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3 Sleep Related Breathing Disorders
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The correction of nose disorders, should be performed to improve OSA tolerance
to CPAP.
Some authors refer that daytime nasal obstruction is an independent risk factor
for OSA [44].
Because increasing nasal resistance, results in increased of negative oropharyngeal pressure during inspiration, leading to upper airway collapse.
The craniofacial morphology, the neck diameter and length, the tongue, the pharynx, and the larynx must be observed.
Features such as retrognathia, tonsillar hypertrophy, enlarged tongue or soft palate, inferiorly positioned hyoid bone, maxillary and mandibular retroposition and
decreased posterior airway space can narrow upper airway dimensions, narrow
upper airway dimensions and promote the occurrence of apneas and hypopneas during sleep.
The most common craniofacial abnormalities associated with OSA are retrognathia and a high palate arch.
Retrognathia pushes the base of the tongue backward, producing a diminished
retroglossal space. In many patients ,that are mouth breathers, since childood,the
palate wil be high.
There is a need to check the temporomandibular joint (TMJ), where a typical
click or jam can be felt on movement which might result from bruxism. I might
worsens the airway collapse.
During mouth examination, many patients present macroglossia or retroposition
of the tongue. This may inuence sleep even more in the supine position.
Malocclusion, mainly in Angle 2, leads to retroposition of the tongue.
A exible berscope is used to evaluate the nose, the nasopharynx, pharynx
walls, epiglottis, and larynx.
The obstruction is more severe, if there is a voluminous tongue.
Mallampati score or Friedman tongue position the score is done to classify the
relation of the tongue and is scored from 1 to 4.
The palatine tonsils’ size is also important, and we can score from 0 to 4, a major
factor for obstruction [16].
The enlarged or elongated uvula and palate contribute to snoring and OSA by
vibration or reduction of the retro-palatine space. Enlarged tonsils can accompany
these features.
The golden standard for pharyngeal evaluation is nose–pharynx–larynx
endoscopy.
Examination can be performed to see the anatomy, the obstruction zone and the
patient breathing pattern.
The examination should be completed in some situations with drug-induced
sleep endoscopy (DISE). Although it may increase cost and time, it allows an accurate airway examination.
OSA patients also may have dental problems, like dental caries, and teeth grinding from bruxism. This can be observed in sleep by the partner.
During the clinical examination, we must pay attention to the cranial anatomy,
the neck diameter, nose, palate, teeth, tongue, pharynx, and larynx.
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F. Fernandes
All ndings should be recorded in the clinical history or examination protocol,
for clinical evaluation and for treatment of the patient.
Finally, the clinical history and examination must be complemented with other
exams to get the precision diagnosis, for a correct treatment [20, 45].
Take-Home Message
• OSA is characterized by repetitive episodes of complete (apnea) or partial
(hypopnea) upper airway obstruction during sleep and can occur in any age
group. It often results in a reduction of blood oxygen saturation and is generally
terminated by brief arousals from sleep. These events last a minimum of 10
seconds.
• Central Sleep apnea is characterized by a crescendo-decrescendo ventilation pat-
tern- associated with central apnea–hypopnea. Heart failure is the primary cause
of CSA-CSB.
• Sleep-related hypoventilation disorder is characterized by insufcient sleep-
related ventilation, resulting in abnormally high arterial partial pressure of car-
bon dioxide (PaCO2) during sleep. There are diverse types.
• Sleep-related hypoxemia is related to signicant hypoxemia during sleep and is
secondary to a medical or neurological disorder.
• Risk factors for OSA include being male, excessive body weight, age, race,
familial and genetic predisposition, alcohol, smoking, and hormonal changes.
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F. Fernandes
Diagnosis: How Is Diagnosis Performed
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EdilsonZancanella, BrunoBernardoDuarte,
MichelBurihanCahali, andCarolinaFerrazde PaulaSoares
4.1 Clinical History
The diagnostic approach of any disease presupposes an investigation initiated by a
detailed anamnesis, pertinent physical examination, and the elaboration of differential diagnoses. The request for complementary tests aims to conrm the diagnosis,
establish the criteria of severity, and assist in clinical considerations for the therapeutic approach.
