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1 Introduction
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Fig. 1.5 Healthy life path
vs. unhealthy trajectory
that shortens lifetime
11
In clinical trials, death is the event with the most signicant weight, so various
studies conducted in the eld of cardiology with antihypertensives have shown that
these drugs produce a slight decrease in blood pressure without modifying the function of the left ventricle. Since these drugs have been shown to increase survival,
they have been included in heart failure treatment guidelines, not so much because
they lower blood pressure, but because of their effect on the most potent health
outcome, death. In the eld of sleep medicine, these studies designed to evaluate the
impact of OSA treatment on mortality still need to be dened [74].
With time, we will have better knowledge of this disease, and death, even though
inevitable, will be postponed.
Take-Home Message
• Obstructive sleep apnea (OSA) is one of the most prevalent sleep disorders in the
general population, with critical pathophysiological sequelae that worsen
patients’ quality of life, leading to increased trafc accidents and a higher mor-
tality rate.
• Sleep-related disturbances have been observed in up to 15% of the current
population.
• These disorders have in common a respiratory failure during sleep, which gener-
ally leads to continuous oxygen desaturations and a series of clinical manifesta-
tions that will give rise to severe metabolic, neurological, and cardiovascular
sequelae.
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12
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1 Introduction
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Pathophysiology ofObstructive Sleep
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Apnea
SaraOp de Beeck, EliVan de Perck,
andOlivierM.Vanderveken
2.1 Introduction
Although several risk factors are known to be related to the development and severity of obstructive sleep apnea (OSA), the true underlying causes (endotypes) of
OSA remain unknown [1, 2]. OSA characterization can be based on ve different
data levels [3]:
1. Risk factors and environment: obesity, medications, allergens, alcohol. This data
level can be treated with, e.g., lifestyle modication such as weight loss or alcohol reduction.
2. Clinical features: cardiovascular disorders, age, metabolic disorders, cancer,
gender, OSA symptoms, neurocognition. This data level can be targeted using
integrated care mechanisms, risk stratication, etc.
3. Pathophysiology: upper airway anatomy, muscle responsiveness, sleep stability,
lung volume, ventilatory drive, arousal threshold. This endotypic group is the
target of the current chapter.
4. Biologic features: neurohormonal changes, inammation, brinolytic imbal-
ance, oxidative stress, endothelial dysfunction and age. These features can partly
be captured using different biomarkers such as IL-6, IL-10 and CRP.
5. Genetics and genomics: pharmacogenetics, epigenetics, RNA and DNA.
2
S. Op de Beeck (*) · E. Van de Perck · O. M. Vanderveken
Translational Neurosciences, Faculty of Medicine and Health Sciences, University of
Antwerp, Antwerp, Belgium
Department of Ear, Nose, Throat, Head and Neck Surgery, Antwerp University Hospital,
Edegem, Belgium
e-mail: sara.opdebeeck@uantwerpen.be; eli.vandeperck@student.uantwerpen.be;
olivier.vanderveken@uza.be
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. M. Baptista et al. (eds.), Obstructive Sleep Apnea,
https://doi.org/10.1007/978-3-031-35225-6_2
17
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S. Op de Beeck et al.
In clinical practice, the data levels of “clinical features” and “risk factors and
environment” are most commonly used. The current chapter will focus on the
pathophysiological data level.
OSA pathophysiology can be subdivided into anatomical and physiological
endotypic traits (Fig.2.1). The site of upper airway collapse is an anatomical trait.
The physiological traits are ventilatory control stability, pharyngeal muscle responsiveness and arousal threshold. Upper airway collapsibility can be categorized into
both categories. The relative contribution of these traits varies between patients and
determines the optimal treatment strategy for each patient [4, 5].
This chapter will discuss the measurement techniques (Fig.2.2) for each of these
traits and their inuence on treatment outcomes (Table2.2).
Fig. 2.1 Overview of
obstructive sleep apnea
(OSA) pathophysiology.
