Investigations for Obstructive Sleep Apnea

Polysomnography

Basically a diagnostic sleep study. Measures sleep cycles of a person by recording information such as:
-Blood oxygen levels (Oximeter)
–Body position (Device placed on chest)
–Brain waves (EEG): Measurement of electrical signals from the brain to determine whether you are awake or asleep and what stage of sleep you are in.
–Breathing rate
–Eye movement (EOG) – to determine REM sleep. Some people have worse symptoms in REM sleep.
–Heart rate

AHI measures the number of atypical breathing incidents during 1 hour of sleep. An AHI of 5 or less is normal; 5 to 14 is mild obstructive sleep apnea; 15 to 29 is moderate obstructive sleep apnea; more than 30 is severe. RDI is AHI/hr. All oxygen desaturations <90% during sleep are considered medically significant.

Performed at a special sleep center. The test is often done during the night so that your normal sleep patterns can be studied. Electrodes will be placed on your chin, scalp, and the outer edge of your eyelids. These must remain in place while you sleep.

Signals from electrodes are recorded while you are awake (with your eyes closed) and during sleep. The time it takes you to fall asleep is measured, as well as the time it takes you to enter REM sleep.

Monitors to record your heart rate and breathing will be attached to your chest. These also must remain in place while you sleep. A specially trained health care provider will directly observe you while you sleep and note any changes in your breathing or heart rate. The number of times that you either stop breathing or almost stop breathing will be measured. In some sleep study centers, a video camera records your movements during sleep.


Multiple Sleep Latency Test: In some cases, a multiple sleep latency test is performed on the day after the overnight test to measure the speed of falling asleep. In this test, patients are given several opportunities to fall asleep during the course of a day when they normally would be awake.

At-Home Sleep Apnea Test: To diagnose sleep apnea, a portable test, which can be conducted at home can be used as an alternative to polysomnogram for diagnosing obstructive sleep apnea. The home tests are portable devices that are composed of a recording device, belts, sensors and other cables. The data gathered overnight has to be reviewed by sleep specialist and thereby diagnosis and treatment plan has to be developed.


Sleep studies can also determine whether you have a problem with your stages of sleep. Normally, NREM and REM alternate 4 to 5 times during a night's sleep. A change in this cycle may make it hard for you to sleep soundly. Non-REM sleep is in turn further divided into four different stages (1 through 4), with stages 3 and 4 often referred to as "deep sleep." Normal sleep patterns break down your time asleep as follows: stage one sleep for 5% of the time, stage two for 55% of the time, stage three and four at 20% of the time and REM sleep for 20%.

ECG

Not a gold standard exam to diagnose OSA. Research has been done to diagnose OSA using ECG, with high success rate (80 to 95% accuracy). Use of algorithms. However, in a sleep study, ECG is used to detect irregularities in heart beat or rhythm. Complications of OSA is right ventricular hypertrophy, which may eventually lead to cor pulmonale. Also may be left ventricular hypertrophy. Can be detected by ECG – right or left axis deviation.

Treatment for Sleep Apnea

Treatment and management
The goals of treating obstructive sleep apnea are to:
• Restore regular breathing during sleep
• Relieve symptoms such as loud snoring and daytime sleepiness
- Lifestyle changes is only for mild OSA
Lifestyle Changes
If you have mild sleep apnea, some changes in daily activities or habits may be all that you need.
• Avoid alcohol and medicines that make you sleepy. They make it harder for your throat to stay open while you sleep. (alcohol causes URT muscle to relax)
• Lose weight if you're overweight or obese. Even a little weight loss can improve your symptoms.
• Sleep on your side instead of your back to help keep your throat open. You can sleep with special pillows or shirts that prevent you from sleeping on your back.
• Keep your nasal passages open at night with nose sprays or allergy medicines, if needed. Talk to your doctor about whether these treatments might help you.
• Stop smoking.
• Gargle with salt water (without swallowing) to shrink your tonsils.
• Develop regular sleep habits, and make sure you get enough sleep at night.
• Use an air humidifier at night.
Mouthpiece/oral appliance
- Help with mild OSA or snoring
- Customize to fit different patients, plastic made.
- It adjust your lower jaw and your tongue to help keep your airways open while asleep.
- Make sure it is comfortable, adjustable.
-
Breathing Devices
CPAP – continuous positive airway pressure for moderate to severe sleep apnea in adults.
- It’s a mask that fits over mouth and nose and blows air into the throat.
- Air pressure adjusted to avoid airway being narrowed or blocked during sleep
- Sleep apnea returns if CPAP stops or not used correctly
- Machine set up by a technician with doctor’s orders
- May cause side effects, dry or stuffy nose, irritated skin on face, sore eyes, and headaches, stomach bloating and discomfort.
- Nasal spray and adding moisture to air is helped to relieve SE.
There is no drug that completely treats sleep apnea. Some of the drugs used in combination with CPAP include:
• Medroxyprogesterone -- side effects may include nausea, depression, excess hair growth, breast tenderness, and fluid retention.
• Protriptyline -- this medication is used rarely. Side effects may include dry mouth, constipation, frequent urination, impotence, and confusion (in the elderly).
• Modafinil -- sometimes prescribed in combination with CPAP to treat excessive daytime sleepiness.

