Chapter 104

Sleep Disordered Breathing Disorders

Surendra K Sharma, Kriti Khanna, Abhishek Sharma

ABSTRACT TABLE 1 │ Types of sleep apnea

Central sleep apnea Effort to breathe is reduced or
Obstructive sleep apnea (OSA), also known as sleep disordered diminished during sleep as the brain
breathing (SDB), is a highly prevalent though under-recognized temporarily stops sending signals to the
public health problem. It is characterized by repetitive episodes of muscles that control breathing
upper airway collapse and consequent hypoxemia during sleep.
Several risk factors like obesity, advanced age, male gender, family Obstructive sleep apnea Respiratory effort is maintained but
history, craniofacial abnormalities, smoking and alcohol consumption ventilation is reduced or obstructed
are known to play a role in development and progression of OSA. because of partial or total occlusion in
OSA is associated with increased cardio-metabolic morbidity and the upper airway
mortality and its role in promoting insulin resistance, hypertension and Mixed apnea It is a combination of central and
atherosclerosis has now been well established. Additionally, in patients obstructive sleep apnea
with OSA syndrome (OSAS), quality of life may also be affected with
increased incidence of road traffic accidents, mood disorders and
neurocognitive deficits. However, awareness regarding this potentially
disabling disorder is lacking among family care physicians and general
public. Polysomnography (PSG) is the gold standard for diagnosis of
OSA. Due to a long waiting list of patients and high cost of PSG study, EPIDEMIOLOGY
prediction models have been formulated to prioritize patients for PSG In 2009, a community based study in South Delhi reported the
study. Comorbid conditions like Type 2 diabetes mellitus, coronary prevalence of OSAS to be 4% in males and 1.5% in females2 which
artery disease, stroke, hypertension, chronic kidney disease and
is similar to the prevalence rate in western population.3 Table
metabolic syndrome frequently coexist with OSA and modify severity
of OSA. Hypothyroidism is a reversible cause of OSA and requires a 4 provides worldwide prevalence of OSA and OSAS in various
careful exclusion before subjecting patients to PSG study. Therapy with community based studies.
continuous positive airway pressure (CPAP) is the first-line treatment for
OSA. However, surgery can provide a cure in some of the symptomatic Risk Factors
anatomical obstructions of the upper airway that contribute to OSA.
Several risk factors are responsible for development and progression
Keywords: Obstructive sleep apnea (OSA), sleep disordered breathing
of OSA. These are categorized into modifiable and nonmodifiable
(SDB)
risk factors (Flow chart 1).

INTRODUCTION Comorbid Conditions

Sleep disordered breathing includes a spectrum of disorders Several comorbid conditions such as insulin resistance and Type
characterized by an abnormal respiratory pattern, in which partial 2 diabetes mellitus, coronary artery disease, hypertension, stroke,
or complete cessation of breathing occurs several times during sleep. chronic kidney disease, dyslipidemia and metabolic syndrome
This leads to daytime somnolence and consequently reduces quality are associated with OSA.11 Treatment of OSA with CPAP modifies
of life with increased likelihood of mood disorders, neurocognitive severity of comorbid illnesses and decreases requirement for drug
impairment and road traffic accidents. Sleep apnea can be of three treatment of the comorbid condition.
different types namely—central, obstructive and mixed (Table 1).
Obstructive sleep apnea is the most common and severe form of Clinical Presentation and Consequences
sleep disordered breathing. It is characterized by disruptive snoring of Obstructive Sleep Apnea
and repetitive episodes of upper airway collapse during sleep. Habitual snoring and excessive daytime somnolence are the key
This results in intermittent hypoxemia, frequent arousals, sleep features of OSAS. Various other symptoms of OSA are summarized in
fragmentation and poor quality sleep. The airway obstruction may Flow chart 2. Consequences of untreated OSA are detailed in Table 5.
also cause episodic sleep-associated oxygen desaturation, episodic
hypercapnia, and cardiovascular dysfunction. Sleep disordered
breathing related definitions are provided in Table 2.1 Daytime
Diagnosis
sleepiness associated with OSA is known as OSA syndrome (OSAS). The diagnosis of OSA is based on elicitation of symptoms with the
Table 3 describes categorization of severity of OSA using various cut- help of questionnaires asked in presence of the sleeping partner or
off values of apnea-hypopnea index (AHI). a family member. The questionnaires help to stratify subjects into
 Pulmonology Section 15

