ADVICE ON SNORING AND SLEEP APNEA
| BUILDING A SNORING AND SLEEP APNEA PRACTICE: SELF-PROMOTION, LIAISONS, AND PRACTICE
POINTERS —Mitchell L. Petusevsky, MD, Chairman, Division of Medicine, Co-Director of Sleep Laboratory, and Staff
Physician in Pulmonary Medicine, Cleveland Clinic Florida, Naples
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| Introduction: snoring—occasional problem in 40% to 45% of people, habitual problem in ≈25%; more common among
men, overweight individuals, and elderly; sleep apnea—undiagnosed in >80% of individuals; more common in men,
postmenopausal women, and overweight individuals; may be present in ≤9% of people by 70 yr of age
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| Self-promotion in community: educate physicians in local hospitals about snoring and sleep-related disease; talk to community,
senior citizen, and service groups; participate in health fairs and screening programs
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| Necessary liaisons: excellent sources of referral include—allergists (some patients with allergic disease may require surgery to
manage snoring problems); bariatric surgeons (before weight-loss surgery, many patients may require preoperative testing and
treatment for snoring and sleep apnea); cardiologists (40%-50% of patients who present with refractory heart failure or hypertension
have sleep apnea); dietitians can help identify patients requiring management of sleep apnea; endocrinologists encounter
many patients who are overweight, snore, and have sleep disorders; neurologists (correlation between Parkinson’s disease,
cerebrovascular accident, and development of sleep disorders); urologists (strong correlation between sleep apnea and some
forms of erectile dysfunction); family practitioners and internal medicine specialists—should be educated about questions
that can identify 70% of patients with simple sleep apnea; appropriate questions determine whether patient snores, awakens
choking or gasping, feels tired during day, or feels refreshed in morning; gastroenterologists—knowledgeable about correlation
between reflux disease and sleep apnea; intravenous (IV) conscious sedation for endoscopy considered good stress test
for sleep apnea; key colleagues include—dentists, ie, many patients who refuse to wear masks will consider using oral appliance;
medical equipment companies with representatives who treat patients properly and provide overnight oximetry; pulmonologists
who cooperate in management of noncompliant patients or surgical candidates; psychiatrists or sleep psychologists
who help manage individuals with insomnia or other problems that cannot be handled by otolaryngologist; weight reduction
specialists
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| Obtain database using: interview of patient and patient’s bed partner; Epworth Sleepiness Scale; physical examination
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| Become affiliated with good sleep laboratory: when evaluating laboratory, determine—whether staff includes experienced
and properly registered polysomnographic technicians; waiting time required to obtain sleep study; accessibility of all
types of masks; policy for performing split-night studies; financing plans accepted; appropriateness of location and appearance;
whether physician can interpret study data
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| Convince patients to “buy into” illness: successful management requires—lifelong commitment by patient; convincing patient
to wear mask; good management tools include—setting up appointments to personally discuss baseline and continuous
positive airway pressure (CPAP) data; scheduling follow-up visits; instituting CPAP compliance and support
programs; developing shared medical visit program; selecting experienced staff member to serve as patient contact
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| Medical therapy: primary treatment for snoring and sleep apnea; stressing role of medical therapy—improves credibility;
promotes better selection of surgical candidates; improves surgical success rates; options for managing snoring include—
weight reduction; positional therapy; avoidance of alcohol and central nervous system (CNS) depressants; nasal corticosteroids
when appropriate; options for sleep apnea include—same techniques used for snoring; CPAP
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| BUILDING A SNORING AND SLEEP APNEA PRACTICE: THE TOP 10 LIST FOR SUCCESS —David Greene, MD,
Head of Otolaryngology, Cleveland Clinic Florida, Naples
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| Sleep apnea: surgery complements medical therapy; partnership between otolaryngologist and pulmonologist crucial for
