4. SLEEP DISORDERSâŚ
⢠Insomnia: 32 million (unreliable estimate)
⢠Sleep Apnea: estimated 18 million Americans
(NHLBI)
⢠Obstructive sleep apnea: 12 million Americans
Narcolepsy: 200,000 Americans (NHLBI
estimate); 50,000 diagnosed.
⢠Chronic Fatigue Syndrome: 500,000 Americans
(CDC/NIAID)
â˘
2011 Health Grades Inc.
5. Obstructive Sleep ApneaâŚ
A Common Problem:
⢠Estimated prevalence: 40 MILLION Americans
who are undiagnosed (1 in 6)
⢠50-90% diagnosed are referred for a sleep
evaluation.
Most do not follow through.
Myers et al, JAMA, 2013
6. CENTRAL SLEEP APNEAâŚ
⢠The sleeper whose problem is central sleep
apnea periodically does not breathe at all, or
breathes so shallowly that oxygen intake is
ineffectual. The brain just seems to shut
down. In either type of sleep
apnea, obstructive or CENTRAL, the lack of
oxygen usually causes the patient to wake, at
least briefly. (Hypopneas)
7. Risk FactorsâŚ
⢠Male gender
⢠Age
⢠Obesity
⢠Neck Circumference > 17.5 inches in men
16 inches in women
⢠Smoking
⢠Craniofacial structures
⢠Smoking
⢠Family History
8. Risk FactorsâŚ
⢠High blood pressure.
⢠High blood pressure in lungs.
⢠Abnormal heart rhythm, heart
failure, coronary artery disease (CAD), or
stroke.
⢠Depression.
⢠Diabetes.
9. Symptoms of OSA in ChildrenâŚ
ďąRestless Sleep
ďąHeadaches
ďąObesity
ďąLarge Tonsils
ďąNoisy Breathing
ďąAllergic Shiners
ďą Runny Nose
ďąFrequent Upper
Airway Infections
ďąEaraches
ďąBedwetting
10. Symptoms of Sleep Apnea in Adults
and ChildrenâŚ
Daytime Symptoms:
⢠Excessive Daytime Sleepiness
⢠Depression / Anxiety / ADHD
⢠Morning Headache
⢠Dry, Irritated Throat & Raspy Voice
⢠Social and Workplace Issues
⢠Short Attention Span, Hot Temper, Impulsive,
Memory Problems
11. Symptoms of Sleep Apnea in Adults
and ChildrenâŚ
Nighttime Symptoms:
⢠Snoring
⢠Witnessed Breathing Pauses
⢠Frequent Awakenings
⢠Frequent episodes of Bedwetting
⢠Insomnia
12. Screening
QuestionnaireâŚ
â˘
â˘
â˘
â˘
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Do you snore?
Are you sleepy during the daytime?
Do you have headaches or sore throats in the AM?
Has anyone witnessed apneas or respiratory gasps?
Do you not get âenough sleepâ despite adequate time
in bed?
⢠If they answer any affirmatively, use the âEPWORTH
SLEEPINESS SCALEâ TO ASSES SEVERITY. We give this
to everyone!
