Nonsurgical Treatment of Obstructive Sleep Apnea

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Nonsurgical Treatment of Obstructive Sleep Apnea

• Ho-Sheng Lin, MD
• Associate Professor
• Department of Otolaryngology/
• Head and Neck Surgery
• SCS Educational Day
• 11/27/07

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Obstructive Sleep Apnea

• Introduction
• Nonsurgical Tx
• Clinical Objectives of Surgical Tx
• Preop Assessment and Periop Management
• Surgical Management

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Definition

• AHI (Apnea Hypopnea Index)
• apnea hypopnea / hour of sleep
• RDI (Respiratory Disturbance Index)
• apnea hypopnea arousal / hour of sleep

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Defining Severity of OSA

• Length of time in apnea event
• ? O2 desaturation
• Apnea-Hypopnea Index (AHI)
• Mild 5-15 events / hour
• Moderate 15-30 events / hour
• Severe gt30 events / hour

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Sleep Disordered Breathing (SDB)Clinical Spectrum
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Incidence of OSA

• Approximately 40 of adults over 40 years old
  snore (about 100 million Americans)
• Middle age (30 60 yo) American
• Young et al.
• 4 of men and 2 of women (18 million)
• RDI gt 5 and symptoms of daytime sleepiness
• Geriatrics
• Ancoli-Israel et al.
• 24 - 42 have RDI gt 5
• Young, 1993 2520 Ancoli-Israel, 1991
  2649

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Incidence of OSA

• National Commission on Sleep Disorders Research
  (1993)
• 18 million Americans suffer from OSA
• 95 of pts w/ OSA may be undiagnosed
• More prevalent than asthma
• Equally prevalent as diabetes

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Etiology

• Partial or complete collapse of upper airway
  during sleep
• Multifactorial
• Anatomic factors resulting in narrowing of
  pharynx
• Skeletal anatomy (micrognathia, retrognathia)
• Soft tissue (macroglossia, tonsillar hypertrophy,
  fatty infiltration of pharyngeal tissue assoc w/
  obesity)
• Neuromuscular factors
• Decreased activity of pharyngeal dilator m
• Increased compliance of pharyngeal airway
• Active inhibition of muscle activity during REM
  sleep
• Alcohol, sedatives, and muscle relaxants

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Risk Factors

• Obesity, body mass index gt 28 kg/m2
• Increased age
• Male sex
• Hypertension
• Hypothyroidism
• Use of sedatives/narcotics/alcohol
• Snoring

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Medical Consequences

• The narrowing and closure of the airway during
  sleep causes fragmented sleep and
  patho-physiologic conditions
• Neurobehavioral Derangement
• Cardiopulmonary Derangement
• Findley, 1988 2671

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Medical Consequences - Neurobehavioral Derangement

• Excessive daytime sleepiness
• Depression
• Impotence
• Personality change, Irritability
• Learning and memory difficulties
• Morning headache
• Lack of energy
• Loss of employment, Uninsurability, Marital
  Discord
• Traffic accident, 7x higher
• Findley, 1988 2671

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Medical Consequences - Cardiopulmonary Derangement

• HTN
• Occur in 50 OSA patients
• About 30 of HTN have OSA
• Repetitive hypoxia and hypercapnia at night may
  contribute to inc in sympathetic tone resulting
  in HTN
• RV hypertrophy and failure
• Resulting from pulmonary HTN due to hypoxemia
• Cardiac arrythmias
• Most common being nocturnal bradycardia, which
  occurs during apneic episode followed by
  tachycardia at resolution of apnea
• MI, angina
• CVA
• Yamashiro, 1993 2669

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Medical Consequences-Mortality

• He et al. (n385)
• Cumulative 8 yr mortality
• 37, pts w/ AI gt 20
• (not treated)
• lt 4, pts w/ AI lt 20
• Inc mortality due to
• Cardiovascular causes
• MI, arrythmias, and strokes
• Accounts for 38,000
• cardiovascular death per year in US
• MVA
• He, 1988 947Partinen, 1988 933

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Indication for Treatment

• AHI 15 or more (moderate-severe)
• AHI 5-14 (mild) and with documented symptoms of
• Excessive daytime sleepiness, or
• Impaired cognition, mood disorders or insomnia,
  or
• Documented hypertension, ischemic heart disease
  or history of stroke

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Non-Surgical Treatment

• Behavioral Modifications
• Weight reduction
• Avoid CNS depressants (alcohol, sedatives)
• Sleep on side w/ tennis ball on back
• External nasal dilators/steroid spray
• Oral Appliances
• CPAP

