Dental Sleep Medicine 2

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Published: Tuesday, 26 August 2014 11:17 Written by 

Dr.Wesam Al-saadi

How to recognize a sleep apnea patient ?

There are risk factors among patients, that can alert us to do further investigation to our patients role out sleep apnea disorder

Risk Factors
Risk factors for sleep apnea include:
• Age — People over the age of 40 are more likely to suffer from sleep apnea, although people of all ages, including children, can be affected
• Gender — Men are more likely to suffer from sleep apnea, although women also are affected
• Snoring — One of the most common markers
• Weight — Being overweight is the main risk factor

Identifying Sleep Apnea
Obesity — a BMI of over 30 — is the most common risk factor in adults. Thin people, however, can develop the condition if anatomic issues are present such as enlarged tonsils. Several other factors can be used to identify patients suffering from sleep apnea.
When trying to identify sleep apnea, questions to ask patients include:
• Do you snore?
• Has anyone seen you stop breathing while you are sleeping?
• Do you get sleepy during the day?
• Do you experience sleepiness while driving?
• Do you suffer from difficult to control hypertension?


There is a Berlin Questionnaire (for sleep apnea)
This questionnaire helps to identify patients with sleep apnea Identify patients in primary care setting,

The sensitivity and specificity of the Berlin questionnaire were 68% and 49% at respiratory disturbance index greater than 5, 62% and 43% at respiratory disturbance index greater than 10, and 57% and 43% at respiratory disturbance index greater than 15.9, so this questionnaire is valid in medical and surgical patients according to The American Thoracic Society.

The questionnaire consists of 3 categories related to the risk of having sleep apnea.
Patients can be classified into High Risk or Low Risk based on their responses to the individual items and their overall scores in the symptom categories.

Categories and scoring:
Category 1: items 1, 2, 3, 4, 5.
Item 1: if ‘Yes’, assign 1 point
Item 2: if ‘c’ or ‘d’ is the response, assign 1 point
Item 3: if ‘a’ or ‘b’ is the response, assign 1 point
Item 4: if ‘a’ is the response, assign 1 point
Item 5: if ‘a’ or ‘b’ is the response, assign 2 points

Add points. Category 1 is positive if the total score is 2 or more points


Category 2: items 6, 7, 8 (item 9 should be noted separately).
Item 6: if ‘a’ or ‘b’ is the response, assign 1 point
Item 7: if ‘a’ or ‘b’ is the response, assign 1 point
Item 8: if ‘a’ is the response, assign 1 point

Add points. Category 2 is positive if the total score is 2 or more points

Category 3
Is positive if the answer to item 10 is ‘Yes’ OR if the BMI of the patient is greater than 30kg/m2.
(BMI must be calculated. BMI is defined as weight (kg) divided by height (m) squared, i.e., kg/m2).
High Risk: if there are 2 or more Categories where the score is positive
Low Risk: if there is only 1 or no Categories where the score is positive

Additional question: item 9 should be noted separately.

BERLIN QUESTIONNAIRE 

CATEGORY 1

1. Do you snore?

_ a. Yes

_ b. No

_ c. Don’t know

If you snore:

2. Your snoring is:

_ a. Slightly louder than breathing

_ b. As loud as talking

_ c. Louder than talking

_ d. Very loud – can be heard in adjacent

rooms

3. How often do you snore

_ a. Nearly every day

_ b. 3-4 times a week

_ c. 1-2 times a week

_ d. 1-2 times a month

_ e. Never or nearly never

4. Has your snoring ever bothered

other people?

_ a. Yes

_ b. No

_ c. Don’t Know

5. Has anyone noticed that you quit

breathing during your sleep?

_ a. Nearly every day

_ b. 3-4 times a week

_ c. 1-2 times a week

_ d. 1-2 times a month

_ e. Never or nearly never

CATEGORY 2

6. How often do you feel tired or

fatigued after your sleep?

_ a. Nearly every day

_ b. 3-4 times a week

_ c. 1-2 times a week

_ d. 1-2 times a month

_ e. Never or nearly never

7. During your waking time, do you

feel tired, fatigued or not up to par?

_ a. Nearly every day

_ b. 3-4 times a week

_ c. 1-2 times a week

_ d. 1-2 times a month

_ e. Never or nearly never

8. Have you ever nodded off or fallen

asleep while driving a vehicle?

