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Sleep Apnea: Missing Link to Many Common Diseases

Oct 10 | 6:00 AM

It needs lot of understanding and expertise to diagnose Obstructive Sleep Apnea and even more comprehension of individual patients condition to manage it effectively. There are a lot of debates surrounding diagnostic measures like polysomnography but what is the gold standard? The management is a holistic approach. Lets look at the fundamentals of the condition and the numerous conservative and modern management strategies.

[Music] um a very good morning to all our viewers i am i am dr naveda from netflix and on behalf of netflix we welcome you all on the sunday morning um today we have with us uh dr rahul sharma who is the head of department of pulmonary critical care and sleep medicine at your target hospital noida and today's topic is one that needs a lot of expertise to diagnose and manage um so let's hear from sir itself over to you sir i'll start the presentation for you thank you and good morning everyone i think it is a good platform to discuss these things and i am very very glad that so many people are logging in probably because they all understand the importance of objective steel paper the disease which is very very ignored and probably the common link to many of the diseases that most of us are suffering from or most of our patients are suffering from probably the symptoms are so awake that we are not able to understand that the pay patient is also suffering from obstructive sleep apnea the common notion is people who snores have obstructive sleep apnea but i'll be discussing in like my slides in couple of minutes that what all you need to see other than snoring in your patient and to start with i will say that not all snorers have sleep apneas so there are n number of other things and inside that you need to take when you are comprehensively evaluating and treating your patient so i'll start with sleep only so sleep is a supercharger for all of us and to our body and we know that this is a natural phenomena that because most part of our body needs rest we believe that heart is continuously working brain is continuously working all of the part of the body is working continuously but they need some kind of rest to rejuvenate all the important aspects of their functioning so and and if you calculate one third of our life we sleep and this is very very important people believe that if they'll sleep less they will do more productivity but it is not like that it is the other way around because your productivity depends on the sound mind and sound body function so it is for you it is necessary for your productivity of two third part of your life that your one third part of life is very very sound and the sad part is although we have lots of gadgets whether it is a apple watch fitbit watch by which we are monitoring our heart rate saturation sleep but somehow none of us know that what to do with this if you are seeing that i am sleeping in that particular time in that particular day what is the next day so we don't know truly that how to interpret that sleep or the gadgets that we are using and the other important thing is that you cannot outsource your sleep it is not possible that somebody else will sleep for you so you need to have a sound sleep to supercharge your body brain for the supercharged activities in the daytime and it is a complex state sleep is not very simple that you close your eyes and you goes to sleep and everything is fine it is a complex state in medical term it has four stages state and one and two and three which is called the lightest sleep and the rem sleep which is called rapid eye movement which is called the deeper sleep and it is basically required a lot of physiological changes behavioral process compared to wakefulness so there are different stages of sleep that we need to understand why i am talking about sleep before sleep apnea because we need to understand if our sleep is not good then the productivity of life goes down irrespective of whether you have any disease or not just think of a day when in the night you have a very poor sleep or you are not able to sleep because of some work the other day goes very very bad and this is happening to the people who are not having quality sleep and sleep apnea is one of the search disorder which is being completely ignored right so why sleep is so essential because it does a lot of work while you are sleeping your body is doing a lot of work for your next day activity it is doing tissue repairing work distribution of the body in terms of new energy decoding of the various activities which has been stored in your brain it is a primary healer most of the time when we are sick we feel sleepy so this is again a natural phenomena to give more support to your immune system and it acts as a healing process when you are sleeping so even in the normal day-to-day life when you are sleeping you are truly repairing your body for the next day so it restore and rejuvenate your body naturally and it is necessary to wake up fresh full of energy in the morning you need to have a very good quality sleep so sleep although is looks very very simple that you go and sleep and come back but it has a lot of lot of importance in your day-to-day activities and success so it is a physiological necessary all the temporary but reversible cyclic process so when you have poor sleep quality literature has suggested that if your quality keeps on you know poor every day every day you are having some kind of sleep disturbances or some kind of sleep which is not sound then it is linked with new onset diabetes you are at a risk of development of diabetes your risk of development of hype tension there are risk of development of stroke four times more than the normal persons depression is very very common you have early alzheimer's and dementia and it starts year before you even think about this so many young patients are developing such kind of disease and sleep apnea is probably one of the missing link that we are never think of when we are treating our patient to diabetes hypotension stroke depression dementia alzheimer's so on and so forth why why why this is a missing link why we are not able to understand or you know diagnose this disease properly because the symptoms are so weight like if you talk about nights time symptoms most of us are not aware of about nighttime symptoms like we do have snoring and our bad partner usually complains and we never realize that we are actually snoring so there are witness sports