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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4518_Библиотеки_им_академика_М_И_Перельмана
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9 Sleep-Disordered Breathing andObstructive Sleep Apnea
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Fig. 9.1 (a, b) Obstructive apnea
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Fig. 9.2 Central apnea
E. C. Kinberg et al.
Fig. 9.3 Mixed apnea
9 Sleep-Disordered Breathing andObstructive Sleep Apnea
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Fig. 9.4 Hypopnea
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Fig. 9.5 Alpha activity on EEG
Fig. 9.6 Theta waves
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Fig. 9.7 Sleep spindles
Fig. 9.8 K complexes
E. C. Kinberg et al.
Fig. 9.9 Delta waves
Treatment
Medical
• Conservative/behavioral modications
– Avoid alcohol, sedatives at bedtime
Sedatives can promote deep sleep, make apnea more pronounced, blunt
drive to arouse and resume breathing
9 Sleep-Disordered Breathing andObstructive Sleep Apnea
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– Weight loss
– Positional therapy: supine position, tongue falls posteriorly enhancing
obstruction
– Bariatric surgery consult for morbidly obese patients
• CPAP (continuous positive airway pressure): gold standard
– Pneumatic splint, prevents upper airway collapse, constant intraluminal pres-
sure during inspiration and expiration
– Moderate-to-severe OSA
Reduces AHI, improved subjective and objective sleep measures, quality
of life measures, decreased cardiovascular events, decreased MVAs
– Complicated by patient adherence
Compliance considered at least 4 h per night, 5 days/week
• BiPAP
– Separately adjustable lower expiratory and higher inspiratory PAP: tolerated
better by some
• APAP (Autoadjusting PAP)
– Autotitrate PAP to select an effective level of CPAP to prevent upper airway
collapse.
– Pressure changes in response to variations, snoring, impedence.
– Consistently high pressures can induce central apneas and are therefore
suboptimal.
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• Oral appliances
– Mild-to-moderate OSA
– Mobilizes mandible and base of tongue anteriorly, maintains patency of pos-
terior oropharyngeal airway
– Complicated by tooth/jaw pain, increase in salivation overnight, dry mouth
– Cost-effective but more effective for milder cases
• Medications
– Insufcient evidence. Theory: increase upper airway dilator muscle tone,
increase ventilatory drive, increase cholinergic tone during sleep versus a
decrease in percent of REM sleep, decreased airway resistance, decreased
surface tension in the upper airway
– Progesterone: respiratory stimulant
– Acetazolamide: increases hydrogen concentration in blood
– Theophylline: increases hypoxic ventilatory drive
– Protryptiline: reduce REM sleep
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E. C. Kinberg et al.
– Oxygen therapy
– Fluticasone: if allergic rhinitis component
– Montelukast (leukotriene receptor antagonist): decreased adenoid size in chil-
dren with mild OSA
– Modanil (central post alpha-adrenergic receptor): promotes alertness, used
to treat narcolepsy and idiopathic hypersomnia, adjuvant for patients on
CPAP who continue to experience excessive daytime sleepiness
– Nasal strips
Can decrease snoring, mouth breathing, and sleepiness
Can improve UPPP selection/outcomes
Surgical: determined by the site of obstruction
• Counseling possibility of multiple or staged procedures, possibility of
tracheostomy
• Nasal: can reduce CPAP pressurerequirements, rarely cures OSA
– Septoplasty
– Turbinate surgery
– Nasal valve repair
– Sinus surgery
– Adenoidectomy
• Palatal
– UPPP with or without tonsillectomy
Remove uvula, redundant tissue from the soft palate and anterior tonsillar pillars
Posterior tonsillar pillars advanced lateral-cephalad direction
Enlarge nasopharyngeal airway in anterior to posterior dimension
Risk of nasal reux temporarily, infection, change in speech
– Transpalatal advancement pharyngoplasty after UPPP if persistent OSA
Remove 1cm of the hard palate, advance the soft palate, secure to tensor
aponeurosis
– Expansion sphincteroplasty
Variation of UPPP
– Uvulopalatal ap
Variation of UPPP
Advancement ap, suture uvula, and distal soft palatal tissue upward onto
soft palate
If VPI, procedure is reversible
Contraindicated in patients with excessively thick palates or uvulas
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– Z-palatoplasty
– Laser-assisted uvulopalatoplasty (LAUP)
Primarily for snoring
CO2 laser, 2 vertical cuts in soft palate on either side of uvula, amputate
lower two-thirds to three-fourths of the uvulaScar retraction and stiffening
of the palate is achieved