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Non-Surgical Treatment

• Weight Reduction
• Exercise
• Diet
• Bariatric Surgery

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Non-Surgical Treatment
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Non-Surgical Treatment Oral Devices

• Compliance rate about 50
• May cause TMJ pain damage to teeth
• May be effective in pts w/ mild OSA
• Bloch et al. (n24)
• RDI changed from an average of 22.6 to 8.7 w/ use
  of mandibular advancement appliance
• Pitsis et al. (n23)
• RDI changed from an average of 21 to 9

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Non-Surgical TreatmentOral Devices

• American Sleep Disorders Association Standards of
  Practice Committee
• Primary snoring
• Pts w/ mild OSA who do not respond to general
  treatment
• Pts w/ moderate to severe OSA who cannot tolerate
  nasal CPAP and who refuse or are not candidate
  for surgical treatment

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Non-Surgical Treatment Oral Devices

• Tongue retaining devices
• Keep tongue in forward position by creating
  negative pressure in a plastic bulb, fit between
  the lips
• Mandibular advancing device
• Cause forward/downward movement of mandible when
  attached to dental arches
• Soft palate lifter
• Effective only for treatment of snoring

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Tongue Retaining Devices
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Mandibular Advancement Devices

• Repositions and stabilizes the mandible tongue
  (sometimes soft palate)
• Increases size of airway in lateral dimension

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Mandibular Advancement Devices

• Advance BOT to ? airway
• Advance and raise hyoid bone, tightening the
  pharyngeal musculature which reduces airway
  collapsibility.
• Stretch the masseter muscles which stimulates the
  genioglossus muscle

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Mandibular Advancement Devices

• TAP (Thornton Adjustable Positioner)
• adjustable mandibular advancement appliance
• ¼ mm incremental advancements
• by the rotation of the knob positioned between
  the lips
• allow for comfortable accommodation

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Non-Surgical Treatment - PAP

• Sullivan introduced CPAP in 1981
• Positive Airway Pressure
• CPAP (Continuous Positive Airway Pressure)
• BiPAP (Bilevel Positive Airway Pressure)
• Provide lower pressure during expiration
• Better tolerated in pts who require high pressure
  during inspiration
• Acts as a pneumatic splint for the collapsible
  upper airway tube
• Titrate the airway pressure needed to overcome
  airway obstruction
• Raising the intraluminal pressure above the
  positive critical transmural pressure of the
  upper airway
• Average CPAP setting is about 5-15 cm H2O
• May be delivered via a nasal or face mask
• Effective in gt90

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Non-Surgical Treatment - CPAP
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NASAL
NASAL
CPAP humidification
NASAL PILLOWS
FULL FACE
NASAL PILLOWS
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HYBRID
ORAL/ORACLE
TOTAL FACE
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Type of Device

• CPAP default mode
• Bilevel PAP high pressure or intolerance
• Auto-titrating devices variable criteria
• CPAP should be attempted first
• No conclusive benefit associated with Bilevel PAP
  or auto-titrating devices

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Positive Airway Pressure Therapy

• Rejection rate of CPAP (5 - 50)
• Engleman and Wild, review of 9 case series
• Before or soon after titration
• Never took CPAP home

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Positive Airway Pressure Therapy

• Compliance rate for CPAP (46 80)
• No set criteria of defining compliance
• Compliance gt 4 hour/night on gt 70 of nights
• Subjective vs objective measures
• Kribbs et al. and Rauscher et al.
• Use counter to objectively measure duration of
  use
• Found pts tend to overestimate duration of use by
  more than 1 hour
• Sanders et al. and Waldhorn et al.
• 75-76, based on subjective reporting
• Kribbs et al. (based on objective measures)
• 46, based on objective measures

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Non-Surgical Treatment - CPAP

• Physical issues
• Facial skin abrasions/discomfort
• Air leaks leading to drying of eye
• Difficulty with expiration
  
• Nasal dryness and congestion
• Sore throat
  
• Abdominal bloating
• Loud noise
  
• Psychosocial issues
• Failure to perceive any benefit (mild OSA)
• Claustrophobia
• Noncompliant /unreliable personality
• Poor motivation
• EtOH or drug abuse
• Psychiatric disease
  
• Mental retardation

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Positive Airway Pressure Tx Problem

• Not a Cure, must be used daily for entire life
• Problem w/ acceptance (80)
• Problem w/ compliance (65)
• PAP effectiveness (52) Accept (80) x
  Compliant (65)