in the breathing that is actually called apnea apnea means absent breathing so during sleep apnea there are times when you do not breathe and it can vary from seconds to minutes and you are not aware about this and suddenly what happened that you just wake up in severe cases you feel breathless your brain wake up you feel breathless and then again you come back to the normal sleep so this these events keeps on repeating and you somehow believe that this is the normal part and parcel of my sleep so you have restless sleep you have frequent visit to the bathrooms these are all night time symptoms which we are most of the time very very unaware like frequent visit to the bathroom people correlated with their diabetes high for water intake prosthetic diseases and other diseases so and and so forth when you talk about daytime symptoms probably we all are burdened or we we all are upset with the work we are doing so we believe that we are working very very hard and truly you are working very very hard but these symptoms should not be correlated with this few people have morning headaches most of the people have daytime lethargy rather than sleepiness sleepiness is a late very very late symptom in the severe disease but you feel uneasy you don't want to work in the morning you don't want to go to the to your workplace you feel very very uneasy lethargic sometimes sleepy you have poor concentration irritability falling asleep during routine activities or you want that i should take a small nap and all these features can be very well correlated with the work or hard work that you are doing and we all believe that this is probably because we are overwhelmed but this is not the symptom of overall people who are working hard also they have a good amount of energy you know activity and that is probably the key of your work if you work with this scenario where you don't want to work you have irritability poor concentration daytime sleepiness then you are probably not working you are just dragging you are just dragging your work and the efficiency goes down very very low so the work that you probably completed in four hours or six hours that will take longer time so rather than working you say that this is a dragging when you have all these symptoms and you because the work is compulsory then you are doing it but you are doing it by dragging towards your work so this is very very important that we must realize all these symptoms and correlate it with the apnea so what is actually sleep apnea sleep apnea is a chronic condition the first picture with a grain tick mark shows the normal breathing pattern when we breathe the air goes inside our lung it comes back and this is the normal cycle but what happens in sleep apnea that because of weight or other factors the air will compromise once the air may compromise you start snoring that snoring can be audible or non-organic most of the female patients the snoring is very very mild or even non-arduino but this compromised airways create a lot of problem and the one thing that we have learned in this covered era is oxygen saturation so what happens that during this blockage there is a slight reduction in your oxygen that reduction in the oxygen gives a signal to the brain that something wrong is happening to my body the brain wakes up they just restore the activity of upper airway where there is a blockage you just briefly wake up which is probably at subconscious level and then the the restoration of the breath starts it again the the and these as you go into the breath the sleep again then this this obstruction appears again so this is a continuous cycle of obstruction and awakening of the brain obstruction and awakening of the brain and this creates all the physiological interruption in the body leading to fragmented and non-restorative sleep so ultimately what it is doing it is doing a poor sleep quality in you the other important thing when i said this to my patient they believe that by checking the normal pulse oximeter that you have at home you can detect these uh these hypoxia episodes or low saturation obviously but that is not true because these uh pulse oximeter that we have it is very very power quality and very very crude parameters what we want to see in your sleep is it has a very very accurate measurements and the machine costs 100 times more than what we are seeing with our pulse oximeter so pulse oximeter is not the way of seeing your low oxygen during sleep but the other point is if you are seeing that your sleep is you have sleep related low oxygen even in your pulse oximeter then it shows that you definitely have some kind of problem or hypoxia or obstruction or sleep apnea so it is the other way around that you cannot rule it out but you definitely rule it in that you have some problem if your pulse oximeter is giving you a positive signal in terms of low oxygen level and this is what actually happens this is the physiology that once you sleep your airway muscle relax the snoring me starts airway blocks leads to breathing stoppage in the breathing oxygen in the blood depleted heart rate slows down body struggle for air then the brain arouses and arousal of brain does not correlate with correlated with your arousal so you might be you might be sleeping but your brain arouses send the signal again restore at everything and then you go to sleep again and then these cycles repeat so this cycle repeats 10 to 100 times in your body and creating all the restorative these the poor sleep quality in this so what does it do so if you have these happening episode in the night it causes sleep fragmentations and hypoxia which leads to cardiovascular complications because every time your oxygen is going down the stress is going on your heart and it creates a kind of inflammation in the body which probably affect all the organ system of the body it causes daytime symptoms to you and ultimately leads to mobility and mortality in you and these are the diseases so if your snoring or apnea goes unnoticed then you have this risk of hypertension stroke heart failure coronary artery disease cardiac rhythm problems type 2 diabetes gastroesophageal reflux nocturnal angina hypothyroidism and neurocognitive behavior and the vice versa also and if you have these diseases which is poorly controlled or controlled on very high medication then also you can link these diseases to your sleep apnea so if you have sleep apnea these diseases will be poorly controlled what do you mean by public control like for hypertension if you are taking more than three drugs or