Obstructive Sleep Apnea (OSA)

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Obstructive Sleep Apnea (OSA)

Adult Sleep Medicine
Author Credentials 

Maria Suurna, MD
Assistant Professor
Department of Otolaryngology, Head and Neck Surgery
Weill Cornell Medicine
New York, NY

Module Summary

Obstructive sleep apnea is one of the major health problems in the adult population. Caring for the patient with OSA can be challenging. The goal of this module is to familiarize physicians with pathophysiology and health conditions associated with this disorder. Multiple diagnostic and treatment options are now available for management of OSA patients.

Module Learning Objectives 
  1. Describe the pathogenesis of obstructive sleep apnea including respiratory physiology, anatomical considerations, and the relationship of OSA to comorbid diseases. 
  2. Discuss the evaluation and diagnosis of patients with suspected OSA.
  3. List treatment modalities, both surgical and non-surgical, available in the management of obstructive sleep apnea along with their relative success rates. 

Anatomy

Learning Objectives 
  1. Describe the anatomical subsites that commonly contribute to upper airway obstruction for each of the areas listed. 
    • Nasal cavity
      • describe how the nasal cavity (a generally non-collapsible structure) can contribute to obstruction
      • flow-mediated reflexes, mouth opening, starling resistor
      • identify the boundaries of the nasal valve
    • Nasopharynx
    • Velopharynx
    • Oropharynx
    • Hypopharynx
      • Discuss contribution of parapharyneal fat pads to pathophysiology of OSA
    • Base of Tongue
      • Discuss the contribution of the lingual tonsils
      • Discuss correlation between tongue fat distribution and OSA
    • Epiglottis
  2. Describe effects of obesity on airway obstruction. 
References 
  1. Schwab RJ, Gupta KB, Gefter WB, et al. Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing: significance of the lateral pharyngeal walls. Am J Respir Crit Care Med.1995;152:1673-89.
  2. Hora F, Napolis LM, Daltro C, et al. Clinical, anthropometric and upper airway anatomic characteristics of obese patients with obstructive sleep apnea syndrome. Respiration. 2007;74:517-24.
  3. Sutherland K, Lee RW, Cistulli PA. Obesity and craniofacial structure as risk factors for obstructive sleep apnoea: impact of ethnicity. Respirology. 2012;17:213-22.
  4. Bradley TD, Brown IG, Grossman RF, et al. Pharyngeal size in snorers, nonsnorers, and patients with obstructive sleep apnea. N Engl J Med.1986;315:1327-31.
  5. Leiter JC. Upper airway shape: is it important in the pathogenesis of obstructive sleep apnea? Am J Respir Crit Care Med. 1996;153:894-8.
  6. Shigeta Y, Ogawa T, Tomoko I, et al. Soft palate length and upper airway relationship in OSA and non-OSA subjects. Sleep Breath. 2010;14:353-8.
  7. Pahkala R, Seppa J, Ikonen A, et al. The impact of pharyngeal fat tissue on the pathogenesis of obstructive sleep apnea. Sleep Breath. 2014;18:275-82.
  8. Kim AM, Keenan BT, Jackson N, et al. Tongue fat and its relationship to obstructive sleep apnea. Sleep. 2014;37:1639-48.
  9. Chi L, Comyn FL, Mitra N, et al. Identification of craniofacial risk factors for obstructive sleep apnoea using three-dimensional MRI. Eur Respir J. 2011;38:348-58.

