Obstructive Sleep

Apnoea

Presenter : Wong Chun Hsien

Ng Shiying
 Terminologies

1. Apnea: Cessation of airflow for 10 sec during sleep,

accompanied by:
Persistent respiratory effort (obstructive apnoea), or
Absence of respiratory effort (central apnoea)

2. Hypopnea: A 30% reduction in airflow for at least

10 sec during sleep that is accompanied by either a 3%
desaturation or an arousal.
 Sleep
Apnoea

Obstructive Central Sleep

Sleep Apnoea Apnoea
(less common)
Central Sleep Apnoea
May occur in isolation or in combination with
obstructive events mixed apnoea
Pathophysio: Prolonged circulation delay between
pulmonary capillaries and carotid chemoreceptors
Hence, with prolonged circulation delay, there is a
crescendo- decrescendo breathing pattern (Cheyne-
Stokes respiration)
Risk factor : CHF, opioid medication, hypoxia
(breathing at high altitude)
3 Key Reasons of
Understanding OSA
1. OSA is a common and under-diagnosed as
awareness levels are low.
2. OSA is closely linked to other serious health
consequences and comorbidities.
3. Treatment is straightforward and cost
effective.
Definition (OSA)
Obstructive Sleep Apnoea (OSA) is a sleep-related
respiratory condition, leading to apnoea (cessation
of breathing for 10 seconds or more), as a result of
intermittent closure or collapse of the pharyngeal
airway during sleep.

OSA affects 12% of the population and occurs

most often in overweight middle-aged men. It can
occur in children, particularly those with enlarged
tonsils or lymphoid hypertrophy.
Anatomy
Upper Respiratory Tract

OSA
 Pathophysiology

During inspiration, intraluminal pharyngeal pressure becomes

increasingly negative, creating a suctioning force.
Because the pharyngeal airway has no bone or cartilage,
airway patency is dependent on the stabilizing influence of the
pharyngeal dilator muscles
Pharynx muscles and tongue muscles played an
important role, such as :
a) Palatoglossus - Elevates posterior tongue
b) Genioglossus Protracts tongue
During wakefulness, upper airway dilating muscles,
including palatoglossus and genioglossus, contract
actively during inspiration to preserve airway
patency.
During sleep, muscle tone declines (neuromuscular
output declines) , impairing the ability of these
muscles to maintain pharyngeal patency.
( pharyngeal patency + Predisposing risk factor ) =
OSA
Incomplete obstruction causes turbulent flow, resulting in
snoring (around 40% of middle-aged men and 20% of middle
aged women snore). - hypopnoea
Most common
Causes or predisposing factors of
obstructive sleep apnoea (OSA)
A) Structural
Nasal Obstruction
Polyps
Septal deviation
Tumours
Trauma
Stenosis

Pharyngeal Obstruction
Adenotonsillar hypertrophy
Mandibular hypoplasia
Micrognathia
High arched palate
Syndromes Downs, Marfans, Prader-Willi, Acromegaly
Non-Structural
Obesity especially central fat distribution
and large neck circumference (>17 inches)
- Narrowing effects of upper airway fat on pharyngeal lumen.
Alcohol and sedative use
Smoking
Age and male sex
Postmenopausal state
Family history of OSA
 Clinical Features
The typical patient is an obese, middle-aged man who
presents because of snoring or daytime somnolence.
His partner often describes apnoeic episodes during
sleep.
Loud snoring
Daytime somnolence
Poor sleep quality
Morning headache
Decreased libido
Cognitive performance
 Diagnostic criteria Harrison

1. - Symptoms of nocturnal breathing disturbances (snoring, snorting,

gasping, or breathing pauses during sleep) ; or
- daytime sleepiness or
-fatigue that occurs despite sufficient opportunities to sleep and is
unexplained by other medical problem

2. five or more episodes of obstructive apnea or hypopnea per hour of

sleep
(apnea-hypopnea index [AHI], calculated as the number of episodes
divided by the number of hours of sleep) documented during a sleep
study.

It can be diagnosed in the absence of symptoms if the AHI is above 15.

Each episode of apnea or hypopnea represents a reduction in breathing for at
 Diagnosis of OSA

1. History
2. Physical examination
3. Polysomnography
 1. History
Nocturnal symptoms:
- snoring
- witnessed apnea
- nocturnal choking or gasping
- restless sleep
- insomnia
Daytime symptoms:
- excessive daytime sleepiness
- fatigue
- memory impairment
 A score of more than 10 suggests clinically daytime sleepiness
although a lower score does not exclude it.
 2. Physical examination
Obesity (BMI > 30kg/m2)
Large neck circumference
Abnormal or increased Mallampati score
Enlarged tonsils
High arched palate
Narrowing of airways
Retrognathia or micrognathia
 3. Polysomnography

GOLD Standard: overnight polysomnogram

Simultaneous recording of multiple physiological signals

during sleep.
 Treatment
1. Behavioral modification
2. Nonsurgical treatment
3. Surgical treatment
 1. Behavioral modification

Weight loss
Cessation of smoking or alcohol intake
Sleep on one side rather than supine
Avoid CNS depressants (sedative)
 2. Non surgical treatment
Pharmacological therapy:
- Modafinil
- Protriptyline (TCAs)
- Paroxetine (SSRIs)
- Nasal decongestants

CPAP
 Continuous Positive Airway
Pressure (CPAP)
The most effective treatment for OSA
It maintains the patency of pharyngeal airway, preventing
collapse of the pharyngeal tissues.
Average setting of CPAP is 5 15 cm H2O
Maybe delivered by nasal or face mask.
3. Surgical treatment