Obstructive sleep apnea (OSA) includes episodes of partial or complete closure of the upper airway which occurs during sleep and causes apnea (by definition a period of> 10 seconds). The symptoms include daytime restlessness, snoring, recurrent awakening, morning headaches and severe drowsiness. Diagnosis is based on sleep history and polysomnography. The treatment consists in a nasal CPAP, mandibular advancement or, in rare cases, a selected operation. The prognosis is good with treatment. Most cases go undetected and untreated, and are often associated with hypertension, atrial fibrillation and other arrhythmias, heart failure and injury or death after car accidents and other accidents that result from hypersomnia.

In patients at risk sleeping destabilized the continuity of the upper respiratory tract, resulting in partial or complete obstruction of the nasopharynx and / or oropharynx.

Obstructive sleep apnea (OSA) includes episodes of partial or complete closure of the upper airway which occurs during sleep and causes apnea (by definition a period of> 10 seconds). The symptoms include daytime restlessness, snoring, recurrent awakening, morning headaches and severe drowsiness. Diagnosis is based on sleep history and polysomnography. The treatment consists in a nasal CPAP, mandibular advancement or, in rare cases, a selected operation. The prognosis is good with treatment. Most cases go undetected and untreated, and are often associated with hypertension, atrial fibrillation and other arrhythmias, heart failure and injury or death after car accidents and other accidents that result from hypersomnia. In patients at risk sleeping destabilized the continuity of the upper respiratory tract, resulting in partial or complete obstruction of the nasopharynx and / or oropharynx. Obstructive sleep apnea hypopnea occurs when breathing is reduced, though not absent. The prevalence of OSA in adults is 2-9%. The disease is underdiagnosed and often remains undetected even in symptomatic patients. OSA is up to four times more common in men and seven times more common in people who are obese (d. H. Body mass index [BMI]> 30). Severe OSA (apnea-hypopnea index [AHI]> 30 / h) increases the risk of death in middle-aged men. Clinical Calculator: Body Mass Index (Quetelet’s index) OSA can cause excessive daytime sleepiness, increasing risks of car accidents, job loss, and sexual dysfunction. Relations with bed partners and roommates and / or roommates can also be adversely affected because these people can get insomnia. Long-term cardiovascular complications of untreated OSA are poorly controlled hypertension, heart failure and atrial fibrillation (even after catheter ablation) and other arrhythmias. Etiology Anatomic risk factors contain the A oropharynx, which is “overflowing” with a short or retracted jaw One prominent tongue base or tonsils A rounded head shape and a short neck A enHalsumfang> 43 cm (> 17 in) thick lateral pharyngeal walls Side parapharyngeal fat pad Anatomic risk factors are common in obese people. Other known risk factors include postmenopausal aging and alcohol or Sedativaeinnahme. In 25-40% of cases have a family history of OSA is present, which may reflect genetic factors that affect the respiratory drive or craniofacial structure. The risk of OSA in a family member is proportional to the number of affected family members. Acromegaly, hypothyroidism and sometimes a stroke can cause or contribute to OSA. Among the diseases that occur more frequently in patients with OSA, including hypertension, stroke, diabetes, hyperlipidemia, reflux esophagitis, nocturnal angina, heart failure and atrial fibrillation or other cardiac arrhythmias. Since obesity is a common risk factor for OSA and obesity hypoventilation syndrome, this disease often occur simultaneously. The inspiratory effort against a closed upper airway inspiratory caused seizures, reduced gas exchange, a disturbance of normal sleep architecture and partial or complete central Aufweckreaktionen (arousals) from sleep. These factors may interact to cause the characteristic symptoms and complaints, including hypoxia, hypercapnia and sleep fragmentation. OSA is an extreme form of a sleep-related increase in resistance of the upper airways. Among the less severe forms that do not cause O2 desaturation include snoring air resistance of the upper airways, the loud inspiration caused, but no waking from sleep Upper airway resistance syndrome, which is characterized by increased snoring, the effort related by respiratory waking from sleep (RERAs) terminates patients with upper airway resistance syndrome are typically younger and less obese than OSA patients complain frequently and daytime sleepiness than patients with primary snoring. Frequent arousals occur, but there are no strict criteria for apneas and hypopneas present. Symptoms, diagnostic tests