TABLE 2 │ Definitions related to sleep disordered breathing

Apnea Apnea is defined as decrease in nasal airflow by ≥ 90% of baseline for at least 10 seconds and at least
90% of the event’s duration must meet the amplitude reduction criteria for apnea.1
Hypopnea Hypopnea is defined as:1
•  Decrease in nasal airflow by ≥ 30% of baseline for 10 seconds plus ≥ 4% oxygen desaturation from
pre-event baseline and at least 90% of the event’s duration must meet the amplitude reduction of
criteria for hypopnea.
OR
•  Decrease in nasal airflow by ≥ 50% of baseline for 10 seconds plus ≥ 3% oxygen desaturation from
pre-event baseline or the event is associated with arousal and at least 90% of the event’s duration
must meet the amplitude reduction of criteria for hypopnea.
Apnea-hypopnea index (AHI) Episodes of apnea and hypopnea per hour of sleep
AHI (expressed as events/hour) = Total number of episodes of apnea + hypopnea
Total sleep duration (in hours)
Respiratory disturbance index (RDI) RDI (expressed as events/hour) = Total number of episodes of apnea + hypopnea + RERAs
Total sleep duration (in hours)
Respiratory event related arousals or RERAs can be defined as increased respiratory effort (for 10
seconds or more) on esophageal pressure recording to maintain a normal airflow leading to an arousal
from sleep as shown on EEG.1
Obstructive sleep apnea syndrome OSAS is defined as sleep disordered breathing associated with excessive daytime sleepiness
(OSAS) OSAS = obstructive sleep apnea (OSA) + excessive daytime sleepiness
Most of the published studies have used AHI rather than RDI for diagnosis

Flow chart 1: Risk factors for the development and progression of obstructive sleep apnea

TABLE 3  │ Categorization of severity of obstructive sleep ASSESSMENT OF SLEEPINESS

apnea (OSA)
OSA AHI ≥ 5 in an overnight PSG study Subjective Assessment
Severity of OSA can be categorized as: This involves the use of sleep questionnaires which have been
validated in various studies and demonstrated to have a high
Mild OSA AHI ≥ 5 to < 15
sensitivity. In Epworth Sleepiness Scale (ESS), the patient’s
Moderate OSA AHI ≥ 15 to < 30 or lowest oxygen saturation ≥ 50% propensity to fall asleep during eight situations ranging from lying
Severe OSA AHI ≥ 30 or lowest oxygen saturation < 50% down to rest, to sitting, to conversing is rated. The likelihood of falling
asleep is rated on a scale from 0–3, with 3 representing the highest
Abbreviations: OSA, Obstructive sleep apnea; AHI, Apnea-hypopnea index; likelihood of falling asleep. The total score ranges from 0–24, with a
PSG, Polysomnography
score of more than 10 suggestive of excessive daytime sleepiness and
hence sleep-disordered breathing.
high and low risk categories and facilitate early diagnosis of patients
who would otherwise remain undetected for a long time. History
Modified Berlin Questionnaire
of co-morbid illness is also elicited. Overnight PSG study is done to Modifications were made in the original Berlin Questionnaire to make
confirm the diagnosis. it suitable for Indian patients according to our country settings.19
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TABLE 4  │ Worldwide prevalence of OSA and OSAS in various community based studies
Author or reference Study design OSA (%) OSAS (%)
Questionnaire Fully Males Females Overall Males Females Overall
(n) supervised
PSG in lab
(n)
Young et al.3 1993, USA 3,515 602 24 9 16.5 4 2 2
Olson et al.4 1994, Australia 441 441 − − 13.5 − − 4.2
Bixler et al.5 2001, USA 16,583 741 7.2 2.2 4.7 3.9 1.2 2.5
Ip et al.6 2001, China 784 153 8.8 − − 4.1 − −
Ip et al.7 2004, China 854 106 − 3.7 − − 2.1 −
Udwadia et al.8 2004, India 658 250 19.5 − − 7.5 − −
Sharma et al.9 2006, India 2,150 150 19.7 7.4 13.7 4.9 2.1 3.6
Vijayan and Patial10 2006, India 7,975 47 4.4 2.5 3.5 2.4 1 1.7
Reddy et al.2 2009, India 2,505 365 13.5 5.6 9.3 4 1.5 2.8
Abbreviations: OSA, Obstructive sleep apnea; OSAS, Obstructive sleep apnea syndrome; n, Number of subjects

