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Sleep Apnea and Athletes |
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SLEEP APNEA AND
ATHLETES
Mark Eric Dyken, M.D.
University of Iowa
College of
Medicine
Sleep Disorders
Center
I. INTRODUCTION
•
Sleep apnea is
common. T he prevalence of obstructive sleep apnea in the general
population is 2 to 5% (2% of women, 4 % of men between 30 and 60 years
of age).
•
Olson et al.
Am J Respir Crit Care Med. 1995.
•
Kripke et al.
Sleep. 1997.
•
Young et al.
NEJM. 1993
I. INTRODUCTION
•
There is an
association between untreated obstructive apnea and hypertension,
cardio/cerebrovascular disease and death.
–
Dyken et al.
Obstructive apnea associated with cerebral hypoxemia and death.
Neurology 2004;62;491-493.
–
Dyken et al.
Transient obstructive sleep apnea and asystole in association with
presumed viral encephalopathy. Neurology 2003;60:1692-1694.
SLEEP APNEA AND
ATHLETES
•
Sleep in
Athletes
–
It’s the “last
frontier” when working with athletes to improve performance and health.
•
“We’ve changed
their diets”.
•
“ --- their
training habits --- ”.
•
“ --- their
strength programs --- ”.
Allan M. Levy, MD.
Associate team physician for the New York Giants football team
SLEEP APNEA AND
ATHLETES
•
“We’ve changed
everything but their sleep habits”.
–
“Now with some
scientific evidence to back physicians up, that might become a bigger
priority”.
–
Bederka.
Tackling Sleep Problems in Athletes. Advance for Managers of Respiratory
Care. Sept/Oct 2003.
FOOTBALL PLAYERS
•
1 STUDY
•
8 randomly
selected NFL teams
•
High and low
risk groups randomly selected for sleep studies (polysomnography)
•
George CFP, et
al. Increased Prevalence of Sleep-Disordered Breathing among
Professional Football Players. N Engl J Med. 2003;348:367-8.
FOOTBALL PLAYERS
•
302 Players
•
Mean age; 25.5
+/- 2.7 years
•
Mean BMI; 31.5
+/- 4.6.
–
52 individuals
with sleep studies (polysomnograms)
FOOTBALL PLAYERS
•
AHI > 10
= significant sleep-disordered breathing (SDB).
•
Offensive and
defensive linemen = 85% of players with SDB.
–
Largest neck
circumferences (48.5 +/- 2.3 cm).
–
Highest BMIs
(36.6 +/- 2.6).
–
Higher blood
pressures
FOOTBALL PLAYERS
•
Estimated SDB in
Professional Football Players
–
14% overall
(nearly 5-times higher than in previous studies of similar aged adults).
–
34% within the
high risk group.
FOOTBALL PLAYERS
•
A 1997 pilot
study (Sleep Tech Consulting Group).
–
Compared to
controls, 13 of 16 linemen from the New York Giants with sleep apnea;
•
Slower reaction
times
•
More lapses in
concentration with daytime performance tests
THE OTHER REPORT
•
Sumo wrestlers
–
Of 23 wrestlers
(16 – 35 years), 11 had significant SDB.
–
BMI > in SDB
(44.3 vs 37.0, P < 0.05).
–
Suzuki N, Fueta
M, To M, Yamada H, Ogawa C, Sano Y. Sleep-disordered breathing among
professional sumo wrestlers in Japan. International conference of the
American Thoracic Society: 2003 May 16-21: Seattle (WA).
SUMO WRESTLERS
–
Winning average
with SDB < non-SDB (0.339 vs 0.444, P = 0.075).
–
Nevertheless,
the non-SDB group winning increased with increased BMI (not true with
SDB group).
II. When to Suspect
II. When to
Suspect
•
A. History
•
B. Physical
examination
II. When to Suspect
•
Summary
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Stereotypically:
•
middle-age or
older
•
Male
•
Elevated
BMI/large neck circumference
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heroic snoring
(sitting up)
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Insomnia
II. When to Suspect
•
Memory/thinking
complaints
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Sleepiness/fatigue
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No
tonsillectomy/adenoidectomy
•
Nocturnal
heartburn
•
Nocturia
•
morning
headaches.
