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RUSSAMENTO E OSAS (SNORING AND OSAS). O. S. A. S Obstructive Sleep Apnea Syndrome.

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Presentazione sul tema: "RUSSAMENTO E OSAS (SNORING AND OSAS). O. S. A. S Obstructive Sleep Apnea Syndrome."— Transcript della presentazione:

1 RUSSAMENTO E OSAS (SNORING AND OSAS)

2 O. S. A. S Obstructive Sleep Apnea Syndrome

3 O.S.A.S Sindrome caratterizzata da: russamento russamento episodi apnoici durante il sonno episodi apnoici durante il sonno

4 OSAS Base della patologia è lapnea che si caratterizza per un interruzione dellattività respiratoria nasale ed orale per almeno 10 secondi e persistenza dei movimenti toracici ed addominali per vincere lostruzione (apnea ostruttiva) Base della patologia è lapnea che si caratterizza per un interruzione dellattività respiratoria nasale ed orale per almeno 10 secondi e persistenza dei movimenti toracici ed addominali per vincere lostruzione (apnea ostruttiva) Se vi è abolizione dei movimenti toracici si parla di apnea centrale Se vi è abolizione dei movimenti toracici si parla di apnea centrale Le apnee costituiscono il sintomo cardine, insieme alle ipopnee, della sindrome delle apnee ostruttive o sindrome OSAS Le apnee costituiscono il sintomo cardine, insieme alle ipopnee, della sindrome delle apnee ostruttive o sindrome OSAS

5 eziopatogenesi Apnea centrale: Apnea centrale: disfunzione dei centri del respiro a livello del SNC, con abolizione dei movimenti toraco- addominali e quindi del flusso aereo ( rara ) disfunzione dei centri del respiro a livello del SNC, con abolizione dei movimenti toraco- addominali e quindi del flusso aereo ( rara ) Apnea ostruttiva periferica: Apnea ostruttiva periferica: collasso delle vie aeree superiori di varia natura, con persistenza dei movimenti toraco-addominali collasso delle vie aeree superiori di varia natura, con persistenza dei movimenti toraco-addominali Apnee di tipo misto periferico-centrale Apnee di tipo misto periferico-centrale

6 RUSSAMENTO Rumore che si produce durante il sonno a causa delle vibrazione di parti molli delle prime vie aeree Rumore che si produce durante il sonno a causa delle vibrazione di parti molli delle prime vie aeree Non si realizza unostruzione completa Non si realizza unostruzione completa È un disturbo di tipo sociale (partner) È un disturbo di tipo sociale (partner) Non ha effetti secondari immediati sullapparato cardiocircolatorio Non ha effetti secondari immediati sullapparato cardiocircolatorio È spia di un decadimento anatomico e funzionale delle prime vie aree che può esitare nellOSAS È spia di un decadimento anatomico e funzionale delle prime vie aree che può esitare nellOSAS

7 Definizione Apnea – cessation of airflow >10 sec, ends in arousal Hypopnea – reduction in airflow with desaturation, ends in arousal Apnea / Hypopnea Index (Respiratory Disturbance Index)

8 Definizione di OSAS RDI 10<20 = mild RDI 10<20 = mild RDI > 20 increases risk of mortality RDI > 20 increases risk of mortality RDI =moderate RDI =moderate RDI >40 =severe RDI >40 =severe Upper Airway Resistance Syndrome (UARS) Upper Airway Resistance Syndrome (UARS) –Shares pathophysiology with OSA –No desaturation, continuous ventilatory effort Snoring Snoring

9 Apnea ostruttiva periferica fattori predisponenti obesità obesità stenosi nasale: stenosi nasale: deviazione del setto deviazione del setto polipi nasali polipi nasali ipertrofia dei turbinati ipertrofia dei turbinati ipertrofia adenoidea ipertrofia adenoidea ostruzioni faringee: ostruzioni faringee: ipetrofia tonsillare ipetrofia tonsillare mega-ugola mega-ugola

10

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12 apnea ostruttiva periferica stadiazione Stadio 0: forti russatori con sporadiche apnee notturne Stadio 0: forti russatori con sporadiche apnee notturne Stadio 1: forti russatori con apnee ma solo in posizione supina Stadio 1: forti russatori con apnee ma solo in posizione supina Stadio 2: forti russatori con frequentissime apnee anche dormendo sul fianco Stadio 2: forti russatori con frequentissime apnee anche dormendo sul fianco Stadio 3: pz. scompensati ipoventilati anche in veglia con gravi apnee notturne Stadio 3: pz. scompensati ipoventilati anche in veglia con gravi apnee notturne

13 apnea ostruttiva periferica conseguenze ipersonnia diurna ipersonnia diurna cefalea cefalea faringodinia mattutina faringodinia mattutina insufficienza respiratoria insufficienza respiratoria cuore polmonare cuore polmonare > patologie cardio-circolatorie > patologie cardio-circolatorie > patologie vasculo-cerebrali > patologie vasculo-cerebrali > incidenti automobilistici !!!!!!!!!!!!! > incidenti automobilistici !!!!!!!!!!!!!

