A 36 years old obese man was suffering from hypertension and snoring. Patient was a known smoker. In Sleep test, there were 5 apnea/hyperapnoes episodes per hour. He was given antihypertensives and advised to quit smoking. Next line of management:
Ans. b. Weight reduction and diet plan (Ref: Harrison 19/e p1723, 18/e p2186-2189)A 36 years old obese man was suffering from hypertension and snoring. Patient wav a known smoker. In Sleep test, there were 5 apnea/hyperapnoes episodes per hour. He was given antihypertensives ami advised to quit smoking. Next line of management is weight reduction and diet plan as patient is having mild sleep apnea (apnea-hypopnea index of 5-15 is mild).'All patients diagnosed with Obstructive sleep apnea/hypopnea syndrome (OSAHS) should have the condition and its significance explained to them and their partners. Rectifiable predispositions should be discussed; this often includes weight loss and alcohol reduction both to reduce weight and because alcohol acutely decreases upper-airway dilating muscle tone, thus predisposing to obstructed breathing.'- Harrison 18/e p2189'The primary treatments of obstructive sleep apnea are: weight loss in those who are overweight, continuous positive airway pressure, and mandibular advancement devices. There is little evidence to support the use of medications or surgery.''Continuous positive airway pressure (CPAP) is effective for both moderate and severe disease; It is the most common treatment for obstructive sleep apnea.''Adherence to CPAP is generally better than that to an MRS, and there is evidence that CPAP improves driving, whereas there are no such data on MRSs. Thus CPAP is the current treatment of choice (for both moderate and severe disease). However, MRSs are evidence-based second-line therapy in those who fail CPAP.'- Harrison 18/ p2189'There is no robust evidence that pharyngeal surgery, including uvulopalatopharyngoplasty (whether by scalpel, laser, or thermal techniques) helps OSAHS patients.'- Harrison 18/e p2189Males are affected more commonly than females in obstructive sleep apnea syndrome.'OSAHS occurs in around 1-4% of middle-aged males and is about half as common in women.'- Harrison 18/e p2186Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS)OSAHS is defined as the coexistence of unexplained excessive daytime sleepiness with at least 5 obstructed breathing events (apnea or hypopnea) per hour of sleepQ.Mechanism of Obstruction:Apneas and hypopneas are caused by the airway being sucked closed on inspiration during sleep. This occurs as the upper-airway dilating muscles like all striated muscles relax during sleepQ.In patients with OSAHS, the dilating muscles fail to oppose negative pressure within the airway during inspirationQ.Factors predisposing to OSAHS* ObesityQ* Shortening of the mandible and/or maxillaQ* HypothyroidismQ* AcromegalyQ* Male sexQ* Middle ageQ (40-65 years)* Myotonic dystrophyQ* Ehlers-Danlos syndromeQ* SmokingQEpidemiology:OSAHS occurs in around 1-4% of middle-aged males and is about half as common in women.The syndrome also occurs in childhood, usually associated with tonsil or adenoid enlargement; and in the elderly, although the frequency is slightly lower in old age.Irregular breathing during sleep without daytime sleepiness is much more common, occurring in perhaps a quarter of the middle-aged male population.Clinical Features:OSAHS causes daytime sleepiness; impaired vigilance, cognitive performance and driving; depression: disturbed sleep; and hypertension.Diagnosis:OSAHS requires lifelong treatment, and the diagnosis has to be made or excluded with certainty. This will hinge on obtaining a good sleep history from the patient and partner, with both completing sleep questionnaires, including the Epworth Sleepiness Score.In those with appropriate clinical features, the diagnostic test must demonstrate recurrent breathing pauses during sleep.This may be full polysomnography with recording of multiple respiratory and neurophysiologic signals during sleep.Treatment:All patients diagnosed with OSAHS should have the condition and its significance explained to them and their partners.Rectifiable predispositions should be discussed; this often includes weight loss and alcohol reduction both to reduce weight and because alcohol acutely decreases upper-airway dilating muscle tone, thus predisposing to obstructed breathing.Treatment: Obstructive Sleep Apnea Hypopnea SyndromeContinuous Positive Airway Pressure (CPAP)Mandibular Repositioning Splint (MRS)SurgeryDrugs* CPAP therapy works by blowing the airway open during sleep, usually with pressures of 5-20 mmHg.* The main side effect of CPAP is airway drying* CPAP use is imperfect, but around 94% of patients with severe OSAHS are still using their therapy after 5 years on objective monitoring.* Also called oral devices, MRSs work by holding the lower jaw and the tongue forward, thereby widening the pharyngeal airway.* Self-reports of the use of devices long-term suggest high dropout rates* Bariatric surgery can be curative in the morbidly obese.* Tonsillectomy can he highly effective in children but rarely in adults.* Tracheostomy is curative but rarely used.* Jaw advancement surgery particularly maxillomandibular osteotomy is effective in those with retrognathia (posterior displacement of the mandible) and should be considered particularly in young and thin patients.* There is no robust evidence that pharyngeal surgery, including uvulop alatopharyngoplasty (whether by scalpel, laser, or thermal techniques) helps OSAHS patients.* Unfortunately, no drugs are clinically useful in the prevention or reduction of apneas and hypopneas.* A marginal improvement in sleepiness in patients who remain sleepy despite CPAP can be produced by modafinil, but the clinical value is debatable and the financial cost is significant.Choice of Treatment in Obstructive Sleep ApneaCPAP and MRS are the two most widely used and best evidence-based therapiesQ.Direct comparisons in RCTs indicate better outcomes with CPAP in terms of apneas and hypopneas, nocturnal oxygenation, symptoms, quality of life, mood, and vigilance.Adherence to CPAP is generally better than that to an MRSQ, and there is evidence that CPAP improves driving, whereas there are no such data on MRSs.Thus, CPAP is the current treatment of choice.However, MRSs are evidence-based second-line therapy in those who fail CPAPQ.In younger, thinner patients, maxillomandibular advancement should be consideredQ.
Uvulopalatopharyngeoplasty
Weight reduction and diet plan
Nasal CPAP
Mandibular repositioning sling
Operative Surgery