Breathing in Sleep
§ How air flows: the anatomy of the nose and throat
§ Discuss symptoms related to snoring
§ Discuss what happens when breathing during sleep is altered
§ Steps for evaluation of snoring and sleep apnea
Snoring and Sleep Apnea § Treatment for sleep apnea and snoring What is it and how do I stop?
Jolie Chang, MD
Associate Professor Director of Sleep Surgery Division Department of Otolaryngology, Head and Neck Surgery
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Snoring Breathing in Sleep
§ Chronic habitual snoring - 20% women; 40% men - Most common symptom of sl eep apnea (35% of those who snore have obstructive sleep apnea)
§ Snoring risk factors - Age, sex, obesity, ETOH or sedative use, smoking, nasal obstruction, asthma, lung disease.
3 4 Photo: www.yogateachercentral.com
1 | [footer text here] Upper Airway Collapsing Pipe
1 . 2a. § Upper Airway – Throat § Lined by muscles you use to swallow and talk
§ Muscles of the throat relax during sleep
2b. 3 .
5 6 http://www-mdp.eng.cam.ac.uk/web/library/enginfo/textbooks_dvd_only/DAN/buckling/mechanisms/mechani sms.html
Snoring - Acoustics Fiberoptic Exam
§ Snoring = noise generated when air flows though a § Done in the office narrowed upper airway § Numbing spray
§ Sound source: flutter or vibration of soft tissues, can be § Look at the nose and throat from multiple sites
Pevernagie et al. Sleep Med Rev. 2010.
2 | [footer text here] Awake Upper Airway Exam Pipe Collapse
9 10 https://www.youtube.com/watch?v=rwdhbfJ3niI
Sleep Endoscopy: Patterns of collapse Effects of primary snoring
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3 | [footer text here] Social Impact More Snoring Relates to Worse Sleepiness § Sleep Heart Health Cohort Study § Bed partner § 6000 self-reported snoring and ESS - Impaired sleep quality § Sleepiness increases with snoring frequency and - Relationship disharmony loudness § Second-hand snoring - Once treated, bed-partner QOL increased, sleepiness, and depression scores improved (Parish & Lyng. Chest 2003)
Gottlieb et al. Am J Respir Crit Care Med. 2000.
Louder Snoring Related to Worse Sleepiness Obstructive Sleep Apnea
§ Repeated collapse of the upper airway during sleep § Leads to reduced oxygen delivery to the lungs and body
§ Impacts sleep type/depth and quality
§ Measured with a sleep study test - Number of times airflow is reduced - Oxygen l evel changes - Sleep stage - Sleep position - AHI = Apnea Hypopnea Index
Kalchiem-Dekel, O. Laryngoscope 2016. 16
4 | [footer text here] Health Risks of untreated OSA What Happens in Sleep Apnea
§ High blood pressure § Heart disease
§ Stroke
§ Obesity
§ Motor Vehicle Accidents § Daytime sleepiness
§ Impaired work performance
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Spectrum: What does snoring mean? Is Louder Snoring Associated with Sleep Apnea Severity?
• 1600 Habitual snorers – Sleep Study and objective measures • Significant correlation between Normal nighttime Mi l d sl eep apnea Severe sleep apnea loudness of snoring and AHI breathing AHI 5-15 AHI >30 – AHI < 5 46dB
Primary snoring Moderate sl eep apnea – AHI >50 60dB AHI<5 AHI 15-30
19 Maimon & Hanly. J Clin Sleep Med 2010.
5 | [footer text here] Evaluation of Snoring Things That Impact Sleep Apnea and Snoring
§ Screen for OSA § Being overweight = more collapse § Sleepiness, daytime symptoms § Sleep position (back is worse than the side) § Bed partner report § Alcohol/sedative use at nighttime: especially - Gasping, Pauses in breathing § Goals of treatment 3-4 hours prior to bedtime
§ Exam § Acid Reflux
§ Treatment options
The Effects of Weight Loss Positive Pressure – Why does it work?
Category BMI
§ BMI § First line treatment – CPAP (continuous positive airway Very Obese >35 pressure) Obese I 30 - <35 § Applies positive pressure during sleep to prevent collapse § Associated with worse outcomes after Overweight 25 - <30 § Different mask interfaces exist most surgical procedures Normal 18.5 - <25
§ Tongue fat correlates with BMI ( Nashi 2007)
§ 10% weight loss ~ up to 47% AHI drop (Johansson 2009)
§ 10% weight gain ~ 32% AHI increase(Peppard 2000)
Nashi et al. Laryngoscope 2007. 24
6 | [footer text here] How to improve CPAP use Oral appliances
§ Getting used to it before sleep § Mouth guard designed to support the jaw and prevent tongue § Improving breathing through the nose collapse
- Treating allergies and congestion § Designed by dental providers § Sleep test done after the guard is made to determine how § Helps determine how symptoms of fatigue will change when the sleep apnea is treated. well it works for sleep apnea
§ CPAP is adjustable and titratable § Other Sleep Issues - Insomnia - Sleep amount
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Exercises for Snoring? Surgery for OSA
§ Snoring and sleep disordered breathing are less common in § Directed at the sites of singers and musicians who played obstruction the digeridoo - More space § Oropharyngeal exercises done - Prevent collapse routinely for 3 months (8 mins 3x/day) showed decrease in - Support muscle tone loss snoring by 50%
Ieto et al. Chest 2015.
7 | [footer text here] Types/Classes of Surgery Soft Tissue Surgery
§ When non-invasive measures fail § Tonsil and palate surgery § Goals: Reduce collapse that happens during sleep § Lingual tonsil surgery
§ Create space § Base of tongue surgery
§ Support tissues § Epiglottis surgery
§ Improve muscle tone
30 Friedman. Sleep Apnea and Snoring.
Snoring and OSA in Kids Bone/Jaw Surgery
§ Maxillomandibular Advancement § Most commonly due to enlarged tonsils and adenoids § Tonsil and adenoid tissue shrink in size as we age
31 Friedman. Sleep Apnea and Snoring. 32 Holty and Guilleminault. Seminars in Orthodontics 2012.
8 | [footer text here] Hypoglossal Nerve Stimulation Nerve Stimulation Therapy § FDA approved first device – Inspire II 4/2014 § Fully implanted system with sleep remote No Stimulation Mild Stimulation
§ Unilateral (right) Hypoglossal Nerve stimulation
§ Improves neuromuscular tone during sleep
Base of Tongue Palate Base of Tongue Palate
Goals of Treatment Conclusions
§ Reduce symptoms: daytime fatigue, snoring § Not all snoring is the same. § Improve quality of life § Things to try:
§ Minimize health risks: mortality, cardiac, motor - Wei ght r educt i on vehicle accidents - Positional sleep (side-sleeping with positioner) - Watch alcohol use prior to bedtime
§ Treatment starts with positive pressure trial - Manage aci d refl ux § If there are signs of sleep apnea: get tested! § Treatment is individualized § Sleep apnea treatment starts with positive pressure, - Snoring and sleep apnea severity & other options exist if that doesn’t work. - Health factors - Patient choice
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