14 Obstructive Sleep Apnea 1-4% of population 1-4% of population Pickwick Papers (1837) Pickwick Papers (1837) Osler (1906) Osler (1906) Guilleminault (1973) - OSAS Guilleminault (1973) - OSAS

15 O.S.A.S Studiata e descritta in modo scientifico solo di recente (da Guilleminault nel 1973)

16 Epidemiologia 85% dei pazienti adulti sono di sesso maschile85% dei pazienti adulti sono di sesso maschile 2% delle donne oltre i 40 anni2% delle donne oltre i 40 anni 4% degli uomini oltre i 40 anni 4% degli uomini oltre i 40 anni circa 2\3 dei pz è obeso circa 2\3 dei pz è obeso lincidenza dellOSAS aumenta con letà lincidenza dellOSAS aumenta con letà

17 Physiology of Sleep REM REM Sleep Latency, REM Latency Sleep Latency, REM Latency Arousal Arousal Woodson, Tucker Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment SIPAC 1996

18 Pathophysiology of OSA Airway size: Airway size:

19 Pathophysiology of OSA Sites of Obstruction: Sites of Obstruction: Obstruction tends to propagate Obstruction tends to propagate

20 Pathophysiology of OSA Findings in Obstruction: Findings in Obstruction: –Nasal Obstruction –Long, thick soft palate –Retrodisplaced Mandible –Narrowed oropharynx –Redundant pharyngeal tissues –Large lingual tonsil –Large tongue –Large or floppy Epiglottis –Retro-displaced hyoid complex

21 Pathophysiology of OSA Sites of Obstruction: Sites of Obstruction:

22 Pathophysiology Pharyngeal collapse Pharyngeal collapse Decreased airway patency Decreased airway patency Increase in negative pressure Increase in negative pressure Becomes a vicious cycle Becomes a vicious cycle

23 Pathophysiology Anatomic narrowing Anatomic narrowing –Requires increased inspiratory pressures Abnormal neuromuscular control Abnormal neuromuscular control –Reflex activation of dilators in response to airway obstruction often fails

24

25 Risk factors Obesity (BMI > 30) Obesity (BMI > 30) Drunkenness Drunkenness Smoking Smoking ORN ORN Hormonic depletion (estrogeni) Hormonic depletion (estrogeni)

26 Tests to determine site of obstruction : Tests to determine site of obstruction : –Mullers Maneuver –Sleep endoscopy –Fluoroscopy –Manometry –Cephalometrics –Dynamic CT scanning and MRI scanning

27 Apnea ostruttiva periferica diagnosi anamnesi e visita ORL tradizionale anamnesi e visita ORL tradizionale valutazione endoscopica delle VADS valutazione endoscopica delle VADS test di Muller test di Muller ossimetria transcutanea ossimetria transcutanea polisonnografia polisonnografia rinomanometria posizionale rinomanometria posizionale tests allergici tests allergici studio del reflusso gastro-esofageo studio del reflusso gastro-esofageo valutazione neurologica e pneumologica valutazione neurologica e pneumologica

28 History Snoring* Snoring* Excessive daytime sleepiness* Excessive daytime sleepiness* Restless sleep Restless sleep Personality changes Personality changes Headaches Headaches Sexual dysfunction Sexual dysfunction Job performance Job performance Sleep hygiene Sleep hygiene Bed partners input * Bed partners input *

29 Physical Exam Vital signs Vital signs Head & Neck exam Head & Neck exam Flexible endoscopy Flexible endoscopy

30 Vital signs Height Height Weight Weight Collar size Collar size Blood pressure Blood pressure Calculate BMI Calculate BMI –Wt (kg) / Ht (meters) squared –Men >27.8, Women >27.3

31 Examination Tongue Tongue Palate Palate Uvula Uvula Tonsils Tonsils Nasal cavity Nasal cavity Hyoid Hyoid Mandible Mandible Maxilla Maxilla