and treatment of snoring and upper airway resistance syndrome are otherwise the same as in OSA. Although symptoms and complaints loud disruptive snoring of 85% of OSA patients is reported, most people who snore do not have OSA. Among the other symptoms of OSA Restless sleep without recovery sleep maintenance difficulties may include choking, wheezing or snorting during sleep, most patients notice these symptoms do not (because they occur during sleep), but are informed of bed and roommate or roommates about it. Some patients wake up with a sore throat or a dry mouth. If they are awake, the patient hypersomnia, fatigue and concentration problems can experience. The frequency of complaints about sleep and the degree of daytime sleepiness did not correlate very highly with the number of nocturnal arousals. Diagnostic symptom criteria sleep studies The diagnosis is suspected in patients with identifiable risk factors, symptoms, or both. The diagnostic criteria consist of day symptoms, nighttime symptoms and sleep monitoring, documenting> 5 episodes of hypopnea and / or apnea per hour. In particular, should overlooks the symptoms ?1 of the following occur: daytime sleepiness, unintentional sleep episodes, non-restorative sleep, fatigue or difficulty staying asleep awakening under his breath, wheezing or choking reports of a bed Genossens about loud snoring, breathing pauses, or both during sleep the patient Clinical Calculator: Epworth sleepiness scale (ESS), the patient and any bed and roommates roommate and should be interviewed. The differential diagnosis of excessive daytime sleepiness is wide and includes reduced quantity or quality of sleep due to poor sleep hygiene sedation or mental status changes through medication, chronic diseases (including cardiovascular or respiratory disease), or metabolic disorders and concomitant treatments Depression alcohol or drug abuse narcolepsy Other primary sleep disorders (eg. as intermittent limb movement disorder, restless legs syndrome) A comprehensive sleep history should be included in all patients who are ? sleep through 65 years of age or older daytime sleepiness, drowsiness or difficulty reports are obese poorly controlled hypertension (caused by OSA caused or versc can be hlimmert), atrial fibrillation or other cardiac arrhythmias, heart failure (which may cause OSA), stroke or diabetes Most patients only report on snoring without other symptoms or cardiovascular risk factors, do not need extensive OSA diagnosis. The physical examination should include evaluation of nasal obstruction, tonsillar and pharyngeal structure and the identification of clinical signs of hypothyroidism and acromegaly. A polysomnography is most appropriate for confirming the diagnosis and quantification of the severity of OSA. Polysomnography includes continuous measurements of the work of breathing by plethysmography, the respiratory flow at nose and mouth with flow sensors, the O2 saturation in the oximetry and the sleep architecture in the EEG and chin EMG (to search for hypotension) and electrooculogram for detecting the occurrence of REM comprises movements. The polysomnography recorded sleep stages and the occurrence and duration of apnea and hypopnea and helps to classify them. The patient is also observed by video and ECG monitoring is used to determine whether cardiac arrhythmia in conjunction with the apnea occur. Other measurements include the activity of the limb musculature (to capture nichtrespiratorischer causes of arousals such as restless leg syndrome, and limb movement disorders intermittent) and the body position (apnea may occur only in the supine position on). The apnea-hypopnea index (AHI) is the total number of episodes of apnea and hypopnea during sleep, divided by the hours of sleep, is the usual summary measure to describe respiratory disturbances during sleep. The AHI values ??can be calculated for different phases of sleep. A Respiratory Disturbance Index (RDI), a similar method describes the number of episodes of certain arousals related to respiratory effort (called respiratory effort related arousals or RERAs) plus the number of apnea and hypopnea episodes per hour of sleep. A arousal index (AI), the number of arousals per hour of sleep when EEG monitoring is used can be calculated. The AI ??can be correlated with the AHI or RDI, but 20% of apnea and desaturation are not accompanied by arousals, or the causes of arousals are different. An AHI> 5 is required for the diagnosis of OSA. A value of> 15 represents a moderate degree of sleep apnea and a value of> 30 for a severe degree of sleep apnea. When snoring loud enough so that it can be heard in the next room, there is a 10-fold increase in the probability of having an AHI> 5th AI and RDI correlate only moderately with the symptoms of a patient. Portable diagnostic tools are more commonly used for