Surgery
- To widen breathing passage, involves removing, shrinking or stiffening excess tissue in the mouth and throat or resetting the lower jaw.
- Shots to shrink tissue or plastic pieces inserted to stiffen loose tissue.
- Surgery to remove tonsils maybe helpful for children. Or wait for tissues to shrink by itself.
Uvulopalatopharyngoplasty (UPPP) -- The operation involves the removal of the uvula and back of the soft palate, often accompanied by tonsillectomy.
In UPPP, soft tissue on the back of the throat and soft palate (the uvula) is removed.
UPPP does not address apnea or snoring caused by obstructions at the base of tongue.
• First patient undergoes soft tissues surgeries, UPPP together with genioglossus advancement or hyoid suspension and usually fails
• Then a maxillomandibular advancement surgery to move the top jaw and bottom jaw forward. (pulling tongue forward)
• High rates of complication
Surgeons usually use either conventional scalpel techniques or newer laser methods (LAUP, or Laser-Assisted Uvulopalatoplasty). LAUP may have a higher rate of success than UPPP, but it also requires the expertise of a surgeon highly skilled in laser procedures.
LAUP Treatment Procedure
A laser beam to remove and tighten floppy soft palate tissue in the back of the mouth, thereby reducing the amount that these tissues contribute to snoring.
LAUP causes mild discomfort after surgery. Local anesthestic.
LAUP needs up to five treatments spaced four to eight weeks apart (although one to three are usual).

Tracheostomy -- to create an opening in the windpipe to bypass the blocked airway if there are anatomical problems (rarely done)
General anesthesia, exposure of the tracheal cartilage rings. The surgeon then creates an opening into the trachea and inserts a tracheostomy tube.
Complementary and Alternative Therapies
Useful in treating sleep apnea caused by allergies.
Homeopathy and nutrition are most likely to have a positive effect.
Nutrition and Supplements
• Diet: Try eliminating mucus-producing foods (such as bananas) for 2 weeks, then reintroducing them to see if you notice any difference in sleepiness or other symptoms.
• Essential fatty acids (EFAs) moderate inflammatory response and decrease allergic response. EFAs are low in obese people. Fish oil, evening primrose oil, flaxseed oil, and borage oil all contains essential fatty acids.
Acupuncture
Some evidence suggests that a type of acupuncture called auriculotherapy acupoint pressure may help treat sleep apnea.


http://www.umm.edu/altmed/articles/sleep-apnea-000156.htm
http://www.nhlbi.nih.gov/health/dci/Diseases/SleepApnea/SleepApnea_Treatments.html
http://www.nlm.nih.gov/medlineplus/ency/article/000811.htm
http://www.sleepdisordersguide.com/topics/laup.html
http://www.nlm.nih.gov/medlineplus/ency/article/002955.htm

Complications & Prognosis Of OSA

Common Problems
¢CVS Problems
¢Daytime Fatigue
¢Complications with Medicine & Surgery
¢Sleep-deprived partners
¢Nocturia
¢Impotence =P
¢GERD
¢ADHD

Daytime Fatigue
¢OSA make normal, restorative sleep impossible.
¢experience severe daytime drowsiness, fatigue and irritability.

Nocturia
¢Increased pressure=increased preload=increased CO
¢Heart works harder
¢Release of ‘atrial natriuretic peptide’(ANP) from atrial myocytes.
¢Function of ANP?

Impotence
¢Many hypothesis….still not confirmed
1.Many men have erections during REM sleep. I don’t okay… Since patients have less sleep..therefore less REM erections.
2.Levels of testosterone drops in patients with sleep OSA. Less testosterone=less manhood=ED

GERD
¢phrenoesophageal ligament (PEL) connects the diaphragm to the lower esophageal sphincter (LES).
¢During OSA ,increased respiratory effort by the diaphragm.
¢PEL will open the LES due to increased activity of diaphragm when threshold is reached.
¢Gastric fluid enter esophagus.

CVS Problems
¢Blood oxygen levels drop.Furthermore, levels of NO drops. Increase in blood pressure leading to hypertension.
¢Severe hypoxia/hypoxemia leads to sudden death…

Attention Deficit Hyperactivity Disorder(ADHD)
¢Definition=co-existence of attentional problems and hyperactivity, with each behavior occurring frequently together.empirical evidence that there is overlap in the central nervous system centers that regulate sleep and those that regulate attention/arousal.

Prognosis
¢Untreated:
1.life-threatening.
2.Fall asleep at inappriopriate times.
Impt: no cure for sleep apnea!!