32

33 Classificazione di Mallampati

34 MALLAMPATI MODIFICATA

35 Test di Muller

36 BOT collapse Hypo- pharynx collapse

37

38 Esame obiettivo

39 Tests Radiologici Cephalometrics Cephalometrics Computed tomography Computed tomography Magnetic resonance imaging Magnetic resonance imaging

40 Cephalometrics Standardized lateral radiographs Standardized lateral radiographs Examines bony and soft-tissue structure Examines bony and soft-tissue structure Two-dimensional evaluation Two-dimensional evaluation Lack of volumetric data Lack of volumetric data Maxillomandibular surgery, oral appliances Maxillomandibular surgery, oral appliances

41 Computed tomography Supine Supine Volumetric reconstruction Volumetric reconstruction Disadvantages Disadvantages –Cost –Weight limitations –Ionizing radiation

42 Magnetic Resonance Imaging Excellent soft tissue anatomy Excellent soft tissue anatomy Multiple planes Multiple planes No ionizing radiation No ionizing radiation Disadvantages Disadvantages –Cost –Weight limitations –Noisy –claustrophobia

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44

45 Evaluation of Sleep Split-Night Polysomnography Split-Night Polysomnography Epworth Sleepiness Scale Epworth Sleepiness Scale

46 Evaluation of Sleep Polysomnography Polysomnography –EMG –Airflow (nasal and oral) –EEG, EOG –Oxygen Saturation –Cardiac Rhythm -- Respiratory movement -- Respiratory movement -- Sleeping position -- Sleeping position –Leg Movements –AI, HI, AHI, RDI

47 Evaluation of Sleep Polysomnography Polysomnography Woodson, Tucker Obstructive Sleep Apnea Syndrome, Diagnosis and Treatment SIPAC 1996

48 Polisonnografia Apnea centrale: disfunzione dei centri del respiro a livello del SNC, durata almeno 10 sec., con abolizione dei movimenti toraco- addominali e quindi del flusso aereo ( rara ) Apnea ostruttiva periferica: collasso delle vie aeree superiori di varia natura, almeno 10 sec. di durata, con persistenza dei movimenti toraco- addominali Apnee di tipo misto periferico-centrale: (caratteristiche di entrambi) (caratteristiche di entrambi) Ipopnea: ipoventilazione secondaria ad ostruzione parziale

49 Polisonnografia Apnea index Apnea index Apnea-Hypopnea index = respiratory disturbance index Apnea-Hypopnea index = respiratory disturbance index Arousal index Arousal index

50 TERAPIA Nonsurgical modalities Nonsurgical modalities Surgical modalities Surgical modalities

51 Nonsurgical Treatment Weight loss Weight loss Sleep hygiene and sedative avoidance Sleep hygiene and sedative avoidance Pharmacotherapy Pharmacotherapy Smoking cessation Smoking cessation Nasal continuous positive airway pressure Nasal continuous positive airway pressure Oral appliances Oral appliances

52 Apnea ostruttiva periferica terapia Terapia farmacologico-comportamentale: Terapia farmacologico-comportamentale: calo ponderale, terapia del GERD, calo ponderale, terapia del GERD, stop fumo, alcool, tranquillanti, stop fumo, alcool, tranquillanti, modifiche della postura a letto! modifiche della postura a letto! antidepressivi? antidepressivi?

53 Nonsurgical Treatment Weight loss Weight loss –Get below trigger weight –Diet, exercise, bariatric surgery, medications Sleep hygiene Sleep hygiene –Avoidance of sedatives –Positional changes

54 Terapia Farmacologica Protriptyline – decreases REM sleep Protriptyline – decreases REM sleep Xanthine based drugs Xanthine based drugs Steroids Steroids Antibiotics Antibiotics Nasal medications Nasal medications

55 Medical Management CPAP since 1981 CPAP since 1981 Very effective Very effective Can be modified and used on a trial basis Can be modified and used on a trial basis –Pressure must be individually titrated –Compliance is as low as 50% »Air leakage, eustachian tube dysfunction, noise, mask discomfort, claustrophobia

56 CPAP Titrated to limit all respiratory events Titrated to limit all respiratory events 50-90% acceptance – better if daytime symptoms improved 50-90% acceptance – better if daytime symptoms improved Side effects in 40-50% Side effects in 40-50%

57 CPAP

58 CPAP

59 CPAP

60 Nonsurgical Management Oral appliance Advances the mandible Advances the mandible Retains the tongue anteriorly Retains the tongue anteriorly

61 Oral Appliances Oral Appliances –May be as effective as surgical options, –However low compliance rate of about 60% in study by Walker et al in 2002 rendered it a worse treatment modality than surgical procedures Walker-Engstrom ML. Tegelberg A. Wilhelmsson B. Ringqvist I. 4-year follow-up of treatment with dental appliance or uvulopalatopharyngoplasty in patients with obstructive sleep apnea: a randomized study. Chest. 121(3):739-46, 2002 Mar.