the diagnosis of OSA. Portable monitors can measure heart rate, pulse oximetry, Effort, position and nasal breathing to estimates of disordered breathing self-reported sleep to deliver, which AHI / RDI is estimated. Portable diagnostic tools are often used in combination with questionnaires (z. B. Stop Bang, Berlin Ask arc) that calculate the risk of patients (sensitivity and specificity of the test depends on the pre-test probability from). When portable tools are used comorbid sleep disorders can not be excluded (eg. As restless legs syndrome). Follow-up polysomnography may still be required to set AHI / RDI values ??in the different stages of sleep, and with changes in position, especially if surgery or therapy is contemplated except positive airway pressure. The measurement of thyroid stimulating hormone can be performed based on clinical suspicion. No other additional tests (for. Example, imaging of the upper airway) has in front a sufficient diagnostic accuracy to be routinely recommended. Prognosis The prognosis is very good if an effective treatment is initiated. Untreated or unrecognized OSA can lead to cognitive impairment as a result of insomnia, which in turn can lead to serious injury or death from accidents, especially traffic accidents. Sleepy patients should be warned about the risks while driving, handling heavy machinery or the exercise of other activities in which uncontrolled sleep attacks would be dangerous. Adverse effects of hypersomnia, such as job loss and sexual dysfunction can seriously affect families. In addition, perioperative complications, including cardiac arrest, been associated with OSA, probably because the anesthesia can cause airway obstruction after a mechanical airway has been removed. Therefore, patients should inform their anesthesiologist about the diagnosis before undergoing any surgery, and hospital stays continuous pressure mask (CPAP) received, if they get a preoperative medication and during the recovery. Therapy control of risk factors CPAP or oral devices In anatomical engagement or persistent disease, respiratory consideration of operation or possibly electrical stimulation of the hypoglossal nerve, the therapeutic goal is the reduction of hypoxic episodes and sleep fragmentation. The treatment is tailored to the patient and the extent of disease-related limitations. Cure is defined as disappearance of the symptoms with reduction of AHI below a threshold value of usually 10 / hr. The treatment initially focuses on the risk factors and then click the OSA itself. Specific treatments for OSA include CPAP, oral appliances and Atemwegoperationen. Control of Risk Factors The initial treatment depends on the optimal control of modifiable risk factors, including, obesity, alcohol and Sedativaeinnahme, hypothyroidism, acromegaly and other chronic diseases. Although a moderate weight loss (15%) may result in clinically meaningful improvements, the weight loss is extremely difficult for most people, especially those who are tired or sleepy. A bariatric surgery reverses the symptoms often around and improved AHI in morbidly obese (BMI> 40) patients, and it may be, however, that the degree of this improvement is not as great as the amount of weight loss. Weight loss, with or without bariatric surgery, should not be viewed as a cure of OSA werden.CPAP Nasal CPAP is in most patients with OSA and subjective daytime sleepiness, the treatment of choice. Compliance is lower in patients who do not experience drowsiness. CPAP improves the patency of the upper airway by maintaining a positive pressure to the easy collapsing upper airway segments. The effective pressure ranks usually from 3-15 cm H2O. The severity of the disease does not correlate with the required pressure. Many CPAP devices monitor the effectiveness of CPAP and titrate the pressure automatically according to internal algorithms. If clinical improvement can be seen, the CPAP effectiveness should be reviewed and the patient for a second sleep disorder (eg. As obstruction of the upper airways) or a comorbid disorder be reassessed. If necessary, the pressure during the monitoring can be manually titrated with repeated polysomnography. Regardless of the improvement in AHI reduced CPAP cognitive impairment and BP. If the CPAP therapy is interrupted, the symptoms appear within a few days again, although short treatment interruptions are usually well tolerated for acute diseases. The treatment is lifelong. Treatment failure of nasal CPAP therapy is most commonly due to a limited patient compliance. Side effects include dryness and nasal irritation, which can be mitigated in some cases by the use of warm air humidifiers, and complaints by an ill-fitting mask. CPAP can be achieved by inspiratory pressure support (BiPAP) are extended in patients with obesity-hypoventilation syndrome to her breath volume to