Flow chart 2: Clinical presentations in patients with obstructive sleep apnea

TABLE 5 │ Consequences of untreated obstructive sleep Avaialable at http://www.ncbi.nlm.nih.gov/pubmed/17085831.

apnea [Accessed on 20/8/2012].
Consequences Odd ratios Reference
Prediction Models
Cardiovascular
This approach helps to prioritize patients for PSG studies and avoids
Prevalent HTN 1.4 Nieto et al.12 unnecessary PSG study in subjects with low probability of having
Incident HTN 2.9 Peppard et al.13
the disease. Gender, body-mass index (BMI), relative-reported
CAD 1.3 Shahar et al.14
Stroke 4.5 Poza et al.15 snoring index and choking index have been found to be independent
CCF 2.4 Shahar et al.14 predictors of OSA in north Indian patients.20,21 Combinations of
Sudden death Not provided Gami et al.16 patient’s symptomology, anthropometry and demographic patterns
have been modeled variously to formulate such equations.
Neurocognitive
Vehicle accidents 7 Teran-Sentos et al.17
Polysomnography
Metabolic effects
Full night supervised, laboratory based polysomnographic study
Insulin resistance Not provided Ip et al.18 or split-night study is required to make a diagnosis of OSA. Various
Abbreviations: HTN, Hypertension; CAD, Coronary artery disease; CCF, parameters that are monitored during PSG are provided in Figure 1.
Congestive cardiac failure Overnight PSG study provides data on AHI, RDI, various sleep stages,
Source: Adapted and modified from Sharma H, Sharma SK. Overview and arousals and lowest oxygen saturation and is manually scored by a
implications of obstructive sleep apnea. Indian J Chest Dis Allied Sci. 2008. trained sleep study technician on the next day.

The questionnaire addresses the presence of frequency of snoring,

Continuous Positive Airway Pressure Titration
day time sleepiness, obesity and hypertension. Risk categorization
done on the basis of the modified Berlin questionnaire is a reliable Continuous positive airway pressure titration involves titra­
tion
predictor for the presence of both mild and moderate OSA. (online). of appropriate pressure for abolition of snoring and apneic and

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Figure 1: Various parameters monitored during polysomnography—a comparison between obstructive sleep apnea, obstructive hypopnea, central sleep
apnea and upper airway resistance syndrome; A. Electroencephalogram (EEG) pattern of sleep; B. Nasal airflow; C,D,E. Ventilatory effort by movements
of chest and abdomen and changes in esophageal pressure (reflect contraction of respiratory muscles); F. Oxyhemoglobin saturation (%). Note: It is to be
noted that oxygen saturation starts falling once the apneic episode is terminated. Respiratory event related arousals (RERAs) can be defined as increased
respiratory effort (for 10 seconds or more) to maintain a normal airflow leading to an arousal from sleep. In upper airway resistance syndrome (UARS),
arousal on the EEG is associated with increasing ventilatory effort due to increased airway resistance, as reflected by more negativity in esophageal
pressure recording. There is no significant oxyhemoglobin desaturation and paradoxical movements of abdomen and chest wall and decreases in airflow
are not observed

