What is Obstructive Sleep Apnoea?
It is the recurrent functional collapse of the upper airway during sleep causing complete cessation of airflow despite continued respiratory effort. It causes a drop in the Oxygen level and an increase in the Carbondioxide levels in the body.
How is Sleep Apnoea diagnosed?
OSA is diagnosed based on a Polysomnography study (Sleep study). The test measures the Apnoea( complete cessation of breathing) Hypopnea (shallow breathing) Index. An AHI greater than 5 indicates Sleep Apnoea. Once diagnosed, other tests that will be required are OPG and lateral cephalogram x-ray, CT craniofacial and airway study, a trans nasal flexible laryngoscopic examination under sedation. All assessments would be supervised by an ENT surgeon who has a special interest in sleep apnoea.
What are the risk factors for Obstructive Sleep Apnoea?
Advancing age, Male gender, Obesity, Craniofacial anomalies including adenotonsillar hypertrophy, Smoking, Menopause, family history, Pregnancy, End stage Renal Disease, Congestive Cardiac failure, COPD /Asthma, Post Traumatic Stress Disorder, Strokes and Polycystic Ovary disease are risk factors for developing OSA.
The incidence of Sleep Apnoea increase significantly with increasing body weight. In one study done the prevalence of Moderate OSA (AHI score >15/hr) increased as follows:
What are the ill effects of Obstructive Sleep Apnoea?
OSA disturbs sleep at night and therefore causes increased daytime sleepiness. It also affects concentration, causes headaches, irritation and cognitive and Psychiatric impairment. At night it causes restlessness and snoring. The cardiac side effects of Sleep Apnoea include Systemic and Pulmonary Hypertension, Coronary Artery disease, Arrhythmias, Heart Failure and Strokes. Sleep Apnoea is associated with Fatty Liver, Metabolic syndrome and Type 2 Diabetes mellitus and increase the chance of Perioperative complications. An AHI >/= 30 is associated with a 203 fold increased risk for all cause mortality.
How is Sleep Apnoea managed?
Treatment for chronic diseases such as heart failure, COPD would need to be optimised first. Obesity and weight reduction would be mandatory requirement for good response to treatment given. The first line in the management would be provision of nocturnal CPAP therapy through an appropriate device.
Oral appliances can be tried if patient is intolerant to nocturnal CPAP. Surgery may be indicated for people who have not responded adequately to nocturnal CPAP and oral devices despite persevering for at least 3 months. Hypoglossal nerve stimulation may also be helpful in select patients. Patient education to change behaviour would be crucial in the successful management of OSA. Complete abstinence from Alcohol and cigarette smoking would be very important too.
What are the indications for nocturnal CPAP treatment?
Nocturnal CPAP is indicated for all patients with OSA who meet the following criteria.
1. AHI > 15/hr with or without symptoms
2. When AHI between 5-14/hr, CPAP is indicated when you have excessive daytime sleepiness and fatigue, insomnia at night or non-restorative sleep, breath holding or choking and gagging in sleep, mood and cognitive disturbances or in the presence of systemic illnesses such as high BP, heart disease, heart failure, strokes, atrial fibrillation and diabetes.
3. RERAs > 10/hr with excessive daytime sleepiness even if AHI is <5/hr (RERA = Respiratory Effort Related Arousal)
Unfortunately, adherence to CPAP use at night is an issue and unto 40% of patients would refuse to use it.
What are the medicines that can be used in people with OSA?
Medicines have a limited role in the treatment of OSA. Medicines such as Theophyllines and Acetazolamide increases the respiratory drive and Desipramine reduces the upper airway collapsibility. Dronabinol 1 hour before sleep can reduce apnoea AHI significantly. Persistent daytime sleepiness can be treated with Modafinil and Armodafinil.
What are the Oral Appliances that can be used in people withOSA?
Nasal splints, expiratory valves, chin straps and mandible advancement devices are some of the appliances available.
Who will benefit from surgery?
Although there is no consensus regarding when or who will actually benefit from surgery, surgery is usually offered for whom a CPAP or a oral device has not been effective, even after a 3 month period. Surgery could be the first line of treatment for children with OSA especially in whom an enlarged adenoid or tonsils is believed to obstruct the airway during sleep. In adults, surgery is planned when there is a fixed correctable airway obstruction. Selection of patients should take into account 3 factors namely, patient’s desire for surgery, existence of a surgically correctable problem and fitness for surgery.
What are the surgical options in Sleep Apnoea management?
The Sleep Surgeon who is usually a ENT surgeon who has special training in Sleep Apnoea will do a complete assessment to identify the site of the airway obstruction, prior to surgery. Nasal abnormalities such as Concho Bullosa, Nasal Polyposis, Septal Deviations and Hypertrophic Turbinates may need to be corrected to improve the airway obstruction. Nasal surgery as a stand alone procedure does not relieve OSA effectively.
Tongue reductive surgeries and surgery on epiglottis may be planned if indicated.
If the obstruction is in the palate or the upper oropharynx due to recurrent uvular swelling, tonsillitis and tonsillar pellets, Uveopalatopharyngoplasty (UPPP) along with tonsillectomy/adenoidectomy may be required to relieve the airway obstruction.
Select patients would require Global Upper Airway procedure with maxillomandibular advancement. This is a large procedure and is usually reserved for those with persistent OSA despite site directed surgical treatments. This has a success rate of 86% and a cure rate of 43%. Lastly, Hypoglossal nerve stimulation may be considered. The FDA recommends this procedure for adults above the age of 22 with moderate to severe predominant OSA and who have failed nocturnal CPAP treatment.
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