Obstructive Sleep
Apnoea
EASO Train The TrainerAnnecy, July 2019
Obesity As A Disease
Abd Tahrani @AbdTahrani
MD, MMedSci, FRCP(London), PhD, SCOPE (National Fellow)
NIHR Clinician Scientist
Senior Lecturer in Metabolic Endocrinology and Obesity Medicie
Honorary Consultant in Endocrinology, Diabetes and Bariatric Medicine
Lead for Translational and Weight Management Research
Trustee, and co-Chair of the Clinical Practice and Obesity Management Committee
I have received support for
research and meetings,
honorarium for advisory work
and equipment support from:
Sanofi Aventis
Eli Lilly
BMS
BI
Novo Nordisk
Disclosures
AZ
MSD
Janssen
Resmed
Philips Resporinics
ImpetoMedical
ANSAR
Aptiva
Outline
Overview of OSA
Is it important to screen patients for OSA in medical weight management ?
Is it important to screen patients for OSA in bariatric surgery services?
How to screen for OSA?
How to treat OSA?
What about Obesity hypoventilation syndrome?
40 year-old woman
BMI 46
12 months in medical weight management
Type 2 diabetes.
On metformin
HbA1c< 7%
RYGB
1st day post op: Patient give opiates… Cardiac arrest…patient
resuscitated dn admitted to ITU
Patient received and discharged
Clinical Case
Definition
Common 2-4%
24% of men and 9% of women have OSA
9% of men and 4% of women have moderate-severeOSA
Characterised by recurrent episodes of partial/complete obstruction of
the upper airways
Associated with O2 de-saturations, changes in sleep architecture,
intrathoracic pressure, autonomic function and episodic changes in
heart rate and hypertension
Risk Factors: Obesity, Gender, Alcohol, Smoking, Age, Ethnicity, Family hx,
Autonomic Dysfunction
Sleep Disordered Breathing
Snoring UARS OSA OSAS
UARS: Upper airway resistance syndrome
OSAS: OSA + Excessive daytime sleepiness
Pathophysiology
Tongue
Soft palate
Airway
Flo
w
Time
Airway Blocked
Flo
w
Time
Open Airway Closed Airway
Sleep (transition from wakefulness and
REM)
Hypoventilation and UA
obstruction
Apnoea/ Hypopnea
Increasing Breathing effort
Hypoxia & Hypercapenea
Arousal
Hyperventilation
Lung volumesUA size
UA dilators toneChemosensitivity
UA resistanceExternal pressure
UA tone UA re-opening
Rapid PO2
PCO2
OSA
Airway obstruction
Sleep disturbance
Intra-thoracic pressure changes
Changes in Sleep Architecture
OSA prevalence in comorbidities
Martin et al. The Lancet, Volume 365, Issue 9464, 2005, 1046 - 1053
Cumulative percentage of individuals with new fatal (A) and non-fatal (B) cardiovascular events in each of the five groups studied
Wisconsin Sleep Cohort: OSA and Mortality: an 18 year follow-up (n =1522)
Young T. et al. Sleep 2008
Anothaisintawee et al. Sleep Med Rev. 2016 Dec;30:11-24. doi: 10.1016/j.smrv.2015.10.002
Subramanian et al. Diabetes Care 2019 May; 42(5): 954-963
PREDICTORS OF OSA IN PATIENTS WITH T2D
Risk factors aIRR (95% CI); p value*
Sex
Male 2.27 (2.09-2.47); <0.001
Female Ref
BMI categories
Underweight/normal weight (<25 kg/m2) Ref
Overweight (25-30 kg/m2) 2.02 (1.54-2.64); <0.001
Obese (>30 kg/m2) 8.29 (6.43-10.70); <0.001
Missing 3.68 (2.31-5.87); <0.001
Smoker categories
Non-smoker Ref
Previous smoker 1.13 (1.04-1.22); 0.004
Smoker 1.10 (1.00-1.22); 0.056
Missing 0.89 (0.40-1.99); 0.773
HbA1c category
≤6.5% (47.500 mmol/mol) Ref
6.5-7.5% (47.501-58.500 mmol/mol) 0.90 (0.82-1.00); 0.044
7.5-8.5% (58.501-69.400 mmol/mol) 1.00 (0.88-1.13); 0.962
≥ 8.5% (69.401 mmol/mol) 0.98 (0.87-1.10); 0.729
Missing 0.88 (0.78-0.98); 0.026
Concurrent conditions within 15 months of diabetes
diagnosis
Foot Disease 1.23 (1.07-1.42); 0.004
Heart failure 1.49 (1.24-1.77); <0.001
Ischaemic heart disease 1.22 (1.11-1.34); <0.001
Hypertension 1.32 (1.23-1.43); <0.001
Depression 1.75 (1.61-1.91); <0.001
Insulin 1.57 (1.42-1.75); <0.001
Tahrani. Diab Vasc Dis
Res. 2017 Sep;14(5):454-462.
doi:
10.1177/1479164117714397.
OSA in T2D Increases the Risk
Retinopathy
CKD
Neuropathy
Foot Disease
CVD
Mortality
OSA Risk Factors
Obesity (neck circumference)
Male gender
Increasing age
Family history
Anatomic abnormalities of the upper airway
Alcohol or sedative use
Smoking
Symptoms and Signs
Symptoms associated with Sleep Apnea:
❑Excessive daytime sleepiness, lack of energy
❑Snoring
❑Sensation of choking during the night
❑Frequent night-time urination
❑Morning headaches
❑Sexual dysfunction
Pre-existing cardiovascular and co-morbidities:
❑Arterial Hypertension
❑Diabetes
❑Heart disease
❑Metabolic Syndrome
Diagnostic studies
Type 1 device: Full Polysomnography (PSG)
– In-lab study including audio-visual.
– Over 24 channels, including EEG, EOG, EMG, ECG, thermistors and pressure transducer, respiratory effort, SaO2, body position, limb movement
Type 2 device: Ambulatory PSG
– In-lab or in-home, with cut down version of PSG and usually without audio-visual
Type 3 device: Polygraph (PG)
– Partial studies using multiple channels at home or in hospital,
– includes pressure transducer, thermistor, snore, respiratory effort, Sao2, body position
– no data on sleep staging
Type 4 device
– Screening devices
– Usually one/two channels
Treatments - General
Weight loss (including Bariatric
Surgery)
Abstain from alcohol and sedatives
Smoking cessation
Positional sleeping
Treatments - Oral Appliances
Treatments - Surgery
Tonsillectomy / Adenoidectomy
– High success rate in children
Genioglossal advancement
– Anterior advancement of tongue
Maxillomandibular advancement
– High success rate with craniofacial abnormalities
Uvulopalatopharyngoplasty (UPPP)
Continuous Positive Airway Pressure (CPAP)
BMI ≥30 kg·m−2
Sleep disordered breathing
Daytime hypercapnia (arterial carbon dioxide tension (PaCO2) ≥45 mmHg at sea
level) during wakefulness
In the absence of an alternative neuromuscular, mechanical or metabolic
explanation for hypoventilation
90% of patients with OHS have obstructive sleep apnoea (OSA)
OHS between 8% and 20% in obese patients
Obesity Hypoventilation Syndrome…. The combination of
Massa et al. European Respiratory Review 2019 28: 180097; DOI: 10.1183/16000617.0097-2018
Pathogenesis
Thank You
@AbdTahrani