Pathogenesis

Learning Objectives 
  1. Skeletal and soft tissue structural factors that predispose patients to obstructive sleep apnea
    • Retrognathia and micrognathia
    • Mandibular hypoplasia
    • Adenotonsillar hypertrophy
    • High, arched palate
    • Inferior hyoid displacement
  2. Non-structural risk factors for OSA
    • Obesity/central fat distribution 
    • Male sex
    • Age/post-menopausal state
    • Race
    • Sleep position
    • REM sleep
    • Genetics
    • Endocrine disorders
  3. Neuromuscular and ventilatory considerations.
    • Discuss each phase of sleep and how it relates to snoring and apnea.
    • List muscle hierarchy of ventilatory recruitment.
    • Contrast ventilatory drive during sleep and wakefulness, including the role of the carbon dioxide and oxygen drive in the phases of sleep.
    • Describe effects of sleep on systemic arterial pressure, heart rate, autonomic function, gastroesophageal reflux, urine output during sleep, and OSA and non-OSA patients.
    • Discuss changes in pulmonary pressures during prolonged apneic events and why this occurs.
    • Understand the respiratory physiology involved in OSA and the contribution of high loop gain to unstable ventilatory control
  4. Describe pathophysiological changes associated with OSA
    • Blood pressure, heart rate, vascular dysfunction and remodeling,
  5. Describe the effects of the following medications on airway obstruction and ventilatory control.
    • Alcohol
    • Sedatives
    • Non-benzodiazepine agonists
    • Tranquilizers
    • Antiepilepsy drugs
    • Antihistamines
    • Opiates
    • Progesterone
    • Acetazolamide
    • Theophylline
    • Protriptyline
    • Oxygen
    • Selective serotonin reuptake inhibitors
  6. Discuss the relationship between obstructive sleep apnea and gastroesophageal reflux disease.
References 
  1. Ryan CM, Bradley TD. Pathogenesis of obstructive sleep apnea. J Appl Physiol. 2005;99:2440-50.
  2. Chuang LP, Chen NH, Li HY, et al. Dynamic upper airway changes during sleep in patients with obstructive sleep apnea syndrome. Acta Otolaryngol. 2009;129:1474-9.
  3. Banno K, Kryger MH. Sleep apnea: Clinical investigations in humans. Sleep Med. 2007 Jun;8(4)400-426.
  4. Kerr P, Millar T, Buckle P, Kryger M. The importance of nasal resistance in obstructive sleep apnea syndrome. J Otolaryngol. 1992;21:189-95.
  5. Susheel P. Patil, Hartmut Schneider, Alan R. Schwartz, Philip L. Smith. Adult Obstructive Sleep Apnea: Pathophysiology and Diagnosis. Chest. 2007 Jul;132(1):325-337.
  6. Rama AN, Tekwani SH, Kushida CA. Sites of obstruction in obstructive sleep apnea. Chest. 2002;122:1139-47.
  7. Neelapu et al. Craniofacial and upper airway morphology in adult obstructive sleep apnea patients: A systematic review and meta-analysis of cephalometric studies.  Sleep Med Rev. 2017 Feb;31;79-90.
  8. Rowley JA, Aboussouan LS, Badr MS. The use of clinical prediction formulas in the evaluation of obstructive sleep apnea. Sleep. 2000 Nov;23(7):929-38. 
  9. Senior BA, Khan M, Schwimmer C, et al. Gastroesophageal reflux and obstructive sleep apnea. Laryngoscope. 2001;111:2144-146
  10. Walker RP. Snoring and obstructive sleep apnea. In: Bailey B, Pillsbury H, editors. Head and neck surgery-otolaryngology. 2nd ed. Philadelphia: Lippincott Raven; 1998.
  11. Young T, et al. Risk factors for obstructive sleep apnea in adults. JAMA. 2004;291(6):2013-6.
  12. Eckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets. Am J Respir Crit Care Med. 2013;188:996-1004.
  13. Ehsan et al. The Effects of Anesthesia and Opioids on the Upper Airway: A Systematic Review. Laryngoscope. 2016 Jan;126(1):270-84.
  14. Deacon NL, Peter G. Catcheside PG. The role of high loop gain induced by intermittent hypoxia in the pathophysiology of obstructive sleep apnea. Sleep Med Rev. 2015 Aug;22:3-14.
  15. Stanchina ML, Malhotra A, Fogel RB, et al. The influence of lung volume on pharyngeal mechanics, collapsibility, and genioglossus muscle activation during sleep. Sleep. 2003 Nov 1;26(7):851-6.
  16. Jordan AS, White DP, Lo YL, et al. Airway dilator muscle activity and lung volume during stable breathing in obstructive sleep apnea. Sleep. 2009;32:361-8.

Incidence

Learning Objectives 
  1. Discuss the prevalence of OSA.
  2. Describe the risk factors for OSA.
  3. Discuss the gender and age in OSA.
  4. Discuss the age groups most affected.
  5. Identify the percentage of patients with obesity who have OSA. 
References 

 

  1. Redline S, Tishler PV, Schluchter M, et al. Risk factors for sleep-disordered breathing in children. Associations with obesity, race, and respiratory problems. Am J Respir Crit Care Med. 1999;159:1527-32.
  2. Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328:1230-35.
  3. Young T, et al. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165(9):1217-39.
  4. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol.  2013;177(9):1006–1014.

Genetics

Learning Objectives 
  1. Genes may act to affect the pathogenesis of OSA in three major areas. Briefly discuss the role of genetics in each of these areas.              
    • Obesity and metabolic disorders.
    • Craniofacial morphology.
    • Upper airway soft tissue structures
    • Ventilatory control and control of circadian rhythm.
  2. Know that next generation sequencing techniques have been used to help identify candidate genes for OSA.
References 
  1. Palmer LJ, Redline S. Genomic approaches to understanding obstructive sleep apnea. Respir Physiol Neurobiol. 2003;135:187-205.
  2. Larkin EK, Patel SR, Goodloe RJ, Li Y, Zhu X, Gray-McGuire C, et al. A candidate gene study of obstructive sleep apnea in European Americans and African Americans. Am J Respir Crit Care Med. 2010 Oct;182(7):947-53.
  3. Schwab RJ. Genetic determinants of upper airway structures that predispose to obstructive sleep apnea. Respir Physiol Neurobiol. 2005 Jul;147(2-3):289-98.