13. Is It a COLD or an ALLERGY?
⢠Cold:
⢠Runny nose and sneezing last 1-3 days; if cold symptoms persist for more
than a week, see a doctor - you may have complications such
⢠as bronchitis or sinusitis
â˘
⢠Sore throat and / or coughing
â˘
⢠General malaise -fever, muscle aches, chills, sweats, loss of
appetite, fatigue -which indicate an infection
â˘
⢠Burning sensation in nose, often accompanied by nasal/sinus tenderness
â˘
⢠Mucus can become yellow, green, thick, foul-smelling or bloody
14. ⢠Allergy:
⢠Persistent watering of nose and eyes lasts anywhere from a few
weeks to several months, depending on the allergen
⢠Itchiness of the nose, eyes and roof of the mouth or back of throat
⢠General feeling of well-being, except for areas experiencing allergic
symptoms; appetite usually is not diminished
⢠In most cases, sinuses are not painful or tender
⢠Mucus is watery and clear
15. We Cannot See Adenoids and Septums
But We CAN See Tonsils and Tongues
Large Adenoids
Deviated Septum
Large tonsils
Wide tongue/Long Uvula
16. Medical Conditions /SinusitisâŚ
â˘
â˘
â˘
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Diabetes
Gastro esophageal reflux disease
Nasal polyps or septal deviation
Disorders of the immune system
(fungal infections are especially risky)
⢠Oral or intravenous steroid treatment
⢠Hypothyroidism -- causes congestion that often
clears up when the condition is treated
⢠Cystic fibrosis -- a genetic disorder in which the
mucus is very thick and builds up
18. DISEASESâŚ
Type II Diabetes
⢠Almost 50% of type 2 diabetes patients have sleep
apnea;1 among obese type 2 diabetes patients, the
prevalence of sleep apnea has been estimated at 86%.
AM J RESPIR CRIT CARE MED.2010 Mar 1;181(5):507-13. doi: 10.1164/rccm.200909-1423OC.
Epub 2009 Dec 17.
⢠76% Congestive Heart Failure
Javaheri S. Sleep-related breathing disorders in heart failure. In: Heart Failure, A Companion
to Braunwaldâs Heart Disease, edited by Douglas L. Mann. WB Saunders, Philadelphia 2010;
471-487
⢠70% Stroke/TIA
http://sleepdisorders.about.com/od/sleepandgeneralhealth/f/Sleep_Apnea_Stroke_Risk.htm
Mar 4, 2013 ...
22. Determine Etiological Factors which would
prevent the success of a therapy program
BY BEING PART OF A team!
1. Deviated Septum
2. Enlarged Turbinates
3. Polyps
4. Enlarged Adenoids and / or Tonsils
5. Allergic Rhinitis and / or Sinusitis
6. Vaulted -Narrow Palatal Arch Formation
REFER! Ask Questions
30. CARDIOVASCULAR
LINKSâŚ
⢠5.7 million people in the US have heart failure
{American Heart Association Statistics}
⢠76% of Heart Failure Patients have SDB
⢠Heart Failure is the MOST expensive disorder to treat
⢠Obstructive Sleep Apnea is noted in 49% of atrial
fibrillation patients and 30% of cardiovascular
patients
⢠OSA presents in 70% of heart attack patients
31. Mortality LinksâŚ
⢠SDB is associated with a 3-fold
increase in mortality risk
⢠Severe sleep apnea raises
premature death risk by 46%
32. Mood Disorder and ApneaâŚ
⢠54.1% of Bipolar patients were found to
be at risk for OSA
⢠Sleep apnea associated with major depression
(2.4% in men, 5.4% in women)
⢠Treatment of OSA ameliorates symptoms
in the short and long term
Soreca, Bipolar Disord, 2012
Wheaton, Sleep, 2012
Scjwartz, J Clin Sleep Med, 2007
33. Restless Legs Syndrome and
Periodic Limb MovementsâŚ
⢠Periodic Leg Movements (PLMD)
⢠Restless Legs Syndrome (RLS)
Movement disorder (Rest increases
symptoms)
⢠Sensory Motor Syndrome
34. Cardiovascular Risk and RLSâŚ
⢠2 times greater risk of heart and
cardiovascular disease
⢠Women with RLS for 3 years are at greater
risk for heart disease
⢠Older Men with RLS are 67% times more
likely to have a stroke than those without
Li,RCircuLlatioSn,2013
35. Are pregnant women at
risk for sleep apnea?
Potential risk factors for SDB in pregnancy:
â˘
â˘
â˘
â˘
â˘
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Nasal congestion and gestational rhinitis (1)
Increased Mallampati scores (2)
Reduction in size of upper airway (3,4)
Weight gain
Reduction in FRC (5) and airway collapsibility (6)
Vacuum effect related to increased ventilator drive (7)
â˘
â˘
â˘
â˘
â˘
â˘
â˘
1-Young T. J All Clin Immunol 1997; 99: S757-62.