The site of upper airway
collapse is an anatomical
trait (blue), while arousal
threshold, muscle
responsiveness and
ventilatory control stability
are physiological traits
(orange). Upper airway
collapsibility can be
categorized into both
categories
Fig. 2.2 Each
pathophysiological trait
can be measured using a
gold-standard, clinical
standard or noninvasive
measurement technique
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2 Pathophysiology ofObstructive Sleep Apnea
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19
2.2 Site andPattern ofUpper Airway Collapse
The upper airway can collapse at different sites: at the level of the soft palate, tonsils, tongue base, lateral walls and/or epiglottis (Fig.2.3). To assess the site of upper
airway collapse, three different techniques can be used: natural sleep endoscopy
(gold standard), drug-induced sleep endoscopy (clinical standard) and ow shape
analysis (noninvasive measurement technique) (Fig.2.4).
Fig. 2.3 The lack of a
bony framework renders
the upper airway
susceptible to collapse,
which can occur at
different levels
Fig. 2.4 The site of upper
airway collapse can be
assessed using three
different techniques:
natural sleep endoscopy
(gold standard), druginduced sleep endoscopy
(clinical standard) and ow
pattern analysis
(noninvasive measurement
technique)
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S. Op de Beeck et al.
2.2.1 Natural andDrug-Induced Sleep Endoscopy
The gold-standard measurement technique to assess the site of upper airway collapse is natural sleep endoscopy (NSE). During overnight sleep, the upper airway is
assessed with endoscopy, and the site, pattern and degree of upper airway collapse
are determined [6, 7]. As natural sleep endoscopy is labor-intensive, challenging to
perform and unpleasant to undergo, this technique is not used in clinical practice.
Instead, drug-induced sleep endoscopy (DISE) is used to determine the site of upper
airway collapse.
During DISE, sleep is mimicked using sedative agents [8, 9]. Sedation is usually
induced using an intravenous injection of midazolam and/or propofol [8]. A exible
endoscope is inserted through the nose to visualize the upper airway (Fig. 2.5).
During the DISE procedure, heart rate and oxygen desaturation are continuously
monitored. The procedure is started in the supine position. Several maneuvers such
as a jaw thrust or lateral head rotation can be adopted to simulate therapeutic
effects [10].
Upper airway collapse is scored using a predened scoring system. Several scoring systems are currently used. A potential scoring system is shown in Fig.2.6 [11].
At each level, the degree of collapse is graded as absent, partial or complete. If a
Fig. 2.5 During druginduced sleep endoscopy,
the upper airway is
assessed during mimicked
sleep with an endoscope
inserted through the nose.
(Adapted from Vroegop
[12])
2 Pathophysiology ofObstructive Sleep Apnea
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Fig. 2.6 Scoring system used in the Antwerp University Hospital (UZA). For each level (palate,
oropharynx, tongue base, hypopharynx and epiglottis), the degree (no, partial or complete collapse) is determined. For partial and complete collapse, the direction is assessed as either anteroposterior, concentric or laterolateral. (Adapted from Verbruggen etal. [13])
Fig. 2.7 Examples of DISE scoring. From left to right: complete concentric collapse (CCCp) at
the level of the palate, complete laterolateral collapse at the level of the oropharynx, complete
anteroposterior collapse at the level of the tongue base, partial laterolateral collapse at the level of
the hypopharynx and complete anteroposterior epiglottic collapse
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partial or complete collapse is present, the direction of collapse is scored as either
anteroposterior, concentric or laterolateral. Examples of DISE scoring are shown in
Fig.2.7.
Agreement between NSE and DISE ndings, only using a bolus injection midazolam, was found to be highest at the level of the epiglottis (92%), followed by the
oropharynx lateral walls (89%), palate (77%) and tongue base (69) [14]. The collapse direction at the level of the palate and epiglottis showed an agreement of 89%
and 92%, respectively. Complete concentric collapse at the palate level (CCCp) was
seen more frequently during DISE than to NSE [14].
2.2.2 Flow Shape Analysis
Recently, noninvasive measurement techniques to determine the site of collapse
were developed using the airow signal.
Negative effort dependence (NED), dened as the percentage reduction in inspiratory ow from peak to plateau (characteristic of ow-limited breaths), is
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