Sleep Apnea

SLEEP APNEA
• Apnoea means no breathing at all.

• There is no movement of air at the level of nose and mouth
PHYSIOLOGY OF SLEEP
A normal healthy adult sleeps for 7–8 h.

Sleep occurs in
two phases: non-REM and REM. The two
phases occur
in semiregular cycles, each cycle lasting
for 90–120 min.
There are thus three or four cycles of
sleep.
NON REM SLEEP
1. Stage I. Transition from wakefulness to
sleep. It constitutes 2–5% of sleep. EEG
shows decrease of alpha and increase of
theta waves. Muscle tone is less. Person
can be easily aroused from this stage.
2. Stage II. Characterized by sleep spindles
or ‘K’ complexes and decrease in muscle
tone. It constitutes 45–55% of sleep.
3. Stage III. Forms 3–8% of sleep,
characterized by delta
waves. It is deep sleep.
4. Stage IV. Forms 10–15% of sleep,
characterized by delta waves. It is deep,
most restful sleep
REM Sleep
• Forms 20–25% of total sleep,

• characterized by
1. rapid eye movements,
2. increased autonomic activity with erratic cardiac and respiratory
movements.
• Dreaming occurs in this stage but muscular activity is decreased so
that
• dreams are not enacted.
TYPES OF SLEEP APNEA
1. Obstructive. There is collapse of the upper airway resulting in
cessation of airflow.
Other factors may be obstructive conditions of nose, nasopharynx, oral
cavity and oropharynx, base of tongue or larynx.
2. Central. Airways are patent but brain fails to signal the
muscles to breathe.
3. Mixed. It is combination of both types
OSA
• Apnoea during sleep causes hypoxia
and retention of carbon dioxide which
leads to pulmonary constriction leading
to congestive heart failure, bradycardia
and cardiac hypoxia leading to left
heart failure, and cardiac arrhythmias
sometimes leading to sudden death.
• During sleep apnoea, there are
frequent arousals which cause sleep
fragmentation, daytime sleepiness and
other manifestations.
ANATOMY
• Obstructive sleep apnea occurs
when the muscles in the back
of throat relax too much to
allow normal breathing. These
muscles support structures
including the back of the roof
of your mouth (soft palate), the
triangular piece of tissue
hanging from the soft palate
(uvula), the tonsils and the
tongue.
CONSEQUENCES OF OBSTRUCTIVE
SLEEP APNOEA
• Congestive heart failure/cor pulmonale

• Polycythaemia and hypertension
• Atrial and ventricular arrhythmias and left heart failure
• Attacks of angina
• Snoring spouse syndrome
• Loss of memory
• Decreased libido
• Traffic accidents
CSA
1. Cheyne-Stokes breathing. This is when your breathing speeds up, slows down, stops, and
then starts again. Each of these cycles can last 30 seconds to 2 minutes. Cheyne-Stokes
breathing is common in people who’ve had heart failure or a stroke. It happens in about half
of central sleep apnea cases.
2. Narcotic-induced central sleep apnea. Opioid medications like morphine, oxycodone, and
codeine can affect your breathing patterns.
3. High-altitude periodic breathing. Many people have trouble breathing when they go up to a
high elevation, usually 2,500 meters (8,000 feet) or more.
4. Treatment-emergent apnea. About 5% to 15% of people who have positive airway pressure
treatment for obstructive sleep apnea get CSA.
5. Medical condition-induced apnea. Health problems like heart failure, Parkinson’s disease,
stroke, and kidney failure can cause CSA.
6. Idiopathic (primary) central sleep apnea. This is when there’s no clear cause.
CLINICAL EVALUATION OF A CASE
OF SLEEP APNOEA
History
Patient’s bed partner gives more reliable information than
the patient himself
History should include:
1. snoring during sleep,restless disturbed sleep, gasping, choking or apnoeic events and
sweating.
2. In the daytime, there is history of excessive daytime sleepiness (Epworth sleepiness scale is
more often used) and fatigue, irritability, morning headaches, memory loss and impotence.
• history of body position during sleep, use of alcohol, sedatives and caffeine intake, mouth
breathing and history of menopause or having hormonal replacement therapy
Physical Examination
Risk factors include male gender, obesity and age above

40 years.
1. Body mass index. Normal BMI, 18.5–24.9; overweight, 25–29%; and obesity,
30–34.9. Obese patients need to reduce weight.
2. Collar size. Collar size should not exceed 42 cm in males and 37.5 cm in females.
3. Complete head and neck examination. Look for tonsillar hypertrophy, retrognathia, macroglossia,
elongated
soft palate and uvula, base of tongue tumours, septal deviation, nasal polyps, turbinate hypertrophy
and nasal
valve collapse. Also examine nasopharynx and larynx.
4. Muller’s manoeuvre. A flexible endoscope is passed through the nose and the patient asked to
inspire vigorously with nose and mouth completely closed. Look for collapse of the soft tissues at the
level of base of tongue and just above the soft palate. Level of pharyngeal obstruction can be found
Systemic examination
To look for hypertension, congestive heart failure, pedal oedema,
truncal obesity and any sign of hypothyroidism
Cephalometric radiographs are taken for craniofacial anomalies and

tongue base obstruction.
Polysomnography
. It is the “gold standard” for diagnosis of sleep apnoea and records various parameters
which include:
• EEG
• ECG
•EOM (electroculogram) - for rolling eye movements
• EMG—recorded from submental and tibialis anterior muscle.
• Pulse oximetry
• Nasal and oral airflow
•Sleep position
•Blood pressure.
• Oesophageal pressure. Negative oesophageal pressure helps to know degree of
breathing efforts made by the patient.
• Split-night polysomnography.
TREATMENT
• NONSURGICAL:
1. Lifestyle changes (weight, smoking & alcohol)
2. Positional therapy
3. Intraoral devices [MAD,TRD]
4. CPAP (continous positive airway pressure).
• surgical
It is indicated for failed or noncompliant medical therapy.
Permanent tracheostomy is the “gold standard” of treatment but it is
not accepted socially and has complications of its own. It is usually not
a preferred option by patients.
Nasal surgery.
Nasal obstruction may be the primary or the aggravating factor for
OSA.
Septoplasty to correct deviated nasal septum, removal of nasal polyps
and reduction of turbinate size help to relieve nasal obstruction.
Sometimes nasal surgery is also indicated for efficient use of CPAP.
Oropharyngeal surgery
Uvulopalatoplasty (UPP) is the most common procedure performed for
snoring and OSA.
Tonsillectomy and/or adenoidectomy.
Surgical treatment is tailored to the level of obstruction:
(a) Nose and nasopharynx (level I).
(b) Soft palate and tonsils (level II).
(c) Tongue base and pharynx (level III).
Maxillomandibular advancement osteotomy.
Osteotomies are performed on mandibular ramus and maxilla.
Osteotomy of the maxilla is like a Le Fort I procedure. These
osteotomies are then fixed in anterior position with plates and screws
Tongue base radiofrequency.

Radiofrequency (RF) is used in five to six sittings to reduce the size of
tongue. RF needle is inserted submucosally. It coagulates tissue
and causes scarring thus reducing the size of tissue
Thankyou.

Sleep Apnea

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SLEEP APNEA

• Apnoea means no breathing at all.

A normal healthy adult sleeps for 7–8 h.

• Forms 20–25% of total sleep,

• Congestive heart failure/cor pulmonale

Risk factors include male gender, obesity and age above

Cephalometric radiographs are taken for craniofacial anomalies and

Tongue base radiofrequency.

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