Patient Evaluation

Learning Objectives 
  1. Outline the relevant history for adult patients with suspected OSA.
  2. Discuss screening tools
    • Berlin Questionnaire
    • STOP-BANG questionnaire
    • Epworth Sleepiness Scale
  3. Describe clinical manifestations of OSA during sleep and during waking hours.
  4. Outline the relevant physical examination for adult patients with suspected OSA including anatomical considerations.
  5. Recognize clinical comorbidities associated with untreated sleep apnea.
  6. Discuss diagnostic modalities. 
    • Nocturnal sleep study
    • Split-night study
    • Daytime sleep study (Nap study)
  7. Discuss indications and differences between polysomnography and home sleep study. 
  8. Recognize obstructive and central events on polysomnographic recordings.
References 
  1. Shepard JW Jr et al. Evaluation of the upper airway in patients with obstructive sleep apnea. Sleep. 1991 Aug;14(4):361–371.
  2. Kapur VK et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Mar;13(3):479-504.
  3. Flemons WW, Littner MR, Rowley JA, et al. Home diagnosis of sleep apnea: a systematic review of the literature. An evidence review cosponsored by the American Academy of Sleep Medicine, the American College of Chest Physicians, and the American Thoracic Society. Chest. 2003;124(4):1543-1579.
  4. Kristo DA, Shah AA, Lettieri CJ, et al. Utility of split-night polysomnography in the diagnosis of upper airway resistance syndrome. Sleep Breath. 2009;13(3):271-275.

Measurement of Functional Status

Learning Objectives 
  1. Define severity criteria for sleep apnea and hypoxemia.
  2. Describe the Epworth Sleepiness Scale (ESS) and its clinical diagnostic significance and limitations.
  3. Describe Functional Outcomes of Sleep Questionnaire (FOSQ).
  4. Describe STOP-BANG Questionnaire.
  5. Describe Berlin questionnaire.
References 
  1. Chervin RD, Aldrich MS, Pickett R, et al. Comparison of the results of the Epworth Sleepiness Scale and the Multiple Sleep Latency Test. J Psychosom Res. 1997;42:145-55.
  2. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14:540-45.
  3. Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999;131(7):485-491.
  4. Friedman M, Wilson MN, Pulver T, et al. Screening for obstructive sleep apnea/hypopnea syndrome: subjective and objective factors. Otolaryngol Head Neck Surg. 2010;142(4):531-535.
  5. Platt AB, Wick LC, Hurley S, et al. Hits and misses: screening commercial drivers for obstructive sleep apnea using guidelines recommended by a joint task force. J Occup Environ Med. 2013;55(9):1035-1040.

Imaging

Learning Objectives 
  1. Discuss indications and limitations of imaging.  Explain how the findings correlate with OSA severity.
    • Cephalometry
    • CT
    • MRI
    • Fluoroscopy

Treatment

Learning Objectives 
  1. Discuss the rationale for treatment of OSA and the implications of comorbid disease. 
  2. Discuss the behavioral treatment options for OSA. 
    • Sleep hygiene
    • Weight loss
  3. Discuss the following non-surgical treatment of OSA.
    • Role of oxygen and stimulants
    • Therapy for nasal congestion
    • Reflux treatment
    • Positional therapy
    • Nasal devices (nasal dilators, nEPAP)
    • Oral appliances 
    • Orofacial myofunctional therapy
    • Positive airway pressure (PAP)
      • Discuss the mechanism by which PAP works.
      • Review the devices available for delivering PAP.
      • Review the data on compliance for PAP and techniques used to improve compliance
  4. Discuss surgical treatment for OSA. 
  5. Discuss the role and indications for bariatric surgery. 
References 
  1. Epstein LJ et al. Clinical Guideline for the Evaluation, Management and Long-tern Care of Obstructive Sleep Apnea in Adults. J Clin Sleep Med. 2009 Jun;5(3):263-276.
  2. Yamashiro Y, Kryger MH. CPAP titration for sleep apnea using a split-night protocol. Chest. 1995;107(1):62-66.
  3. McArdle N, Devereux G, Heidarnejad H, et al. Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med. 1999;159:1108-114.
  4. Walker RP. Snoring and obstructive sleep apnea. In: Bailey B, Pillsbury H, editors. Head and neck surgery-otolaryngology. 2nd ed. Philadelphia: Lippincott Raven; 1998.
  5. Ramar K, et al. Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015. J Clin Sleep Med 2015;11(7):773–827.
  6. White DP. New therapies for obstructive sleep apnea. Semin Respir Crit Car Med. 2014; 35(5):621-8.
  7. Aarab G, Lobbezoo F, Hamburger HL, et al. Oral appliance therapy versus nasal continuous positive airway pressure in obstructive sleep apnea: a randomized, placebo-controlled trial. Respiration. 2011;81:411-19.
  8. Veasey SC, et al. Medical therapy for obstructive sleep apnea: a review by the Medical Therapy for Obstructive Sleep Apnea Task Force of the Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 2006 Aug;29(8):1036-44.
  9. Morgenthaler TI, et al. Practice Parameters for the Medical Therapy of Obstructive Sleep Apnea. Standards of Practice Committee; American Academy of Sleep Medicine. Sleep. 2006 Aug;29(8):1031-5.

