Interdisiplinary Approach to Diagnosis and Treatment of Sleep Related Breathing Disorders

Lecture given 10/9/2025

what are the 6 categories of sleep disorders?

insomnia, sleep related breathing disorders, central disorders of hypersomnolence, circadian rhythm sleep wake disorders, parasomnias (sleep talking, sleep walking, enuresis), sleep related movement disorders (restless legs, sleep bruxism)

what are some circadian rhythm sleep wake disorders?

delayed sleep phase, shift work sleep disorders, jet lag

sleep related breathing disorders

nonspecific, umbrella term encompassing a spectrum of respiratory alterations during sleep

sleep disordered breathing

a continuum of snorers to severe OSA

caused by a decrease in upper airway size and patency during sleep

hypercapnia and hypoxemia

AHI

number of sleep apneas and hypopneas per hour

apnea

reduction in airflow by >90% for >= 10 seconds, desaturation and arousals are not considered

hypopnea

reduction in airflow by >30% from baseline, reduction in SaO2 by >=3% or arousal, episode lasts at least 10 seconds

respiratory event related arousals (RERA)

subthreshold (<3%) respiratory event which fragments sleep (causes an arousal)

10 second episode of increasing effort or nasal pressure waveform flattening causing arousal (when it doesn’t meet criteria for apnea or hypopnea)

RDI

number of respiratory events per hour (apneas, hypopneas, and RERAs)

apnea index

number of apneas per hour of sleep

what is a normal AHI count for adults?

<5/hour

what is a mild OSA AHI count for adults?

5-15/hour

what is a moderate OSA AHI count for adults?

15-30/hour

what is a severe OSA AHI count for adults?

>30/hour

what affects OSA prevalence?

age, gender, BMI

after what age does gender not affect OSA prevalence?

50

after what age does BMI not affect OSA prevalence?

60

are males or females more suscptible to OSA?

males

what are the health consequences of sleep disordered breathing?

mortality, cardiovascular, neurocognitive, endocrine, excessive daytime sleepiness, quality of life impairment, behavioral and psychosocial impairment

what is considered apnea in pediatrics?

pause in respiration for two breaths vs 10 seconds

what is considered hypopnea in pediatrics?

reduction in airflow by 30% for two respiratory cycles accompanied by reduction of O2 saturation by 3% or arousal

what is an OSA AHI count for pediatrics?

one or more per hour of sleep

what affects the prevalence of OSA in pediatrics?

age (2-8), gender (boys), race/ethnicity (african americans), preterm birth (3-5x more likely)

why are children 2-8 at the highest risk of OSA?

largest lymphoid tissue size before they begin to shrink

what are night-time signs of OSA that can be observed in children?

snoring, observed apneas, sleep terrors, sleep bruxism, enuresis, sleep walking, excessive sweating, restless leg syndrome, abnormal sleeping position, insufficient sleep

what are day-time signs of OSA that can be observed in children?

ADHD, worsening of adolescence circadian phase delay, mood, increased appetite, headaches, growth concerns

how should OSA be diagnosed in children?

screening (history, questionnaires, clinical examination) and polysomnography or referral

BEARS questionnaire for pediatrics OSA

bedtime problems

excessive day time sleepiness

awakenings during night

regularity and duration of sleep

sleep disordered breathing

is the pediatric sleep questionnaire a good method of diagnosis?

yes, it has a sensitivity of 0.85 and specificity of 0.87

STOP BANG

questionnaire for adults to determine risk of OSA

epworth sleepiness scale

quick in-office test, assesses the propensity to sleep in 8 situations, maximum score is 24, score under 10 is normal

when doing a clinical evaluation for OSA, what should you look for?

BMI, neck size, retrognathia/micrognathia, tongue (freidman score, mallampati score, scalloping), soft palate length, uvula size, tonsils (brodsky score), nose septum/inferior turbinate/alares, respiration, arches width/shape/teeth inclination, check for complications like HBP and CHF

tonsillar hypertrophy scale

1- less than 25%

2- 25-50%

3- 50-75%

4- more to 75%

classes of tonsillar hypertrophy scale?

have patient stick their tongue out

class 1- soft palate, uvula, fauces, pillars are visible

class 2- soft palate, uvula, fauces visible

class 3- soft palate, base of uvula visible

class 4- only hard palate visible

lateral cephalometry for radiographic evaulation

does not provide significant positive or negative predictive value for OSA

CBCT for radiographic evaulation

no significant benefit for airway assessment, head and tongue posture not standardized, difficult to find accurate thresholds for airway, low intra and inter rater reliability when assessing airway volumes

why is CBCT not a good way to evaluate the upper airway?

lack of standardization of head and tongue posture, greater intra and inter examiner reliability for airway volume than minimum cross-sectional area, lack of an established protocol for determining a standardized threshold when measuring airway

DISE

drug induced sleep endoscopy

what percentage of people who have airway obstruction have it in the soft palate region?

