Management of Obstructive Sleep Apnea (PDF)
(Sprache: Englisch)
This textbook addresses the current state of the art of the diagnosis and management of snoring and obstructive sleep apnea, a problem affecting up to 40% of the population with enormous associated costs and impact. It covers every aspect of this common...
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This textbook addresses the current state of the art of the diagnosis and management of snoring and obstructive sleep apnea, a problem affecting up to 40% of the population with enormous associated costs and impact. It covers every aspect of this common complaint: the causes, initial investigation and diagnosis, and treatment options, for both adults and children. Illustrated with diagnostic imaging, diagrams of local anatomy and surgical approaches, it features contributions from experts in each of the many clinical specialties involved with the management of these patients.
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5 Medical therapy (p. 89-90)Richard B Berry
Indications for treatment
The indications for treatment of obstructive sleep apnea (OSA) have expanded since the original description of the syndrome. It is now recognized that milder forms of this disorder can be associated with daytime sleepiness and that treatment can improve symptoms and the quality of life. Over a decade ago, it was recognized that obstructive hypopnea (reductions in airflow during periods of high upper airway resistance) had the same consequences as obstructive apnea. The frequency of apneas and hypopneas are added to determine the apnea hypopnea index (AHI) as an indicator of disease severity. Subsequently, the upper airway resistance syndrome (UARS) was described in patients with daytime sleepiness but little or no apnea, hypopnea, or desaturation.
They exhibited repetitive arousals (brief awakenings) associated with episodes of increased inspiratory effort demonstrated by esophageal pressure monitoring. The sleepiness of these patients improved after treatment of the upper airway narrowing. Arousal from respiratory stimuli is related to the level of inspiratory effort and can occur in the absence of apnea or desaturation. Experimentally induced repetitive arousals have been demonstrated to cause daytime sleepiness in normal individuals in the absence of arterial oxygen desaturation. Thus, daytime sleepiness in UARS is believed to occur secondary to arousals from increased respiratory effort during periods of high upper airway resistance.
The term respiratory effort-related arousals (RERAs) has recently been widely adopted to describe events characterized by increased respiratory effort leading to arousal from sleep which do not meet criteria for apnea or hypopnea. The recognition of the importance of RERAs has led to the understanding that the AHI alone may not adequately characterize the degree of respiratory- induced sleep disturbance in
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individuals with milder OSA. Rather than being a separate syndrome, most now feel that the upper airway resistance syndrome is simply part of the spectrum moving from non-arousing snoring at the milder end to full-blown sleep apnea at the severe end.
While many will agree with this concept, how to utilize RERAs is still somewhat controversial. A consensus conference suggested that the RERA index be added to the AHI to give a true respiratory disturbance index (RDI). This assumes that RERAs and apnea/hypopneas disturb sleep equally (not proven). However, as most laboratories do not utilize esophageal pressure monitoring, precise identification of RERAs may be difficult. Recently, the use of nasal pressure or pneumotachograph monitoring of airflow rather than thermistors has been utilized to identify periods of airflow limitation (inspiratory flattening). A period of flattening followed by the abrupt return of a round airflow profile has been thought to correctly identify periods of increased upper airway resistance.
Thus, RERAs could be identified by a pattern of flow limitation followed by arousal and reversal of flow limitation. However, almost all population studies have used thermistors, so little normative information is available with this technique. Another controversial point is whether one should count flow-limited events not associated with arousals. Certainly, not all apneas and hypopneas are associated with clear-cut cortical arousal.8 Events associated only with abrupt change in respiration/heart rate/blood pressure also appear to cause daytime sleepiness.
While many will agree with this concept, how to utilize RERAs is still somewhat controversial. A consensus conference suggested that the RERA index be added to the AHI to give a true respiratory disturbance index (RDI). This assumes that RERAs and apnea/hypopneas disturb sleep equally (not proven). However, as most laboratories do not utilize esophageal pressure monitoring, precise identification of RERAs may be difficult. Recently, the use of nasal pressure or pneumotachograph monitoring of airflow rather than thermistors has been utilized to identify periods of airflow limitation (inspiratory flattening). A period of flattening followed by the abrupt return of a round airflow profile has been thought to correctly identify periods of increased upper airway resistance.
Thus, RERAs could be identified by a pattern of flow limitation followed by arousal and reversal of flow limitation. However, almost all population studies have used thermistors, so little normative information is available with this technique. Another controversial point is whether one should count flow-limited events not associated with arousals. Certainly, not all apneas and hypopneas are associated with clear-cut cortical arousal.8 Events associated only with abrupt change in respiration/heart rate/blood pressure also appear to cause daytime sleepiness.
... weniger
Bibliographische Angaben
- Autoren: Jack L Gluckman , Jonas T Johnson , Mark H Sanders
- 2001, Englisch
- Verlag: Taylor & Francis Group Plc
- ISBN-10: 0203449800
- ISBN-13: 9780203449806
Abhängig von Bildschirmgröße und eingestellter Schriftgröße kann die Seitenzahl auf Ihrem Lesegerät variieren.
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