sleep apnea Flashcards
snoring definition
partial airway obstruction that reduces airflow but does not cause arousal from sleep
like hypnoapnea
you can snore and not have sleep apnea
25 % of men and 15% of woman are habitual snorers
30-50% of asymptomatic snorers have sleep apnea
snoring is risk factor for
- HTN, CVA, MI
upper airway resistance syndrome
exaggerated breathing effort and snoring created by high resistance to airflow in the upper airway
this causes fragmented sleep and significant daytime drowsiness (no evidnece of apnea on testing)
general effect of upper airway resistance syndrome
this causes fragmented sleep and significant daytime drowsiness (no evidnece of apnea on testing)
evidence of apnea with upper airway resistance syndrome
no
evidence of apnea with upper airway resistance syndrome
no
snoring and sleep apnea relationship
30% of snoreers have sleep apnea
obstructive sleep apnea syndrom definition
stoppage of breathing for 10 seconds or more for at least 5 x a hour
oxyen saturation in the blood decreases more than 4%
apnea events end with an arousal from sleep
arousals lead to chronic daytime sleepiness and other symptoms
apnea events ends when
with an arousal from sleep
arousals lead to
chronic daytime sleepiness and other symptom
hyponea definition
decrease in airflow with oxygen deaturations greater than 4% and an arousal from sleep
snoring usually associated
risks of OSA
increased rate of motor vehicle accidents
increased risk of unemploment
unisuraility
marital discord
cardiovascular consequences
apnea hyponea index (AHI)
the average number of apneas plus hypopneas per hour of sleep
predisposing factors for OSA
increaseed age
increased weight / obesity
male gender
disproportionate upper airway anatomy
alcohol
OSA syndtom
loud snoring
irregular breathing
restless sleeep
excessive daytime sleepiness
witnessed apnea by partner in bed
major risk factor for OSA
obesity
- losing weight can signficanttly improve sleep apnea
need to lose over 10 kg weight
severity of apnea defined by
length of time of apnea event and percentage of oxygen desaturation
mild OSA
apnea- hypnea index
5-15 events / hour
moderate OSA
apnea- hypnea index
10-40 events / hour
severe OSA
apnea- hypnea index
over 40 events/ hour
anatomic predisposition
reduced posterior airway space
posterior rotation of mandible
tongue posterior and inferior
hyoid inferior placed
decreased A-P diameter of cranial base
decreased
A-P diameter of maxilla/ manidble
decreased posterior facial height (VME)
polysomnogram aka?
looks at?
sleep study
EEG - brain waves
EMG - muscles
ECG - heart
respiratory airflow and effort
blood oxygen ssaturation
pulse rate
body position
what your dentist might if you snore or have obstructive sleep apnea
elongated uvula and soft palate that can contact the tongue
enlarged tonsils which partially obscure the airway
the tongue is large and usually rests above the biting surface of the teeth
what your dentist might if you snore or have obstructive sleep apnea
elongated uvula and soft palate that can contact the tongue
enlarged tonsils which partially obscure the airway
long uvula
the tongue is large and usually rests above the biting surface of the teeth
a normal class I tongue is at or below the level of occlusal plane
effects of oral appliances
bring mandible and base of tongue forward palate and mandibular rotation
prevention of mandibular opening during sleep
downward mandibular rotation
support soft palate and uvula
increased genioglossus activity
goals of oral repositioning devices
50-75% of maximum protrusion
start movement slowly
vertical dimension increased by 5 mm
indications for use of oral appliances
primary snoring
mild to moderate OSA
poor tolerance of nasal CPAP
failure of UPPP
- surgical technique to remove uvula and soft palate
use of appliance during travel
use in combination with other treatmetns
benefits of CPAP
always eliminates snoring if properly titrated
elimniates or reduces dangerous OSA, hypopnea and oxygen desaturation of blood
protocol for for oral appliances
trial evaluation for 2-3 months
subjective symptom assessment
ceph with appliance in place
repear overnight sleep study
repeat evaluation / recall
protocol for for oral appliances
medical assessment and polysomnography by sleep specialist FIRST
- oro-facial / dental evaluation
- design, fabricate, fitting, training, adjustment
trial evaluation for 2-3 months
subjective symptom assessment
ceph with appliance in place
repear overnight sleep study
repeat evaluation / recall
contraindications for oral appliances
severe sleep apnea
obesity
TMJ problems
poor dentition
- like perio and could extract the teeth with appliance use
steep mandibular plane angle
sleep deprivation statistics
32 % of americans sleep 6 hour or less per night
23% of adults fell asleep at the wheel during the past year
sleep time has decreased 20% over last century
statistics of snoring
approx 40% of adults over 40 snore
stastics of signs of OSA on testing
9% of men
4% of woman
HAVE SIGNS ON TESTING
statistics of signs and SYMPTOMS of OSA
4% of men and 2% of woman
general prevelance of OSA
as prevalent as diabetes or asthma!!!