hypopneic events. It is ideally done on the second day or on the TABLE 6 │ Alternatives to PSG for diagnosis of obstructive
second half of the same night in the split-night study. In the resource- sleep apnea
limited settings like India, most centers prefer split-night studies for 1. Partial channel PSGs
cost reasons. For a good quality PSG study, 6 hours sleep is necessary.
2. Partial night or daytime PSGs
Alternatives to Overnight Polysomnography 3. Portable sleep monitoring devices for use at home; actigraphy
Laboratory based supervised overnight polysomnographic study for 4. Various apnea screening devices currently undergoing validation
diagnosis of OSA has several limitations which include high cost, 5. Automatic pressure titrating CPAP based direct pressure titration
necessity of performing the study in a sleep laboratory, technical study in suspected sleep apnea patients for diagnosis and
expertise required and long analyzing time needed by the operator. management
The alternative diagnostic approaches include use of home based 6. Radiology: Imaging of the head and neck for anatomic
unsupervised portable PSG equipment and various other apnea abnormalities predictive of sleep apnea: Cephalometry,* MRI,
screening devices such as actigraphy and use of apnea screens. These acoustic reflections and CT scans
are summarized in Table 6. Apnea screening devices are currently 7. Anthropometric measurements such as neck circumference
undergoing validation for their regular use.
8. Nasopharyngeal and laryngeal endoscopic measurements of both
structure and function
TREATMENT
Abbreviations: PSG, Polysomnography; MRI, Magnetic resonance imaging; CT,
Treatment of OSA involves elimination of factors that modify the Computed tomography
severity of OSA and are detailed in Table 7. *Cephalometry is the measurement of dimensions of the head with relation to
specific reference points to assess facial growth and development.

Continuous Positive Airway Pressure

Therapy with CPAP is the first-line treatment for OSA. It delivers air
at a high flow (20–30 liters/min) to the upper airway and provides delivery with patient’s effort. In contrast to the conventional fixed
a constant mechanical splint (i.e. air at pressure) to prevent airway pressure (F-CPAP) in which the pressure remains constant throughout
collapse during sleep, thus abrogating apneas and hypopneas. sleep, in A-CPAP the pressure delivered to the airway fluctuates
Continuous positive airway pressue (CPAP) use reduces intermittent according to patient’s requirement. A-CPAP is significantly more
hypoxia, respiratory effort, sympathetic stimulation, arousals and effective in correcting the deranged metabolic parameters in OSA
sleep fragmentation. However, counseling sessions are mandatory to patients, apart from better patient comfort.22 It has been suggested
ensure patient’s adherence to CPAP treatment. that prescription of A-CPAP can circumvent PSG study.23 However,
The auto-adjusting pressure titrating CPAP (A-CPAP) is the there is no consensus on this and majority recommend PSG study for
automatic pressure-titrating version which coordinates airflow assessment of baseline severity of SDB.
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 Section 15 Chapter 104  Sleep Disordered Breathing Disorders

TABLE 7 │ Treatment of obstructive sleep apnea

Treatment Improvement in OSA
1. Lifestyle modification for obesity –  Decrease in AHI, CPAP pressures and snoring
–  Weight reduction –  Ameliorates the risk for co-morbid conditions like CAD,
–  Bariatric surgery in some patients with morbid obesity hypertension and metabolic syndrome
2. Treatment of nasal congestion and deviated nasal septum –  Helps in reducing the severity of OSA
–  Use of nasal anti-histaminic drops or sprays and topical steroids –  Improves CPAP compliance
–  Surgery in subjects with deviated nasal septum
3. Body positioning during sleep –  Improves OSA in some patients
–  OSA patients should sleep on their sides or in prone posture
–  Avoidance of supine sleeping accomplished with a tennis ball
4. Thyroid hormone replacement therapy for hypothyroidism –  Improves OSA in patients with hypothyroidism and OSA
5. Pharmacologic treatment of excessive daytime somnolence in selected –  Helps in promoting wakefulness in patients who still have
patients daytime sleepiness despite of CPAP use
•  Modafinil (primary metabolite of adrafinil) –  Improves alertness and subjective and objective sleepiness
Mode of action
–  Acts through norepinephrine, dopamine reuptake and may also
act with central histaminergic system
Dosage
–  200 mg in the morning on empty stomach; can be increased to
400 mg per day (the second dose can be used in the afternoon)
•  Armodafinil (R-enantiomer of racemic drug modafinil)
–  Achieves better plasma concentration and is prescribed at a dose
of 150−250 mg per day.
Abbreviations: OSA, Obstructive sleep apnea; AHI, Apnea-hypopnea index; CPAP, Continuous positive airway pressure; CAD, Coronary artery disease

