WEBVTT 1 00:00:10.900 --> 00:00:13.700 I would like to thank assimilate by mid university for giving me 2 00:00:13.700 --> 00:00:18.800 this opportunity to share the knowledge of topic which is 3 00:00:19.300 --> 00:00:24.500 really you can say under diagnosed and and also 4 00:00:24.500 --> 00:00:28.700 you can say it is obviously not treated up to the mark. 5 00:00:28.800 --> 00:00:35.400 So the topic is sleep apnea. So the term itself will 6 00:00:35.400 --> 00:00:39.100 tell you that this is sleep apnea due to obstruction in your 7 00:00:39.500 --> 00:00:44.900 airway pathway during the sleep. And we will be discussing about 8 00:00:46.000 --> 00:00:51.000 in brief what is obstructive sleep apnea, how it is diagnosed, what 9 00:00:51.000 --> 00:00:54.600 are the symptoms which you should look for a patient in obstructive 10 00:00:54.600 --> 00:00:58.500 sleep apnea and followed by what are the treatment options do we 11 00:00:58.500 --> 00:01:03.300 have. So to start with first of all let us see what 12 00:01:03.300 --> 00:01:07.300 are the sleep disorder breathing spectrums. OSA is one of the sleep 13 00:01:07.300 --> 00:01:12.600 disorder breathing spectrum and the sleep disorder breathing is present when 14 00:01:13.900 --> 00:01:18.300 the there are repetitive episodes of apnea or hypopnea during the sleep 15 00:01:18.700 --> 00:01:23.400 and this apnea or hypopnea during the sleep is associated with sleep 16 00:01:23.400 --> 00:01:28.900 fragmentation, arousals and reduction in the oxygen levels. So 17 00:01:28.900 --> 00:01:34.000 this is very clear that is whenever a OSA patient is asleep 18 00:01:34.100 --> 00:01:37.900 that is during the night or during the morning hours his he 19 00:01:37.900 --> 00:01:43.200 is experiencing apnea episodes that is his breathing is stopped. And 20 00:01:43.600 --> 00:01:49.200 with along with this apnea episodes his sleep is fragmented 21 00:01:49.200 --> 00:01:54.700 that is it's not very well or well managed sleep and 22 00:01:54.800 --> 00:01:58.700 he has arousals in between. He keeps waking up from the sleep 23 00:01:59.000 --> 00:02:04.800 and during this this what all incidences 24 00:02:04.800 --> 00:02:08.800 he also has a decrease in oxygen levels. So all these put 25 00:02:08.800 --> 00:02:12.900 together you can term it as a sleep disorder breathing and in 26 00:02:12.900 --> 00:02:17.000 this sleep disorder breathing OSA is just one of the component and 27 00:02:17.000 --> 00:02:22.400 we have other disorders also like obesity, hypoventilation 28 00:02:22.400 --> 00:02:27.700 syndrome, central sleep apnea syndrome and upper airway respiratory upper airway resistance 29 00:02:27.700 --> 00:02:32.800 syndrome UARS. So but the most common thing is obstructive sleep apnea 30 00:02:32.800 --> 00:02:37.400 or hypopnea syndrome which we are going to discuss now in the 31 00:02:37.700 --> 00:02:43.000 coming slides. And common with all these entities is narrowing or complete 32 00:02:43.000 --> 00:02:49.000 obstruction of your upper airway. The in this picture 33 00:02:49.300 --> 00:02:53.000 I would like to show you whenever a person is asleep the 34 00:02:53.000 --> 00:02:58.200 air flow which flows through the nostrils, posterior pharynx and slowly 35 00:02:58.200 --> 00:03:03.600 it enters the glottis through this pathway whereas obstructive sleep apnea patients 36 00:03:03.700 --> 00:03:08.800 experience different symptoms because of obstruction 37 00:03:08.800 --> 00:03:13.500 in their upper airway. So the air flow is completely blocked during 38 00:03:14.500 --> 00:03:18.600 sleep and this leads to obstructive sleep apnea. You can clearly see 39 00:03:18.600 --> 00:03:23.200 here there is a blockage in the air flow. So what are 40 00:03:23.200 --> 00:03:28.200 the causes affecting this upper airway patency that that is what 41 00:03:28.300 --> 00:03:33.300 factors will keep our upper airway open during 42 00:03:33.300 --> 00:03:37.400 sleep and what factors will lead to the collapse of the upper 43 00:03:37.400 --> 00:03:42.400 airway. So to start with first of all the most common thing 44 00:03:43.200 --> 00:03:48.300 or the most what you say the background 45 00:03:48.300 --> 00:03:53.200 of this problem you you should know is the relation between the 46 00:03:53.200 --> 00:03:58.100 soft tissue and bony enclosure of your upper airway. Whenever the normal 47 00:03:58.100 --> 00:04:02.400 soft tissue is there in a normal bony enclosure then the airway 48 00:04:02.400 --> 00:04:06.600 size will be normal and in obesity what happens is soft tissue 49 00:04:06.600 --> 00:04:11.500 increases disproportionately and the bone knee space is very less then the 50 00:04:11.500 --> 00:04:16.800 airway compresses and also in certain conditions when the maxilla and mandible 51 00:04:16.800 --> 00:04:22.500 are very small then also it can you can see this it 52 00:04:22.500 --> 00:04:27.600 can accommodate the tongue and other structures easily airway 53 00:04:28.300 --> 00:04:33.200 will collapse. So the soft tissue the relation between the bony enclosure 54 00:04:33.200 --> 00:04:36.600 and soft tissue plays a major role in maintaining the patency of 55 00:04:36.600 --> 00:04:41.400 the airways and also let us see the other factors like anatomical 56 00:04:41.400 --> 00:04:46.200 configuration already we have seen. And lung volumes if a person is 57 00:04:46.200 --> 00:04:49.900 having lower lung volume there will be less traction on the upper 58 00:04:49.900 --> 00:04:55.200 airway and the upper airway tends to collapse and a person with 59 00:04:55.700 --> 00:05:00.900 lesser surfactants