2- Pilkington S. Br J Anesth 1995; 74:638-42
3- Iczi B. ERJ 2006; 27:321-7
4- Iczi B. AJRCCM 2003; 167:137-40
5- Crapo R. Clin Obstet Gynecol 1995; 39:3-16
6- White DP. AJRCCM 2005; 172:1363-70
7- Edwards N. Thorax 2002; 57:555-8
36. Consequences of Apnea for
Pregnant WomenâŚ
⢠Pregnancy associated with lower residual
volume and lower functional residual
capacity (FRC)
⢠Lower oxygen reserve because of lower
FRC and higher oxygen consumption
37. PreeclampsiaâŚ
PEC is an important cause of:
â˘
â˘
â˘
â˘
â˘
Infant prematurity
Neonatal morbidity
Maternal morbidity and mortality
Maternal ICU admissions
Precursor of cardiovascular disease
38. Consequences of Apnea on Fetus:
⢠Concern for fetal wellbeing with recurrent
desaturations and possible hypoventilation
(Data from high altitude residents strongly
suggests risk of growth restriction and
PEC with chronic hypoxia)
(Doctors in Denver are very aware of the risks!)
39. Gestational DiabetesâŚ
Diabetes occurring during pregnancy
⢠30-50% of women with GDM end up
developing DM later in life
⢠GDM is cause for infant morbidity
⢠Other complications
40. Reflux - Another IssueâŚ
⢠In a study presented at the 70th Annual
Scientific Meeting of the American College of
Gastroenterology, 81 patients with
documented sleep complaints at least three
nights per week underwent polysomnographic
sleep evaluations. 26 percent had acid reflux.
Of those who suffered with reflux, 94 percent
of the recorded reflux events were associated
with arousal from sleep or awakening.
53. Sleep StudyâŚ
â˘
â˘
â˘
â˘
Typical resultâŚ
Time in bed: 9 hours 47 minutes
Time asleep: 6 hours 46 minutes
AWAKE: 3 hours due to Arousals
( I did one just to find out what happens. I do not have
OSA, but I did not sleep well!)
55. Tonsillectomy/AdenoidectomyâŚ
⢠Chronic or recurrent tonsil infectionsâTonsillectomy
may reduce the number, but will not completely
eliminate, these infections.
⢠Peri-tonsillar abscess (pocket of infection spreading
outside the tonsil)
⢠Enlarged tonsils causing obstruction of the
throat
⢠Adenoids blocking the
nasal airway
62. Issues with MedicationsâŚ
⢠Benzodiazepines, hypnotics, narcotics
may relax the airway more in patients
who have sleep apnea.
⢠Narcotics can contribute to central sleep
apnea.
64. CPAPâŚ
⢠CPAP is still considered the
âGold Standardâ by most physicians.
Compliance: Low
65. Myofunctional Therapy with
a TEAM APPROACH
ďś
Helps to minimize snoring by training the
tongue to rest in a normal posture
ďśChanges head and neck posture which
opens the airway
ďśAllows for better nasal breathing (noses
are âuse them or lose themâ)
ďśChanges sleep behavior with better sleep
rejuvenation
ďśChanges facial esthetics
CHANGES LIVES!
66. APP for Patientâs Monitoring
Their OWN SnoringâŚ
SNORELAB.COM
for IPHONES
Snoreclock.com
for DROIDS
67. SNORELAB.COMâŚ
⢠This woman snored so loudly that her whole
family wore ear plugs to sleep!
⢠She started the exercise program and went to
Seattle to care for her elderly mother.
⢠She has sent a âSNORE REPORTâ every day!
74. SummaryâŚ
⢠Successful treatment of snoring and
sleep apnea is totally dependent
upon an accurate diagnosis of the
region of obstruction and treatment
that is directed at the ETIOLOGY!
75. SleepâŚ
â[Sleep is] the golden chain that ties
health and our bodies together.â
Thomas Dekker (1572-1632)