62 Oral appliances Advances the mandible Advances the mandible Retains the tongue anteriorly Retains the tongue anteriorly Most effective in nonobese patients with retro or micrognathia Most effective in nonobese patients with retro or micrognathia Better for mild to moderate cases Better for mild to moderate cases 51% achieve normal sleep, 61% improved RDI < 20 51% achieve normal sleep, 61% improved RDI < 20 Consider TMJ dysfunction and occlusal changes Consider TMJ dysfunction and occlusal changes

63 Surgical Management Therapy should be directed toward presumed site of obstruction Therapy should be directed toward presumed site of obstruction »This does not always guarantee results

64 Trattamento chirurgico Algorithms Algorithms –Riley et al 1992 »Studied 2 phase approach for multilevel site of obstruction (Stanford Protocol): Phase 1: Genioglossal advancement, hyoid myotomy and advancement, UP3 Phase 1: Genioglossal advancement, hyoid myotomy and advancement, UP3 Phase 2: Maxillary-Mandibular advancement in 6 months if phase 1 failed Phase 2: Maxillary-Mandibular advancement in 6 months if phase 1 failed Reported >90% success rate in patients who completed both phases Reported >90% success rate in patients who completed both phases Other studies have lowered this number Other studies have lowered this number Testing is done at 6 months Testing is done at 6 months

65 Riley-Powell-Stanford Protocol

66 Post operative PSG at 6 months Post operative PSG at 6 months Phase I = 61% success Phase I = 61% success Phase II = % success Phase II = % success

67 Trattamento chirurgico Measures of success – Measures of success – –No further need for medical or surgical therapy –Response = 50% reduction in RDI –Reduction of RDI to < 20 –Reduction in arousals and daytime sleepiness

68 Trattamento chirurgico Perioperative Issues Perioperative Issues –High risk in patients with severe symptoms –Nasal CPAP often required after surgery –Nasal CPAP before surgery improves postoperative course –Risk of pulmonary edema after relief of obstruction

69 Trattamento chirurgico Tracheostomy Tracheostomy –Primary treatment modality –Temporary treatment while other surgery is done –Thatcher GW. et al: tracheostomy leads to quick reduction in sequelae of OSA, few complications (see table II) –Once placed, uncommon to decannulate Thatcher GW. Maisel RH. The long-term evaluation of tracheostomy in the management of severe obstructive sleep apnea. [Journal Article] Laryngoscope. 113(2):201-4, 2003 Feb.

70 Tracheotomia Bypasses all areas of obstruction Bypasses all areas of obstruction Virtually 100% effective Virtually 100% effective Two indications Two indications –Temporary procedure during airway reconstruction –Severe OSA when CPAP refused, ineffective, or not tolerated or if other conditions exacerbated by the apneas Line the tract with skin flaps Line the tract with skin flaps Lack of social acceptance Lack of social acceptance

71 Trattamento chirurgico Nasal Surgery Nasal Surgery Improved symptoms and CPAP Improved symptoms and CPAP –Septoplasty –Turbinate reduction –Functional nasal reconstruction –Limited efficacy when used alone –Verse et al 2002 showed 15.8% success rate when used alone in patients with OSA and day- time nasal congestion with snoring (RDI<20 and 50% reduction) Adenoidectomy Adenoidectomy

72 Trattamento chirurgico Retropalatal obstruction Retropalatal obstruction Retrolingual obstruction Retrolingual obstruction

73 ALTERAZIONI DI PALATO MOLLE ED UGOLA

74 NELLAFFRONTARE IL PROBLEMA VELARE NELLOSAS NON SI PUO PRESCINDERE DA UNA RISOLUZIONE DEL PROBLEMA TONSILLARE

75 Grado 0 esiti di tonsillectomia Grado I tonsille atrofiche intraveliche Grado II tonsille appena visibili minimamente debordanti dal pilastro anteriore Grado III tonsille ipertrofiche occupanti uno spazio pari a 3/4 dellistmo delle fauci Grado IV tonsille completamente ostruenti listmo delle fauci (kissing tonsils) SITUAZIONE TONSILLARE