– Cautery-assisted palatal stiffening (CAPSO)
Remove mucosa off midline of soft palate, induces scar tissue resulting in
stiffer palate
– Radiofrequency ablation of soft palate
Soft palate coagulation necrosis causes scarring and contraction of tissue,
shorter stiffer soft palate
Ofce-based procedure, local anesthesia
– Palate implant
Used for snoring
3 to 5 implantable rods inserted into the palate for scar formation
Risk of implant extrusion
– Injection snoreplasty
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Ofce-based procedure for snoring
Inject sclerosing agent (alcohol, sodium tetradecyl sulfate) into midline of
soft palate
The Friedman criteria were developed to predict the success of a UPPP for indi-
vidual patients (Fig.9.10)
• Stage 1: 80%
• Stage 2: 40%
• Stage 3: 8%
Palate Tonsil BMI
Stage I 1 3, 4 <40
2 3, 4 <40
Stage II 1, 2 0, 1, 2 <40
3, 4 3, 4 <40
Stage III 3 0, 1, 2 Any
4 0, 1, 2 Any
Any Any >40
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Fig. 9.10 Left modied Friedman tonsil classication. 0 surgically removed tonsils, I tonsils hidden within tonsil pillars, II tonsils extending to the pillars, III
tonsils extending 3/4 of the way to the midline, IV tonsils completely obstructed. Right modied malampatti classication. I tonsils, pillars, and soft palate are
clearly visible; II uvula, pillars, and upper pole are visible; III only part of soft palate is visible; IV soft palate is not visible
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To keep the staging simple:
1. Maximum BMI for a stage 1 or 2 patient is 40.
2. If the tonsils are size 3 or 4, the patient is stage 1.
(a) Exception: if the palate is also a 3 or 4, then its stage 2.
3. If the BMI is > 40, the patient is stage III.
• Tongue base
– Partial midline glossectomy
CO2 laser, electrocautery, plasma knife, coblation
Risk of bleeding from lingual artery, hypoglossal nerve injury, hematoma,
abscess, dysphagia, taste disturbance
– Lingualplasty
– Lingual tonsillectomy
– Radiofrequency tongue base ablation
Four lesions at circumvallate papilla to reduce tissue volume at the
tongue base
• Hypopharyngeal
– Genioglossus advancement
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More anteriorly positioned tongue with increased tension on the
genioglossus
Rectangular geniotubercle osteotomy with advancement
Risk of dental root injury, mandible fracture, hematoma
– Hyoid myotomy/suspension
Hyoid mobilized anteriorly and superiorly via attachment to the mandible
or to thyroid cartilage
Risk of numbness, infection, seroma, fracture, death
– Tongue suspension
Base of tongue to anterior oor of mouth
– Maxillomandibular advancement
Most effective surgical procedure for OSA
Enlarges pharyngeal and hypopharyngeal airway
Risk of malocclusion, relapse, nerve paresthesia, nonunion, malunion,
temporomandibular joint tenderness, infection
• Tracheotomy
– Bypass the site of upper airway obstruction
– Indications: morbid obesity, arrhythmia with apnea, severe apnea with desatu-
ration, cor pulmonale, no response to dietary modications or CPAP, chronic
alveolar hypoventilation
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Postoperative care
• There is an increased risk of airway compromise from edema, respiratory rate
alteration secondary to narcotics, possibility of bleeding and difculty with
intubation
• Repeat polysomnography at 3–4 months postoperatively
E. C. Kinberg et al.
Upper Airway Stimulation (UAS; Hypoglossal
Nerve Stimulators)
Electrical stimulators are implanted and connected to pleural sensing leads. The
stimulators activate pharyngeal dilators during the inspiratory phase of respiration.
Focused stimulation produces the most signicant clinical outcomes.
• Tongue protruders: genioglossus
– Innervated by medial branch of CNXII
• Tongue retractors: hyoglossus, styloglossus
– Innervated by lateral (C1) branch of CNXII
FDA approved indications:
• Moderate-to-severe sleep apnea (AHI range: 15–65).
• Age: 18 and older.
• Must have failed positive airway pressure treatment (CPAP, BiPAP, etc.).
– Failure criteria
AHI >15 with usage
Poor compliance of less than 4 hours per night 5 nights per week
Unwillingness to use the device
• Do not have complete concentric velar collapse.
Contraindications:
• More than 25% of the apneas are central or mixed.
• Pregnant patients, or plan to become pregnant.
• Presence of other implanted devices that may interfere with the system.
• High BMI.
Major trial:
• STAR trial (stimulation therapy for apnea reduction)
– 126 patients with moderate-severe OSA and BMI <32 underwent UAS.
– Median AHI decreased from 30 to 6, and 2/3 of participants were complete
responders.
– 86% reported excellent adherence.
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