three drugs for your hypertension this is called skin this is called resistance hypertension so resistance hypertension if you are having you have a very high chances of having sleep apnea same goes for your diabetes if you're using high doses of medication and your diabetes is not well controlled probably you have developed some kind of insulin resistance inside your body and that creates poor response to your medication and you have uncontrolled diabetes which again leads to so many other complications so so this is very very important that you see these diseases in two aspects people are who are newly developing these diseases you look for sleep apnea and people who already have these diseases are and are controlled on high medication or are not controlled then you look for sleep apnea and the other important thing is that it increases the risk of motor vehicle accident because of your poor response time lethargy drowsiness more than 10 times so it is not a hazard for you it is a social hazard so in u.s this is the victim that every pilot truck driver any sort of driver they screen them for sleep apnea before they give them the license because it is putting not only you at risk but the society also is at risk if your sleep apnea is not built and this is the data from us that 7 out of 10 adults with type 2 diabetes have sleep apnea so 70 of the diabetics are suffering from sleep apnea which goes unnoticed in most of the power same goes for your hypertension so in hypertension also if you see 30 to 40 percent of the patient has significant obstructive sleep apnea and 70 of the type 2 diabetes patients also have sleep apnea and all these things work in tandems you are in a spiral where your diabetes will not control till you control your sleep apnea sleep apnea is not controlled till you control your diabetes so this this is the way that it is a very complex scenario so whenever we see such patient we should think about sleep apnea in these patients and these are the list of diseases that can happen to you if you are not being diagnosed with your sleep apnea you are ignoring the symptoms of your sleep apnea stroke dementia poor sleep non-alcoholic fatty liver disease type 2 diabetes obesity stress on the heart grd sexual dysfunction frequent nighttime urination if you have all these symptoms or any of these symptoms probably this is the time when you screen yourself for uh sleep apnea and this is again a very very important fact that we have learned here see so many patients who died in the night and we say that this is because of heart attack patient has heart attack in the night and patient is not wake up in the morning but this is this is again in the deputy journal of any gm where this study was published and they they find out that most of the people who are dying in the early morning hours 12 a.m to 6 a.m although they are dying with cardiac disease but the most common underlying disease in these patients are uncorrected objectively because most of the cardiac death per se you don't have sleep apneas from 6 a.m to 12 so this is again a very very important study and uh you know inside it gives that that the risk is even fatal when you are ignoring your sleep apnea and cbrt of your sleep apnea also correlate with the certain kind of that i will be coming to the severity what it is and the most sad reality of osa is that majority of the patients even the doctors are unaware of this disease even i'm talking about united states where eighty percent of moderate to severe oversight cases are still undiagnosed and even if you diagnose this disease people do not correlate their symptoms to sleep apnea and 90 of these patients believe that they never had this problem so it is a problem which you need to search actively rather than wait for the symptoms to appear patient comes to you and then you diagnose so that is why it is called the common link between so many diseases so if you have any kind of disease probably you need to think of this in india we don't have such data because we hardly see or think about this so the other important thing is snoring as soon as i talk to anyone about sleep apnea they correlate with snoring although snoring is a very very frustrating thing that if somebody or your partner is snoring then it is probably we all have experience in some part of our life that how difficult or how irritating it is but it is not the only thing although it is distracting especially for the partner but it is not uncommon and the data suggests that about half of all the people who have known at some point of time in their life and snoring can occur roughly in 57 of the adult male and 40 percent of the women so is the snoring bad for me so this is the common question then you need to decide between primary snorers and sleep apnea primary snorers are those who do not have symptoms of sleep apnea or whom oxygen is not dipping down in the night during sleep apnea and they are usually infrequent snorers that once in a while they are snoring but not routinely or daily they are snoring so the patient who has who are snoring regularly he is at the high risk of sleep apnea these are the patient who should be evaluated and diagnosed for sleep apnea condition in these patients and this i have already explained that all these symptoms can be there if you are having sleep apnea so this is these are some of the indication which has been given by indian guidelines and this is again a surprising thing that we have indian guidelines from ministry of health and welfare over sleep apnea which is called innova guidelines so the primary risk factor is weight gain or overweight next circumference more than 17 or 4. 