Sleep Related Breathing Disorder &

Obstructive Sleep Apnea:

Are they the Same?

Jennifer Ann Mendoza-Wi, MD, FPCP, FPCCP, FCCP, FAPSR

Professor, Lyceum Northwestern FQ Duque College of Medicine
Past President, Philippine College of Chest Physicians
 Objectives
O Discuss the types of sleep disordered
breathing (SDB)
O Discuss Obstructive Sleep Apnea
(OSA)
O Discuss the Diagnosis and
Management of Obstructive Sleep
Apnea (OSA)
Sleep-Disordered Breathing
O is an umbrella term for several chronic conditions
in which partial or complete cessation of
breathing occurs many times throughout the
night, resulting in daytime sleepiness or fatigue
that interferes with a person’s ability to function
and reduces quality of life
O Symptoms include snoring, pauses in breathing
described by bed partners and distrubed sleep
Types of Sleep Disordered Breathing (SDB)

O Obstructive Sleep Apnea (OSA)

O Central Sleep Apnea (CSA)
O Complex Sleep Apnea (CompSA)
 Central Sleep Apnea (CSA)
O Clinically defined by a lack of drive to breathe
during sleep, resulting in repetitive periods of
insufficient ventilation leading to compromised
gas exchange, in contrast to OSA where there is
ongoing respiratory effort.
O These nocturnal breathing distrubances can
lead to various comorbiditiies and can increase
the risk for cardiovascular events.

• Sleep–Related Breathing Disorders in Adults: Recommendations for Syndrome Definition and Measurement Techniques in
Clinical Research. The Report of an American Academy of Sleep Medicine Task Force SLEEP, Vol. 22, No. 5, 1999
• Peppard et al. Increased Prevalence of Sleep-Disordered Breathing in Adults. Am J Epidemiol. 2013
• Eckert. Central Sleep Apnea pathophysiology and treatment. Chest. 2007
• Morgenthaler T. Complex sleep apnea syndrome: is it a unique clinical syndrome? Sleep Vol 29 No 9 2006
http://www.journalsleep.org/Articles/290911.pdf
 Central Sleep Apnea (CSA)
O Known variations are:
O high altitude-induced periodic breathing,
O idiopathic CSA,
O narcotic-induced CSA and
O Cheyne-Stokes respiration (CSR)
O The pathophysiology and the prevalence of the
various forms can very greatly
O Patients don’t often snore, so the condition
sometimes goes unnoticed
• Sleep–Related Breathing Disorders in Adults: Recommendations for Syndrome Definition and Measurement Techniques in
Clinical Research. The Report of an American Academy of Sleep Medicine Task Force SLEEP, Vol. 22, No. 5, 1999
• Peppard et al. Increased Prevalence of Sleep-Disordered Breathing in Adults. Am J Epidemiol. 2013
• Eckert. Central Sleep Apnea pathophysiology and treatment. Chest. 2007
• Morgenthaler T. Complex sleep apnea syndrome: is it a unique clinical syndrome? Sleep Vol 29 No 9 2006
http://www.journalsleep.org/Articles/290911.pdf
 Complex Sleep Apnea (CompSA)

O Clinically defined as a combination of

obstructive sleep apnea with central sleep
apnea or Cheyne-Stokes breathing pattern
O Present with both a reduced upper airway
tone, resulting in an obstruction during
sleep, and unstable ventilatory control,
resulting in a cessation of respiratory effort
leading to a central apnea
Obstructive Sleep Apnea
O Obstructive sleep apnoea (OSA) is a common
chronic disorder affecting about 2–4% of the
adult population, with the highest prevalence
reported among middle-aged men [Young et al.
1993].
O The condition is characterized by repetitive
episodes of complete or partial collapse of the
upper airway (mainly the oropharyngeal tract)
during sleep, with a consequent
cessation/reduction of the airflow [Guilleminault et
al. 1976; Guilleminault and Quo, 2001].
Ther Adv Chronic Dis. 2015 Sep; 6(5): 273–285.
doi: 10.1177/2040622315590318
 Obstructive Sleep Apnea (OSA)
O The most common form of sleep-disordered
breathing
O Characterized by repetitive upper airway collapse
during sleep resulting in apneas ( cessation of
airflow) and hypopneas (reduced airflow)
O Is associated with many adverse health
consequences, including an increased risk of
death
• Sleep–Related Breathing Disorders in Adults: Recommendations for Syndrome Definition and Measurement Techniques in
Clinical Research. The Report of an American Academy of Sleep Medicine Task Force SLEEP, Vol. 22, No. 5, 1999
• Peppard et al. Increased Prevalence of Sleep-Disordered Breathing in Adults. Am J Epidemiol. 2013
• Eckert. Central Sleep Apnea pathophysiology and treatment. Chest. 2007
• Morgenthaler T. Complex sleep apnea syndrome: is it a unique clinical syndrome? Sleep Vol 29 No 9 2006
http://www.journalsleep.org/Articles/290911.pdf
 Obstructive Sleep Apnea (OSA)
O Prevalence- affects 25% of men and 10% of
women in the USA although most are
asymptomatic
O The primary indications of upper airway
obstruction are:
O Lack of muscle tone during sleep
O Excess tissue in the upper airway
O The structure of the upper airway and jaw
• Sleep–Related Breathing Disorders in Adults: Recommendations for Syndrome Definition and Measurement Techniques in
Clinical Research. The Report of an American Academy of Sleep Medicine Task Force SLEEP, Vol. 22, No. 5, 1999
• Peppard et al. Increased Prevalence of Sleep-Disordered Breathing in Adults. Am J Epidemiol. 2013
• Eckert. Central Sleep Apnea pathophysiology and treatment. Chest. 2007
• Morgenthaler T. Complex sleep apnea syndrome: is it a unique clinical syndrome? Sleep Vol 29 No 9 2006
http://www.journalsleep.org/Articles/290911.pdf
 Risk Factors
O Obesity
O Male gener
O Some Ethnic groups- African American, Asian,
Native American
O Nasal obstruction
O Large tonsils particularly in children
O Underactive thyroid gland
O Use of alcohol
O Tobacco
O Use of sedatives
O Menopause in women
O Higher levels of testosterone
 Diagnosis
O Polysomnogram (sleep test)
O Measures approximately a dozen physiologic parameters
during sleep
O A breathing pause of 10 seconds or more is termed an
apnea
O An apnea is associated with oxygen desaturation and other
bodily responses as the person struggles to breath eg.
flexing of muscles including those of the airways, and
change in the electrical activity of the brain as measured by
an EEG.
O Desaturation and arousals also occur with hypopnea
(partial decrease in air flow).
O The apnea-hypopnea index is the number of apneas and
hypopneas that occur per hour of sleep and is an
important measure of severity of sleep apnea along with
depth of desaturation
The obstructive events (apnoeas or hypopnoeas) cause a progressive
asphyxia that increasingly stimulates breathing efforts against the
collapsed airway, typically until the person is awakened
The diagnosis of OSA is made through different levels of nocturnal
monitoring of respiratory, sleep and cardiac parameters (polisomnography
or nocturnal cardio-respiratory poligraphy), aimed to detect the obstructive
events and the following changes in blood oxygen saturation (SaO2) [Berry
et al. 2012; American Academy of Sleep Medicine, 2014].
The most commonly used index to define the severity of OSA is the
apnoea/hypopnoea index (AHI), calculated as the number of
obstructive events per hour of sleep and obtained by nocturnal
cardiorespiratory monitoring
Management
Indications for the management of obstructive sleep apnoea based on the apnoea
hypopnoea index (AHI). Continuous positive airway pressure (CPAP) should be considered as
the first choice of treatment, whereas positional treatment is indicated only when positional
apnoeas have been documented.
 Continuous positive airway pressure (CPAP) is still recognized as the
gold standard treatment