II. When to Suspect
•
Nevertheless,
infants, children, women, and thin, healthy people without frank
complaints of sleepiness can also suffer from significant apnea.
III. How to
Diagnose
III. How to
Diagnose
•
A.
Polysomnography
•
B. Multiple
Sleep Latency Test
III. How to
Diagnose
•
A.
Polysomnography
–
1. Combination
of EEG, EMG, EOG
III. How to
Diagnose
•
Obstructive
sleep apnea-hypopnea (OSAH)
•
Apneas and
hypopneas
–
apnea; complete
upper airway obstruction
–
hypopnea;
partial upper airway obstruction
III. How to Diagnose
OSAH
•
A/H duration;
minimum 10 seconds
•
oxygen
desaturation 4% or greater
•
and/or
micro/arousals
•
oximetry tracing
with “saw-tooth” pattern
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EKG;
tachy-bradycardia/asystole
III. How to Diagnose
•
OSAH
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Severity
–
1.
Apnea/hypopnea index (AHI); the number of events divided by sleep time
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2. Lowest oxygen
saturation (SaO2 low)
–
3. Cardiac
dysrhythmia
–
3. Sleepiness
III. How to Diagnose
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OSAH severity
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1. AHI
–
mild; 5-15
events/hour
–
moderate; 15-30
events/hour
–
severe; > 30
events/hour
•
2. SaO2
low
–
> 90% = normal
–
80%-90% = mild
–
70%-80% =
moderate
–
< 70% = severe
III. How to Diagnose
•
OSAH severity
•
3. Cardiac
dysrhythmia
–
severe = any
event inducing arrhythmia
III. How to
Diagnose
•
OSAH severity
•
4. Sleepiness
–
As determined by
the multiple sleep latency test
III. How to Diagnose
•
Multiple Sleep
Latency Test (MSLT)
–
Quantifies/qualifies sleepiness from micro/arousals
–
Perform 1 1/2 to
3 hours after polysomnogram
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Five-20 minute
nap attempts, separated by 2-hour intervals
III. How to
Diagnose
•
B. MSLT
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Sleepiness
severity determined by mean sleep latency (average time to fall asleep
for each nap)
•
>
10 minutes = normal
•
>5
and < 10 minutes = moderate
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< 5 minutes =
severe
IV. How to Treat
IV. How to Treat
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Present
therapeutic mainstays
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1. Continuous
positive airway pressure therapy (CPAP)
–
2.
Uvulopalatopharyngoplasty (UPPP)
IV. How to Treat
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Supplemental
therapeutic interventions
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Good dietary
habits
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Low-level
exercise
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Avoidance CNS
depressants
IV. How to Treat
•
C. Other
therapies
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1. Other
surgeries
•
Tonsillectomy/Adenoidectomy
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Nasal
reconstruction
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Maxillo-mandibular
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Cranial-facial
advancement procedures
•
Laser-assisted
UPPP
•
Somnoplasty
IV. How to Treat
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C. Other
therapies
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2. Appliances
•
Generally not
“curative”
•
Mandibular
positioning devices
•
Tongue retaining
devices
IV. How to Treat
•
C. Other
therapies
–
3. Medications
•
Protriptyline (Vivactyl)
increases airway muscle activity through central mechanism
•
Provera (medroxyprogesterone)
•
Diamox
•
Theophylline
•
Oxygen (decrease
number, increase duration obstructions)
V. CONCLUSIONS
•
Insomnia and
sleepiness are common. Good diet, exercise, and avoidance of unnecessary
drugs can improve sleep, and simplify the diagnosis and treatment of
sleep apnea should it exist.
VI. Specific Questions
Hypotheses
OSA related to
shape of oropharynx.
Male gender may
exacerbate (not cause) apnea.
Advancing age may
exacerbate (not cause) apnea.
Weight gain may
exacerbate (not cause) apnea in some cases.
Weight loss may lead to
improvements; rare cure.
Overweight is
relative.
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