76 Grado 0 esiti di tonsillectomia Grado I tonsille atrofiche intraveliche Grado II tonsille appena visibili minimamente debordanti dal pilastro anteriore Grado III tonsille ipertrofiche occupanti uno spazio pari a 3/4 dellistmo delle fauci Grado IV tonsille completamente ostruenti listmo delle fauci (kissing tonsils)

77 Trattamento chirurgico Uvulopalatopharyngoplasty (UPPP) Uvulopalatopharyngoplasty (UPPP) –The most commonly performed surgery for OSA –Severity of disease is poor outcome predictor –Levin and Becker (1994) up to 80% initial success decreased to 46% success rate at 12 months –Friedman et al showed a success rate of 80% at 6 months in carefully selected patients Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 2002; 127: 13–21.

78 UPPP Fujita (1981) Fujita (1981) Most common procedure Most common procedure 1st line tx for retropalatal collapse 1st line tx for retropalatal collapse 10-50% success 10-50% success

79 UPPP

80

81 UPPP – Fujita / Ikematsu

82 Uppp PRE E POST

83 UPP

84 Trattamento chirurgico UP3 Complications UP3 Complications –Minor »Transient VPI »Hemorrhage< 1% –Major »NP stenosis »VPI

85 Trattamento chirurgico Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing: Cahali, 2003 proposed the Lateral Pharyngoplasty for patients with significant lateral narrowing: Cahali MB. Lateral pharyngoplasty: a new treatment for obstructive sleep apnea hypopnea syndrome. Laryngoscope. 113(11):1961-8, 2003 Nov.

86 Trattamento chirurgico Lateral Pharyngoplasty Lateral Pharyngoplasty

87 Trattamento chirurgico Lateral Pharyngoplasty Lateral Pharyngoplasty –Median apnea-hypopnea index decreased from 41.2 to 9.5 (P =.009) –No control group –No evaluation at 12 months

88 LAUP Laser Assisted Uvulopalatoplasty Laser Assisted Uvulopalatoplasty –High initial success rate for snoring –Rates decrease, as for UP3 at twelve months –Performed awake

89 COMPLICANZE LAUP- STENOSI

90 Surgical Management Radiofrequency Ablation – Fischer et al 2003 Radiofrequency Ablation – Fischer et al 2003 Radiofrequency device is inserted into various parts of palate, tonsils and tongue base at various thermal energies Fischer et al 2003 At 6 months Showed significant reduction of: RDI (but not to below 20) Arousals

91 TERAPIA INTERSTIZIALE RVFR palatale RVFR palatale

92 TERAPIA INTERSTIZIALE: TERAPIA INTERSTIZIALE: Coblator - Cold Ablation (ablazione fredda). E un sistema bipolare che lavora ad una frequenza di 10 KHz. Lablazione dei tessuti avviene per dissociazione molecolare, anziché per vaporizzazione od esplosione cellulare. I tessuti vengono quindi ridotti in molecole di idrocarburi ed ossidi, Lavora tra i 40 ed i 70°.

93 IMPIANTI PALATALI: procedura semplice ed efficace consiste nellinserimento nello spessore del palato molledi tre barrette di materiale sintetico (poliestere) a lento riassorbimento; lo scopo della procedura è causare un irrigidimento velare e di conseguenza minori vibrazioni del palato, monoseduta IMPIANTI PALATALI: procedura semplice ed efficace consiste nellinserimento nello spessore del palato molledi tre barrette di materiale sintetico (poliestere) a lento riassorbimento; lo scopo della procedura è causare un irrigidimento velare e di conseguenza minori vibrazioni del palato, monoseduta

94 Tongue reduction Lingual tonsillectomy Lingual tonsillectomy Laser midline glossectomy Laser midline glossectomy Lingualplasty Lingualplasty Radiofrequency volumetric tissue reduction Radiofrequency volumetric tissue reduction

95 Trattamento chirurgico Tongue Base Procedures Tongue Base Procedures –Lingual Tonsillectomy »may be useful in patients with hypertrophy, but usually in conjunction with other procedures

96 Trattamento chirurgico Tongue Base Procedures Tongue Base Procedures –Lingualplasty »Chabolle, et al success rate of 77% (RDI<20, 50% reduction) in 22 patients in conjunction with UPPP »Complication rate of 25% - bleeding, altered taste, odynophagia, edema »Can be combined with epiglottectomy