in their lungs will have increased surface 60 00:05:00.900 --> 00:05:04.600 tension leading it can also lead to the collapse of the upper 61 00:05:04.600 --> 00:05:09.700 airway. And also sleep related decrements in muscle activity. You all 62 00:05:09.700 --> 00:05:13.200 know that whenever we go into REM sleep there will be a 63 00:05:13.200 --> 00:05:19.200 lot of muscle relaxation and if a patient is I 64 00:05:19.200 --> 00:05:23.200 mean if a person is not having any OSA then his sleep 65 00:05:23.200 --> 00:05:28.200 related muscle activity is mild compared to wakefulness whereas in 66 00:05:28.200 --> 00:05:33.500 OSA patients this is the muscle activity is very much decreased. So 67 00:05:33.600 --> 00:05:37.900 they are they just tend to collapse. That also leads to collapse 68 00:05:37.900 --> 00:05:42.900 of the upper airway. So these are certain factors which 69 00:05:42.900 --> 00:05:47.900 will lead to obstructive sleep apnea. So as you people 70 00:05:47.900 --> 00:05:53.700 know that OSA patients generally present with snoring. Yes, the 71 00:05:53.700 --> 00:05:58.500 most common symptoms which are present is with snoring and along with 72 00:05:58.500 --> 00:06:03.600 snoring they also have other symptoms like daytime sleepiness 73 00:06:03.800 --> 00:06:06.600 that is during the daytime while they are sitting idle they just 74 00:06:06.600 --> 00:06:12.100 dose off or during driving or during doing some other work during 75 00:06:12.100 --> 00:06:17.100 their daily routine activities also they tend to just dose off. So 76 00:06:17.800 --> 00:06:22.000 whenever we are taking history of any patient who we are suspecting 77 00:06:22.000 --> 00:06:27.000 OSA if a person has snoring does he have OSA? That means 78 00:06:27.000 --> 00:06:30.700 I'm going I'm asking that does all snorers have OSA? The answer 79 00:06:30.700 --> 00:06:36.000 is no. Some patients have only snoring without OSA. So these 80 00:06:36.000 --> 00:06:41.000 patients can be labeled as primary snorers and it does 81 00:06:41.200 --> 00:06:46.500 it occurs occasionally only and does not result in significant daytime impairment 82 00:06:46.700 --> 00:06:50.000 because there is no disruption of sleep. This is called primary snoring. 83 00:06:50.400 --> 00:06:56.200 But if snoring is present daytime sleepiness and 84 00:06:56.200 --> 00:06:59.500 during sleep the patient is waking up with breath holding or choking 85 00:06:59.500 --> 00:07:05.000 episodes. Or he has been diagnosed with hypertension, mood disorder, 86 00:07:05.600 --> 00:07:10.700 cognitive dysfunction, he has history of coronary artery disease, congestive heart 87 00:07:10.700 --> 00:07:15.900 failure, stroke, atrial fibrillation or type diabetes. Any of them 88 00:07:16.200 --> 00:07:19.100 if you are having so OSA is said to be present when 89 00:07:19.400 --> 00:07:24.400 either A and B and B is based sleep recording 90 00:07:24.400 --> 00:07:28.100 shows the following. That is the patient will undergo a sleep study 91 00:07:28.100 --> 00:07:32.000 and this sleep study shows five or more predominantly obstructive sleep apneas. 92 00:07:33.000 --> 00:07:38.000 Or C that is sleep recording shows 15 or more predominantly obstructive 93 00:07:38.400 --> 00:07:44.000 respiratory events. So the patient should have the symptoms like daytime sleepiness 94 00:07:44.400 --> 00:07:50.600 or disturbed sleep during night. Along with that the PSG the polysomnography 95 00:07:50.700 --> 00:07:55.000 or sleep study should show that he is having obstructive events during 96 00:07:55.000 --> 00:08:00.100 the night. Okay. So then you will label him as OSA whereas 97 00:08:00.100 --> 00:08:03.100 if the patient is not having any of these and he has 98 00:08:03.100 --> 00:08:06.800 only snoring then you will label him as a primary snorer and 99 00:08:06.800 --> 00:08:10.600 you will see what are the factors which is leading to snoring. 100 00:08:12.100 --> 00:08:17.400 So this is about what is OSA, what is the definition, 101 00:08:18.000 --> 00:08:22.400 how do they present and about snoring. So as you all people 102 00:08:22.400 --> 00:08:27.600 know we should don't we should not consume alcohol and drive 103 00:08:27.600 --> 00:08:32.500 the vehicles. So similarly I mean in the similar way when a 104 00:08:32.500 --> 00:08:36.900 person takes alcohol and he drives a vehicle he can dose off 105 00:08:36.900 --> 00:08:41.900 during driving or he can just I 106 00:08:41.900 --> 00:08:47.300 mean involve in road traffic accidents. Similarly OSA patients also 107 00:08:47.400 --> 00:08:53.200 can dose off during driving or any other activities like during 108 00:08:53.200 --> 00:08:58.300 the daily routine activities. So OSA I'm I'm just highlighting this 109 00:08:58.300 --> 00:09:03.600 because I'm just I just wanted to highlight that OSA is 110 00:09:03.900 --> 00:09:09.300 very detrimental and it can cause some motor vehicle crashes 111 00:09:09.800 --> 00:09:15.000 and OSA can lead to cardiac arrhythmias or OSA can lead to 112 00:09:15.100 --> 00:09:20.200 strokes, brain strokes and it can also cause MI and 113 00:09:20.700 --> 00:09:25.300 and sleep apnea is also linked to potential threat to reproduction that 114 00:09:25.300 --> 00:09:29.600 is infertility can also happen in OSA patients. So these are all 115 00:09:29.900 --> 00:09:33.500 complications of OSA if it is not treated correctly, if it is 116 00:09:33.500 --> 00:09:37.500 not treated directly. I mean it is not if it is not 117 00:09:37.500 --> 00:09:42.200 diagnosed correctly and if it's not treated then the person cannot have 118 00:09:42.200 --> 00:09:46.600 all these complications. So how these all these things are happening, why 119 00:09:46.600 --> 00:09:51.000 the patient can develop MI, why the patient can have stroke, why 120 00:09:51.000 --> 00:09:55.300 the patient can have infertility when a patient is having OSA. As 121 00:09:55.300 --> 00:10:00.100 I already told OSA is obstructive sleep apnea and during sleep he 122 00:10:00.100 --> 00:10:05.100 has up sleep breathing it's stopped 123 00:10:05.100 --> 00:10:12.100 that is apnea. So whenever we experience 124 00:10:12.700 --> 00:10:18.100 apnea during sleep the intrathoracic pressure will become negative. 