Medical Therapies

Learning Objectives 
  1. Discuss Indications for DISE. 
  2. Describe DISE technique. 
  3. Know airway classification system.
  4. Understand benefits and limitations of OSA treatment outcomes.
References 
  1. Schwab RJ. Upper airway imaging. Clin Chest Med. 1998;19:33-54.
  2. Neelapu BC et al. Craniofacial and upper airway morphology in adult obstructive sleep apnea patients: A systematic review and meta-analysis of cephalometric studies.  Sleep Med Rev. 2017 Feb;31:79-90.
  3. Abramson Z, Susarla S, August M, Troulis M, Kaban L. Three-dimensional computed tomographic analysis of airwayanatomy in patients with obstructive sleep apnea. J Oral Maxillofac Surg. 2010 68(2):354-362.
  4. Susarla SM, Abramson ZR, Dodson TB, Kaban LB. Cephalometric measurement of upper airway length correlates with the presence and severity of obstructive sleep apnea. J Oral Maxillofac Surg. 2010 68(11):2846-2855.
  5. Barrera JE. Sleep magnetic resonance imaging: dynamic characteristics of the airway during sleep in obstructive sleep apnea syndrome. Laryngoscope. 2011 121(6):1327-1335.
  6. Bhattacharyya N, Blake SP, Fried MP. Assessment of the airway in obstructive sleep apnea syndrome with 3-dimensional airway computed tomography. Otolaryngol Head Neck Surg. 2000;123:444-9.
  7. Suratt PM, Dee P, Atkinson RL, et al. Fluoroscopic and computed tomographic features of the pharyngeal airway in obstructive sleep apnea. Am Rev Respir Dis. 1983;127:487-92.
  8. Hohenhorst W, Ravesloot MJL, Kezirian EJ, de Vries N. Drug-induced sleep endoscopy in adults with sleep-disordered breathing: Technique and the VOTE Classification system. Operative Techniques in Otolaryngology. 2012;23:11-18.
  9. De Vito A, Carrasco M, Vanni A, et al. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath. 2014;18:453-465.
  10. Blumen, M, Bequignon E, Chabolle F. Drug-induced sleep endoscopy: A new gold standard for evaluating OSAS? Part I: Technique. Eur Ann Otorhinolaryngol Head Neck Dis. 2017 Apr;134(2):101-107.
  11. Blumen M, Bequignon E, Chabolle F.  Drug-induced sleep endoscopy: A new gold standard for evaluating OSAS? Part II: Results. Eur Ann Otorhinolaryngol Head Neck Dis. 2017 Apr;134(2):109-115.

Complications

Learning Objectives 
  1. Discuss morbidity and mortality associated with undiagnosed and untreated obstructive sleep apnea.
  2. Describe association of the following comorbidities with OSA.
    • Cardiovascular diseases
    • Neuropsychiatric diseases
    • Metabolic diseases
    • Genitourinary disorders
  3. Recognize perioperative complications associated with undiagnosed and untreated OSA. 
References 
  1. Kendzerska et al. Untreated obstructive sleep apnea and the risk for serious long-term adverse outcomes: A systematic review. Sleep Med Rev. 2014 Feb;18(1):49-59.
  2. Young T, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort.  Sleep. 2008 Aug;31(8):1071-8.
  3. Johnson KG, Johnson DC. Frequency of sleep apnea in stroke and TIA patients: a meta-analysis. J Clin Sleep Med. 2010;6(2):131-7.
  4. Jackson ML, Howard ME, Barnes M. Cognition and daytime functioning in sleep-related breathing disorders. Prog Brain Res. 2011;190:53-68.
  5. Lam JC, Mak JC, Ip MS. Obesity, obstructive sleep apnoea and metabolic syndrome. Respirology. 2012;17(2):223-236.
  6. Ravesloot MJ, van Maanen JP, Hilgevoord AA, van Wagensveld BA, de Vries N. Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery. Eur Arch Otorhinolaryngol. 2012;269(7):1865-1871.
  7. Marin JM, Carrizo SJ, Vicente E, et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005;365:1046-53.
Resources 

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