97 Trattamento chirurgico Lingual Suspension: Lingual Suspension:

98 Trattamento chirurgico Lingual Suspension: Lingual Suspension:

99 Trattamento chirurgico Hyoid Myotomy and Suspension Hyoid Myotomy and Suspension –Advances ( the tongue base ) hyoid bone anteriorly and inferiorly –Advances epiglottis anteriorly –Enlarges retrolingual airspace Performed in conjunction with other procedures Performed in conjunction with other procedures –Dysphagia may result

100 Trattamento chirurgico Mandibular Procedures Mandibular Procedures –Genioglossus Advancement »Rarely performed alone »Increases rate of efficacy of other procedures »Transient incisor paresthesia

101 Mandibular Osteotomy with Genioglossus Advancement Enlarges the retrolingual airway without disturbing dentition Enlarges the retrolingual airway without disturbing dentition Prevents retrolingual collapse Prevents retrolingual collapse

102 Trattamento chirurgico Maxillary-Mandibular Advancement

103 Maxillomandibular Osteotomy and Advancement Severe disease Severe disease Failure with more conservative measures Failure with more conservative measures Midface, palate, and mandible advanced anteriorly Midface, palate, and mandible advanced anteriorly Limited by ability to stabilize the segments and aesthetic facial changes Limited by ability to stabilize the segments and aesthetic facial changes

104 Trattamento chirurgico Maxillary- Mandibular Advancement Maxillary- Mandibular Advancement –Performed in conjunction with oral surgeons

105 Pediatric OSAS Many features are different Many features are different 2% of children 2% of children Males = Females Males = Females Peak at age 2-5 Peak at age 2-5

106 Pediatric OSAS Snoring – severity not predictive Snoring – severity not predictive Many are mouth breathers Many are mouth breathers –Adenoid facies (15% have OSAS) Excessive daytime sleepiness Excessive daytime sleepiness Obesity vs. FTT Obesity vs. FTT Increased respiratory effort Increased respiratory effort

107 Pediatric OSAS Parasomnias Parasomnias Restless sleep Restless sleep Aggressive behavior Aggressive behavior Learning disabilities Learning disabilities Enuresis Enuresis

108

109 Pediatric OSAS Impaired growth Impaired growth –Possible impairment of release or end- organ response to GH –Increased caloric effort with respiration –Difficulty with eating Cor pulmonale Cor pulmonale Associated with GERD Associated with GERD

110

111 Diagnosis History * History * Physical exam * Physical exam * The child who always snores, has restless sleep secondary to obstruction, & has apneic episodes per the parents virtually always has PSG confirmation ( Brouillette) The child who always snores, has restless sleep secondary to obstruction, & has apneic episodes per the parents virtually always has PSG confirmation ( Brouillette)

112 Polisonnografia Not cost effective Not cost effective Considerations Considerations –CNS disease –Age < 2 –Increased surgical risks –Family desires –Discordant exam

113 Polysomnogram

114 Diagnosis Lateral neck radiographs Lateral neck radiographs Chest x-rays Chest x-rays EKG EKG

115 Terapia Tonsillectomy & adenoidectomy Tonsillectomy & adenoidectomy

116 Down Syndrome OSAS = % OSAS = % Physical factors Physical factors –Small midface and cranium –Narrow nasopharynx –Large tongue –Muscular hypotonia –Obesity –Small larynx Congenital heart disease / cor pulmonale Congenital heart disease / cor pulmonale UPPP UPPP

117 Trattamento chirurgico Algorithms Algorithms –Friedman et al developed a staging system for type of operation:

118 Surgical Management Algorithms: Algorithms: –Friedman et al:

119 Surgical Management Algorithms: Algorithms: –Friedman et al: »Success = RDI<20 and RDI reduced 50% Friedman, Michael MD; Ibrahim, Hani MD; Joseph, Ninos J. BS Staging of Obstructive Sleep Apnea/Hypopnea Syndrome: A Guide to Appropriate Treatment. Laryngoscope. 114(3): , March 2004.

120

121 Algorithm Weight loss Weight loss CPAP CPAP Consider oral appliances for milder cases Consider oral appliances for milder cases

122 Conclusions Physiology of Sleep Physiology of Sleep Evaluation of Sleep Evaluation of Sleep Definition of Obstructive Sleep Apnea (OSA) Definition of Obstructive Sleep Apnea (OSA) Prevalence of OSA Prevalence of OSA Pathophysiology of OSA Pathophysiology of OSA Medical Treatment of OSA Medical Treatment of OSA Surgical Treatment of OSA Surgical Treatment of OSA


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