125 00:10:18.900 --> 00:10:25.200 And there will be increased left ventricular transmural pressure gradient which 126 00:10:25.200 --> 00:10:30.400 will lead to increased oxygen demand by the myocardial muscles, increased 127 00:10:30.400 --> 00:10:35.900 vascular stress and there can also be endothelial dysfunction. 128 00:10:37.300 --> 00:10:42.500 So these things will lead to can lead to MI. So not 129 00:10:42.500 --> 00:10:48.100 only this during arousals for example the patient is having he 130 00:10:48.100 --> 00:10:53.300 just left off due to obstruction. There is snoring and suddenly wakes 131 00:10:53.300 --> 00:10:58.200 up because of this stoppage in breathing. During this arousals there will 132 00:10:58.200 --> 00:11:02.700 be sleep fragmentation and when you get up suddenly I think most 133 00:11:02.700 --> 00:11:06.900 of you might have experienced also there will be a sympathetic activation 134 00:11:07.100 --> 00:11:12.300 which will lead to tachycardia, acute rise in BP and 135 00:11:12.300 --> 00:11:17.100 this can also lead to insulin resistance. Again all together these things 136 00:11:17.100 --> 00:11:22.200 can lead to MI, sustained hypertension and 137 00:11:22.200 --> 00:11:27.600 all other consequences. Whenever there is a stoppage in breathing obviously 138 00:11:27.600 --> 00:11:32.600 the oxygen levels come down and there will be hypoxia, reoxygenation cycle. 139 00:11:32.900 --> 00:11:37.600 There will be reactive oxygen species generation, oxidative stress will be there 140 00:11:38.100 --> 00:11:43.100 and there will be inflammatory cascade again together 141 00:11:43.100 --> 00:11:48.200 can lead to a decreased oxygen delivery and again these complications 142 00:11:48.200 --> 00:11:53.100 can come up. So there are multiple multiple pathways in which this 143 00:11:53.100 --> 00:11:59.800 OSA can lead to sustained hypertension, myocardial ischemia, LV 144 00:11:59.800 --> 00:12:05.000 failure, arrhythmias and also whenever there is arrhythmias there can be microemboli 145 00:12:05.100 --> 00:12:10.300 and this can cause stroke that is cerebrovascular events. So 146 00:12:10.300 --> 00:12:16.400 this is a pretty complicated slide. I think I 147 00:12:16.400 --> 00:12:21.800 have made it simplified. Then then comes so 148 00:12:21.800 --> 00:12:27.000 this is about the pathophysiology. Then comes how do you diagnose patient 149 00:12:27.000 --> 00:12:32.200 with OSA. So what are the questions you should ask in 150 00:12:32.200 --> 00:12:37.200 the patient with OSA. The first most important point which 151 00:12:37.200 --> 00:12:42.300 I already mentioned is excessive excessive daytime sleepiness that is because 152 00:12:42.300 --> 00:12:47.300 the patient has disturbed sleep in the night. The body tries to 153 00:12:47.800 --> 00:12:53.000 compensate with mechanism that is excessive 154 00:12:53.000 --> 00:12:57.800 excessive daytime sleepiness. The person tries to sleep tries to try sleep 155 00:12:57.800 --> 00:13:02.400 during the mornings because he due to OSA his nighttime sleep is 156 00:13:02.400 --> 00:13:06.600 disturbed. Okay. How do you calculate this? So this is I mean 157 00:13:07.600 --> 00:13:11.700 calculated by a scale that is we will give a set of 158 00:13:11.700 --> 00:13:16.700 questionnaire. How likely are you dosing off or 159 00:13:16.700 --> 00:13:21.000 falling asleep during the following situations like sitting and reading TV, watching 160 00:13:21.000 --> 00:13:25.400 TV, sorry sitting and reading, watching TV, sitting inactive in a public 161 00:13:25.400 --> 00:13:29.500 space as a passenger in a car for an hour or without 162 00:13:29.500 --> 00:13:34.100 a break, lying down to rest in afternoon when circumstances permit, sitting 163 00:13:34.100 --> 00:13:38.200 and talking to someone, sitting quietly after lunch without alcohol in a 164 00:13:38.200 --> 00:13:42.100 car while stopped for a few minutes in the traffic. So three 165 00:13:42.100 --> 00:13:47.400 means high chances of dosing, zero means would never dose off. If 166 00:13:47.400 --> 00:13:50.800 this score reaches more than 10 then definitely this person is said 167 00:13:50.800 --> 00:13:56.800 to have excessive daytime sleepiness. And 168 00:13:57.300 --> 00:14:01.600 there is one more important questionnaire which I would like to highlight 169 00:14:01.900 --> 00:14:06.300 in the slide is this is stop bank questionnaire. What is stop 170 00:14:06.300 --> 00:14:11.000 bank questionnaire? In S T O P stop B A N G 171 00:14:11.000 --> 00:14:16.000 S bank. So I think first two lines have been 172 00:14:17.200 --> 00:14:22.400 disappeared. So so S means snoring. If the patient is having 173 00:14:22.400 --> 00:14:27.100 snoring then we will take one point and T means tiredness. O 174 00:14:27.100 --> 00:14:31.000 is observed. Has anyone observed you stop breathing or choking gasping during 175 00:14:31.000 --> 00:14:35.700 your sleep? P is pressure. Do you have or have are you 176 