providing total care; factors enhancing practice opportunities—prevalence of snoring and sleep apnea; exponential increase
in clinical knowledge; need to increase awareness that sleep disordered breathing (SDB) presents important health
issue
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| Top 10 tips for practice success: screen all patients for snoring and excessive daytime sleepiness; make screening part of intake
form and review of systems; before proceeding with pharyngeal surgery or somnoplasty, obtain sleep studies routinely to diagnose
and stage sleep apnea (many patients sicker than you think; if in doubt, obtain computerized overnight oximetry before
sending patient to sleep laboratory); provide screenings at health fairs; maximize medical therapy; work to identify candidates
for bariatric surgery who require treatment for obstructive sleep apnea (OSA); develop relationships with sleep centers and
pulmonologists; treat nasal airway obstruction to convert CPAP failures to CPAP responders; work with hospital to locate airway
observation rooms close to nursing station (provide continuous monitoring of O2 saturation); learn about SDB—
multifactorial problem; associated with multiple risks; never guarantee cure; CPAP remains primary therapy; current management
focuses more on improving aerodynamics and not on ablation
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| WORK-UP AND POLYSOMNOGRAPHY —Dr. Petusevsky
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| Snoring: potentially serious medical problem; exacerbated by—consuming alcohol before going to sleep; deep sleep; any
factor producing bulky tissue or anatomic variance; nasal obstruction; point—when first made aware of snoring problem,
individual should seek help from specialist
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 | Patient evaluation: determine whether—patient awakens tired and experiences excessive daytime sleepiness and fatigue;
bed partner has observed changes in patient’s personality; point—if answers to all questions negative, patient has benign
snoring; polysomnography (PSG) indicated when—answer to any interview questions yes; results on Epworth
Sleepiness Scale abnormal; physical examination detects anatomic obstruction; patient demonstrates increased activity
of sympathetic nervous system
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| Sleep apnea: potentially life-threatening; airway obstruction occurs repeatedly throughout night; with each episode, O2 levels
fall and heart and brain deprived of O2 ; patient—awakens with loud snore; becomes excessively tired and sleepy during
day; faces increased risk for heart attack, stroke, seizure, fatal rhythm disturbance, sudden death, and motor vehicle accident
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| Basic work-up: look for evidence of snoring, gasping, choking, and daytime sleepiness; assess characteristics of witnessed
apnea; determine whether—patient awakens in morning with dry mouth and headache; uses CNS depressants; physical
examination includes—determining body weight and body mass index (BMI); determining neck size (>17.5-in neck
correlates with sleep apnea); examination of upper airway; patient history should include information provided by—
bed partner; test data from previous management of sleep disorder
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| CPAP intolerance: if patient initially CPAP tolerant, determine whether—mask defective; CPAP equipment outmoded and
defective; patient gained or lost weight since initial study; if patient was never CPAP tolerant, determine whether—mask,
pressure, or humidity problems exist; patient had inadequate titration (major reason for noncompliance with CPAP); or requires
special mask that does not become displaced with change in patient’s position; noncompliant patients—may be
helped by newer, more comfortable masks and techniques
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| Polysomnography (PSG): indicated for—diagnosing sleep-related breathing disorders; performing CPAP titration and preoperative
evaluation of SDB; evaluating deterioration in initially favorable response to surgery or use of dental appliances;
investigating marked weight gain or loss; evaluating narcolepsy (PSG should be followed by multiple sleep latency testing)
or testing for rapid eye movement (REM) sleep–related behavior disorders; assessing patients suspected of having nocturnal
seizures or periodic limb movements of sleep; detecting SDB in individual with persistent insomnia; components of
evaluation—electroencephalography (EEG); electro-oculography (EOG) to measure eye movements and to detect REM
sleep; electrocardiography (ECG); electromyography (EMG) to detect periodic limb movements or to diagnose REM
