Literature Reading OSA

Literature Reading
Medical Therapy
for
Obstructive Sleep Apnea
Desti Kusmardiani
Pembimbing:
dr. Melati Sudiro, Mkes, Sp.T.H.T.K.L (K)
DEPARTMENT OF OTOLARYNGOLOGY – HEAD AND NECK SURGERY

FACULTY OF MEDICINE PADJADJARAN UNIVERSITY
HASAN SADIKIN HOSPITAL
BANDUNG
2015
1
Definition
Obstructive Sleep Apnea (OSA)
• repetitive partial or complete collapse of the
upper airway during sleep, resulting in
disruptions of normal sleep architecture and
usually associated with arterial desaturations
• Friedman M. Sleep Apnea and Snoring : Surgical and Non-Surgical Therapy. Edisi ke 1. Elsevier Health Sciences; 2009.
• Fairbanks DNF, Mickelson SA, Woodson BT. Snoring and obstructive sleep apnea.Edisi ke 3. New York: Raven Press; 2003.
2
Epidemiology
OSAS 2-4% from general population
• Prevalence OSAS  men (3-7%) > woman (2-5%)
snoring  30-50% from general population

• can occur at any age,
• typically presents at the ages of 40-60 yo
Prevalence of OSAS in children 1-3%

•Prevalence of snoring in children higher  12%
Asghari A, Mohammadi F, Kamrava S, Jalessi M, Farhadi M. Evaluation of quality of life in patients with obstructive sleep apnea. Eur Arch
Otorhinolaryngol. 2012:1-6
3
Etiology
MULTILEVEL OBSTRUCTION IN UPPER AIRWAY
Bailey BJ, Johnson JT, Newlands SD. Head & Neck Surgery - Otolaryngology.Edisi ke 4. Lippincott Williams & Wilkins; 2006. 4
Hypertrophy of right inferior
concha with total obstruction
Septal deviation
5
Adenoid Hypertrophy
Elongation of palatum mole

(white arrow)
6
Hypertrophy tonsil and
adenoid.
macroglossia
Retrognatia /retroposition of
mandibula
Omega shape
on epiglotis
7
Pathophysiology
Resistor model of OSA
Successful management of OSA requires adequate

Increase In the upstream pressure or reduction In the
Critical closing pressure
Bailey, Byron J. Head & Neck Surgery - Otolaryngology, 5th Edition, 2014
Diagnosis
• Anamnesis:
Type of sleep disturbance, Snoring, Apneas, Waking up, Bed
partner reports
• Physical examination:
Review of system: Respiratory , Cardiovascular,
Gastrointestinal, Urinary, Vascular, Musculoskeletal,
Neurologic, Endocrine, Psychiatric
• Spesific Examination:
Laboratory, Polisomnography, radiology
Anamnesis
Adult Children
Heavy persistent snoring Snoring
Excessive daytime sleepiness Restless sleep
Apneas as observed by bed partner Sleepiness
Choking sensations while waking up Hyperactivity
Gastroesophageal refl ux Aggression and behavioral
Reduced ability to concentrate disturbance
Memory loss Frequent colds or coughing
Personality changes Odd sleeping positions
Mood swings
Night sweating
Nocturia
Dry mouth in the morning
Restless sleep
Morning headache
Impotence
10
Friedman M. Sleep Apnea and Snoring : Surgical and Non-Surgical Therapy.Edisi ke 1. Elsevier Health Sciences; 2009.
Epworth Sleepiness Scale (ESS)
Epworth Sleepiness Scale
Situation : 0 1 2 3
1. Sitting and reading
2. Watching TV
3. Sitting inactive in a public place
4. Being a passenger in a motor vehicle for an hour or more
5. Lying down in the afternoon
6. Sitting and talking to someone
7. Sitting quietly after lunch (no alcohol)
8. Stopped for a few minutes in traffic while driving
Score
Total score
0 = would never doze or sleep.

1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping 11
ESS
SCORE CATEGORY
0-8 Normal
9-12 Mild
13-16 Moderate
>16 Severe
• ESS is a popular treatment outcome measure for assesing the

benefit of positive airway pressure for treating sleep apnea
•ESS score above 10 is often used to indicate significant sleepiness
Max H, in Obstructive Sleep Apnea Diagnosis & Treatment, Informa Healthcare , New york, 2007
Questionnaires :
• Child Health Questionarie Parent Form (CHQ-PF),