81% (most common)

what percentage of people who have airway obstruction have it at the tongue base region?

46.6%

what percentage of people who have airway obstruction have it in the hypopharyngeal region?

38.7%

what percentage of people who have airway obstruction have it in multiple regions?

68.2%

what is the most common multilevel collapse?

combination of soft palate and tongue base

what is the difference between newborns and 18 month olds in terms of their pharyngeal development?

newborns pharynx are similar to other primate- uvula and epiglottis are in close proximity

around 18 months the larynx descends to the level of C5

helps with phonation

long face syndrome/adenoids face

chronic mouth breathing causes dentofacial deformities

extended head (craniocervical) posture and forward inclined cerevical column, excessive anterior facial height, incompetent lip posture, flared external nares, steep mandibular plane, posterior dental crossbite, protruding maxillary teeth

in lab polysomnogram (PSG)

gold standard in the diagnosis of SRBDs, minimum of 7 parameters (EEF, EOG, EMG, ECG, flow, resp, effort, O2)

what are PSG indications for children?

differentiating between snorers and ones with OSA, understand how severe OSA is based on AHI, baseline and post treatment to evaluate effect of interventions, combine the findings with day and night time symptoms

what are the primary therapies to treat OSA?

positive airway pressure, oral appliances

what are the secondary therapies to treat OSA?

weight loss, positional therapy, avoidance of alcohol and sedatives, exercises, hypoglossal nerve stimulation device, surgery (upper airway or bariatric)

are there any cures for OSA?

most treatments (including primary therapies) are not a cure, but surgery may be a cure

CPAP

not a cure but a treatment

expected outcomes are improved daytime sleepiness, reduced motor vehicle accidents, can reduce blood pressure, improves cognitive dysfunction in patients with dementia, improves QOL, reduces depression and anxiety, reduces healthcare costs

what is defined as CPAP adherence?

more than 4 hours of use per night on 70% of the observed nights

how does obesity affect OSA?

at least 45% of obese patients have OSA, 70% of OSA patients are obese

how does weight loss affect OSA?

tongue fat decreases, helps increase lung volume, improves leptin levels

a 10% reduction of weight can lead to 25% reduction in AHI

how can positional therapy affect OSA?

over 50% of OSA patients have a positional component to this disorder- changing supine vs on the side or neck position may help

what are the indications for hypoglossal neurostimulation?

overweight, moderate to severe OSA, CPAP intolerant

what are contraindications for hypoglossal neurostimulation?

BMI >32, AHI<15 or AHI>65, central apneas, concentric upper airway collapse

what do oral appliances/mandibular advancement devices do?

pull the mandible forward to increase the size of the airway

they will move teeth!

what is the efficacy of oral appliance therapy?

~50%

mild/moderate OSA ~75% success

severe OSA <50% success, unpredictable

rem related OSA- only about 12% of patients will have normalization of AHI

who are poor responders to oral appliances?

older, obese, severe OSA, mild/moderate OSA and obese, patients on CPAP pressure higher than 13cm H2O, limited maximum protrusion, increased mandibular plane angle, oropharyngeal crowding (high mallampati score)

who are good responders to oral appliances?

shorter soft palate length, minimal retroglossal airway, short anterior face height, mandibular retrusion

what are the dental/occlusal side effects of oral appliances?

lingual tipping of maxillary incisors, distal tipping of maxillary molars

mesial tipping of mandibular molars, labial tipping of mandibular incisors

decrease in overjet, changes in occlusal contacts, decrease overbite (possible open bite), crowding/interproximal spacing

what is the first line treatment for children with OSA?

adenotonsillectomy

what is the second line treatment for children with OSA?

CPAP

indicated when adenotonsillectomy is not successful or OSA is so severe that AT is not enough

disadvantages include expense, adherence, anxiety, sleep disruption, nasal and skin effects, midface remodeling

what happens to children who are compliant with CPAP?

maxillary retrusion, counterclockwise tipping of the palatal plane, flaring of the maxillary incisors

what are orthodontic treatments for childhood OSA?

protraction facemask, RME, functional appliances, behavior modification, surgical intervention

rapid maxillary expansion (RME)

disarticulated maxillary and palatal bones move laterally with the most inferior and anterior parts moving furthest, lateral walls of nasal air passages are carried outwards, trans-alar width increases and nostrils widen

what does facemask therapy do?

moves the maxilla downward and forward and rotates the mandible

t/f removing 4 premolars causes OSA

false