43.2 centimeter in nail men and 16 inches in female a is more than 40 male gender structural factor related to your craniofacial profile ethnicity in ethnicity asian population has more tendency to develop sleep apnea as compared to uh american population at less obesity so our central obesity is the key factor here rather than overall obesity and the family history of sleep happening is also important so how do you diagnose when we look into these patients again this is a you know important thing that physical examination appears normal appears normally means that you see a fat guy and you ignored everything because of their obesity that he has a double chin he has thick neck short neck obesity the malampathy score is high nasal polyps are there in last on six in last but we all see such patient on a daily basis but never think of the diagnosing sleep apnea in these patients but these are some of the risk factors which goes as obesity and we believe that everything is normal because in the classical teaching what we see we see chest heart lung and brain and all these functions behave properly when these patients are awake so these are the guidelines i was talking about these are called nosa guidelines and these guidelines has given some recommendation that who should be screened for when we are talking about uh sleep apnea american college of pediatrics recommends that all the children adolescent who snores regularly should be screened for obstructive sleep apnea and these are the guidelines patient with snoring daytime sleepiness obesity hypertension anyone uh possibly cognitive heart failure uh congestive heart failure diabetes coronary artery disease stroke metabolic syndrome nocturnal dystrophy again any one of the this disease if you are having you need to uh screen for screen operation for objective sleep apnea drivers eyelid railway drivers heavy machinery worker who are at high risk or at social hazard irrespective of presence or absence of comorbidities should be strongly evaluated for sleep apnea so how do you diagnose sleep apnea so we have talked about clinical symptoms which are very very vague we have talked about physical examination which often goes unnoticed then we look into the risk factor which again risk factor then then there are polysomnography which is the whole standard and i will be talking about this so these are some of this you know screening questionnaire that has been given if you feel that your patient might have sleep apnea then you need to screen operation with effort sleepiness code which is the universally adapted score and by doing this what you are seeing you are seeing the chances of your patient being dosed off in particular situation they have given eight situation you score them on the basis of that how likely your patient is going to sleep or dose off during that particular situation you score them if the score is more than 10 then there are high likely chances of [Music] the patient having sleep apnea other is a very very important and very very simple score that is stop bank questionnaire so it stands for snoring tiredness in the morning time if you have observed that your breathing is stopped the partner need to answer this question if you have hypertension if your bmi is more than 35 is more than 50 next circumference more than 40 centimeter so if you have any three items out of uh eight items that is being given there then you might have sleep apnea again these screening questionnaire are just for screening and these are not 100 effective we do see patient who has some kind of underlying medical condition which is like heart failure coronary artery disease diabetes and these are the patients who are at very very high likelihood of having sleep apnea so if you still feel that your patient has some factor but it is not properly fitting into your skin questionnaire you can confirm all these patients with gold standard which is called polysomnography it is so in this covey era we have realized the importance of portable monitoring at home also and the gold standard is type 1 attended full montage polysomnography which has to be done in sleep laboratories and there are multiple things that we monitor that is again non-invasively we look into your easy or brain activity we look into your eye or ocular activity we look into your nasal flows that whether you are having any kind of obstruction or not we look into the position sensor thoracic weight abdominal well for your respiratory pattern pulse oximeter for your oxygenation limb emg movement ecg and so on and so forth and by doing so so we have simplified studies which can be done at home but it is not for the patient who has any kind of commodity it is for simply obese person who has no other commodity and you in your screening questionnaire found that the person has a very high likelihood of having sleep but if your patient has comorbidities your patient has vague symptoms and you believe that your patient is not fitting into a very high probability of sleep apnea still you think that your patient has sleep apnea these are the patient who needs in hospital or in sleep laboratory monitoring of your sleep for the accurate assessment of your sleep sleep apnea because once the patient is going at home the number of channels that we are going to use is less because the patient has to to handle all these by by his own so this is very very important if you have high likelihood when you send the patient for home sleep monitoring if the height likelihood is not there or the patient has any kind of comorbidities then this is very very important that you do our in-lab monitoring and this is the kind of you know bizarre bizarre lines that comes up and you need to stays your patients sleep then you need to look into the ecg snoring and then stays apneas hypotenuse and everything and it is a tedious task it takes somewhere around two to three hours to decipher this whole night polysomnography and this is mind you what you are seeing on the screen is just a 30 second graph so you need to see this graph every 30 second for the whole night and then decide that what is the exact problem in my patient and once you did this these are some of the scientific definition which has been given like apneas hypopneas and by doing calculating that you calculate apnea hypopnea index and this is the number on the basis of which you decide whether your patient is normal they have mild objective sleep apnea moderate sleep abstractive severe sleep apnea on the basis of this number five to 15 15 to 30 and more than 30 managing osa is again a challenge because this most important thing you know these people is to lose weight so if you have mild which is defined by you know apnea hypopnea index of 5 to 15 then probably you can lose your weight by doing exercise you should avoid alcohol you should quit smoking you should avoid any kind of seriously because 25 of these people feel that they are not sleeping properly and they take sleeping pill which further aggravates your sleep apnea the consequences of this increases faster so this is again very very important if you have sleep apnea do not use sleeping pills or do not prescribe your patient are sleeping right when you lose weight then then this is a important thing that one person changing your weight decreases your ahi or apnea hypopnea index by three percent so people believe that why not do a bariatric surgery and get rid of my weight very fast but the