erhöhen.Protrusionsschienen snoring rails were designed to shift or the lower jaw forward to at least one falling back of the lower jaw during sleep prevent. Some were also designed to pull the tongue forward. The use of such devices to treat snoring and OSA is increasingly accepted. Comparisons between the devices and CPAP show with mild to moderate OSA equivalence, but no results from cost-benefit studies verfügbar.Operative procedures are surgical procedures to correct anatomical factors such as enlarged tonsils and nasal polyps, which contribute to the obstruction of the upper airways ( so-called anatomical process) should be considered. Even with macroglossia and Micrognathia operations are possible. Surgery is the treatment of choice when an anatomical impairment is identified. In the absence of an impairment of the evidence, however, is missing to support surgery as the treatment of choice. The Uvulopalatopharyngoplastie (UPPP) is the most commonly used surgical procedures. It consists of a resection of the submucosal tissue of the tonsils to the arytenoepiglottischen wrinkles with resection of nasal polyps to increase the upper respiratory tract. In a study, wherein the CPAP used as a bridge to surgery, although equivalence with CPAP has been shown that both methods are not directly compared. UPPP could not be successful in patients who are morbidly obese or have an anatomical airway constriction. In addition, the detection of sleep apnea after UPPP is more difficult because the snoring is missing. These silent obstructions can cause apnea that are as difficult as those that occur before surgery. Additional surgical procedures include the center line glossectomy, hyoid bone enlargement and the operational shift of the mandible and maxilla forward. The operational relocation of the mandible and maxilla forward is offered as a second procedure sometimes after nichtkurativer UPPP. The optimal tiered approach is not known. Tracheotomy is the most effective therapeutic maneuvers in OSA, but is used as a means of last election. It bypasses the obstruction site and is indicated for those patients who are most affected (those with pulmonary heart disease such. B.). Laser-assisted Uvuloplastie, uvular splints and radiofrequency tissue ablation have been recommended as treatments for loud snoring in patients without OSA. Although they may temporarily reduce the volume of snoring increases their effectiveness over months to years ab.N. hypoglossal stimulation A new anatomical not process is the stimulation of the upper airway. In the stimulation of the upper respiratory an implanted device is used to activate one of the 12 cranial nerve (hypoglossal nerve). This is the “rescue” – therapy and can successfully sein.Zusätzliche treatments Additional therapeutic measures are often used in selected patients with moderate to severe disease who do not tolerate CPAP therapy, but have in the treatment of first choice no value. Modafinil can be used against the residual sleepiness in OSA in patients who use CPAP effectively. Additional O2 improves blood oxygenation, but it can no positive clinical effect can be predicted. In addition, O2 may in some patients induce respiratory acidosis and morning headaches. A number of drugs were used for stimulation of the central respiratory drive (for. Example, tricyclic antidepressants, theophylline), however, may be narrow therapeutic or both not recommended routinely due to their limited efficacy. Nasal dilators and throat sprays that are sold without prescription for snoring, have not been adequately studied to benefit in OSA to nachzuweisen.Patientenschulung and outreach A well enlightened patient and his family come up with a method of treatment, incl. Tracheotomy, along better. Patient support groups offer helpful information and support the timely treatment and follow-up effect. Summary obesity, anatomical abnormalities of the upper airway, family history, certain diseases (e.g., B. hypothyroidism, stroke), and the use of alcohol or sedatives increase the risk of OSA. Patients snore typically have a restless and unerholsamen sleep and often feel daytime fatigue and sleepiness. Most people who snore do not have OSA. Among the diseases that occur more frequently in patients with OSA, including hypertension, stroke, diabetes, reflux esophagitis, nocturnal angina, heart failure and atrial fibrillation or other cardiac arrhythmias. The diagnosis is confirmed by polysomnography. Modifiable risk factors are kotrolliert and most patients are treated with CPAP and / or oral appliances that are designed to open the airway. Surgical procedures are used for abnormalities that cause adverse effects on the respiratory system, or if the disease is not treatable. More information American Sleep Apnea Association Stop Bang Questionnaire

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