Sleep Disordered
Breathing
CHOL SHIN, MD. PhD. FCCP
PULMONARY AND CRITICAL CARE DEPT
PULMONARY SLEEP DISORDER CENTER
KOREA UNIVERSITY ANSAN HOSPITAL
1. Definition
2. Types and Diagnosis
3. Epidemiology
4. Clinical manifestations
5. Pathophysiology
6. Treatments
Sleep Disorder Breathing
Snoring UARS
Sleep Apnea
Criteria(1)
MILD SAS
AI 5-10
RDI 10-20
LOUD SNORING AND/OR HYPERSOMNOLENCE
MODERATE SAS
AI 10-20
RDI 20-40
SEVERE SAS
AI 20+
RDI 40+
1.OSA(Obstructive Sleep Apnea):Upper Airway
2.CSA(Central Sleep Apnea) : CNS
3.Mixed :CSA+OSA
OSA
Awake
STATE
Asleep
Expiration
Airflow
Inspiration
Effort Pes
CSA
STATE Awake
Asleep
Expiration
Airflow Inspiration
Effort Pes
Mixed
STATE Awake
Asleep
Expiration Apnea
Airflow
Inspiration
Effort Pes
Prevalence of Sleep-Disordered Breathing
N=3513 questionnaires (1843F, 1670M)
602 underwent PSG (250F, 352M), Age 30-60 year
25
AHI>5+EDS
20
Percent
AHI>5
15 24
10
9
5
2 4
0
Fema Male
N Engl J Med,Young et al,1993;17:1230-35
Obstructive Sleep Apnea Syndrome
SYMPTOMS
Excessive Sleepiness
Snoring
Apneic Episodes
Choking or Gasping in Sleep
Nocturia
Tiredness upon Awakening
Features of Excessive Sleepiness
Motor vehicle crashes
Work related accidents
Impaired school or work performance
Social embarrassment
Marital problems
Memory and concentration difficulties
Depression
Impaired quality of life
Driving and Sleep Apnea
Sleep Apnea Controls P Value
29 35
Accident
0.41 0.06 median
AI30
apnea
apnea
young
young
Cassell et al. 1989
PATHOPHYSIOLOGY
Cephalometric X-ray
POLYSOMNOGRAPHY
• The two main polysomnographic
tests performed to diagnoses
obstructive sleep apnea syndrome
are the:
1.All night polysomnogram
2.Split night polysomnogram
At Home Polysomnography
A sleep study performed at home
in the patient’s own bedroom
utilizing portable equipment.
POLYSOMNOGRAPHY MONTAGE
Sleep staging
Respiratory measures
Electrocardiography
Oxygen saturation
Limb movement activity
Video monitoring
End-tidal carbon dioxide
DIFFERNTIAL DIAGNOSIS
Upper Airway Resistance Syndrome
Central Sleep Apnea Syndrome
Central Alveolar Hypoventilation
Syndrome
Primary Snoring
UPPER AIRWAY
RESISTANCE SYNDROME
Clinical Features
Excessive daytime sleepiness
Transient repetitive alpha EEG arousals
Arousal >10 per hour
Sleep fragmentation
With or without snoring
Without oxygen desaturation
Occurs equally in males and females
UPPER AIRWAY RESISTANCE
SYNDROME
EEG
EMG
EKG
Expired CO2
Esophageal
0
balloon -10
-20
-30
SaO2 100
(%) 75
1 minute
Treatment
TREATMENT OF OBSTRUCTIVE
SLEEP APNEA SYNDROME
Behavioral Treatment
Medical Treatment
Oral Appliance Treatment
Surgical Treatment
BEHAVIORAL TREATMENT
1.Attain an ideal body weight
2.Sleep on the side
3.Avoid sedative medications before sleep
4.Avoid being sleep deprived
5.Avoid alcohol before sleep
6.Elevate the head of the bed
7.Promptly treat colds and allergies
8.Avoid large meals before bedtime
9,Stop smoking
MEDICAL TREATMENT
1.Weight Loss
2.Pharmacological
3.Oxygen Therapy
4.Nasopharyngeal Intubation
5Nasall CPAP
6.BiLevel CPAP
7.Automatic CPAP
8.Oral Appliances
CONTINUOUS POSITIVE AIRWAY
PRESSURE (CPAP)
Compliance
• Patient compliance varies between 60% and
75% by subjective reports.
• Occult monitoring has shown lower rates of
compliance.
• Reasons for poor compliance:
– Cosmetic reasons,skin abrasion,nasal
stuffiness,eye discomfort,claustrophobia,
nocturnal awakenings, mask pressure, noise, and
poor motivation
Continuous Positive
Airway Pressure(CPAP)
1 2 3
Case report
- Name : 맹 oo
- Sex : Male
- Age : 45 years
- Medical history : HTN(+), UPPP (before 5 years)
- Indication
: Snoring, Wittness apneic events, Obesity,
Headache, Concentration dysfunction, Chronic
fatigue , excessive daytime sleepiness
• Physical exam
- Height : 163 cm
- Weight : 83 kg
- Blood pressure : 180/115 mmHg
- BMI : 31.1 WHR : 1.03
- Neck circumference : 39 cm
- Chest circumference : 100 cm
- Abdomen circumference : 101 cm
• Epworth Sleepiness Scale score : 19
Polysomnography
PSG CPAP application
Sleep architecture (%)
stage 1 54.7 10
Stage 2 6.3 42
SWS (3+4) 0.5 5.8
stage REM 28 31
Sleep efficiency(%) 71.2 87.4
RDI(apnea + hypopnea) 75.7 6
Average O2 while non-REM 84% 98
Average O2 while REM 79% 98
Lowest desaturation point 46% 85
Arousal index (#/hours) 60.8 18.1
General PSG( hypnogram, O2 saturation, body position, Arousals )
CPAP application
CONCLUSION
• SDB is an important medical disorder
• Treatment is essential, not only to improve
the symptoms that include sleepiness, but also to
prevent the development of cardiovascular
complications.
• Effective treatments exist