Anamnesis in sleep medicine also has its usefulness in identifying risk factors, conducting clinical research, and differential diagnoses of sleep diseases. It is well known
that, in adults, the main symptom of sleep disease is excessive daytime sleepiness.
However, it is also seen for clinical psychiatric and drug disorders [1]. To differentiate
4
E. Zancanella (*)
Discipline of Otorhinolaryngology at the Faculty of Medicine of the University of Campinas,
Campinas, Brazil
Sleep Medicine Service in the Otolaryngology Division, Hospital of Clinics,
Campinas, Brazil
B. B. Duarte
Otorhinolaryngology Service at Hospital PUC-Campinas, Campinas, Brazil
Discipline of Otorhinolaryngology at the Faculty of Medicine of the Pontical Catholic
University of Campinas, Campinas, Brazil
M. B. Cahali
Division of Sleep Medicine and Sleep Surgery, Department of Otolaryngology, Hospital das
Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil
Division of Sleep Medicine and Sleep Surgery, Department of Otolaryngology, Hospital do
Servidor Público Estadual de Sao Paulo, Sao Paulo, Brazil
C. F. de PaulaSoares
Otorhinolaryngology at Faculty Assis Gurgacz, Cascavel, Brazil
© 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_4
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if the excessive daytime sleepiness is caused by Obstructive Sleep Apnea (OSA), it is
crucial to carry out a complete clinical history and a complete sleep history, addressing
various issues, such as sleep habits and the number of hours spent per night.
To make an adequate history considering a patient’s sleep, it is essential to know
of the variability of normal sleep. If health professionals who work with sleep do
not look at this peculiarity of sleep physiology, the clinical history will become
inadequate. Sleep considered as “normal” must be interpreted through variables that
include age group, culture, ethnicity, gender, genetics, and individual [2]. Roughly
speaking, normal sleep occurs when an individual wakes up with a refreshing sleep
sensation, without excessive daytime sleepiness, on the following day. However,
this analysis is relatively supercial to a health professional who proposes to assist
individuals with sleep complaints.
It is known that there are several risk factors for the development of snoring and
OSA, so it is crucial to question them in the anamnesis of a patient with suspected
obstructive sleep [3]. The following questions should always be present in a sleep
anamnesis for these patients:
– When did the symptoms start?
– Do symptoms correlate with weight gain?
– Did symptoms start after starting new medications or alcohol use?
– Have day and night symptoms worsened with increased frequency and intensity
of snoring?
– Is there a relationship between symptoms and menopause?
– Is there a relationship with symptoms of gastroesophageal or pharyngeal–laryn-
geal reux?
– Is there a family history of nocturnal snoring or OSA?
E. Zancanella et al.
These questions are important because obesity, alcohol consumption, menopause, medications that cause muscle relaxation, and pharyngeal–laryngeal reux
are risk factors for obstructive sleep breathing [3, 4]. In addition, some studies show
a correlation between OSA and gastroesophageal reux (GERD) [5].
Excessive daytime sleepiness (EDS), as the main symptom of sleep disorders in
adults, can be evaluated objectively and subjectively. The objective instruments for
assessing EDS are the wakefulness maintenance tests (MWT) and multiple sleep
latencies (MSLT), which are tests that are difcult to logistic, and little used in clinical practice [1, 6]. The subjective instruments for evaluating EDS are sleep questionnaires. In addition to the questionnaires to assess EDS, there are others specic
to each sleep disease and assess patient’s quality of life with symptoms or after
treatment [7]. These questionnaires will be covered below.
4.1.1 Sleep Questionnaires intheApproach totheOSA
Sleep questionnaires are essential for triaging severe cases, to measuring the impacts
of sleep on individual life quality, deciding the best complementary sleep examination method to be requested, monitoring the response to the proposed treatments,
for epidemiological studies and [3].
Name:
T
In a car, while stopped for a few minutes in the traffic
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4 Diagnosis: How Is Diagnosis Performed
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4.1.1.1 Epworth Sleepiness Scale (ESS)
ESS is currently the subjective test for evaluating drowsiness most used in clinical
practice. It is relatively simple and self-administered, which quanties the risk of
the individual falling asleep in 8 specic daily life situations [7]. Most studies consider that a score lower than 10 points means the absence of excessive daytime
sleepiness. A score greater than or equal to 10 points is classied as excessive daytime sleepiness [8] (Fig.4.1).
