Vincent ENT, Head and Neck Surgery Specialist Clinic - Klang, Shah Alam, Subang, PJ, KL and more...

OSA Part 1 - What ? How? Who ? Am I the One ? What is OSA and how does OSA happen? Breathing problems can occur during sleep giving rise to disorder called 'Sleep -disordered breathing (SDB)' "Apnea" = Derived from the Greek word for "lack of breath," means a condition whereby a person stops breathing for at least 10 seconds, or even longer. Therefore, "Sleep apnea" = apnea occurring during a person's sleep There are 3 types of sleep apnea: (as in the Venn diagram) 1. Obstructive-OSA is the commonest type of sleep apnea 2. Central 3. Mixed Central sleep apnea (CSA) occurs when breathing effort stops resulting in reduction and cessation of airflow during sleep. It is usually caused by various neurologic disorders and failure of the breathing centre in the brain. Normally during sleep, the muscles that control the tongue and soft palate hold the airway open. Snoring occurs as a result of sound produced by vibrations of the soft tissue structures which can be due to turbulent flow through a narrowed airway. In OSA , these upper airway muscles relax, resulting in snoring and breathing difficulties. The degree of narrowing depends on the severity of these soft tissue collapse, therefore the name "Obstructive" . However, in OSA, one continues with his breathing effort, though with much difficulty (as compared to CSA where the persons stops his breathing effort-involuntarily). Therefore, in OSA, one stops breathing repeatedly and intermittently for at least 10 seconds, may last for 30 seconds or even longer. The more severe the OSA, the more frequent the cessation of breathing. The patient also tends to breathe through the mouth in order to overcome the obstruction. With no/reduced air flowing into the lungs, oxygen levels drop and carbon dioxide levels rise in the blood. The level of carbon dioxide would rise so much as to remind the brain to resume breathing, hence causing the arousal. Eventually, the patient awakens abruptly and resumes breathing. He quickly falls back to sleep again -and resumes the loud snoring. During the brief arousal from deep sleep, the blood pressure spikes up, sometimes by as much as 30 mm Hg systolic (the top number in your hypertension reading). As the person goes back to sleep, typically unaware of having awakened, the throat muscles relax once again, the airway closes, and the sleep apnea pattern is repeated again and many times throughout the entire night. These subsequent and frequent arousals, although necessary for breathing to restart, prevent the patient from getting enough restorative, deep sleep - hence waking up feeling unrefreshed and excessively sleepy the next day, affecting the quality of your life, work and relationships in the long run. ...... Is this you ? What is the difference between snoring and OSA ? While everyone with SDB tends to snore, but not everyone who snores has SDB. Snoring in the absence of SDB is termed primary or simple snoring i.e. snoring without obstructive apnea, frequent arousals or gas exchange abnormalities that brings about health complications. Snoring is very common in OSA, but its absence does not exclude OSA. Therefore a proper consultation with clinical examination is necessary. (Are you confused yet ? Hopefully things are clearer as you read on) What is the current problem with OSA ? Lack of awareness (thank you for reading this, at least there is one less person less aware of OSA now) In a US study, it is estimated that up to 93% of females and 82% of males with moderate to severe OSA remain undiagnosed. There is also much room of improvement in terms of awareness of this condition among the doctors (i.e general practitioners, physicians, surgeons alike. So, why should I worry if I have OSA ? OSA can cause serious health problems. In addition to affecting the quality of your life due to disrupted sleep patterns, untreated OSA (through chronic complex body physiological and biochemical changes) can lead to: 1. Stroke (Almost 70% of people who had suffered from a stroke have sleep apnea) 2. Hypertension (>35% of people with sleep apnea suffer from hypertension) o People with mild to moderate sleep apnea were twice as likely to become hypertensive. o People with moderate to severe sleep apnea were almost 3 times as likely to become hypertensive. o Usually, normal adults who do not have OSA will typically experience nighttime blood pressure drops of about 10%. o In OSA, during sleep, the heart tries to counter the build-up of carbon dioxide by pumping harder. Increases in arterial pressures of 30 mm Hg or more do occur. 3. Increased risk for heart attack (myocardial infarction) (in >35% of sleep apnea patients) o Among 6 major disease groups reviewed, cardiovascular diseases which occupied third place as a cause of death in 1950 emerged as the number one killer during the 1970s and has remained so since o Mortality due to coronary heart disease has increased by more than three fold over the last 40 years and is still rising -Cardiovascular/heart disease is in fact the number 1 killer in Malaysia ! 4. Increased risk of motor vehicle accidents (7 times more likely to occur in OSA patients) -even without OSA, some of us are already sleepy when driving especially after a stressful tiring day. What more with OSA. 5. Increased risk of work-related accidents 6. Reflux disorder i.e repeated overflow of stomach/gastric contents into the esophagus (Gastroesophageal Reflux Disease, GERD ) or throat (Laryngopharyngeal Reflux, LPR) 7. Diabetes -increasing evidence linking OSA and exacerbation of diabetes 8. Appetite increase - OSA causes increased appetite stimulant hormone (ghreline) and decresed appetite suppresant hormone (leptin). Increased appetite leads to worsening of the vicious cycle of OSA and obesity. 9. Depression - People with sleep apnea often complain of fatigue, lack of energy and poor sleep, all of which are hallmarks of depression. 10. Memory loss 11. Increased incidence of marital disharmony - even 'spousal arousal syndrome' has been coined as a result the bed partner’s snoring 12. Decreased quality of life There are thousands of clinical research papers backing these data. Still, the list is being expanded at a worrisome rate (no joke really!) as new research data pours in. How do know if I probably have OSA? The dominant symptoms of OSA are excessive sleepiness, impaired concentration and snoring. OSA symptoms include: • Restless sleep, moving around or unusual sleep position • Choking episodes-waking up at night to 'catch a breath' • Nocturia/enuresis - awaken as a result of SDB, and then they notice the urge to urinate • Morning headache • Excessive daytime sleepiness (EDS) -a very common symptom, may cause o Personality changes -eg. irritability o impaired cognitive skills o Job performance to be affected • weight gain • sexual dysfunction- decreased libido • sedative use-in an attempt to improve sleep at night, some may develop dependance Bed partner's input are good indicators: -look for choking episodes, witnessed episodes of breathing cessation (apnea), tossing and turning in bed. For screening purposes, Epworth Sleepiness Score can be used as as a validated guide as a method of assessing the likelihood of falling asleep or EDS in 8 different situations. Download link here. Who is at risk of OSA? Having all these physical attributes put you at a higher risk for OSA: • increased neck circumference [ > 17 inches (43cm) in men, > 16 inches (38cm) in women]. • short neck • body mass index (BMI) > 30 kg/m2 o The excess adipose tissue of obese individuals acts to narrow the airway and alter airway shape, increasing the susceptibility of the upper airway to collapse. • a high Modified Mallampati score (a uniform clinical method af assessing the palate space in the mouth) • the presence of retrognathia (lower jaw displaced backwards) • lateral peritonsillar narrowing, • large tongue (macroglossia), • tonsillar hypertrophy, • elongated/enlarged uvula, • high arched/narrow hard palate, • nasal abnormalities (polyps, septal deviation, valve abnormalities, turbinate hypertrophy) and/or • overjet (protrusion of upper jaw over the lower jaw) (Clinical examination and flexible endoscopy of the upper airway can identify the above findings) Smoking and alcohol consumption also contribute to snoring and OSA, not to mention it is already a known high risk factor for heart/cardiovascular disease OSA is common among those with heart/cardiovascular disease. -It affects as many as 30% of coronary artery disease patients, 50% of congestive heart failure patients, 60% of stroke patients and 80% of drug resistant hypertensive patients High-risk factors: • obesity • congestive heart failure • atrial fibrillation • treatment refractory hypertension • type 2 diabetes • stroke, nocturnal dysrhythmias • pulmonary hypertension • high-risk driving populations (such as bus drivers, pilots, commercial truck drivers), • patients being evaluated for bariatric surgery (surgery to correct morbid obesity). OSA General info Prevalence rate is about- 2% in women, 4% in men 85% of OSA patients are of the male gender 2/3 of OSA patients are obese ...read here for the new pandemic -THE OBESITY PANDEMIC incidence increases with aging -its prevalence increases 2-3 times in older persons (>65 y) compared with individuals aged 30-64 years. About 1% to 10% of children have sleep apnea; In young children, sleep apnea is usually caused by enlarged tonsils and adenoids Prevalence of OSA in women appears to increase after menopause More interesting facts here about sleep and snoring. I'm not even fat or obese, can I still have OSA? Yes, you can still have OSA even if your thin. The "Box vs Contents concept" holds true -theory of relativity.. That is, you have a risk of airway narrowing if ...you have a small bony frame ‘box’ eg small jaw bones, although the soft tissue contents are of normal size ...or you have larger-than-normal ‘contents’ eg. large tonsils, large tongue, thick walls in the throat, although you have jaw bones of normal size What about OSA in children ? All snoring and apnea is abnormal in children About 2% of children are affected, with a peak incidence at age 2-5 years old Unlike adults (who tend to be obese), apneic children tend to be underweight & short True daytime sleepiness as in adults is unusual in children- hyperactivity and irritability on waking more common. Many are mouth breathers Usually due to adenotonsillar hypertrophy unless craniofacial abnormalities in certain congenital syndromes (eg. small lower jaw bone structures).