sleep–related behavior disorder; pulse oximetry; microphone to record snoring; video camera to record body position; nasal
pressure and airflow monitoring; measurement of chest and abdominal movement to identify attempts at breathing
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| Sleep staging: wakefulness indicated by alpha waves and closed eyes; light sleep—stage 1 (lasts ≤10 min; breathing slow and
regular; heartbeat regular; blood pressure falls; blood flow to brain decreases; body movement minimal; patients easily
awakened; EEG demonstrates low-voltage theta rhythm; combination of theta waves and slow, rolling eye movement considered
characteristic); stage 2 (brain waves slow; sleep spindles and K complexes develop; eye movement declines; patient
less easily awakened; pulse and body temperature drop; apnea absent; airflow at nose and movement of chest and abdomen
remain rhythmic and regular); delta sleep (slow-wave, stages 3 and 4 sleep)—deep sleep; brain waves slow; patient difficult
to awaken; once awakened, patient exhibits “sleep drunkenness”; eye movement or other muscle activity absent; most likely
stage where sleep terrors, sleepwalking, or enuresis occur; REM sleep—breathing rapid, shallow, and irregular; eyes demonstrate
jerking movement; limb muscles protectively paralyzed; dreams frequently frightening and violent; dream state begins
at 90 to 120 min and continues every 90 min thereafter in progressively longer fashion until patient awakens in morning;
caveat—because obstruction occurs most often during REM sleep, adults must wear CPAP mask all night, every night
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| Pathology: REM sleep with arousal in patient with central apnea—findings include sawtooth waves, atonia, no airflow or
pressure through nose, and no movement of chest or abdomen (if patient had obstructive apnea, there would be no pressure
or flow in nose, with movement of abdomen and chest); as apnea ends, changes in EEG pattern indicate arousal; patient
in stage-2 sleep with classic OSA and arousal—characteristic findings include absence of snoring and air flow at
nose, marked movement of chest and abdomen, and termination of apnea with burst of snoring and arousal on EEG;
CPAP eliminates both apnea and snoring
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| Split-night study: patient monitored during first half of night, and CPAP titration done during second half; provides information
on patterns of activity occurring through night; monitors patient’s response to CPAP; detects other problems that
require treatment, eg, periodic jerking limb movements with arousal and restless leg syndrome
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| Detailed treatment report: essential for reimbursement; documents—clinical indication; study procedure; sleep parameters
during baseline and CPAP titration; body positions; respiratory events; pressures and titrations used during CPAP; codes for
CPAP orientation and fitting of mask; oximetry and telemetry data; number of arousals; limb movement data; final assessment
includes—diagnosis; conclusions from CPAP titration; treatment recommendations; disclaimers concerning impaired driving,
weight reduction, and avoiding alcohol and CNS depressants
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| NOSE AND NASAL SURGERY IN OBSTRUCTIVE SLEEP APNEA —Dr. Greene
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| Nose: tip of respiratory tree; provides thermal regulation; acts as resistor that matches impedance of upper and lower airways, affects
length of expiration, and provides positive end expiratory pressure (PEEP) for lungs; regulates pulmonary function, ie, too
much or too little resistance impairs lung function; increased nasal resistance linked to SDB via—altered airflow dynamics;
stimulation of neural reflexes; genetic predisposition; points—nasal breathing provides better lung function than oral breathing;
nasal obstruction linked to worsening sleep apnea; oral breathing—develops once critical airway resistance reached;
mandible and tongue drop posteriorly and cause obstruction
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| Patient evaluation: indications for nasal surgery in SDB—nasal obstruction during day; chronic mouth breathing at night;
anatomic obstruction; impaired CPAP tolerance; diagnostic work-up includes—anterior rhinoscopy; Cottle maneuver;
lifting nasal tip to detect profound “tiptosis”; nasal endoscopy during nasolaryngoscopy; computed tomography (CT) and
cephalometrics to lesser degree; sinus disease—common among patients with SDB; area of concern because many of
these people do not complain about obstruction caused by sinus problem; obstruction can be caused by—intranasal tumors;