_ a. Yes

_ b. No

If yes:

9. How often does this occur?

_ a. Nearly every day

_ b. 3-4 times a week

_ c. 1-2 times a week

_ d. 1-2 times a month

_ e. Never or nearly never

CATEGORY 3

10. Do you have high blood pressure?

_ Yes

_ No

_ Don’t k

Medical Tests to Diagnose Sleep Apnea Patients

• Acoustic Pharyngometry

Acoustic Pharyngometry ® (APh) is a non-invasive, objective assessment of the vocal tract, which provides the cross-sectional area and volume of the upper airway. APh requires the participant to exhale slowly into a wave tube. The wave tube has a mouth piece that keeps the participant’s tongue in position (not blocking the airway) and ensures that all exhaled air passes through it.
Sound waves are emitted and the system’s microphone captures the acoustic reflections of the airway. Then the system measures the amplitude of the reflections and time of arrival at the microphone.
The APh constructs a plot showing airway area and distance from the lips/teeth (0 point on x-axis) to the glottis. For accuracy, it is best to analyze data with another person who is familiar with analysis. It is also helpful to analyze the data the same day it was recorded


• Acoustic rhinometry



A simple reproducible technique for measuring nasal airflow, which is used to identify fixed lesions—e.g., septal deviations—or alterations in cross-sectional areas induced by allergens or drugs.

Method
a spark generator produces an acoustic click, which travels past a microphone and is directed through the nasal passages via a conduit; the click is reflected back from the various nasal contours and received by the microphone. A computer program analyses the direct and reflected sounds, producing a graph of the cross-sectional area of the nasal passage from the vestibule to the nasopharynx.

• Home Sleep Study

In order to diagnose SLEEP APNEA or other sleep disorders, a patient must undergo a polysomnography (sleep study). This is typically done in a sleep lab, requiring the patient to spend the night in-lab, while the polysomnography (PSG) equipment records his/her physiological data. However, today with technological advancements a polysomnograpy can be performed at home and is called home sleep testing (HST) or a home sleep study.
BENEFITS OF HOME SLEEP TESTING?
1. The patient self-administers the home sleep test, and is able to spend the night in the patient's own bed in familiar surroundings (reducing first night effect).

2. Home sleep testing, a home sleep study, can be especially advantageous to the home-bound, elderly, or those with chronic illness, who require specialized care such as a nurse or family member spending the night, expensive transportation costs, etc. It is also beneficial for those with trouble arranging time out of their schedules to spend the night in-lab.

3. The typical cost of a home sleep test or a home sleep study is only a fraction of the cost of an in-lab sleep study, and typically yields similar results in the diagnosis of obstructive sleep apnea.
Choosing the Right Portable Sleep Monitor for Home Sleep Testing
Important criteria to watch for while selecting a portable sleep monitor for your practice are:
1- Recording of Proper Physiological Data:
Per the American Academy of Sleep Medicine (AASM) clinical guidelines, the proper OSA evaluation requires portable monitoring that record at least:
1. Airflow (pressure-based)
2. Pulse oximetry
3. Heart rate
4. Respiration effort measured via Respiratory Inductive Plethysmography (Type III monitor).
Other parameters that are strongly recommended are snore, temperature-based airflow (thermistor) for apnea confirmation and body position for positional apnea estimation. Some devices also record muscle activity (EMG channel), which could be of particular help to dentists during OA titration since it can evaluate bruxism.

2-Ease of Use:
Clearly, a system that is small, light and allows for easy self-administration of the sleep test in the home is preferred, as it avoids a sleep technologist from having to go to the patient's house, saving time and money. Typically hook-up of sensors in HST will require: Wrapping a RIP belt around the chest, placing and securing a pulse ox on the patient's index finger, and wearing a nasal cannula. This is only minimally invasive and painless. Sometimes a thermistor may be used along with the nasal cannula to confirm apneas.

Ease of use and data quality are doubly assured if the portable sleep monitor is designed with checks in place to indicate proper placement of the sensors (some monitors have light and others have sound indicators). Additionally, a monitor that includes anautomatic check for validity of prior night sleep data would be particularly helpful as it can afford a fast way to repeat the study if needed (maybe due to a disconnected sensor). Selecting a monitor with a pre-programmed ON/OFF time can ensure proper data recording even if the patient forgets to hit the start button.

In summary, choosing the right portable sleep monitor that offers ease of use for the patient, and appropriate physiological data for the physician's facility, while using sleep lab methodology, is the first step in deploying Home Sleep Testing the right way.

References

- http://www.thoracic.org/
- http://www.sleepapnea.org/
- http://www.waisman.wisc.edu/
- http://www.clevemed.com/

 

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