00:14:35.700 --> 00:14:41.000 being treated for high BP? BMI B is BMI BMI 177 00:14:41.000 --> 00:14:45.900 more than 35 age more than 50 years. Next circumference if it's 178 00:14:45.900 --> 00:14:50.000 greater than 17 in males as greater than 16 in females. Gender 179 00:14:50.300 --> 00:14:54.800 male gender has higher risk of OSA. So the stop bank questionnaire 180 00:14:54.800 --> 00:14:59.000 is a screening tool for OSA. In obese patients a score of 181 00:14:59.000 --> 00:15:02.800 zero to three indicates a low risk of OSA whereas a score 182 00:15:02.800 --> 00:15:07.700 of six to eight has a high risk of OSA and if 183 00:15:07.700 --> 00:15:12.000 a patient has more than six of this stop bank score then 184 00:15:12.000 --> 00:15:17.000 this should patient should be subjected to a sleep study to rule 185 00:15:17.000 --> 00:15:22.100 out OSA. So let us see what is sleep study or 186 00:15:22.100 --> 00:15:27.400 polysom. Okay. Sleep study or polysomnography 187 00:15:27.500 --> 00:15:33.400 is a method for the definitive diagnosis of sleep disorder breathing. And 188 00:15:33.500 --> 00:15:39.100 it includes the recording of sleep signals, the respiratory effort, how 189 00:15:39.100 --> 00:15:42.600 much the patient is breathing or whether the breathing is getting stopped 190 00:15:42.600 --> 00:15:47.700 in between during the sleep. All these will be recorded along with 191 00:15:47.800 --> 00:15:53.000 the muscle movements recording will be done and also there 192 00:15:53.000 --> 00:15:57.500 will be cardio vascular signals that is ECG also will be recorded. 193 00:15:57.700 --> 00:16:03.200 So during sleep the technician will connect these electrodes 194 00:16:03.400 --> 00:16:08.400 to the patient as you can see over the head 195 00:16:08.800 --> 00:16:12.400 and over the chest part to detect respiratory events that is whether 196 00:16:12.400 --> 00:16:17.100 the patient is going into apnea or hypopnea. So all this will 197 00:16:17.100 --> 00:16:22.100 be recorded and this this recorded set of information 198 00:16:22.100 --> 00:16:26.000 is called a polygraph. And the sleep scoring is performed for time 199 00:16:26.000 --> 00:16:30.200 episodes of either 20 to 30 seconds. So each 30 seconds they 200 00:16:30.200 --> 00:16:35.400 will divide and these are called epochs. So each 30 seconds 201 00:16:35.400 --> 00:16:38.300 is an epoch and each in each 30 seconds they will say 202 00:16:38.300 --> 00:16:41.200 whether there is any apnea or hypopnea. And 203 00:16:45.000 --> 00:16:45.900 an arousal is an increase in EEG frequencies for at least three 204 00:16:48.500 --> 00:16:52.500 seconds and less than 15 seconds. So they will check in between 205 00:16:52.500 --> 00:16:57.100 if there is a change in EEG frequency and they will term 206 00:16:57.100 --> 00:17:02.300 it as arousal if it meets the criteria. And you can see 207 00:17:02.300 --> 00:17:06.300 in this graph it is very clear. So this is this 208 00:17:07.300 --> 00:17:11.900 is one epoch where you can see there is a EEG change. 209 00:17:13.000 --> 00:17:18.500 I think I can take a pointer. Yes. So so this 210 00:17:18.500 --> 00:17:24.200 is a EEG change where this arousal. And you can see the 211 00:17:24.200 --> 00:17:29.200 arousal is happening just before this apnea event. This obstructive 212 00:17:29.200 --> 00:17:32.600 sleep apnea has happened here. The patient has stopped breathing. How did 213 00:17:32.600 --> 00:17:37.600 you know this the nasal and air flow has become zero 214 00:17:37.600 --> 00:17:42.000 here this flat line. That means there is no flow. So in 215 00:17:42.000 --> 00:17:46.700 this you can see in this picture that is an oronasal thermistor 216 00:17:46.700 --> 00:17:50.400 is missing. There will be a small thermistor kept over your nose 217 00:17:50.800 --> 00:17:53.700 and that will detect whether you're breathing or not and if you 218 00:17:53.700 --> 00:17:58.200 are here you can see the breathing is stopped and whenever someone 219 00:17:58.300 --> 00:18:02.100 catches you just closes your nose and mouth you just wake up 220 00:18:02.100 --> 00:18:05.800 right. So same thing is happening. So he's not breathing and he 221 00:18:05.800 --> 00:18:09.900 suddenly wakes up this arousal. So this can be termed as one 222 00:18:10.000 --> 00:18:14.100 obstructive sleep apnea event. This is one apnea. This is second one. 223 00:18:14.300 --> 00:18:20.700 So so and and so forth. If a patient has five apneas 224 00:18:20.700 --> 00:18:25.700 or hypopneas in one hour that is for one hour if 225 00:18:25.700 --> 00:18:29.400 has more than five then it is it can be labeled as 226 00:18:29.500 --> 00:18:35.100 obstructive sleep apnea. So that is about polysomnography 227 00:18:35.100 --> 00:18:40.200 or a sleep study and there are four levels of 228 00:18:40.300 --> 00:18:45.300 sleep studies. For example you can say there are 229 00:18:45.300 --> 00:18:50.500 different types of investigations for each test. 230 00:18:51.100 --> 00:18:56.400 So similarly sleep studies are also divided into level 231 00:18:56.400 --> 00:19:00.800 one, level two, level three and level four. Level one is attended 232 00:19:00.800 --> 00:19:06.000 polysomnography that is attended sleep study inside a hospital. Okay. Level 233 00:19:06.000 --> 00:19:10.100 two is unattended that is the technician will not be there. Will 234 00:19:10.100 --> 00:19:13.800 only attach the electrodes and just he will leave the place and 235 00:19:13.800 --> 00:19:17.000 he will come next day morning. He will collect the data. That 236 00:19:17.000 --> 00:19:20.800 is level two. Level