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 2 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 11 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 17 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 25 26 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 9 | [footer text here].