Although widely used, its real value for patients with OSA is not yet fully established; often, even a patient with severe OSA may not present the symptom of ESS
[9]. In a study to screen professional drivers for the diagnosis of OSA, low sensitivity (53.2%) and low specicity (58.8%) were found for the diagnosis of moderate
and severe OSA [9].
The ESS is reproducible when applied at different times; a study showed no
changes in the values answered by the volunteers after 71 days of the application [10].
When the correlation between ESS and polysomnography values is checked, a
study demonstrated that the higher the AHI value, the higher the ESS [8]. Another
THE EPWORTH SLEEPINESS SCALE
oday’s date: Your age (years):
Your sex (male = M; female = F):
How likely are you to doze off or fall asleep in the following
situations, in contrast to feeling just tired? This refers to your usual
way of life in recent times. Even if you have not done some of these
things recently try to work out how they would have affected you.
Use the following scale to choose the most appropriate number for
each situation:
0 = would never doze
1 = slight chance of dozing
2 = moderate change of dozing
3 = high chance of dozing
Chance
of
dozingSituation
Sitting and reading
Watching TV
Sitting, inactive in a public place (e.g. a theater or a
meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstanc es permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
Fig. 4.1 The Epworth Sleepiness Scale. (Taken from article [8])
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study found that the ESS values were signicantly higher in severe OSA carriers
when compared with mild and moderate apneas (p<0.001). However, no statistical
difference was found in the ESS values between mild and moderate forms [11].
E. Zancanella et al.
4.1.1.2 Berlin Questionnaire
The Berlin questionnaire is a tool used to verify the probability of an individual having OSA.Unlike sleepiness scales, such as ESS, the evaluation by this questionnaire
is directly related to the OSA entity. Therefore, it is recommended to be used in
primary health units by family physicians to screen individuals who need to perform
polysomnography [3].
This questionnaire uses symptom and physical examination data to achieve the
nal score. It consists of 10 questions divided into three categories, including: (1)
The severity of snoring, including a question about OSA (items 1–5 of the questionnaire); (2) Excessive daytime sleepiness and fatigue (items 6–9); (3) Presence of
systemic arterial hypertension or obesity (item 10). In addition, the questionnaire
also includes information about age, gender, height, and weight [12].
If the individual responds positively to at least one item in two of the three categories, it is classied as high risk for OSA.The Berlin questionnaire has a sensitivity between 69 and 86%, and a specicity of 56–95%, with a positive predictive
value ranging from 77 to 96% for OSA diagnosis in patients with such suspected
disease [3]. In addition, a Korean study demonstrated a strong correlation between
positive Berlin questionnaire results and AHI [12].
In clinical practice, the Berlin questionnaire has another practical utility in consultations performed by anesthesiologists before surgical procedures. Knowing the
increased risk for anesthetic and surgical complications in patients with OSA, it is
used in preanesthetic consultations to verify the need to perform a sleep monitoring
test or prevent possible surgical and anesthetic complications in individuals with
suspected OSA.
4.1.2 STOP-BANG Questionnaire
The STOP questionnaire was developed by Chung etal. [13] to be applied by anesthesiologists in preanesthetic consultations to assess the suspected diagnosis of
OSA.It consists of four YES/NO questions about snoring, physical fatigue, witnessed sleep breathing pauses, and systemic blood pressure. It presents a sensitivity
of 79.5% and specicity of 48.6% to detect individuals with an AHI greater than 30
events per hour [13]. STOP is a mnemonic rule for the 4 English terms: Snoring,
Tiredness, Observed apneas, and blood Pressure.
To increase the sensitivity and specicity of this questionnaire, it was proposed
the addition of four factors to the STOP questionnaire: body mass index (BMI), age,
cervical circumference, and gender. Thus, the STOP-BANG questionnaire was created, which increased sensitivity to almost 100%, although specicity decreased to
37% [14]. STOP-BANG obeys the mnemonic rule of English terms, namely:
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Snoring, Tiredness, Observed apneas and blood Pressure (STOP), BMI, Age, Neck
circumference, and Gender (BANG).
