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World Sleep Day: New non-contact techniques to diagnose sleep apnea during Covid-19

World sleep day: New ways to diagnose sleep apnea during Covid-19.

March 19 will be observed as World Sleep Day this year. On this day, let's talk about one of the most common diseases - obstructive sleep apnea - and new contact techniques used to diagnose it.

Written by Editorial Team |Updated : March 19, 2021 12:01 PM IST

Much like eating and drinking, sleep is crucial to maintain overall health and well-being. Did you know we spend more than one-third of our lives sleeping? Sleep is essential for restorative function, energy conservation, repair of cells, hormone secretion (diurnal/nocturnal), relieve tiredness and get rest and recovery.

Sleep is a biological, chemical, and physiological process that forms a triad of health along with exercise and nutrition. Poor quality of sleep can have dangerous consequences in the long run. Lack of sleep can increase your risk of developing anxiety, depression, hypertension, CVD, Type II Diabetes. It may lead to work-related accidents, vehicular, road traffic accidents, work absenteeism, frequent hospitals, and GP visits. Sleep-related diseases have become a global epidemic as it threatens the health and quality of life for up to 45% of the world population.

How To Know The Quality Of Sleep?

If you are thinking about how you can judge or label whether one's sleep is good or bad. There are certain elements, factors that can decide the quality of your sleep, including the duration, continuity (seamless sleep) and depth of sleep.

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A simple indicator of a good night's sleep is when you wake up feeling fresh and rejuvenated, not wanting to sleep more, without any heavy headedness or headache. If one's sleep is consistently poor then it needs special attention to diagnose which kind of sleep disorder, the person is suffering from.

There are various sleep-related disorders like insomnia, OSAS, restless leg syndrome, parasomnia, sleep talking, sleepwalking, narcolepsy and many more. OSAS, itself, as a single entity causes 40% of disorders out of these all. One can understand the high prevalence of OSAS.

What is sleep apnea?

Obstructive sleep apnea (OSA) is the cessation of breathing for more than 10 seconds, repeatedly, altering body hemodynamics which can lead to chronic health disorders

The most common symptom of OSA is loud and chronic snoring. Other symptoms are excessive daytime sleepiness, choking or gasping during sleep, lack of concentration, restless sleep, and headache in the morning. Recent research shows that OSA is associated with many serious conditions. If left untreated, it can result in a growing number of health issues like diabetes, hypertension, MI (myocardial infarction), stroke (CVA), obesity etc.

OSAS affects almost 20% of the population. 90% of people remain undiagnosed and less than 1 % get treated due to lack of awareness among the general population.

Screening For OSAS

There are certain quick screening methods available for OSAS like STOP-Bang Questionnaire, Berlin Questionnaire and Epworth Sleepiness Scale (ESS). The most widely preferred questionnaire is the STOP-Bang questionnaire.

STOP-Bang Questionnaire:

  • Do you snore loudly?
  • Do you feel tired, sleepy, fatigued the entire day?
  • Has anybody observed you stop breathing (Obstruction) during sleep?
  • Do you have high blood pressure?
  • Is your BMI (body mass index) more than 35 Kg/m2?
  • Are you over the age of 50?
  • A neck circumference greater than 40 cm
  • Gender Are you a male?

If you have said 'yes' to more than 3 questions is at the highest risk of OSAS. Once screened and labelled as a high-risk category, proper diagnosis and management would help.

Diagnosis of OSAS

Diagnosis of OSAS is done based on ENT (OSA Surgeon) surgeons' opinion, sleep study, DISE (Drug-Induced Sleep Endoscopy) and Dynamic MRI. OSA specialist physical examination includes throat, tongue, laryngeal, nasal assessment as well as neck circumference, BMI, any congenital, bony deformity leading to static obstruction etc.

This examination gives a fair idea about the location of the obstruction and the type of obstruction in the airway if it is static or dynamic. A sleep study is mandatory to confirm the diagnosis and assess the severity of OSA. It can be done in the comfort of your home. A sleep study report enables the specialist to establish whether the person has sleep apnea and if he has determined its severity.

Sleep Study

A sleep study is a study done either at a sleep lab, hospitals or at home. It is performed overnight to collect the sleep-related vital parameters changes, data. There are various types of sleep study, including type I, II, III and IV.

Sleep study type I is performed in sleep labs or hospitals, where a sleep technician hooks the person up with various wires and sensors. It is attended the whole night by a technician and performed for the whole night, a minimum of 8 -9 hours. It has separate leads for ECG, EEG, EMG, Nasal airflow, snoring sound recorder, abdominal and chest belts to record breathing efforts, pulse oximeter, body position sensors, a video camera for whole night recording etc. Generally, sleep study type II is advised for suspected neurological causes or other non-OSA causes like Restless leg syndrome etc.

Type III study is broadly used when OSA is suspected. It is performed at home. The machine is portable. It is easy to hook up as fewer channels used as compared to type I.

Type II and IV is in between these two main types of the sleep study.

Newer Non-Contact Technique Sleep Study Method

These non - contact sleep study techniques are ideal in the Covid situation.

Ballistocardiography (BCG) technique

This one is a new method of sleep study, which works on the principle of ballistocardiography (BCG). This technique records heartbeat, respiration, body movements in a non-invasive manner. In this method, a strip-like mat containing sensors is kept below the sleeping mattress and a probe is applied to one of the fingers. It collects the data for a total sleeping time which can later be retrieved.

Many people are not comfortable with sleeping with so many sensors, wires on one's body when you are hooked up for sleep study. This situation itself may disturb the sleep of that individual making him or her uncomfortable. In such cases, the non-contact technique sleep study method works well.