tx for snoring
avoid alcohol weight loss CPAP - prob overkill - position therapy oral appliances *
T/F pulse oximetry is a poor screening tool
true
we need sleep study
severity of apnea defined by?
length of time of apnea event
percentage of time apnea event
percent of oxygen desaturation
apnea - hypoapnea ndex is
mild - 5-15 (5-20 on other slide) events/hour
moderate 15-40 (20-40 on other slide) events/ hours
severe over 40 events/ hour
risks of OSA
increased rate of motor vehicle accidents
increased risk of unemployment
uninsurability
martial discord
cardiovascular consequences
sleep breathing disorder continuim
snoring –> UARS–> Hypopnea –> apnea –> hypoventilation
signs and symptoms of OSA
- snoring and intermittent pauses
- excessive daytime sleepiness
- awakness due to gasping and choking
- fragmented, non-refreshing sleep
- poor memory and clouded intellect
- personality changes
- decreased sex drive
- morning headaches
predisposing factors for OSA
- increased age
- increased weight / obesity
- male gender
- disproportionate upper airway anatomy
- alcohol and sedative hyptonics
- hypothyroidism
collar size and neck size
men over 17 and woman over 15
increased risk
upper airway configuration in apneics
apneic airway has an A-P configuration
NARROWED LATERALLY due to the lateral soft tissue structures – pharyngeal wall and fat pads
VOLUME of lateral pharyngeal walls, soft palate and fat pads are SIGNIFICANTLY LARGER in apneic patients
primary screening tool
epworth questions
over 10 = OSA
epworth norms
- breakdown
normal is 5.9 (so 6 or less)
OSA = 11.7
Narcolepsy = 17.5
behavior treatment and avoidance with OSA
weight loss
body positioning
avoidance of CNS depressants
avoidance of upper airway irritants
only one that really raises oxygen saturation
CPAP
continuous positive airway pressure
side effects of oral appliances
excessive salivation
transient discomfort of teeth, TMJ
dry mouth - xerostomia
soft tissue irritation
occlusal changes
effectiveness of oral appliances
85-90 % effective in snoring
60-70% effective in mild - moderate OSA
10% complication rate
success is highly variable and DOES NOT IMPROVE lowest sa02 levels
george gauge
intra-oral device used to register correct jaw position for mandibular repositioning appliances
measures prottrusion and retrusion of mandible
start at HALF OF MAXIMUM
CLASSIFICATION of oral appliances
mandibular repositioning devices
tongue retaining devices
tongue retaining devices for?
edentulous
CPAP success?
80-90%
but 40-60% non- compliance issues
20% complication rate
increases lowerst Sa 02
general over arching treatment of snoring
- behavioral tx and avoidance of risk factors
- contious positive airway irritants
- oral appliance therapy
- surgery
downfall of Uvulopalatopharynggoplasty
painful
removes the uvula palate and tonisls
ONLY 40% SUCCESS WHEN PERFORMED ALONE
ONLY
phase I sureries
UPPP/ tonsilectomy
mandibular anterior segmental osteotomy with genioglossus muscle advancement
possibly include hyoid bone
stabilization
success increases when do them together
like UPPP alone = 40-50
all three together = 60-70%
phase II surgeries
success?
implicatino
maxillomandibular advancement (MMA)
maxilla and mandible advanced forward 10 mm - usually combined with advancement of genial tubercles / genioglossus muscle (total of 20 mm for genioglossus)
success rate of approx 97% – bt invasive and a lot of surgery
airway is increased at multiple levels
tongue base
palate
nasal valve
maxillomandibular advancement success rate
90-98%