Nasal CPAP (nCPAP) is highly effective in controlling symptoms, improving

quality of life and reducing the clinical sequelae of sleep apnoea
Ther Adv Chronic Dis. 2015 Sep; 6(5): 273–285.
doi: 10.1177/2040622315590318
 Other PAP Modalities
O Other positive airway pressure modalities are available
for patients intolerant to CPAP or requiring high levels
of positive pressure.
O Mandibular advancement devices, particularly if custom
made, are effective in mild to moderate OSA and provide
a viable alternative for patients intolerant to CPAP
therapy.
 Role of Surgery
O The role of surgery remains controversial.
O Uvulopalatopharyngoplasty is a well established
procedure and can be considered when treatment
with CPAP has failed
O Maxillar-mandibular surgery can be suggested to
patients with a craniofacial malformation
O Tracheotomy
 Alternatives to PAP
O Positional Therapy-simple ‘tennis ball technique’,
consisting of a tennis ball strapped to the back
to discourage supine position, supine alarm
devices and a number of positional pillows
O Oral Appliances-Mandibular advance splints
O Weight loss improves symptoms and morbidity in
all patients with obesity and bariatric surgery is
an option in severe obesity.
O A multidisciplinary approach is necessary for an
accurate management of the disease.
 Uvulopalatopharyngoplasty
(UPPP/ UP3)
O A surgical procedure or
sleep surgery used to
remove tissue and/or
remodel tissue in the throat.
O This could be because of
sleep issues
O Tissues may typically be
removed include: tonsils,
adenoids
 Maxillomandibular advancement
O Osteotomy of the maxilla and
mandibular
O Advancement of the skeleton
structures passively induces anterior
displacement of the soft palate and
the tongue with a simultaneous
widening of the pharyngeal space.
O A mean reduction of AHI of 87% has
been reported and there is general
consensus that this represents the
most effective surgical apprach after
tracheotomy.
O This should be reserved for selected
patients when all other approaches Prinsell, 2002
have failed Randerath et al, 2011
Epstein et al, 2009
CPAP and BiPAP
Positive Airway Pressure Treatment
O The elimination of nocturnal apnoeic events and
intermittent hypoxia is a key goal to controlling OSA
effectively.
O PAP devices function as a pneumatic support that
allows one to maintain upper airway patency by
increasing the upper airway pressure above a ‘critical’
value (pressure value below which the airways collapse).
O The device is applied to the patient, through a nasal or
oronasal mask, overnight or during sleep hours at a set
positive pressure.
O The pressure to apply can vary with the severity of OSA
and higher pressures are needed to abolish those
apnoeas occurring during rapid eye movement sleep, in
the supine position or in the presence of severe obesity.
Positive Airway Pressure Treatment
O For each patient, the effective pressure is obtained
after one or more nights of PAP titration.
O PAP therapy is indicated in all patients with an AHI
greater than 15, independently from the presence of
comorbidities, type of work and severity of symptoms;
O if the AHI is above 5 and below 15, PAP is indicated
in the presence of symptoms (i.e. sleepiness,
impaired cognition, mood disorders) or in the
presence of hypertension, coronary artery disease or
previous cerebrovascular accidents [Epstein et al.
2009]
 SDB & OSA- Are they the
same?
O SDB describes a group of disorders
cgaracterised by :
O 1) abnormal respiratory patterns (eg the
presence of apneas or hypopneas; or
O 2) insufficient ventilation during sleep
O OSA, the most common form of SDB, is
associated with many other adverse health
consequences, including an increased risk
of death.
Thank you