study has shown that irrespective of if you are doing a bariatric surgery the chances of you being getting the weight is high and you cannot completely cure your obstructive sleep apnea component even after doing bariatric surgery so bariatric surgery is not being recommended for the treatment of sleep apnea because of obesity but yes if you have other commodities you are morbidly obese not able to walk endocrine disorders then probably bariatric surgeries are being recommended but not for the sole purpose of treating your obstructive sleep apnea the other problem is if you have moderate to severe disease then you cannot lose your weight by yourself why because there is a hormone which produces in our body in sleep apnea that is called grayling and it increases the weight of your body body so you gain weight because of your poor sleep despite you have low appetite and we all keep on tracking your thyroid profile and thyroid profile keeps on coming normally you are not eating anything and still you are gaining weight so this weight gain is a spiral because of some endocrine changes in your body because of sleep apnea you are not able to decrease it till the time you are treating your obstructive sleep apnea so the therapy for the patient who has moderate to severe sleep apnea is very very simple that is called cpap machine what this machine does it creates a kind of airway strength inside your throat so that this episode that i was talking about in the early part of the mechanism of sleep apnea does not happen at all so you are completely safe and breathing properly without any obstruction or apnea during the sleep and this causes so so this this basically uh improves the sleep apnea symptoms that you are having in the daytime and also decreases the risk factor that you you you are prone to because of your uncontrolled sleep apnea so this is the gold standard treatment till now worldwide for the management of sleep apnea the problem comes because of compliance and complication as soon as you say your patient that i'll be [Music] asking you to put a small mask on your nose and then you sleep they believe that they can't do this but believe me you give these machines to trial on them and they'll come and say thank you to you because most of these people once that sleep is optimized because of the airway strengthening that we are doing uh during our uh cpap therapy for their sleep apnea they sleep very very comfortably on all the obstruction nighttime disturbance frequent awakening brain activity all these things settled so they feel very very comfortable but once you show this machine initially to these patients they are very very reluctant to use it so here comes the rule of counseling and importance of make them understand the disease and their future consequences despite being that once the patients start using machine the response come immediately on the next morning and it keeps on improving the day more the day you are using this machine but the adherence is less and simply the one reason that you feel comfortable after some days and the residual effect persists for two to three days so so once they they are up and active and their sleep apnea component is well controlled they try not to use that machine and that is the common tendency and they feel that everything is going fine but over a period of time these things sets in again and the risk increases further so you need to counsel your patient on every visit and this is a dynamic process of treating your patient's disease that is it is not a one-time job that you have diagnosed absolutely sleep apnea given them a cpap and that's it and you forgot your patient because every time the patient is coming you need to read into the data that has come with this machine once once you are using that is called data download every time patient needs to [Music] patient has to instructed about coming up with that data download you need to see whether the patient is using that machine whether it is effective how much is the ahi whether the patient the fit is proper or patient has any kind of complication most of the initial hiccups comes in the first week when the patient is getting adjusted to that machine they have some kind of leak they are not able to you know put it properly they have nasal dryness nasal congestion air leaks or if they are putting it very very high then they might have nasal aberration so you need to counsel your patient and the first few days are very very important once the patient realize the importance and see the effect of this machine and feel that it is very very comfortable that they they show a good adherence so this is very very important that we should counsel our patient during the therapy time also and the compliance can be improved by improving confidence of your patient by giving them optimal titration this is again an important point that when we do sleep study we feel that our patient has sleep apnea and we advise them a auto cpap machine which is the most horrible thing you are doing to your patient because auto machine does not mean that it will do anything everything automatically you need to titrate this machine also with the optimal titration give a window and then you prescribe this machine to operation what happened that you give an auto cpa machine patient also believe that everything will be automatically corrected and somehow the machine does not disturb the purpose that we want from our patient and patient lose confidence in the machine and you and then that patient is very very you know very very uncompliant to the machine because they say that that machine is not working for me but the problem was that you have not properly titrated it is like titrating your glasses titrating your specs then you have vision problem until unless you titrate your vision properly the patient is not going to use that spectacle so this is the same way with this you need to titrate adequately and that will boost up the confidence of your patient that yes the machine is benefiting me i am having good response in the morning then you need to choose the correct machine for the patient the patient is very very important when you are using this machine because machine starts from cpap auto cpap bypass so you need to actually titrate your patient and look into the demand that what is required for your patient and then the correct machine should be provided to your patient correct mass is again equally important because if the mask is not fitting well patient will have leak leak through the mouth leak through the nose