• Pediatric Sleep Questionaire (PSQ),
• Obstructive Sleep Disorder–6 (OSD-6), dan
• Obstructive Sleep Apnea-18 (OSA-18)
OSA-18  sensitivity 95% and specificity of 90%, so it is accurate to use as a

single questionnaire to measure sleep-disordered breathing.
Bower MC, Ray MR. Pediatric sleep disorder. in clinician’s guide to pediatric sleep disorder. Editor: Richardson MA,
Friedman NR, 2006:1-18. 13
14
Systemic Evaluation Physical Examination
• Obesity
• Hipertention
• Hormonal disturbances
• Heigh, weight, neck
circumferences and BMI
• Mental states & conciousness
Nose and nasofaring
• External nose
• Air passage with anterior
rhinoscopy or with nasal
endoscope
• Posterior rhinoscopy
/nasopharyngoscopy
Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology - Head and Neck Surgery.Edisi ke 2. McGraw-Hill Companies,
Incorporated; 2008.
Bailey BJ, Johnson JT, Newlands SD. Head & Neck Surgery - Otolaryngology.Edisi ke 4. Lippincott Williams & Wilkins; 2006. 15
A Standardized History and Physical
Form for Patients with a Sleep Disorder
POLYSOMNOGRAPHY
Friedman M, Sleep apnea and snoring : surgical

and non-surgical therapy, Elsevier Inc,2009, snoringremediescenter.com
5/17/2019 21
assessed from the number of micro-arousals that cuts
the sleep, ↓ O2 saturation, heart rate and rhythm, as
well as the duration of each episode stopping
breathing`
sleep architecture
and the degree of
severity of OSA
patients were
assessed by the
apnea-hypopnea
index (AHI)
Eckert DJ, Malhotra A. Pathophysiology of Adult Obstructive Sleep Apnea. Proceedings of the American Thoracic Society.
2008;5(2):144-53.
5/17/2019 22
Respiratory disturbance
index (RDI)
or • Number of apnea dan hypopnea / hour
apnea-hypopnea index •RDI / AHI ≥ 5x/hour  sleep apnea (adult)
(AHI)
Severity of OSA
Severity of OSA Adult AHI
None 0-5
Mild 6-20
Moderate 21-40
Severe >40
Sargi Z, Younis RT. Pediatric Obstructive Sleep Apnea: Current Management. ORL. 2007;69(6):340-4.
5/17/2019 23
Therapy
• Medical/ non surgical therapy

• Surgical therapy
Medical Therapy
Pharmacologic Therapy
Positive Airway Pressure
Oral Appliance
Weight Loss
Positional Therapy
Oxygen Therapy
Oropharyngeal Exercise
Behavioral Modification
Pharmacologic therapy
• Drugs that Increase Respiratory Drive:
medroxyprogesterone (Cycrin, Provera) ;
Protriptilyne (Vivactil)
• Serotonin
Paroxetine (Paxil, Paxeva)
• Etanercept (Enbrel)
• Modafinil
Pharmacologic therapy
• Modafinil (100-200mg ) is approved by the US FDA

>>> in patient with residual daytime sleepiness
despite optimal use of cpap
• Selective serotonin reuptake inhibitor agents such as
paroxetine (Paxil) and fluoxetine (Prozac)>> increasing
genioglossal muscle activity and decrease rem sleep
(apneas are more common in REM)
Yeh SB, Schenck CH. Khasiat modafinil di 10 pasien Taiwan dengan narkolepsi: Temuan menggunakan beberapaLatency Sleep Test dan
27
Epworth Kantuk Skala. Kaohsiung J Med Sci.2010
Treatment of Nasal Obstruction
• Nasal obstruction is an independent risk factor for
both snoring and OSA
• Related with nasal congestion
• Topical nasal steroid therapy improved subjective
sleep quality
• Brouillette et al. reported a reduction in the AHI from
10.7 to 5.8 with fluticasone nasal spray in a selected
group of pediatric patients
• Nasal decongestan
Treatment of Hypothyroidism
• Hypothyroidism ---- weight gain, tongue
enlargement, muscle dysfunction
• Synthetic thyroid hormone levothyroxine
Treatment of Acromegaly
• Acromegaly characterized by hypersecretion of
growth hormone
• Sleep apnea result form structural abnormalities
induced by GH leading to upper airway narrowing,
and increased respiratory drive leading to breathing
instability due to increased gain of the respiratory
controller
• Treatment with ocreotide (sandostatin) may lead to
improvement of sleep disordered breathing
Positive Airway Pressure
• PAP systems consist of a generator that directs
airflow downstream to the patient via tubing and an
interface.
• Positive pressure is introduced into the upper airway
providing a pneumatic splint through the entire
length of the collapsible pharyngeal segment and
thus maintaining airway patency and effective
control of breathing.
Continuous Positive Airway Pressure
• First modality described and still the most
widely used.
• This modality delivers the same pressure to
the patient during both inspiration and
expiration and remains unchanged throughout
the night
Bilevel Positive Pressure
• Bilevel positive pressure (BIPAP) provide the ability to
independently adjust the inspiratoty (IPAP) and
expiratoty (EPAP) pressure such that the pressure
delivered during exhalation is lower than that
delivered during inhalation
• Two modes:
 S-Mode
 ST-mode
Autotitrating Continuous Positive
Airway Pressure
• Autotitrating device employ computer algorithms to
detect changes in airflow and adjust the delivered
pressure accordingly.
• Autotitrating devices are available in both
autotitrating continuous positive airway pressure
(APAP) and autotitrating BIPAP (auto bilevel) forms.
PAP Interfaces: Examples of the three most common categories of mask Interfaces for
positive pi'QSsure 1herapy are depleted: (A) nasal pillows, (I) nasal mask_ and (C) full-
face mask
Oral Appliance
Mandibular Repositioning Appliance (MAD)
• most commonly used type of oral appliance
• a nontitratable type and a titratable type
Tongue Retaining Device (TRD)

