SNORING and OBSTRUCTIVE SLEEP APNEA

Christine Del Monte- Dayanghirang

Dynamics of Snoring

SLEEP
ACTIVE physiologic state involving dynamic changes in
neural, metabolic and cardiorespiratory functions

VENTURI EFFECT
Acceleration of airflow as a current of air enters a narrowed
passageway

Why do we sleep?
Functions of Sleep

Repair and restoration

Energy conservation

Information consolidation
Bodily Changes During Sleep

Metabolism generally slows

Decrease heart rate and blood pressure

Core body temperature falls

Release of growth hormones

Increase of melatonin production

STAGES of SLEEP
1. The complex process of sleep involves multiple stages
that make up a SLEEP CYCLE
2. 90-110 min (adults)
45min ( 1 yo)
3. REM Rapid Eye Movement sleep
4. nonREM or N sleep
Stages of sleep
N sleep

First stage of sleep

HR, BP and Breathing drop to levels lower than when

awake

75% of total sleep time ( 50% in children)

3 stages - N1, N2 N3

Ave 4-6 cycles a night

Stage N1

Very brief, initial phase of sleep and after

awakenings during the night

Lasts less than 10 min

Brain waves slow down ( from alpha to theta waves)

5% of TST

Eyes displays slow rolling movements, muscles begin

to relax
Stage N2

Lasts 30-60min : makes up 50% of TST

High amplitude, slow-wave brain activity (delta)

Eyes stop moving, muscles more relax

Stage N3

Slow wave sleep or deep sleep

Inc delta waves

Lasts 20-40min : 20% of TST

May disappear towards later sleep cycles

Parasomnias are common

R sleep (REM)

Active sleep eyes move rapidly, muscles twitch,

HR/BP/ RR fluctuate

Most dreams happen

Lasts a few min to an hour ( towards the end of the

sleep)

Makes up 25% of TST ( 50% IN CHILDREN)

SNORING
SNORING is a sleep related breathing disorder

BERNOULLIS PRINCIPLE
A partial vacuum or negative pressure exists at the outer
edges of a current of flowing air or water
The faster the airflow, the greater the negative pressure
SNORING

Noise produced during sleep caused by PARTIAL

obstruction of airflow

In a narrowed airway ( nasal, pharynx), inc negative

pressure builds up in the pharyngeal area

When this
pressure
exceeds the
tension
provided by
the airway
dilator
muscles,
the airway
collapses

The fast
moving column of air that meets resistance can induce
vibration at various points along the airway - snoring.

Snoring therefore represents obstructed breathing

31% males and 19% females are habitual snorers

Snoring is part of a spectrum of sleep related breathing

disorder

Spectrum of SDB
ASYMPTOMATIC SNORER
Inc upper airway resistance
UPPER AIRWAY RESISTANCE
SYNDROME
Inc arousals, lack of significant O2
desaturation
OBSTRUCTIVE SLEEP APNEA SYNDROME
Apnea:Hypopnea , hypoxemia
Daytime consequences
OBESITY HYPOVENTILATION SYNDROME
Awake hypoventilation
SNORING AND OBSTRUCTIVE SLEEP APNEA
Snoring is the hallmark of OSA

Prevalence
HABITUAL
SNORING
SDB
GENDER

MAJOR
CAUSE

ADULT
9-25%
2-8%
MALE:FEMAL
E
2-4:1
obesity

Sleep Medicine
CHILD
112%
1-4%
MALE:FEMAL
E
1:1
Enlarged
Adenoids and
tonsils

AdenoTonsillar Hypertrophy

Obstructive Sleep Apnea

OSA is a disorder of breathing during sleep
characterized by prolonged partial upper airway obstruction
(hypopnea) and/or intermittent complete obstruction (apnea)
that disrupts normal ventilation during sleep and normal
sleep patterns
CPG, AAP, 2002

Repetitive collapse of upper airway during sleep lead to

brief and frequent arousals
Fragmented sleep leads to excessive daytime sleepiness

Signs & Symptoms of OSA

Kryger et al,Principles and Practice of Sleep Medicine, 4 thed
2005

Excessive daytime sleepiness

Loud habitual snoring

Gasping or breathing pauses in sleep

Dry mouth, headache on waking

Signs & Symptoms of OSA

Non-restful sleep

Nocturia

Depression

Physically restless sleep

Hyperactivity and attention-deficit disorders in

children

BMI > 30

Neck circumference > 40cm

Large tongue

Retrognathia

Adenotonsillar hypertrophy for children

FRIEDMAN PALATE POSITION

Why should we be concerned of OSA?