abrasions eye irritations all these things also leads to uncompliance in your patient humidification is also important in five to seven percent of the patient where they feel the dryness of the mouth and humidification is now nowadays is mandatory in most of the machine and it is coming up with the machine the routine follow-up and a dynamic process that i was talking about is again very very important when you are treating your patient on a long term base basis education and understanding of the machine and disease gives a lot of confidence and compliance to your patient that is again not to be forgotten in these patients although there are surgical methods also available in terms of nasal airway surgeries but most of these methods are for pediatric population and people who are not getting good response with the cpap and it has a lesser efficacy as compared to the cpap machine which is a gold standard so all these things are still under trial and very few people's needs this and this is again a more complicated process where you need to undergo a surgery under general anesthesia so cpap is always a gold standard and all these therapies has also been evaluated against cpap and found inferior to cpap as far as the management of sleep apnea is concerned these are some non-surgical management and we do see such kind of devices even uh you know new devices on facebook social media but most of these devices has very poor efficacy just understand that if you are not putting something over your nose how can you put something inside your mouth and sleep so this is this is very very important and it is mainly for the patients who have this sleep apnea because of poorer poor or dental or orthodontics problems so this is this is uh basically for them not for everyone or every patients of sleep apnea this is one of my doctor who has you know who who was obese since the time he was studying in mbbs he was sweating the or he always had these blood parameters which are absolutely normal he met two accidents because of excessive sleepiness he snores like hell when we were in you know hostels uh he met two accident and we also got to know this when i completed my sleep medicine course and then we advised them that you should use cpap and this was the message that he given me after that that i do not snore now the machine is doing wonderful job for me my wife sleeps better as the cpap machine is less noisy than my previous snoring i see other falling asleep at the moon and while i'm awake and fresh i do not have to wake up in the night to urinate i am not depressed no longer use medication even though my work studio is just as busy as the time of my car accident i can drive without being tired so these these are the things that we do not realize until and unless we start using these therapies so so so so this was the last line that how i wonder how my life could have been different if i my osa had been diagnosed earlier so most of the people are suffering this disease on their day-to-day retreat and they believe that this is the part in life of their routine that their life will always be groggy sleepy lethargy but it is not the case if you diagnose your patient properly on time probably you can give the maximum benefit and more productivity to your to your patients so these are the puzzles which i was talking about the missing link so we treat our patient for hypertension we treat our patients for stroke snoring diabetes but we never you know join these puzzles and come to a conclusion that sleep apnea could be one of the aggravating factor or the soul factor for all these diseases to our patient and when we we you know diagnose these patients probably this patient has a better outcome so sleep apnea is basically a wake-up call where the disease is very very common the consequences are very very dangerous easily recognizable and probably hundred percent treatable but you need enough sleep both in quality and quantity to get benefit of sleep magic that is what the last line is plain and simple the science is clear that the sleep is essential for physical mental emotional and your brain so you should not miss this sleep apnea whether you are suffering from any disease or not so you should always be very very careful so this is what the puzzle is when the puzzle is complete the picture is very very clear that the only thing is we need to understand that when it becomes a medical matter when do patients begin to see these symptoms as a reason to visit their physician which is almost never happens and when do physicians start thinking of osa probably this is the message that i want to give that we should at least start you know thinking in terms of diagnosing or at least you know at least thinking or suspecting sleep apnea to our patients who are not doing good in their life thank you very much for your patience if you have any question i'll be very very happy to answer thank you so much for this presentation was uh really amazing and it's such a common condition that usually goes under diagnosed um so there are a few questions and so we have a question from dr anirudh his question is what's the pathophysiology behind the development of hypertension in case of chronic sleep apnea so the the thing is very very simple when you talk into the pathophysiology of hypertension people believe that it is because of inflammatory state in the body that is happening and this inflammation is being aggravated by sleep apnea person when you are having sleep apnea you are having hypoxia which is stressing your heart creating more oxygen antioxidants in your body and creating a kind of inflammation which increases the risk of hypertension diabetes and all these things in the patient i hope that answers your question um sorry uh his question is um so can you please talk a little bit more about uh titration and how do we do that so when you diagnose your patient in as sleep apnea during your sleep study there are two ways to titrate one is called split night study where in the single night you do the titration in the first half you diagnose your patient has sleep apnea and the second half you start titrating your patient how do you titrate you put a sleep machine and it has a sensor which is attached to the monitor that on which we are you know observing the patient's apneas and other parameters you slowly increase the titration every 15 to 20 minutes by one centimeter and look into the apneas hypopneas rares as well as snoring which is happening to your patient once these things settle as you increase the pressure that