• holds the tongue forward in a suction bulb mechanism
• a viable option in edentulous patients
Thermoplastic Splints
• improved mandibular advancement
• less side effects and noncompliance compared to boiland-
bite thermoplastic appliances
Types of oral appliances: A:. The TAP device Is an effective, commonly Used, tltratable
MRA. B: MRA In place. C: The TRD a less common appliance that uses a suction bulb
to keep the tongue protruded during sleep. D: TRD In place
Effectiveness
Effect of oral appliances on the airway: Lateral cephalometric radiograph in a patient

with OSA. before (A) and after {B) application of a MAD. Note the enlargement of the
pharyngeal airway with the oral appliance at both the retrolingual and retropalatal
portions of the airway.
Weight Loss
• Histopathologic analysis of the tongue has revealed
that obesity is associated with increased lingual fat
deposition and increased size and weight of the
tongue
• weight loss  significant reduction in the size of the
parapharyngeal fat pads and an increase in the
volume of the upper airway
Relationship between Weight change and AHI
Weight Loss
• Diet & exercise:
Low calori diet, weight-bearing for more than 20
minutes five days a week
• Pharmacological:
Aminorex (Menocil), dexfenfluramine (Fen-Phen),
Orlistat (Xenical), Sibutramine (Meridia)
• Bariatric
Positional Therapy
• lateral sleeping position
• Head of bed elevation, or postural therapy
• Critical dosing pressure has been shown to be
more negative, signifying greater upper airway
stability
Oxygen Therapy
• Oxygen therapy may also be combined with
positive pressure therapy.
• Selected OSA patients with other confounding
conditions such as obesity hypoventilation,
CHE or chronic obstructive pulmonary disease
(COPD) may benefit from supplemental
oxygen
Oropharyngeal Exercise
• OSA patients have increased genioglossus
muscle activity during wakefulness; this
compensation is lost during sleep
• These findings may serve as the basis for
improvement in OSA with oropharyngeal
exercises
regular didgeridoo playing
Behavioral Modification
• Sleep deprivation may predispose to or
worsen existing OSA
• Maladaptive behaviors that may negatively

impact sleep quality and quantity include
caffeine, alcohol or nicotine consumption,
insufficient sleep duration, shift work or a
poor sleeping environment
Medical Therapy for OSA
47
HIGHLIGHTS
• OSA is the most common sleep-related respiratory
disturbance in both children and adults and as a
worldwide problem
• Successful management of patients with OSA
requires a comprehensive sleep history and
examination, proper diagnostic evaluation, and an
individualized approach that takes into account each
patient's unique presentation and considers all
available and applicable treatment options.
5/17/2019
HIGHLIGHTS
• First-line therapy for OSA is PAP therapy. Oral
appliances can also provide adequate therapy
for select patients with OSA.
• Other treatment options can play an
important role as well and include weight loss,
smoking cessation, behavioral medications,
positional therapy, treatment nasal
obstruction
5/17/2019 48
THANK YOU

Literature Reading OSA

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Literature Reading OSA

Uploaded by

Copyright:

Available Formats

Literature Reading

DEPARTMENT OF OTOLARYNGOLOGY – HEAD AND NECK SURGERY

snoring  30-50% from general population

Prevalence of OSAS in children 1-3%

Elongation of palatum mole

Resistor model of OSA

Successful management of OSA requires adequate

0 = would never doze or sleep.

• ESS is a popular treatment outcome measure for assesing the

•ESS score above 10 is often used to indicate significant sleepiness

• Child Health Questionarie Parent Form (CHQ-PF),

OSA-18  sensitivity 95% and specificity of 90%, so it is accurate to use as a

Friedman M, Sleep apnea and snoring : surgical

• Medical/ non surgical therapy

Positive Airway Pressure

• Modafinil (100-200mg ) is approved by the US FDA

Tongue Retaining Device (TRD)

Effect of oral appliances on the airway: Lateral cephalometric radiograph in a patient

• Maladaptive behaviors that may negatively

You might also like