one is the technician is present throughout the 237 00:19:20.800 --> 00:19:26.000 study. Okay. And his sleep study with recording of at least three 238 00:19:26.000 --> 00:19:29.500 cardio respiratory parameters and a body posture. That is you will not 239 00:19:29.500 --> 00:19:34.000 record all the parameters. You will only select three parameters and just 240 00:19:34.000 --> 00:19:39.100 you record. Level four is recording of oxygen saturation only and one 241 00:19:39.400 --> 00:19:43.200 more parameter. So level four is least that is we can just 242 00:19:43.200 --> 00:19:46.800 say that there is hypoxia or not with the other parameter whereas 243 00:19:46.800 --> 00:19:49.300 level one and level two are highest. That is you can tell 244 00:19:49.300 --> 00:19:54.500 sleep stages in which stage which the apnea is happening. Okay. 245 00:19:54.600 --> 00:19:58.200 Whether this is obstructive sleep apnea or a central sleep apnea. All 246 00:19:58.200 --> 00:20:01.800 these can be told by level one and level level three, level 247 00:20:01.800 --> 00:20:05.300 four will only tell you that there is some disturbances going on 248 00:20:05.300 --> 00:20:09.000 or not but it can't classify which type of disturbance it is. 249 00:20:09.700 --> 00:20:13.500 Okay. So gold standard is obviously level one and level two when 250 00:20:13.500 --> 00:20:18.700 it is done correctly also can be considered. Okay. This is about 251 00:20:18.700 --> 00:20:23.000 type of sleep studies and as I already told you a typical 252 00:20:23.000 --> 00:20:27.800 sleep study entails a whole night of recording. Okay. Patients found to 253 00:20:27.800 --> 00:20:30.900 have a sleep apnea a return on a subsequent night for a 254 00:20:30.900 --> 00:20:36.000 second sleep study during which level of CPAP necessary to abolish these 255 00:20:36.000 --> 00:20:40.800 events is determined. That is for example first night I mean during 256 00:20:40.800 --> 00:20:46.000 the during the test the whole night the 257 00:20:46.000 --> 00:20:48.600 sleep study will run and you will get the info on the 258 00:20:48.600 --> 00:20:53.100 next day. So you will take it as OSA is present. During 259 00:20:53.100 --> 00:20:58.500 the next session you will keep a CP and 260 00:20:58.500 --> 00:21:03.500 you will just titrate the pressure required to abolish this obstructive 261 00:21:03.500 --> 00:21:08.100 sleep apnea events. I'll just discuss in detail about CPAP and all 262 00:21:08.100 --> 00:21:12.300 those things in the coming slides. This is called a conventional sleep 263 00:21:12.300 --> 00:21:16.800 study but you can do like this also. First three hours during 264 00:21:16.800 --> 00:21:20.700 the sleep study you can just do sleep study. Next three hours 265 00:21:20.700 --> 00:21:24.200 you can keep a CPAP during night. That is called split night. 266 00:21:24.200 --> 00:21:29.400 Okay. Or you can do on two nights during 267 00:21:29.400 --> 00:21:35.200 the first session you will have only the recording of sleep. 268 00:21:35.300 --> 00:21:39.700 So during the second session you will have the CPAP titration. Split 269 00:21:39.700 --> 00:21:43.400 night is first three hours you will do diagnostic test. During the 270 00:21:43.400 --> 00:21:48.400 next three hours you will keep the CPAP. Okay. So 271 00:21:48.400 --> 00:21:51.700 this is about types of sleep studies, what is a split night 272 00:21:51.700 --> 00:21:55.000 sleep study and all those things. Now let us move on to 273 00:21:55.000 --> 00:22:00.200 the treatment part. And see as I already told you okay 274 00:22:00.800 --> 00:22:05.500 that the sleep study I mean sleep apnea occurs mostly in obese 275 00:22:05.500 --> 00:22:11.000 individuals due to the large soft tissue mass which is where 276 00:22:11.000 --> 00:22:16.200 the bony component is unable to keep it. So weight loss 277 00:22:16.200 --> 00:22:21.200 is an excellent strategy. Okay. Whenever a patient is having weight 278 00:22:21.200 --> 00:22:26.400 loss and then there is definitely the patient can improve from 279 00:22:26.400 --> 00:22:31.200 the OSA perspective. Okay. And also they should maintain a good sleep 280 00:22:31.200 --> 00:22:35.000 hygiene that is the fix their bedtime and wake up time should 281 00:22:35.000 --> 00:22:38.700 be fixed so that he will have a good sleep. And also 282 00:22:38.700 --> 00:22:42.800 you should avoid ingestion of stimulants that is tea or coffee just 283 00:22:42.800 --> 00:22:47.800 before going to bed or exercise during evening or nighttime. 284 00:22:47.800 --> 00:22:51.800 These are all stimulants right. You can't get sleep and nowadays as 285 00:22:51.800 --> 00:22:55.600 you all know the screen time that is if you go on 286 00:22:55.600 --> 00:22:59.600 seeing your screens, TV, mobile phones or laptops for a prolonged time 287 00:22:59.600 --> 00:23:04.800 during evening time or nighttime melatonin cannot be produced 288 00:23:04.800 --> 00:23:08.700 in our body and you won't get good sleep and it will 289 00:23:08.700 --> 00:23:12.900 lead to sleep disturbances. So you should follow all these general measures 290 00:23:13.100 --> 00:23:18.800 and you should try to lose weight where 291 00:23:20.200 --> 00:23:25.400 the OSA part can come down. Okay. Now pharmacological therapy not really 292 00:23:25.400 --> 00:23:30.500 helpful especially in these OSA patients. Now there are certain 293 00:23:30.500 --> 00:23:34.400 studies going on certain drugs which can increase the muscle tone of 294 00:23:34.400 --> 00:23:39.600 the upper airway that is during sleep these muscles 295 00:23:39.700 --> 00:23:44.700 