is the time when you decide that this is the pressure on which all the apneas are gone hypopneas are gone snoring is minimal and there is no respiratory arousal in your patient and on the basis of that you decide that what is the appropriate pressure for your patient you keep that pressure for at least 30 minutes to your patient to see that there is no further apneas and on the basis of that the next day report is generated deciding about that what is the severity of sleep apnea and what is the best pressure and machine that you can utilize to your patient thank you sir what is the management of sleep apnea after anesthesia after anesthesia so so this is again a very very important questions when we are talk we are looking into the post anesthesia complication in our patients most of these patients are obese and they have sleep apnea so during surgery most of these surgeries are being done under general anesthesia where you have incubated your patient so the you have already bypassed the obstructive part of your disease but when you are making your patient being recovered from that anesthesia probably putting a small cpap or bipap during the recovery phase gives a good support to the patient for these sleep apnea related symptoms because otherwise the chances of these patients being retaining the co2 and going into the ventilator again is very very high so supporting these patients during recovery phase in cpap is a good way to improve the sleep sleep apnea symptoms post anesthesia in these patients thank you so much can you please elaborate on surgical modalities for the treatment of sleep apnea so surgical modalities are very very important as far as the pediatric sleep apnea is there because in pediatrics when your child is snoring and the symptoms are completely altogether different they have uh you know they are hyperactive not sleeping snoring tossing and turning on the bed very small sleep still very very awake but they are very very poor concentrated they don't concentrate on a single activity and on the basis of that you decide that your patient your kid has some kind of sleep related problem and most of the time the sleep related problem in pediatric population is because of adrenal tonsils so the surgery is very very important in that particular kid they have obstruction because of adenoids and tonsils and the surgery has a very good and very effective role there we did a research on this and we found that almost every patient is getting completely cured of sleep apnea in that particular age group but if you delay this surgery in the pediatric population let's say most of us believe that our adenoids will go by the age of nine year or ten years our tonsils are very very supportive for us but in patients who are having sleep apnea [Music] who have sleep apnea because of this problem in them they are rather doing harm because our brain developed by the age of 10 11 years our facial profile changes if we are keep on snoring during the night time most of these kids are mouth breathers they have their nasal congestions their [Music] so all these changes also put these kids for the future risk of sleep apnea so early modalities of sleep apnea management in pediatric population are surgical so that is adenotoxic other than this uvalo palatoplasty tongue reduction jaw advancement these are for the patient who have very severe disease and we are not able to control this disease with our cpap then probably they go for the surgery but the results of surgery is not more than fifty percent in these patients uh there's dr dipali shah who's asked are there any effects of breathing exercises in um osa so breathing exercises always is helping keep you healthy but you have sleep apnea if converted to weight reduction probably that will help otherwise in how much time does the chronic disease start showing improvement after using cpap for moderate or severe sleep apnea so as far as sleep apnea symptoms are concerned the effect you will see on the next day if you sleep in the night suddenly the symptoms goes from the next day over all response takes minimum three weeks to three months to show response but again it is a kind of thing that you are every day preventing that obstructive apnea in your patient so unless you lose weight and do your lifestyle modification the symptoms will not completely cure and you will have to use that machine over a long period of time so along with the use of machine it is very very important that you change your lifestyle reduce your weight so that you can get rid of this machine also in future is there any medication available for osa [Music] so as such no medication is giving true benefit in osa the medications are available for the patients who have excessive sleepiness not because of fossil but because of narcolepsy for oyster the best treatment is weight reduction followed by cpap thank you you will have tried few medication but it is not that effective right now rule of dentist in intra-oral diagnosis and management of osa so intra-oral diagnosis as i showed in one of my slides that is called friedman scoring or modified malamparty scoring if you feel that the score is high you really need to see that whether your patient has sleep apnea or not or not the other important things male occlusion or male dentition which is again a problem in pediatric population if you keep their sleep apnea untreated they have overcrowding of teeth over jet most of the time we see that that kids are having these braces in the early part of their life to make them back but these are some of the the markers in your oro dental evaluation where you can see that if there is an overjet hydrogenation high treatment scoring overcrowding of teeth then you can suspect flip happening in these patients after how much time can we reassess the patient after we have prescribed a cpap and is there any chance that the patient might not require cpap if he continues to use it properly and if the patient continues his lifestyle modification like weight loss and etc absolutely i think this is a very important question when you are prescribing your patient a cpap machine i usually ask my patient to come after five days with all kind of difficulties facing with that machine the first and foremost thing is that the patient should understand their disease then the machine what the machine is doing for them and if they'll not use this machine what will happen then they are very very receptive to use this machine and then you look into the problems whether they have you know leakage in the machine