Sleep Apnea

 

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Ylice Bridges and Irena Tran

Top Contributors - Irena Tran, Ylice Bridges, Lucinda hampton, Venugopal Pawar, Kim Jackson, 127.0.0.1, Elaine Lonnemann, Admin, WikiSysop, Adam Vallely Farrell and Lilian Ashraf  

Definition/Description

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Prevalence

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Characteristics/Clinical Presentation

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Associated Co-morbidities

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Medications

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Diagnostic Tests/Lab Tests/Lab Values

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Etiology/Causes

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Systemic Involvement

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Medical Management (current best evidence)

Healthcare practitioners have utilized a variety of methods to treat individuals with OSA due to upper airway obstruction, including: weight reduction, sleep positioning, pharmacological treatments, oral appliances (OA), and upper air reconstructive or bypass surgeries. Weight reduction via diet and exercise have shown to be beneficial, but it is not as effective when used by itself.⁴ Positional maneuvers can be used to adjust sleeping position and avoid laying in supine with the help of positional devices, such as pillows.³ The sleeping position can help increase airway size and opening.⁴ Pharmacological interventions are not the ideal method for treatment of OSA, but topical nasal corticosteroids have been shown to be useful adjuncts to other OSA interventions.⁴ 

Dental appliances that can be used for treatment are mandibular repositioning appliances (MRA) and tongue retaining devices (TRD).⁴ MRA holds the mandible in an advanced position, and the TRD holds the tongue in a forward position, both in an attempt to avoid blockage of the upper airways while sleeping.⁴ These oral appliances (OA) can be used for those with mild to moderate OSA, those who did not benefit from CPAP, and those who prefer OA.⁴ Positive airway pressure (PAP) is a common method of treatment for mild, moderate, and severe OSA.⁴ PAP provides pneumatic splinting to maintain the opening of the upper airway and effectively decreases AHI (Apnea Hypopnea Index), which is the number of apnea or hypopnea episodes per hour of sleep.^4,5 Normal AHI is less than 5 per hour.⁵ PAP can be provided in several ways: continuous (CPAP) (BPAP), and autotitrating (APAP) and via three interfaces: nasal, oral, or nasoral.⁴ 

There are also surgical interventions to improve passages via nasal, oral, oropharyngeal, nasopharyngeal, hypopharyngeal, laryngeal, and global airways.⁴ Surgeries are beneficial for those with "severe obstructing anatomy" and unsuccessful treatments with CPAPs or OAs.⁴ These methods have shown varying degrees of success, so there is no consistent best treatment plan for all, but the combination of several of these therapies have proved to be effective.⁴

There is a new treatment option, the insertion of the Hypoglossal Nerve-Stimulating System (HGNS), that is currently being studied.³ The Hypoglossal Nerve is the cranial nerve that innervates the tongue, especially the genioglossus muscle, and it plays a large role in maintaining airway patency.³ Specifically, the genioglossus "protrudes the tongue, dilates the pharynx, and mitigates airflow obstruction during sleep."³ The study focused on HGNS via submental transcutaneous stimulation, direct fine wire stimulation, and direct hypoglossal stimulation.³ Studies showed that submental transcutaneous stimulation aroused patients from sleep without clear improvements in the "airflow dynamics," but it is now being re-evaluated for the potential use of "prolonged, low-intensity transcutaneous stimulation" to increase lingual muscle tone and improve airway patency.³ In regards to the use of direct fine wire stimulation, it produced effective contractions of the genioglossus that improved pharyngeal patency as shown with and without simultaneous contractions of the lingual muslces.³ Finally, the use of direct hypoglossal stimulation via implantation of "hypoglossal cuff electrodes" around the proximal and distal nerve trunk was able to increase pharyngeal patency and decrease pharyngeal collapsibility without arousing the patients.³ The implanted cuff electrodes had to be manually applied during sleep, but with the significant findings from the studies, there are currently "efforts to develop a fully implantable therapeutic HGNS system."³

Physical Therapy Management (current best evidence)

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Differential Diagnosis

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Case Reports/ Case Studies

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Resources

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Recent Related Research (from Pubmed)

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References

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3. Epstein L, Kristo D, Strollo Jr. P, Friedman N, Malhotra A, Patil S, et al. Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults. Journal of Clinical Sleep Medication 2009; 5(3): 263-276. http://pharexmedics.com/wp-content/uploads/2015/11/sleepapnea_ebook.pdf (accessed 3 April 2016).