doesn't relax and they they can be actively 296 00:23:44.800 --> 00:23:48.700 opening your airways. Those are in the pipeline. Those drugs are being 297 00:23:48.700 --> 00:23:54.400 studies and one more is position therapy. That is they 298 00:23:54.700 --> 00:23:57.600 they tend to say that when a patient lies flat that is 299 00:23:57.600 --> 00:24:02.600 supine the tongues fall posteriorly and there can be a obstruction 300 00:24:03.000 --> 00:24:08.000 for the upper airway. So when we asked him patients 301 00:24:08.000 --> 00:24:11.000 to lie on the sideways on the right lateral or the left 302 00:24:11.000 --> 00:24:15.300 lateral side there will be no obstruction with the tongue. So that 303 00:24:15.300 --> 00:24:20.600 can also be tried. Okay. However these are all like general 304 00:24:20.600 --> 00:24:24.700 measures, weight loss, position therapy. All these you can try in mild 305 00:24:24.700 --> 00:24:30.100 cases only. Okay. That is AHI is only five 306 00:24:30.100 --> 00:24:35.100 to 15. Okay. AHI means apnea hypopnea index on the sleep study 307 00:24:35.100 --> 00:24:38.600 report. It has given that five to 15 it is only mild 308 00:24:38.700 --> 00:24:42.700 and the patient is not having much comorbids. That is the patient 309 00:24:42.700 --> 00:24:47.600 does not have heart disease. That the patient has only mild hypertension, 310 00:24:47.900 --> 00:24:52.300 no history of brain stroke. In these patients you can try these 311 00:24:52.300 --> 00:24:57.700 and you can just try to treat OSA conservatively but 312 00:24:59.500 --> 00:25:03.600 in moderate cases that is if AHI score is more than 15 313 00:25:04.100 --> 00:25:09.500 or in mild cases also if he has significant comorbidities like 314 00:25:09.800 --> 00:25:14.500 heart tissues or brain strokes, all these things then you should go 315 00:25:14.500 --> 00:25:20.200 for a positive airway pressure therapy, PAP therapy. In PAP 316 00:25:20.200 --> 00:25:23.800 therapy means positive airway therapy that is you can see in this 317 00:25:23.800 --> 00:25:27.100 picture. This is a machine which will give a positive airway through 318 00:25:27.100 --> 00:25:32.000 this pipeline to your upper airway. It will help the upper airway 319 00:25:32.400 --> 00:25:36.700 to just open up. This is called continuous positive airway pressure or 320 00:25:36.700 --> 00:25:41.700 CPAP. Or you can give a BiPAP that is by by level. 321 00:25:41.700 --> 00:25:47.200 There will be two pressure levels and the inspiratory 322 00:25:47.200 --> 00:25:50.700 pressure and the expiratory pressure and one more is auto CPAP that 323 00:25:50.700 --> 00:25:54.400 is auto CPAP is nothing but they will set a maximum pressure 324 00:25:54.400 --> 00:25:57.800 and a minimum pressure and this pressure will be delivered between these 325 00:25:57.800 --> 00:26:02.800 two points. Now these are various types of devices which we 326 00:26:03.600 --> 00:26:10.500 prescribe and each patient is different and you know we'll 327 00:26:10.500 --> 00:26:15.900 prescribe each I mean we'll prescribe the device depending 328 00:26:15.900 --> 00:26:20.900 on the patient's requirement. And let us see this is 329 00:26:20.900 --> 00:26:26.200 about CPAP, BiPAP and auto CPAP. For intraoral devices 330 00:26:27.200 --> 00:26:31.000 although CPAP is a treatment of choice for patients with moderate or 331 00:26:31.000 --> 00:26:35.800 severe OSA for mild cases you can also try intraoral devices that 332 00:26:35.800 --> 00:26:40.800 is I think I don't have those pictures. 333 00:26:42.600 --> 00:26:46.800 In certain patients due to this bony issues that is small mandible 334 00:26:47.100 --> 00:26:52.900 and all those things there are certain devices which can just 335 00:26:53.700 --> 00:26:57.100 protrude your mandible a bit further during sleep. You just need to 336 00:26:57.100 --> 00:27:01.100 keep it like a brace and inside your mouth while sleeping. That 337 00:27:01.100 --> 00:27:04.700 helps in protruding your mandible a bit further so that the tongue 338 00:27:04.700 --> 00:27:08.100 there will be no tongue fall. Okay and you can breathe easily. 339 00:27:08.400 --> 00:27:13.100 These intraoral devices are not used routinely. We don't use routinely. These 340 00:27:13.100 --> 00:27:18.200 are like having used in European countries 341 00:27:18.200 --> 00:27:23.000 but in our India it is not used routinely. And yes coming 342 00:27:23.000 --> 00:27:27.300 to CPAP is a cornerstone of treatment. CPAP is a treatment of 343 00:27:27.300 --> 00:27:30.300 choice for patients with moderate or severe OSA. I already told you 344 00:27:30.400 --> 00:27:33.000 that it is whenever AHI is more than 15 then you should 345 00:27:33.000 --> 00:27:36.900 go for this CPAP. CPAP is indicated in all patients with AHI 346 00:27:36.900 --> 00:27:41.800 greater than 30 and on those patients with AHI more than five 347 00:27:41.800 --> 00:27:47.200 with associated symptoms of coma. And I have already 348 00:27:47.300 --> 00:27:52.600 discussed about auto CPAP. Auto CPAP is more tolerable. Okay. 349 00:27:52.800 --> 00:27:56.700 In according to the patient's requirement it will deliver between a minimum 350 00:27:56.700 --> 00:28:02.000 and maximum pressure. BiPAP is it will help in opening the lungs 351 00:28:02.000 --> 00:28:05.800 at the end of expiration. There will be no collapse of the 352 00:28:05.800 --> 00:28:11.000 airways. Subjects will feel more comfortable when using BiPAP when compared 353 00:28:11.000 --> 00:28:17.100 to normal CPAP. So the most important thing which we 354 00:28:17.100 --> 00:28:20.500 do fail I mean