that is causing eye irritation dryness of the mouth proper fit is not there some kind of other difficulties so so all these things usually for the first few follow-ups you need to do it frequently so that the patient is very very confident and adaptive to that machine and after that usually you require three months follow-up of these patients once they start using these machines and or if the patient has any kind of symptoms which reappears in the in the in in between then they can concert you the other important thing is if they'll do a lifestyle modification definitely the cpap the sleep apnea improves but as i said that it is very very easy to say to reduce weight but it is very very difficult to truly reduce weight so if they are very very compliant reduce their weight most of the time this is related to their weight and most of the time these things goes away can osa be resolved on its own or a cpap always needed so it can resolve by its own if you reduce your weight and the corrective measures can be taken in terms of in pediatric population here's what i found uh adrenal tonsils in adult population most of the time it is the nasal obstruction and obesity so if you if you can modify these factors most of the time the things improves to the back to the normal level because nobody is coming up or born with the overseas all these things are acquired disease because of our lifestyle lifestyle so if we modify our lifestyle go back to the previous state probably all these things will go away doctor he says his father is a patient of chronic osa and he complains of heating of the mask due to which he has a headache so what would be the further course of action so heating of the mask is most of the time because of the old machines that that was there the other important thing is if you are not using humidifier in your machine then the air sometimes comes as dry and it looks more heated so the machine service is required is the one thing and humidification will also help in cooling down the temperature of your machine we have one more question are the systemic signs of osa same in children as in adults no it is totally different so i i did my you know i did my thesis on sleep apnea and pediatric population so they have all together different signs they are not sleepy in the day they are not showing any sign of lethargy most of the time they are very very hyperactive they have poor concentration they have poor scores in the schools but they looks very very smarter during the day so this is what you need to see and you need to look into the patient's perspective you need to ask the patient most of them has mouth breathing that is an important thing and again that is a late sign so if you feel like a kid is having not regaining weight this is again a very very important because most of the energy during the night goes away in bypassing that airway obstruction in these kids so if they're not gaining weight poor concentration hyperactivity all these things can be a sign of sleep apnea and again the scoring is different in these patients because what i have showed you that if you have more than five events in the night then you comes into the category of five mild sleep apnea for kids it is only one they should not have even a single apnea episode in the night so even if they are having single episode that's this is that the pediatric kid is having sleep apnea does also time matter as far as circadian rhythms are concerned so is sleeping from 3 a.m to 10 a.m okay 3 a.m to 10 a.m so that that is basically a delay state syndrome which most of us are suffering from because of the lifestyle and most of most of us are sleeping late in the night so this is the biological clock which you have shifted slightly upward right so per se this biological clock doesn't harm you but the circadian rhythm leads to so many things in that you are you know you are having so many primary things that can appear because of this that delays fit syndrome can leads to sleep apnea in the later part of your life the natural process so we should sleep in the proper time but yes people depending on their work they are sleeping in you know in different time zone and that creates problem only when you are shifting your time zone so if you keep on doing the same thing in the same time zone probably that is the new life for you you should not gain weight and other risk factors should be avoided so the question was is it possible for a dentist to treat sleep apnea i think you are asking because this can create sleep apnea absolutely the research is going on and people who have retrograde maxillary and the job problems or the dedication problem which is basically obstructing their sleep probably there becomes the role of dentist and there is a lot of research going on oral appliances dental appliances which probably in future gives you the better result than cpap but right now cpap is the gold standard only where you believe that correcting a particular part of your face will give you more airway where it is worth what would be the frequency of pressure titration for cpap so pressure digestion only required once you have done this in the sleep study with titration it is only required when your patient gain more than 10 of their weight or lose more than 10 percent of their weight so that is how pressure titration is required whether you need to decrease the pressure or increase the patient depending on the patient's symptoms as well as the weight gain and weight loss thank you so much sir i'm sure all our viewers have all the daughters here have understood and will apply what you have taught today and it'll be really beneficial for them and we look to uh we hope to have you again on our platform soon thank you so much i think this is a very very important and ignored disease and when we see such patients they are in a very very miserable and bad shape so early diagnosis at the physician and for every doctor who is seeing any kind of specialty and if they can link this disease to to their patient probably the benefit is much much more than once the patient reaches to us in the tertiary center thank you very much everyone for their patient 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dr. Rahul Sharma

Dr. Rahul Sharma

Senior Consultant & Head | Pulmonology, Sleep & Critical Care Medicine | Yatharth Super Specialty Hospitals, Noida

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dr. Rahul Sharma

Dr. Rahul Sharma

Senior Consultant & Head | Pulmonology, Sleep...

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