Morbidity of OSA in Adults

Hypertension

Ischemic heart disease

Impaired glucose tolerance ; Type II diabetes

Stroke

Increased risk of fatal traffic accident

Mechanisms for CVS risk of OSA

OSA
Intermediar
y
Mechanism
Hypoxemia
Sympathetic
activation
Reoxygenation
Endothelial
Dysfunction
Hypercapnia
Vascular
oxidative
stress
Intrathoracic
Inc
pressure
coagulation
changes
Arousals
Metabolic
dysregulatio
n

Cardiovascula
r Risk
Hypertension
CHF
Cardiac
arrhythmias
Cardiac
Ischemia
Cerebrovascul
ar disease

JAMA 2003
Metabolic Syndrome

Disruption of Ghrelin and Leptin production

Obesity

Insulin Resistance
METABOLIC SYNDROME & OSA
The presence of OSA had a sixfold increase in the odds of
metabolic syndrome compared with those without OSA
Redline, S. et. Al., Am J RespirCrit Care Med 2007:176:401-408

Insulin Resistance

Among 2000 subjects subjected to 2-hour OGTT

Insulin resistance is higher in AHI>15

AHI <5
9.35 % impaired OGTT

AHI >15
15% impaired OGTT
SLEEP Heart Health Study 2004
The Little Snorer
Morbidity of OSA in children
Failure to thrive
Developmental delay
Neurocognitive abnormalities
Behavioral disorders
Enuresis
Systemic hypertension
Pulmonary hypertension
Cor pulmonale
Death
Metabolic Syndrome & OSA
OSA (in the absence of obesity) is not an important risk
factor for MS in young children
Tauman R. et.al., Pediatrics 2005:116;e66-e77
Kaditis, AG, et.al., Pediatric Pulmonology 2005;40:515-523

However, similar to adults, when obesity and OSA are

present in children, the risk for MS is increased
De la Eva RC., et.al., J Pediatric 2002:140:654-659
Waters KA, et.el., Am J RespiCrit Care Med 2006:174:455-466

ADHD

56.8% of children with ADHD had OSA, 10.25% had

PLMD. Evaluation of Sleep disorders should be
considered before starting drug treatment for ADHD

Results from a systematic review suggest that children

with ADHD have higher daytime sleepiness, more
movements in sleep, and higher AHI compared with
controls

Huang, YS, J SLEEP Res,2004

Cortese, S., SLEEP 2006

ADHD and OSA: A Treatment Outcome Study

Huang, YS, et.al., SLEEP med, 2007; jan. 8 (1);18-30
66 ADHD 2 groups: I- Tx with MPH
II Tx with T&A

The surgical group had an ADHD total score of 21.16+/7.13 on the ADHD rating scale (ADHD-RS) post-surgery
compared to 31.52+/-7.01 pre-surgery (p=0.0001), and
the inattention and hyperactivity subscales were also
significantly lower (p=0.0001).

results were significantly different between surgically and

MPH-treated groups (ADHD-RS p=0.007). The surgical
group also had a TOVA ADHD score lower than -1.8 and
close to those obtained in normal controls.
ENURESIS

1/3 of children with OSA

Due to
1. Decrease arousal response
2. Impaired aerodynamics (Inc. intra-abdominal
pressure inc. bladder pressure)
3. Altered secretion of hormone that regulate fluid
balance ( atrial natriuretic peptide, ADH)

PRO-INFLAMMATORY STRESS

OSA has increased inflammatory cytokines and markers

associated with atherosclerosis

Inc C-reactive protein

Inc. IL-6, IL-18

Larkin, et. Al Circulation 2005 111(15)

Neurobehavioral Implications of Habitual Snoring In children

OBrien, LM., et.al, PEDIATRICS July 2004,114(1); 44-99

To investigate if Primary Snoring (PS) is associated with

serious morbidity
81 PS and 37 Normal (5-19yo)
PS children were found to perform worse on measures
related to attention, social problems, and
anxious/depressive symptoms. In addition, although
within the normal range, both overall cognitive abilities
and certain language and visuospatial functions were
significantly lower for the PS group than for the control
subject

Diagnosis
Polysomnography is the gold standard
American Academy of Pediatrics CPG 2007
Diagnostics for OSA

Questionnaire
Neck xray
Audio
recording &
questionnaire
Video
recording &
Questionnaire

Sensitivity
81%
90%
92%

Specificity
51%
50%
29%

94%

68%

American Academy of Pediatrics CPG for OSA, 2002

All children should be screened for snoring.

As part of routine health care maintenance for all

children, pediatricians should ask whether the patient
snores. An affirmative answer should be followed by a
more
detailed
evaluation.
(Evidence
for
this
recommendation is good, and the strength of the
recommendation is strong.)