OSA is a stress on the heart, and if left untreated, leads to many complications that YOUR body will later have to take a beatIng for !

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In a normal subject, air flows into the nose and throat before entering the windpipe into the lungs.

In an OSA patient, upper airway obstruction reduces/prevents airflow through the nose and/or throat, subsequently into the lungs. This can be caused by narrowing or backward collapse of the soft palate (yellow line), tongue (green line), and/or epiglottis (black line) in the animation. (source of unlabelled diagram: Netter Atlas of Anatomy)

BASE OF TONGUE

20 interesting facts about sleep and snoring. (source : The British Snoring & Sleep Association)

No..it’s no longer a laughing matter

Continue to OSA Part 2 -Diagnosis & Treatment

LEVEL OF OBSTRUCTION Physical attributes and findings determine the level of obstruction in OSA. Understanding the level of obstruction is crucial in treating OSA. Other than a thorough clinical examination, flexible endoscopy of the upper airway (FNPLS) in the comfort of the ENT clinic can yield much information.

Epworth Sleepiness Scale questionaire

This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.

Keen to know more about OSA Disorder Services provided here ?

OSA leaves you unrefreshed in the next morning, feeling like a ’zombie’ !

NEW evidence linking obstructive sleep apnea (OSA) to cardiovascular/heart disease (eg. hypertension, stroke, heart attack)- the No.1 killer in Malaysia .. Are you at risk ?

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The obesity pandemic (as appeared in Malaysian daily The Star on 23/9/11

Why is “SLEEPING SOUNDLY” not as beautiful and healthy as it sounds anymore ?