This questionnaire has the advantage of being very direct and applied quickly
(usually takes about 1–2min). A score of at least three afrmative answers is used
as a cutoff point to separate individuals with a low and high risk of having OSA [9].
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4.2 Physical Examination intheDiagnosis ofOSA
The recognition of characteristics on physical examination, which are associated
with the presence and/or severity of OSA clinical suspicion, allows early and individualized intervention for the patient. Despite having been the target of studies for
more than 40years, there is no nding of high-specicity physical examination for
the diagnosis of sleep apnea [15]. However, the heterogeneity of pathophysiological
and clinical phenotypes may reason the absence of a characteristic sign. Still, several populations and case-control studies had shown anthropomorphic characteristics associated with the prevalence and severity of OSA and therapeutic success
rates. In addition, a higher prevalence of OSA in middle age and male gender are
highlighted [16].
Body mass index (BMI) is, admittedly, a measure of overweight and obesity is
strongly correlated with OSA diagnosis [3].
A BMI greater than 25kg/m2 increases the risk of apnea by 2 times, and BMI
greater than 30kg/m2 increases the risk four times [17]. Other measures related to
body adiposity, such as neck circumference (NC) and the ratio between waist and
hip, correlate with moderate OSA. Still, after correction with a model including
BMI, NC, and waist-hip ratio, only BMI and NC are risk factors [16]. A NC of at
least 40cm has a sensitivity of 61% and a specicity of 93% for OSA regardless of
gender. Several diagnostic screening questionnaires containing age, gender, BMI,
and NC showed high predictive diagnostic power [3, 12, 13, 18].
The specic physical examination of the upper airways has some relationships
with the therapy to be indicated [19–21]. Nasal alterations with associated septal
deviation and of inferior turbinate hypertrophy have a higher prevalence among
apneic rather than controlled-group individuals [19], without an association with the
severity of OSA [22]. Nasal breathing difculties are related to poor adaptation to
continuous pressure equipment (CPAP) [23] (Fig.4.2).
The oropharynx examination of the is subjectively standardized by the position
of the structures within the cavity. We classied the palatine tonsils in 5°: 0 tonsils
removed; 1 occupies less than 25% of the space between the sidewall and the midline; 2 occupies between 25 and 50% of the area between the lateral wall and the
midline; 3 occupies more than 50% and less than 75% of the space between sidewall
and midline; 4 occupies more than 75% up to 100% of the distance between the side
walls and the midline. The actual volume of tonsils is agreed with subjective classication, with a correlation between tonsillar hypertrophy and the presence of
sleep apnea, but not with severity [24]. The position of the relaxed tongue inside the
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E. Zancanella et al.
Mandible
Tonsils
Epiglottis
Adenoids
2
Trachea
Uvula
3
Soft
palate
1
6
Tongue
4
Hyoid bone
Hard
palate
8
1
7
2
6
9
4
3
5
Fig. 4.2 (a) Normal anatomy. (b) Typical anatomical changes in obstructive sleep apnoea syn-
drome (OSAS): a long soft palate and enlarged uvula (1); a reduced retroglossal pharyngeal airway
space (2); an increased distance between the hyoid bone and the mandible(3); a shorter and more
vertical mandible (4); a retro-position of the mandible, which is measured by the angle (retrognathia) (5); dental overbite or loss of normal dental occlusion (6); tonsillar hypertrophy (7); adenoid
hypertrophy (8);and macroglossia (unusual large tongue) (9). [Lévy, P. etal. (2015) Obstructive
sleep apnoea syndrome. Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.15]
ab
Fig. 4.3 Mallampati classication, Friedman adaptation et al. 1999. (a) Mallampati 1. (b)
Mallampati 2. (c) Mallampati 3. (d) Mallampati 4
mouth concerning the palate is classied as the Mallampati index (Fig. 4.3).
Alterations of the oropharynx (such as positioned retro palate, thick palate, and
uvula, medialized tonsillar pillars, and tonsillar hypertrophy, grade 3 or 4) are associated with the presence of OSA [19, 21, 25]. The association of BMI, Mallampati
classication and tonsils grade was organized into a model that predicts the OSA
risk and the success of pharyngeal surgery. In adults, uvulopalatopharyngoplasty
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