Peripheral Arterial Tonometry (PAT) Technique

In this technology, just a single, finger probe is used for the evaluation. It is one sleep test and disposable sleep kit ensuring no contamination risk. The reports are comprehensive and easy to interpret.

Once a sleep study is carried out with either of the methods, a report is generated with the help of overnight collected data and dedicated software, an app created for the same.

The report is comprehensive. It displays various factors like pulse rate, snoring, breathing efforts, apneas, hypopneas, Oxygen saturation etc. It also provides the Apnea-Hypopnea Index (AHI) which decides the severity of OSA.

AHI below 5 is considered as normal, 5 to 20 mild, 20 to 40 moderate and above 40 is considered as severe OSA.

Diagnosis and severity detection leads one to the further management aspect of OSA. At this point, it becomes extremely important to mention that few people are simple snorers without any airway obstructive symptoms. It can be very well diagnosed by a sleep study. Such simple snorers are treated or managed differently as compared to the ones with obstructive symptoms.

In simple snorers, the aim of treatment is not to relieve obstruction but to eliminate snoring sound. It can be managed by using simpler techniques like lasers, Injection somnoplasty, exercises etc.

If AHI falls between 6 to 40, that person needs further evaluation of OSA, to know the exact location, site of airway obstruction. It can be a single site or multiple sites.

As per VOTE classification, the site can be Vellum, Oropharynx, Tongue or Epiglottis. DISE (drug-induced sleep endoscopy) or Dynamic MRI helps to assess the site of obstruction.

DISE (Drug-Induced Sleep Endoscopy)

As the name suggests, it is an endoscopic study to know the exact level of airway obstruction while a patient is sleeping. Sleep is induced by using drugs like Dexmed or Propofol. It is performed in OT. Once desired level of sedation is achieved, a flexible nasopharyngolaryngoscope is introduced through the nose and gently advanced further towards the larynx while evaluating various sites like the vellum, oropharynx, and base tongue, on the way down till epiglottis and vocal cords. A report is written stating the levels of airway obstruction as per VOTE classification.

Dynamic MRI

Dynamic MRI also shows the exact location of the obstruction. It is performed in an MRI gantry where the patient sleeps naturally without any sedation.

The advantages of this method are, no anaesthesia or hospitalisation and performed in natural sleep.

The results of both assessment methods are comparable where one can replace another

Management of OSAS

This condition can be very well managed holistically. Multiple treatment options like surgery, laser, co ablation, radiofrequency methods, non-surgical options like use of C PAP, Bi-PAP machines, fat loss programme, exercise, lifestyle modifications are combined as per the individual need.

Every person with OSAS is treated keeping in mind his or her requirements, meaning the treatment is customized to suit their needs, age, gender, profession, health condition etc.

Surgical Treatment

Surgical treatment options are nasal surgeries (like Septoplasties, Turbinoplasties, Turbinetomies, Endoscopic sinus surgeries for nasal polyposis, tumours), palatal surgeries (like palatoplasties, its various modified techniques, Palatal Implants), Base tongue surgeries (like Midline glossectomy or lingualplasty, SMELLSubmucosal Midline Endoscopic Lingualbase lysis, TORSTrans Oral Robotic Surgery, MMA( Maxillomandibular Advancement), Hyoid Suspension, Genioglossus Advancement, Bariatric Surgery, RFVTR(Radiofrequency Volumetric Tissue Reduction), Tracheostomy etc. From this basket of surgical options available, required surgeries are selected for a particular person to address airway obstruction. In this way, surgical treatment is tailormade for every individual by treating the surgeon.

Non-Surgical Treatment

Non-surgical treatment options include CPAP(Continuous Positive Airway Pressure), Bi-level Therapy, Nocturnal Oxygen Therapy, Upper airway Exercises( for mild OSA), Sleep Hygiene, Lifestyle modification( Diet, Fat loss), Oral appliances etc.

CPAP is a safe, effective, and most widely accepted therapy for OSA. CPAP machine increases air pressure in one's throat so that the airway does not collapse during sleep. This involves a pump that provides air under gentle pressure to a mask that covers one's nose and or mouth during sleep. The major drawback of this machine is poor Compliance.

Alternate Treatment

Myofunctional exercises are also accepted widely for mild grade OSAS and even as a maintenance therapy post-treatment. This includes lip, tongue, palate, neck, and throat exercises. Yoga has a very important role to play. Especially Bhramari, Ujjayi pranayama, Kapalbhati and Simhasana are the few to name which has positive effects on the management of Snoring.

Taking into consideration, various factors like patient's AHI score, age, profession, other comorbidities, personal choices, OSA specialist decides holistic line of treatment. It is a combination of surgical as well as non-surgical methods to get desired results.

Sleep Hygiene

Lastly, everyone should follow these good sleep habits, sleep hygiene for a quality sleep experience.

  • Establish a good sleeping time and waking time
  • If one is taking nap, then that should not exceed 30 minutes
  • Avoid excessive alcohol, smoking, at least 4 hours before sleep time
  • Avoid caffeine 6 hours before bedtime
  • Avoid heavy, sugary, and spicy food, 4 hours before bedtime
  • Exercise regularly but not right before bedtime
  • Use comfortable bedding
  • Find a comfortable room temperature setting and keep the bedroom well ventilated
  • Block out all distracting noises and eliminate as much light as possible
  • Reserve your bed for sleep and sex only. Avoid using it for work or general recreation

(Authored by Dr. Kavita Chaudhary, Consultant - ENT, Jupiter Hospital, Pune)

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