sleep apnea… · what is obstructive sleep apnea (osa) understand diagnosis and treatment...
TRANSCRIPT
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Sleep Apnea…The Not so Silent Killer
Dominic A. Munafo, Jr., M.D., F.ABSMChief Medical Officer
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What is obstructive sleep apnea (OSA)
Understand diagnosis and treatment
Understand the basic pathophysiology
Know three conditions highly associated with OSA
Today’s Goals
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Insidious condition of repetitive partial orcomplete airway collapse during sleep
Frequently associated with:• obesity• diabetes• heart disease
What is Obstructive Sleep Apnea (OSA)
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The Obstructed Airway
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Spectrum of Disease
• Snoring
• Upper Airway Resistance Syndrome -(UARS)
• Sleep Apnea– Obstructive– Central
• Obesity Hypoventilation Syndrome -(OHS)
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Pulmonary Disease and Obesity
Obesity
Simple Obesity Obesity Hypoventilation
Exercise intoleranceDyspnea on exertionIncreased post-op risk
1. pneumonia2. atelectasis
EucapnicFrequent OSALikely increased respiratory drive
HypercapnicFrequent OSAAbnormal respiratory drive
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Scope of the Problem
• 20 - 30 million Americans
• Wisconsin sleep cohort study
– 626 subjects age 30-60
– AHI > 5 in 9% of women
– AHI > 5 in 24% of men
Young T, N Engl J Med 1993;328
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Scope of the Problem
• OSA Prevalence in other disease states– Obesity – 75%
– Type II DM – 72% (moderate & severe – 66%)
– Hypertension – 50 to 75%
– CAD & A. Fib. – 50%
– CHF – 50 to 75%
– Depression – 40 to 45%
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• Most common symptoms
– Loud snoring
– Witnessed apnea
– Excessive daytime sleepiness
– Waking up choking & gasping
– Cognitive impairment
Obstructive Sleep Apnea
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• Most common signs– Obesity– Neck size ≥ 17 men ≥ 16 women– Nasopharyngeal narrowing– Maxillo-mandibular anomalies– Hypertension– Stroke– Heart failure
Obstructive Sleep Apnea
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• Clinical suspicion
• Consistent signs and symptoms
• Overnight sleep study looking
for respiratory events (HST or
PSG)
How to Diagnose Obstructive Sleep Apnea
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Apnea – no airflow ≥ 10 seconds
Hypopnea – reduced airflow ≥ 10 seconds, usually associated with oxygen desaturation or evidence of arousal
What are Respiratory Events
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Diagnosing OSA
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Consequences of Untreated OSA
Wolk, R. et al. Circulation 2003;108:9-12
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Consequences of Untreated OSA
Leung, et al. Am J Respir Crit Care Med 2001;164:2147-65
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Consequences of Untreated OSA
200
0
150
- 50
150
0
Baseline Phenylephrine OSA
150 - 0 = 150 200 - 0 = 200 150 - (- 50) = 200
Calculation of LV transmural pressures
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Consequences of Untreated OSA
200
0
150
- 50
150
+ 10
CPAP = 10 Phenylephrine – α1 agonist OSA
150 - 10 = 140 200 - 0 = 200 150 - (- 50) = 200
Calculation of LV transmural pressures
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Effects of the Supine Position
• V/Q mismatch
• Shunting
• Lung bases well perfused but poorly ventilated
• Reduced lung volumes
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Effects of the Supine Position
• Practical consequence
during general anesthesia
– More rapid decline in
oxygen saturation during
apnea,
< 2 minutes vs. 6 minutes
when breathing 100%
oxygen
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Severity Scale of OSA
• Apnea Hypopnea Index - (AHI)– Mild sleep apnea - 5 – 15 events / hour– Moderate sleep apnea - 16 – 30 events / hour– Severe sleep apnea - > 30 events / hour
• Who to Treat ?– AHI ≥ 30– AHI 5 - 29 ⇒ if symptomatic or if co-morbidities present
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OSA is associated with:
• Nocturnal blood pressure elevation
• Independent risk factor for hypertension
• Changes in LV geometry and function
• Metabolic Syndrome
Consequences of Untreated OSA
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Increasing prevalence of childhoodobesity and it’s complications couldactually result in the current generationsof children living less well and for ashorter time than previous generations
Ultimate Consequences
* Daniels, Future Child. 2006 Spring;16(1):47-67
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Treatment Options for OSA
• Permanent weight loss
• Continuous positive airway pressure (CPAP)
• Oral appliances
• Oral and/or maxillo-facial surgeries
• Tracheostomy
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CPAP Therapy for OSA
• Applied via nasal mask
• Acts as pneumatic splint
• Compliance limits utility
• Mask fit crucial
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