Are children predisposed to snoring if their parents are ‘snorers’?
¢Chest(April 2006)
¢Researchers from Cincinnati Children's Hospital studied 681 children, 45% girls, 80% white.
¢parents filled in questionnaires-to determine if there was a link.
¢20% of the mothers and 46% of the fathers were habitual snorers .

Result
¢Incidence of snoring among infants who had at least one parent who was a habitual snorer was 3 X>than infants whose parents did not snore.

Definition, Apopnea-Hypopnoea Index (AHI) , anatomy

Definition of OSA
- a sleep disorder
- Pauses in breathing during sleep due to airway obstruction
- 1 or more breaths are missed during each episode, occurring repetitively throughout sleep
- Breathing is interrupted by obstruction in airway despite the effort to breathe, preventing an adequate flow of air

Apopnoea-Hypopnoea Index
• To assess the severity of sleep apnoea
• Total number of complete cessation (apnoea) and partial obstructions (apopnoea) of breathing occurring per hour of sleep
• Pauses in breathing must last for 10s

Classification :
•Mild = 5-15
•Moderate = 15-30
•Severe = >30

Anatomy (the ones i think are relevant to Karim's case)
- Mouth
- tongue
- palate
- tonsils
- trachea

Diabetic Screening Test

TESTS
The best screening test for diabetes, the fasting plasma glucose (FPG), is also a component of diagnostic testing. The FPG test and the 75-g oral glucose tolerance test (OGTT) are both suitable tests for diabetes; however, the FPG test is preferred in clinical settings because it is easier and faster to perform, more convenient and acceptable to patients, and less expensive. An FPG ≥126 mg/dl (7.0 mmol/l) is an indication for retesting, which should be repeated on a different day to confirm a diagnosis. If the FPG is <126 mg/dl (7.0 mmol/l) and there is a high suspicion for diabetes, an OGTT should be performed. A 2-h postload value in the OGTT ≥200 mg/dl (11.1 mmol/l) is a positive test for diabetes and should be confirmed on an alternate day. Table 2 presents the diagnostic criteria for diabetes. Fasting is defined as no consumption of food or beverage other than water for at least 8 h before testing.
Nondiabetic individuals with an FPG ≥110 mg/dl (6.1 mmol/l) but <126 mg/dl (7.0 mmol/l) are considered to have IFG, and those with 2-h values in the OGTT ≥140 mg/dl (7.8 mmol/l) but <200 mg/dl (11.1 mmol/l) are defined as having IGT. Both IFG and IGT are risk factors for future diabetes. Normoglycemia is defined as plasma glucose levels <110 mg/dl (6.1 mmol/l) in the FPG test and a 2-h postload value <140 mg/dl (7.8 mmol/l) in the OGTT.

If necessary, plasma glucose testing may be performed on individuals who have taken food or drink shortly before testing. Such tests are referred to as casual plasma glucose measurements and are given without regard to time of last meal. A casual plasma glucose level ≥200 mg/dl (11.1 mmol/l) with symptoms of diabetes is considered diagnostic of diabetes. A confirmatory FPG test or OGTT should be completed on a different day if the clinical condition of the patient permits.
Laboratory measurement of plasma glucose concentration is performed on venous samples with enzymatic assay techniques, and the above-mentioned values are based on the use of such methods. The A1C test values remain a valuable tool for monitoring glycemia, but it is not currently recommended for the screening or diagnosis of diabetes. Pencil and paper tests, such as the American Diabetes Association’s risk test, may be useful for educational purposes but do not perform well as stand-alone tests. Capillary blood glucose testing using a reflectance blood glucose meter has also been used but because of the imprecision of this method, it is better used for self-monitoring rather than as a screening tool.

role of GP+fitness for driving+insurance

a health assessment is done before a driving permit is given

sleep problems
vision
dibetis
heart problems
epilepsy
blackouts and fainting
psychiatric disorders
age related decline


The Driver Licensing Authority always makes the final decision


Generally, only longer-term conditions will impact on your
licence status and will need to be reported to the
Driver Licensing Authority.
The relationship between you and your doctor is confidential,
therefore your doctor will not normally communicate directly
with the Driver Licensing Authority. He or she will provide
you with advice about your ability to drive as well as with
a letter or report to take to the authority.

In South Australia and the Northern Territory,
however, doctors are required by law to report
drivers who they believe to be medically unfit
to drive to the Driver Licensing Authority.

http://www.austroads.com.au/aftd/cvd.html



Apnea Index of:
0-10 - typically no additional life insurance cost
11-20 - 50% table rating increase over standard life insurance rates
21-30 - 100% table rating increase over standard life insurance rates
31-40 - 150% table rating increase over standard life insurance rates
Above 40 - decline.

http://www.lifeinsuranceadvisors.com/life-insurance-for-sleep-apnea.html