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OSA is characterized by repetitive episodes of complete (apnea) or partial (hypopnea) upper airway obstruction during sleep that often result in oxygen desaturation and terminate with brief arousals. By definition, apnea and hypopnea events last for 10 seconds or longer and are accompanied by continued efforts to breathe. Obstructive hypopneas are typically defined by a decrease in airflow of 30% or more with desaturation of 4% or more (Strollo and Rogers 1996; Figure 22–7). Because the neurocognitive and cardiovascular outcomes are similar for apneas and hypopneas, these events are typically counted together in providing an overall index of severity, the apnea–hypopnea index (AHI; number of apneas and hypopneas per hour of sleep) (Gottlieb et al. 1999). Mild OSA is defined as an AHI between 5 and 15, moderate OSA as an AHI of 15 to 30, and severe OSA as an AHI of greater than 30. In addition to apneas and hypopneas, the OSA syndrome includes a complaint of daytime sleepiness or insomnia, loud snoring, and/or episodes of breath holding, gasping, or choking during sleep. Other findings include complaints of fatigue, memory and cognitive difficulty, obesity, and hypertension or other cardiovascular disease.

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FIGURE 22–7. Obstructive apnea and obstructive hypopnea.A, Diagrammatic representation of obstructive apnea. Increasing ventilatory effort is seen in the rib cage, the abdomen, and the level of esophageal pressure (measured with an esophageal balloon), despite lack of oronasal airflow. Arousal on the electroencephalogram (EEG) is associated with increasing ventilatory effort, as indicated by the esophageal pressure. Oxyhemoglobin desaturation follows the termination of apnea. Note that during apnea, the movements of the rib cage and the abdomen (Effort) are in opposite directions (arrows) as a result of attempts to breathe against a closed airway. Once the airway opens in response to arousal, rib-cage and abdominal movements become synchronous. B, Diagrammatic representation of obstructive hypopnea. Decreased airflow is associated with increasing ventilatory effort (reflected by the esophageal pressure) and subsequent arousal on the EEG. Rib-cage and abdominal movements are in opposite directions during hypopnea (arrows), reflecting increasingly difficult breathing against a partially closed airway. Rib-cage and abdominal movements become synchronous after arousal produces airway opening. Oxyhemoglobin desaturation follows the termination of hypopnea.Source. Adapted from Strollo PJ, Rogers RM: "Obstructive Sleep Apnea." New England Journal of Medicine 334:99–104, 1996.

FIGURE 22–8. Potential sites of airway instability.Cross-sectional view of the upper airway depicting the potential sites of airway instability (arrows).Source. Reprinted from Buysse DJ (ed): Sleep Disorders and Psychiatry (Review of Psychiatry Series, Volume 24, Number 2; Oldham JM and Riba MB, series editors). Washington, DC, American Psychiatric Publishing, 2005, p. 82. Copyright 2005, American Psychiatric Publishing. Used with permission.

FIGURE 22–9. Upper airway in obstructive sleep apnea, without treatment and with CPAP treatment.Cross-sectional view of the upper airway, illustrating closure at the level of the palate and base of tongue typically seen in obstructive sleep apnea (A) and when the airway is pneumatically splinted open with continuous positive airway pressure (CPAP) (B).Source. Reprinted from Buysse DJ (ed): Sleep Disorders and Psychiatry (Review of Psychiatry Series, Vol 24, No 2; Oldham JM and Riba MB, series editors). Washington, DC, American Psychiatric Publishing, 2005, p. 93. Copyright 2005, American Psychiatric Publishing. Used with permission.

FIGURE 22–10. Surgical treatment for adult obstructive sleep apnea.A, Appearance of the oropharynx prior to uvulopalatopharyngoplasty (UPP), with dotted line identifying site of incision. B, Postoperatively, with sutures in place. C, Phase I, UPP and genioglossal advancement. D, Phase II, maxillomandibular advancement.Source. Reprinted from Buysse DJ (ed): Sleep Disorders and Psychiatry (Review of Psychiatry Series, Volume 24, Number 2; Oldham JM and Riba MB, series editors). Washington, DC, American Psychiatric Publishing, 2005, pp. 98–99. Copyright 2005, American Psychiatric Publishing. Used with permission.
Table Reference Number
TABLE 22–8. Comorbidities and consequences associated with obstructive sleep apnea syndrome

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