nasal valves; septum; turbinates; mucosa; nasal cycle and reflexes; allergic rhinitis; sinusitis; polyposis
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| Integrated approach to nasal surgery for SDB: when patient with nasal airway obstruction fails initial CPAP—perform
nasal surgery; repeat CPAP to determine patient’s response to therapy; caveat—some patients never tolerate CPAP
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| Surgical candidates “for cure” of OSA who cannot tolerate CPAP: require 2-stage approach; stage 1 requires—
uvulopalatopharyngoplasty (UPPP) with combination of tonsillectomy and radiofrequency tongue base ablation; patient
continues on nasal CPAP; stage 2—deals with nasal obstruction; implemented once patient heals from initial surgery;
includes conservative turbinoplasty when necessary; performed concomitantly with second radiofrequency
tongue ablation; if patient has undergone preoperative septoplasty, perform tongue ablation in office; postoperative
care—perform symptomatic assessment ≈2 mo after surgery; repeat PSG at ≈3 mo; if patient fails repeat PSG—
consider hyoid or genioglossus advancement; in some cases, more tongue base ablation can salvage situation
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| Nasal surgery tips: maximize medical therapy; do not eliminate ability of nose to act as resistor; avoid aggressive surgery
(4-turbinate surgery makes patient nasal cripple); if sleep apnea significant, maximize CPAP first; consider staging nasal
and pharyngeal surgery—severity of apnea and medical status key concerns; if procedures performed concomitantly, nasal
packing worsens SDB and prevents patient from using CPAP; point—maintain 24-hr monitoring of O2 saturation
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| Maintain close relationship with sleep clinic: some patients may have marked sinusitis, but have adapted to problem and
become asymptomatic; CPAP and sleep evaluation may bring otherwise unrecognized problems to light
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Educational Objectives
| The goal of this program is to educate the listener about the management of sleep apnea and snoring. After hearing and assimilating
this program, the clinician will be better able to:
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| 1. Develop a successful community practice for treating snoring and sleep apnea.
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| 2. Implement 10 recommendations for successfully managing patients who present with sleep apnea and snoring.
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| 3. Determine the appropriate use of polysomnography in the workup of patients with sleep apnea and snoring.
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| 4. Establish the correlation between nasal obstruction and sleep disordered breathing (SDB).
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| 5. Develop an integrated approach to nasal surgery for SDB.
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Discussed on This Program
Midazolam HCl [Versed]
Oxycodone HCl [OxyContin, others]
Propofol [Diprivan]
Suggested Reading
Boyd EL, Philpot EE: Obstructive sleep apnea, nasal congestion, and snoring: their systemic effects and impact on quality
of life. Allergy Asthma Prac 25:43, 2004; Chesson AL et al: The indications for polysomnography and related procedures.
Sleep 20:423, 1997; Fairbanks DNF, Woodson BT, Mickelson SA. Snoring and Obstructive Sleep Apnea. 3rd ed. Lippincott
Williams & Wilkins, 2003; Heinzer RC et al: Lung volume and continuous positive airway pressure requirements in obstructive
sleep apnea. Am J Respir Crit Care Med 172:114, 2005; Johns MW: Daytime sleepiness, snoring, and obstructive
sleep apnea. The Epworth Sleepiness Scale. Chest 103:30, 1993; Kim ST et al: Polysomnographic effects of nasal surgery
for snoring and obstructive sleep apnea. Acta Otolaryngol 124:297, 2004; Littner M: Polysomnography in the diagnosis of
the obstructive sleep apnea-hypopnea syndrome. Chest 118:286, 2000; Rey M et al: Relation between polysomnography
parameters and apnea index in obstructive sleep apnea syndrome. Respiration 61:14, 1994.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. The following has been disclosed:
Dr. Greene is affiliated with ArthroCare Corporation, Aventis, GlaxoSmithKline, and Schering.
Drs. Greene and Petusevsky gave their scientific presentations at the 4th Annual Cleveland Clinic Otolaryngology Symposium
2005, presented March 17 to 19, 2005, in Naples, Florida, by Cleveland Clinic Florida. The Audio-Digest
Foundation thanks the speakers and the Cleveland Clinic Florida for their cooperation in the production of this program.
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