we do face in our routine practice whenever 355 00:28:20.500 --> 00:28:25.600 we prescribe any gadget like CPAP, BiPAP or auto CPAP 356 00:28:25.800 --> 00:28:29.600 to our patients with OSA they tend to ask us how many 357 00:28:29.600 --> 00:28:34.700 days should I keep it. Yeah. The answer is once a 358 00:28:34.700 --> 00:28:39.900 patient is having OSA obviously must be kept for a 359 00:28:40.200 --> 00:28:44.800 maybe long time some in some patients must be kept for a 360 00:28:45.300 --> 00:28:50.600 lifetime also. Okay. So there there will be definitely adherence 361 00:28:50.600 --> 00:28:56.100 issues that is synchrony between the patient and the CPAP 362 00:28:56.200 --> 00:29:01.200 machine may or may not be there. So there are certain factors 363 00:29:01.200 --> 00:29:05.800 which are affecting the adherence like if at all a patient feels 364 00:29:06.300 --> 00:29:11.300 symptomatic relief with the machine then obviously the patient will 365 00:29:12.800 --> 00:29:17.000 tend to keep it daily. And if there are certain side effects 366 00:29:17.000 --> 00:29:22.000 like nasal congestion and there is a patient feels a dryness 367 00:29:22.000 --> 00:29:26.800 of the mouth during initial stages of keeping CPAP then he may 368 00:29:26.800 --> 00:29:30.500 refuse it. So you should first counsel the patient that he may 369 00:29:30.500 --> 00:29:34.500 have these BiPAP therapy because there will be a lot of dry 370 00:29:34.500 --> 00:29:38.100 air which is coming through the machine and it is delivering. And 371 00:29:38.100 --> 00:29:41.100 if at all if the patient is feeling these issues you can 372 00:29:41.100 --> 00:29:46.400 add a humidifier to your machine and you should so initial acceptance 373 00:29:46.400 --> 00:29:51.500 is very much important whatever convey. And what are the methods 374 00:29:51.500 --> 00:29:56.600 to improve the adherence that is intensive education. You should 375 00:29:56.700 --> 00:30:00.600 educate the patient what are the benefits of taking the CPAP, how 376 00:30:00.600 --> 00:30:04.400 you can prevent brain strokes or heart attacks during with the help 377 00:30:04.400 --> 00:30:09.000 of the simple device and you can add humidifier if needed and 378 00:30:09.100 --> 00:30:13.400 if at all the patient is not happy with CPAP you can 379 00:30:14.600 --> 00:30:19.600 prescribe auto CPAP or a BiPAP CPAP depending on 380 00:30:19.900 --> 00:30:25.400 on the patient's acceptance. So whenever a patient uses a CPAP 381 00:30:25.500 --> 00:30:31.100 and first three months correctly it strongly indicates a long-term use and 382 00:30:31.600 --> 00:30:35.800 the most important thing is the patient must use at least six 383 00:30:35.800 --> 00:30:39.800 hours per night. Okay. This is not like keeping for one or 384 00:30:39.800 --> 00:30:45.200 two hours during sleep at least six hours you should continue this 385 00:30:45.400 --> 00:30:49.200 CPAP or BiPAP. I was discussing about these intraoral devices in the 386 00:30:49.200 --> 00:30:54.500 earlier slide. These let us just take 387 00:30:54.500 --> 00:30:59.300 a quick walk through these. However we are not using them routinely 388 00:30:59.300 --> 00:31:04.100 but you should have an idea. There are all devices like tongue 389 00:31:04.100 --> 00:31:08.700 retaining device, palatal lifting, mandibular advancing which I have explained you. So 390 00:31:08.700 --> 00:31:14.300 indications are like primary snorers only mild OSA. Okay. Where 391 00:31:14.300 --> 00:31:17.600 weight loss and CPAP have not been viable options due to various 392 00:31:17.600 --> 00:31:22.800 issues. They may have or the patient is not accepting 393 00:31:22.800 --> 00:31:27.600 CPAP then they were only you should go for intraoral devices. Okay. 394 00:31:28.900 --> 00:31:32.900 Why I am saying repeatedly that these are not routinely recommended because 395 00:31:33.000 --> 00:31:37.300 they do not reduce AHI as much as CPAP and higher the 396 00:31:37.300 --> 00:31:40.600 AHI the less benefit of intraoral devices and there will be side 397 00:31:40.600 --> 00:31:46.300 effects like excess salivation, transience, discomfort after awakening, temporomandibular 398 00:31:46.300 --> 00:31:51.400 joint discomfort etc. So these are certain intraoral devices 399 00:31:51.800 --> 00:31:56.900 although they're not used routinely. So that is about obstructive sleep 400 00:31:56.900 --> 00:32:02.300 apnea diagnosis and treatment. So just to 401 00:32:02.300 --> 00:32:07.400 quickly finish off we will also see what is central sleep apnea. 402 00:32:07.400 --> 00:32:11.100 Obstructive sleep apnea is you are having the obstruction just locally but 403 00:32:11.100 --> 00:32:15.400 a central CPAP apnea is you're not getting the ventilatory signals that 404 00:32:15.400 --> 00:32:19.300 is your brain is not giving the inputs to your lungs. You 405 00:32:19.300 --> 00:32:23.700 should breathe during the sleep. So this happens during in central sleep 406 00:32:23.700 --> 00:32:28.200 apnea patients. You can see in this picture clearly obstructive sleep apnea 407 00:32:28.200 --> 00:32:32.100 due to local factors. It is getting obstructed whereas in central CPAP 408 00:32:32.100 --> 00:32:36.100 the brain itself is not everything locally is fine. Everything is patent 409 00:32:36.100 --> 00:32:41.400 but the brain is not giving any signals to to 410 00:32:41.400 --> 00:32:45.500 the lungs to breathe. So this is called central sleep apnea. This 411 00:32:45.500 --> 00:32:50.900 is a simple sleep study report of obstructive 412 00:32:50.900 --> 00:32:54.600 sleep apnea patient and central