Benefits of Continuous Positive TABLE 8 │ Adverse events associated with continuous positive
Airway Pressure Use airway pressure (CPAP) use
Obstructive sleep apnea patients with CPAP adherence of •  Various side effects associated with CPAP use
5 hours or more per night lead an improved quality of life with reduced –  Mouth dryness
daytime sleepiness. Long-term treatment with CPAP reduces blood – Conjunctivitis
pressure significantly in OSA patients who receive anti-hypertensive –  Skin irritation
treatment. Other benefits of using CPAP include increased cardiac –  Pressure sores
output, increased stroke volume and reduced risk of cardiovascular –  Nasal congestion
mortality. A 13% reversal of metabolic syndrome in OSA patients has – Epistaxis
–  Nasal and upper airway dryness.*
been reported after CPAP therapy.24 CPAP therapy has also shown
to significantly decrease albuminuria in north Indian patients with •  Other difficulties include:
moderate-to-severe OSA.25 Various adverse events associated with – Claustrophobia
CPAP use are listed in Table 8. –  Mask leaks
–  Difficulty in exhaling
Bilevel Positive Airway Pressure Therapy – Aerophagia
–  Chest discomfort.
Bilevel positive airway pressure (BiPAP) can be helpful in patients
•  Treatment with CPAP is costly and hence not available to all OSA
with high CPAP pressures and underlying lung diseases with airflow
patients
limitation such as chronic airway obstruction and bronchial asthma
which increase the effort of breathing.26 In BiPAP, the inspiratory •  CPAP use may be problematic in electricity-deprived areas of the
positive airway pressure (IPAP) is set to prevent upper airway country.
closure while expiratory positive airway pressure (EPAP) stabilizes *Humidifier available in the CPAP machine helps to overcome nasal and upper
the collapsible airway at end expiration such that the patient can airway dryness
comfortably trigger the delivery of an IPAP.

Oral Appliances surgery requires proper patient assessment and selection. Various
Patients with mild-to-moderate OSA and those who do not tolerate surgical procedures for the treatment of OSA are summarized in
CPAP can be prescribed oral appliances. Such appliances are Table 9.
designed to keep the upper airway open or decrease the upper airway
collapsibility by advancing the lower jaw forward or by keeping the REFERENCES
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TABLE 9 │ Surgical procedures for obstructive sleep apnea

Surgery Indication Result
Septoplasty Deformed septum Improved CPAP tolerance
Nasal polypectomy Airway obstruction Improved CPAP tolerance
Tonsillectomy/Adenoidectomy Enlarged and hypertrophied tonsils/ Treats OSA (especially in children)
adenoids
Uvulopalatopharyngoplasty Most common surgical procedure for OSA Treats snoring, decreases AHI, long-
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uvula and trimming of soft palate
Pillar procedure Stabilizes soft palate Decreases snoring and AHI
MMA Upper jaw (maxilla) and lower jaw In selected patients, efficacy equals
(mandible) repositioning CPAP
Abbreviations: CPAP, Continuous positive airway pressure; OSA, Obstructive sleep apnea, AHI, Apnea-hypopnea index; MMA,
Maxillomandibular advancement
Note: It is to be noted that laser treatment of the soft palate termed “laser uvulopalatoplasty” may benefit patients who suffer from
severe snoring-related problems.
Source: Adapted and modified from Sharma H, Sharma SK. Overview and implications of obstructive sleep apnea. Indian J Chest Dis
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