Obstructive sleep apnea syndrome G47.31

Obstructive sleep apnea syndrome (OSAS) is a sleep-related breathing disorder (SBAS), an apnea syndrome occurring during sleep with obstruction of the upper airways.

About 2-4% men and 1-2% women suffer from obstructive sleep apnea (Maspero C et al. 2015). Sleep apnoea = breathing pause during sleep with a duration =/>10sec >5x/h. Obstructive sleep apnea is thus one of the most common widespread diseases. In older age and in obesity, the estimated frequency is between 15% and 19% for men and between 9% and 15% for women.

Collapse of the pharyngeal musculature due to a decrease in the tone of the pharyngeal muscles during sleep, often during REM sleep (REM = rapid eye movement). The activity of the respiratory musculature is maintained, including the respiratory movements. Favouring factors are diseases of the oro-/nasopharynx. This concerns tonsil hyperplasia, nasal polyps, nasal septum depression, macroglossia, retrognathia, enlarged uvula, etc.

In children, obstructive sleep apnoea syndrome is most commonly caused by hyperplasia of the pharyngeal or palatal tonsils (Marcus CL et al. 2012).

The flow of breath is impaired by a dislocation of the throat during sleep. It can be reduced, but also completely eliminated, which is equivalent to a respiratory arrest (apnoea). Such events can occur very frequently per hour of sleep time. They are measured by the Apnea-Hypopnea Index(AHI). The single event is > 10 sec. long.

Thus, apnea in OSAS is a pause in breathing during sleep caused by an obstruction in the upper airways. At the same time, the breathing activity is maintained - the respiratory muscles thus perform futile breathing movements. The breathing pauses are often accompanied by loud and irregular snoring. The organism reacts to sleep apnoea with a life-savingarousal reaction(arousal). This leads to a resumption of breathing. This activates the whole body: the heart beats faster, blood pressure rises significantly and the muscles tense up. The sleeper often also moves his arms and legs. The pauses in breathing are ended by a few deep and long breaths, whereby the person affected does not usually wake up or remember, but enters a lighter sleep stage. Breathing pauses and waking reactions of the body prevent restful sleep.

Sleep is fragmented through constant wake-up reactions, the proportion of deep sleep and dream sleep decreases and can even tend towards zero (sleep fragmentation). This sleep is no longer restful. The result is, among other things, increased daytime tiredness with a tendency to fall asleep during the day.

Loud irregular snoring with respiratory arrest

Increased daytime tiredness/drowsiness with a tendency to fall asleep (microsleep) during monotonous activities (e.g. long driving -7 times higher risk of accidents, working at the PC, reading (Costa G 2017).

Furthermore:

• limited ability to concentrate (hyperactivity)
• reduced hearing ability, usually: conductive hearing loss (Spinosi MC et al. (2017)
• intellectual decline in performance
• Depressive moods, forgetfulness
• Dry mouth in the morning, morning headaches
• Potency disorders (erectile dysfunction)

"Obstructive sleep apnea" is a significant "cardiovascular risk factor" that is often not directly perceived by the affected person. The following symptoms are observed as complications:

• Arterial hypertension resistant to therapy (often without nocturnal blood pressure reduction during 24-hour measurement).
• Nocturnal hypoxia-induced, often bradycardic arrhythmias up to AV block (Xie J et al. 2017).
• Characteristic: apnea-induced sinus arrhythmia (Herold G 2018).
• Worsening of pre-existing heart failure.
• Respiratory global failure
• Increasing risk of myocardial infarction: With OSAS, the risk of myocardial infarction increases 3-fold, and the risk of stroke increases 4-fold.
• Tendency to increased insulin resistance.

MAD (mandibular advands devices): Mandibular advancement devices enlarge the pharynx, this method is used by the dentist or oral surgeon. This method is used by the dentist or oral surgeon and allows therapy for mild obstructive sleep apnea syndrome (Ierardo G et al. 2017).

nCAP therapy: Standard therapy is the nCPAP therapy (= nasal continuous positive airway pressure) using a nasal mask. It basically represents continuous nocturnal positive airway pressure breathing with a nasal or full face mask. With an individually determined positive pressure of 5-13mbar in inspiration and expiration, a so-called pneumatic splinting of the hypotonic pharynx can be achieved (Sanna A 2017).

BIPAP-therapy: At higher pressures, for example above 10 cm H2O, BIPAP-therapy (bilevel positive airway pressure) is necessary. In this dual method, a higher pressure is built up mechanically during inspiration and a lower pressure during expiration.

Surgical therapy methods:

• Uvulovelopharyngoplasty (UVPP) by laser or conventional methods only helps in individual cases of obstructive sleep apnea syndrome. The indication must be determined exactly.
• Septoplasty
• Conchotomy

Further accompanying, important therapeutic measures:

• Prevention of supine position by a special vest or cushion in the back. This simple and inexpensive procedure can be helpful for patients with postural obstructive sleep apnea syndrome, either by sea or in combination with CPAP therapy.
• Weight reduction (BMI), preferably through a change in diet. Weight loss of 20% can reduce AHI (Apnea Hypopnea Index) by up to 20%.
• Sleep hygiene
• Sport and exercise
• Tongue muscle training
• no alcohol immediately before bed rest
• no "heavy meals before bed rest
• Conversion in particular of sleeping pills under medical supervision

Obstructive sleep apnea can also occur in combination with central sleep apnea.

Arterial hypertension can only be described as essential if SAS (sleep-related breathing disorder) is ruled out. SAS is one of the most common causes of secondary hypertension (Wang S et al. 2018)

1. Costa G (2017) The obstructive sleep apnea syndrome (OSAS): implications for work and occupational health. Med Lav 108:251-259.
2. Herold G et al (2016) Internal Medicine. Herold Publisher SS 346-349
3. Ierardo G et al (2017) Obstructive Sleep Apnea Syndrome (OSAS): evaluation and treatment of odontostomatological problems. Med Lav 108:293-296.

4. Maspero C et al (2015) Obstructive sleep apnea syndrome: a literature review. Minerva Stomatol 64:97-109.

5. Marcus CL et al (2012) Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 130: e714-55.
6. Sanna A (2017) Obstructive Sleep Apnea Syndrome (OSAS): Continuous Positive Airway Pressure (CPAP) therapy and other positive-pressure devices. Med Lav 108:283-287.
7. Spinosi MC et al (2017) Hearing loss in mild OSAS and simple snoring patients. Otolaryngol Pol 71:11-15.
8. Wang S et al (2018) Analysis of OSAS incidence and influential factors in middle-aged and elderly patients with hypertension. Minerva Med doi: 10.23736/S0026-4806.18.05635-5.
9. Xie J et al (2017) Correlation Analysis between Obstructive Sleep Apnea Syndrome (OSAS) and Heart Rate Variability. Iran J Public Health 46:1502-1511.