Complex, high-risk patients should be referred to a

specialist. (Evidence is good that these children are at
increased surgical risk and require more complex
management; the strength of the recommendation is
strong.)

Patients with cardiorespiratory failure cannot await

elective evaluation. It is expected that these patients will
be in an intensive care setting and will be treated by a
specialist; thus, these patients are not covered in this
practice guideline.
OSA, CPG, AAP

Adenotonsillectomy is the first line of treatment for most

children. CPAP is an option for those who are not
candidates for surgery or do not respond to surgery.
(Evidence for and strength of the recommendation are
strong.)

High-risk patients should be monitored as inpatients

postoperatively. (Evidence that these patients are at high
risk of postoperative complications is strong. Strength of
the recommendation is strong.)

Patients should be reevaluated postoperatively to

determine whether additional treatment is required. All
patients should undergo clinical reevaluation. High-risk

patients should undergo objective testing. (Evidence is

good, strength of the recommendation is strong.)
TREATMENT

Tonsillectomy & Adenoidectomy

Positive Airway Pressure

Medication (?)
PAP

PAP EFFECTIVENESS
Reduction in AHI from 27 to 3/hour
Improvement in O2 saturation from 77 to 89%
Marcus, CL.,et.al., Pediatrics 2006;117e422-e451

However, compliance with PAP is poor.

Updates in Surgical Treatment

Hallower, Ann et.al.,CHEST,2007;132:2030-2041

T&A
Tongue base surgeries
Rapid Maxillary advancement
Nasal Surgeries
Septal deviation
Hypertrophied turbinates
Polyps

Important Points To Remember

SNORING is not normal. It is a sleep-related breathing

disorder

Snoring is the hallmark of OSA

OSA refers to the blockage of the upper airway during

sleep that causes one to stop breathing periodically
Risk Factors for OSA
Obesity
Large neck size ( >40cm)
Male gender
Upper airway structural disorders ( large tongue, large tonsils)
Symptoms causing Inc. Risk of OSA
Nighttime Symptoms

Loud snoring

Choking or gasping

Witnessed apneas

Excessive movement

Excessive sweating

Inc. freq of urination

Feeling groggy first thing in the morning upon

waking

Daytime

Is there a role for medical treatment?

Oral Leukotriene Modifiers
Goldbart, AD, et.al.,AJRCCM 2005;172(3):364-370

Children aged 2-10yo with mild OSA

24 subjects received oral montelukast daily for 16 weeks
16 controls

Oral Leukotrienes

Symptoms
Excessive sleepiness and fatigue
Dryness of mouth on awakening
Morning Headache
Inattention, forgetfulness and lack of concentration

Conditions that warrant evaluation by a sleep specialist

Hypertension

Obesity

Diabetes

Large neck circumference

Congestive Heart Failure

Stroke

Recurrent atrial fibrillation

Coronary artery disease

Cardiovascular disease
Treatment Options for OSA

Lose weight

Avoid alcohol and sedating medications

Stop smoking

Avoid supine position during sleep

Exercise regularly

Treat nasal allergies

Goldbart, AD, et.al.,AJRCCM 2005;172(3):364-370

Montelukast induced significant reductions

Adenoid/NP significantly decreased from 0.76
0.03 to 0.56 0.03 (p < 0.001)
PSG picture generally improved (AHI, Apnea index)
increased LT1-R and LT2-R protein expression and
higher levels of LTB4 and LTC4/D4/E4 emerged in
children with obstructive sleep apnea vs control

Intranasal Steroid & Oral Leukotriene Modifiers

Kheirandish, L. et al. Pediatrics 2006;117 e61-e66

Nasal steroid/Montelukast group

Improvement in AHI (3.9/H to 0.3/H)
Inc. SpO2 (87.3% to 92.5%)
Decreased Arousal index (4.6/H to 0.8/H)

Medications

Generally, no medications will prevent your airway

from closing

In children, when the airway obstruction is mainly

due to enlarged adenoids, medication may play a role
in the treatment
Mask Treatment

CPAP Continous Positive Airway Pressure

Oral Appliance

Mandibular advancement device

Tongue-retaining device
Surgery

Soft palate surgery

Nasal surgery

Maxillomandibular surgery

Bariatric surgery
Tracheostomy

O - Has anyone OBSERVED you to stop breathing

during your sleep?
P - Do you have or are you being treated for high
blood PRESSURE?

Pediatric Airway Course

S.T.O.P

S - Do you SNORE loudly?

T - Do you often feel TIRED , fatigued or sleepy

during the daytime?

Learning, Memory, Mood

sleep on it

During Sleep
Memory integration
Processing