy
D. Nasopharyngoscopy
fujita = upper airway obstruction classification system
Type 1 = oropharnx obstruction
tx= UPPP, T and A removal, palatal surgery to remove excess
Type II = ORO and Hypopharynx obstruction - most common
Tx: Phase I: UPPP, geniohyoid advancmeent
Phase 2: MMA and tongue procedures
Type III = Hypopharynx obstruction
Tx: MMA, tongue procedures, advance hyiod bone
Surgery indications Stanford Protocol, RDI, ESS, LSAT?
RDI >20
LSAT <90
Epworth sleep scale >11
CPAP is gold standard treatment
How long do you wait after any treatment of OSA before moving toward another treatment?
Require repeat PSG at 6 months s/p initial tx
If unchanged or worsened consider cpap if not used prior or phase 2 tx
Stanford Protocol Phase 1 treatment consists of?
Success?
Nasal obstruction correction (turbinates, septum)
Pharyngeal obstruction correction (T and A, UPPP)
Hypopharyngeal obstruction (hyiod resuspension or genio advancement)
Success = 42-75%
Stanford phase 2 Protocol treatment consists of?
success?
MMA or tracheostomy
success >90%
Features of OSAS?
Nocturnal insomnia, Fatigeu, mornign headaches, snoring, sexual impotence, EDS = excessive daytime somnolence
How is OSAS diagnosed?
a. Intraoral exam
b. Cephalometric exam
c. Muellers maneuver
d. sleep study
d. sleep study
PSG is gold standard and quantifies severrtywith EMG, EEG, EKG, oronasal airflow, chest wall effort, body position, snore microphoen, O2 saturation, durations >6hours
Sleep histories are very important - what charactertics are indicative of OSAS?
BEARS acronym for sleep history
B = bedtime routine E= EDS yes or no? A = awakenings at night/early morning R= duration of sleep/consistency S = snoring
REM makes up how much of total sleep?
20-25%
Epworth Sleepiness Scale ?
subjective exam of 8 questions rated 0-3 evaluating EDS
Score 0-24 (24 = worst)
Where is the most common source of obstruction in OSA?
soft palate and lateral pharyngeal walls
What do the Mallampati, Brodsky, and friedman classifications measure?
What soft tissue needs to be evaluated?
Mallampati = soft tissues of oropharnx
Brodsky = tonsils
friedman = palatal position
Uvula, adenoids, tongue, soft palate.
Patients with OSAS have:
a. increased Co-Pog
b. Increased posterior airway space
c. Increased hyiod-mandibular plane
d. Shortened length of soft palate
c. Increased hyoid-mandibular plane
lower and more posterior hyoid = increased distance between hyoid and mandible = steeper plane
In OSA SNA and SNB are both lower than normal
what is Muellers manuever?
Nasopharyngoscopy with valsalva maneuver
creates negative pressure to see collapse of soft tissue
Medical tx of OSAS?
avoid EtOH and CNS depressants
Weight loss - if obese - Bariatric surgery also effective
CPAP - always initial therapy
Rx-Progesterone, Protriptyline
Oral appliances - sdjustable are better and can reduce snoring
tongue retaining vs anterior repositionign devices vs Klearway device (most common)
Postional therapy
The most effective treatment for OSAS is a weight loss b LAUP c CPAP d MMA
c CPAP
continuous positive airway pressure 7-15 cm H2O
poor compliance
90-95% succes if compliance
BiPAP = Bilevel = changes with inspiration vs expirations = improved compliance
Staging of treatment
- Presx eval = Physical exam, PSG, 3D CT, Nasopharyngoscop
- trial of CPAP- BiPAP or oral appliance
- Phase 1 stanford = 60% success
- PSG 6 months after
- Phase 2 = 90 % success= MMA
Sx palatal procedure - retropalatal obstruction
ablative = good for snoring, poor success with OSA
Injection snoreplasty = sclerosing agent to Nasopharynx
CAPSO = scarring of soft palate
Radiofrequency ablation, Palatal implants
Laser assisted uvulplasty (LAUP) - usually recommended.
Expansion sphincter pharyngoplasty = better than UPPP
Z-palatopharyngoplasty + UPPP = good success
tonsillectomy = 40% success- may be good prior to CPAP
UPPP what is it?
uvuloplatopharyngeoplasty
T and A, removes uvula, anterior pillar resection, lateral pharyngeal wall mucosa resection
50% of pts have 50% reduction in AHI
Overall it is not reliable - not recommend for moderate or severe OSA
A 48 yo with OSAS and RDI of 110 presents with Pulmonary HTN, intermittent ventricular ectopy, and CHF. What surgical tx is indicated for this pt?
a. Septoplasty and turbinectomy
b. UPPP
c. tracheostomy
d. MMA
c. tracheostomy
100% cure rate but due to complications is a last resort
Does Nasal surgery significantly improve OSAS?
No, minimal if any improvements.
It may improve snoring and CPAP compliance.
Septorhinoplasty may increase internal nasal valve
Implanted Upper Airway Neurostimulation is recommend for who?
OSAS pts who have failed most other forms of therapy
Implant stimulate CN XIII/hypoglossal to activate and elevate tongue
Keyhole procedure?
removal of medial and anterior portion of tongue for macroglossia
Radio frequency tongue ablation = scarring and contraction of posteior tongue.
Can suture from tongue base to screw in geniohyiod tuburcle.
Mixed success for both - recommend for mild to moderate OSA who wont use CPAP or oral appliances
genioglossus advancement?
does not advance geniohyoid only the tongue.
Must advance 10-12mm of bony thickness ( make window - turn 90 degrees and fixate)
50-75% success, especially if combined with UPPP
risk of mandible fx
Placement of inferior horizontal osteotomy of a rectangular osteotomy for genioglossus advancement for OSAS too inferiorly risks?
a. mandible fracture
b. mental nerve paresthesia
c. genioglossal detachment
d. mentalis detachment
a. mandible fracture
What procedure would advance geniohyoid muscle and genioglossus?
BSSO advancement
genioplasty advancement
Hyoid suspension procedures… how do they work?
Can suspend to mandible to move forward and superiorly
can suspend to thyroid cartilage to move anteriorly
better success to thyroid
Transverse expansion help OSAS?
Yes! RME and SARPE both help dramatically
how does MMA work?
Multilevel skeletal surgery designed to enlarge veloorohypopharyngeal airway without direction manipulation (nonablative) of soft tissues.
It advances the anterior pharyngeal tissues indirectly ( soft palate, tongue, suprahyoid muscles) that attach to the maxilla, mandible and hyoid bones.
It improves all three levels of upper airway (NP, OP, HP)
what is MMA advancement
?
Goal = 10-12 mm of advancement
Poor success if <8mm of advancement
risk of esthetic defects/facial appearances.
90+% success
consider larger plates and screws
best alternative to TRACH and CPAP
MMA indications?
LOOK at Neck- chin - throat angle!!! ( chin to chest = likely need this)
Severe OSAS
unwilling to use CPAP or oral appliance
Lower BMI, lower pre op AHI, younger age = better success
how does MMA affect airway volume and turbulence?
increase airway volume
decreases turbulence
Keys to OSAS treatment
What is severity of disease?
mild OSA = palatal sx or oral appliance
moderate-severe = consider MMA if CPAP non complaint
What treatments can patient tolerate (CPAP)?
CPAP is always intial tx
What is the level of obstruction?
