Obstructive Sleep Apnea

Epidemiology

• Prevalence of 4% for women and 9% for men in US, though some studies suggest this is much higher.
  – M:F ratio of 2-3:1 (evens out post-menopause)
  – 80 – 92% is undiagnosed
• Increased Prevalence with age >65yo

Symptoms of OSA

Nocturnal symptoms:

• Snoring, usually loud, habitual
• Witnessed apneas, which often interrupt the snoring
• Nocturia (esp. in peds)
• Insomnia
• Restless sleep, with patients often experiencing frequent arousals

Daytime symptoms:

• Morning headache, dry or sore throat
• Excessive daytime sleepiness (EDS) that usually begins during quiet activities
• Cognitive deficits; memory and intellectual impairment
• Personality and mood changes, including depression and anxiety
• Sexual dysfunction, including impotence and decreased libido
• GERD

Physical Exam

• Obesity – Body mass index (BMI) greater than 30 kg/m2
• Large neck circumference – Greater than 43 cm (17 in) in men and 37 cm (15 in) in women
• Abnormal (increased) Mallampati score
• Narrowing of the lateral airway walls
  i. independent predictor of the presence of OSA in men but not women
• Enlarged (ie, “kissing”) tonsils (3+ to 4+)
• Small mandible

Lateral narrowing

Treatment (peds)

• T&A
• Curative in 80% of pts
  1. Less effective in
     • obese pts
     • African American
     • Higher AHI
     • Small tonsils
     • Teens
• Consider DISE in pts with persistent OSA vs. CPAP

Treatment (adults)

• Mild OSA
  • Behavioral modification
  • Weight loss
  • positioning
• Mild to Moderate
  • Option for mandibular advancement splint
• Mild to Severe
  • CPAP
    • Nasal pillows—> nasal mask—–>full face
  • BiPAP

Failure to tolerate PAP therapy…….

Surgical Candidacy (general)

• Failure to tolerate CPAP in any severity of OSA
  • Claustrophobia, mask irritation, tubing issues, nasal obstruction
• Refusal to use CPAP
• Mild to Moderate OSA with a discrete source of obstruction

Considerations for OSA Surgery

• In General (historically) Surgery is high morbidity with low return
• Pt selection is key
• Set realistic expectations for patients (esp. overweight)
• Goals of Surgery
  • Adjunct to non-surgical therapy
  • Salvage Therapy for non-surgical failures.

Options

Surgical Decision making

• Severity of disease
  • AHI and disease burden
• Patient goals
• Age
• Pattern of airway collapse

Role of Nasal Surgery

• Good option for snoring and UARS patients
• Typically, will not cure OSA
  • Improve CPAP tolerance
  • As part of multilevel surgery – improved outcomes
  • Improve sleep related Quality of Life
    • Decreases sleep fragmentation, daytime sleepiness

Role of nasal surgery

– Surgical Success rate in nasal surgery group was 68% compared to 55% in no nasal surgery group (P=.002).
– Nasal surgery alone does not significantly affect AHI, ESS.

Uvulopalatopharyngoplasty (UPPP)

UPPP

Friedman scale for pt selectio

HGNS Patient Selection

– AHI 15-65
– BMI <32 kg/m2
– Failure to tolerate CPAP
– <25% central apneas – Age >18
– No source of fixed upper airway obstruction (eg severe ATH, mass, etc.)

Contraindications

– > 25% central apneas
– Concentric collapse of the velopharynx
– Any physical finding that would compromise the performance of UAS
– Any condition that has compromised neurologic control of the UA
– Pt who cannot operate remote w or w/o assistance.
– Pregnant
– Other implants that may interact with UAS
– Pts who require MRI of the chest
– Safe for all other MRIs

STAR trial – outcomes

Future Directions

• Bilateral HGNS
  • Via transcutaneous stimulation
  • Currently being trialed in Europe

Eastwood, PR et al. Bilateral HGNS in Adults with OSA. European Resp J. 2020