sleep apnea. Here you can see the 413 00:32:54.600 --> 00:32:59.900 chest movements are present in obstructive sleep apnea that 414 00:33:00.200 --> 00:33:03.900 patient is trying to breathe. The the chest is moving but due 415 00:33:03.900 --> 00:33:07.100 to this obstruction is unable to breathe. There is no nasal flow 416 00:33:07.300 --> 00:33:09.900 whereas here the chest there is no chest movement that is the 417 00:33:09.900 --> 00:33:13.000 brain signals are not there to the chest and it's not moving 418 00:33:13.000 --> 00:33:17.200 at all and there is no nasal flow. So that is about 419 00:33:17.200 --> 00:33:19.200 central sleep apnea. Upper airway resistance syndrome is also one or more 420 00:16:41.200 --> 00:16:45.000 component which is different from obstructive sleep apnea where the patient is 421 00:16:45.900 --> 00:16:48.500 not obese but still has this sleep apneas. That is UARS. 422 00:16:52.600 --> 00:16:52.600 UARS patients are young young age group males with lower 423 00:16:57.600 --> 00:16:57.600 body mass index. CPAP is still the most frequent recommended treatment option 424 00:17:02.400 --> 00:17:02.400 for them. So that is about various 425 00:17:06.300 --> 00:17:07.300 sleep disorder breathing 426 00:33:47.800 --> 00:33:50.500 where we are focused more on obstructive sleep apnea which is most 427 00:33:50.500 --> 00:33:55.500 common. So I will like to conclude my talk by saying 428 00:33:55.500 --> 00:34:01.000 that sleep related breathing disorders are increasingly common. And recognition 429 00:34:01.200 --> 00:34:05.600 that sleep medicine is a unique discipline is very important. The primary 430 00:34:05.700 --> 00:34:10.800 care physicians general physicians should definitely try to refer the patients 431 00:34:10.800 --> 00:34:15.300 to a sleep specialist if needed. And an enormous impact of sleep 432 00:34:15.300 --> 00:34:20.500 is disturbances on many aspects of our life is present definitely 433 00:34:20.700 --> 00:34:25.000 as I have already showed you. If you don't treat sleep apnea 434 00:34:25.000 --> 00:34:28.800 patients what happens, so what are the complications to the patients face 435 00:34:29.200 --> 00:34:34.800 and also there is a very much need to educate the community 436 00:34:34.800 --> 00:34:38.900 regarding the symptoms of sleep disorder breathing and informing that there is 437 00:34:38.900 --> 00:34:44.200 there are specific treatments which exist do exist and they really work 438 00:34:44.200 --> 00:34:46.900 like a magic to the patient. So I have already explained you 439 00:34:46.900 --> 00:34:53.700 in detail about this obesity and sleep apnea. Everything 440 00:34:54.600 --> 00:34:59.900 the pathophysiology of obstructive sleep apnea especially in obese individuals 441 00:35:00.700 --> 00:35:06.200 is due due to their increased soft tissue in their upper respiratory 442 00:35:06.200 --> 00:35:12.200 tract where their bony structures are unable to incorporate 443 00:35:12.200 --> 00:35:17.300 them. During wake awake situations during daytime the 444 00:35:17.300 --> 00:35:21.700 muscles tend to open the airways in a good manner. However during 445 00:35:21.700 --> 00:35:28.300 sleep these muscles tend to relax. And there will be collapse 446 00:35:28.300 --> 00:35:32.500 of the upper airway because of crowding of the upper airway due 447 00:35:32.500 --> 00:35:36.600 to increased soft tissue due to obesity. So this is how it 448 00:35:36.600 --> 00:35:42.300 happens in obese individuals actually. All right sir. Moving 449 00:35:42.300 --> 00:35:47.700 on to the next question. What are the basic or potential 450 00:35:47.700 --> 00:35:52.900 cardiovascular consequences of untreated obstructive sleep apnea and 451 00:35:53.000 --> 00:35:58.000 how they can impact in long-term health? Yeah. 452 00:35:58.000 --> 00:36:01.300 So this this point was also discussed in detail that is during 453 00:36:01.300 --> 00:36:06.500 sleep apnea there will be hypoxia and 454 00:36:06.600 --> 00:36:11.800 there will be again reoxygenation. So this cycle will lead to 455 00:36:12.000 --> 00:36:17.000 inflammatory cascade. There will be reactive oxygen species forming. These 456 00:36:17.000 --> 00:36:22.800 reactive oxygen species will tend to damage your heart, your small 457 00:36:22.800 --> 00:36:27.800 blood vessels and there will be plaque formation and everything. 458 00:36:27.800 --> 00:36:33.200 So this can lead to MI myocardial infarction. Okay. 459 00:36:33.300 --> 00:36:38.400 There will be increased oxygen demand by your myocardial muscles and also 460 00:36:38.600 --> 00:36:42.900 there will be arrhythmias because of sympathetic activation. Whenever you are just 461 00:36:42.900 --> 00:36:47.800 waking up suddenly because of hypoxia during sleep your sympathetic system is 462 00:36:47.800 --> 00:36:53.100 activated suddenly and there will be arrhythmias. Okay. So you got MI, 463 00:36:53.100 --> 00:36:57.500 you got arrhythmias and due to sympathetic activation there will be increased 464 00:36:57.900 --> 00:37:02.900 blood pressure that is hypertension. Okay. So most of the times when 465 00:37:03.600 --> 00:37:09.100 in general physicians do refer to the specialty that obese 466 00:37:09.100 --> 00:37:14.500 individual who is whose BP is uncontrolled and history of recent angina. 467 00:37:14.600 --> 00:37:19.800 So these people generally tend to have OSA. Okay. So 468 00:37:19.800 --> 00:37:24.800 these are certain myocardial issues which are faced by 469 00:37:24.800 --> 00:37:29.900 the patient with sleep apnea. All right sir rightly mentioned. So 470 00:37:29.900 --> 00:37:34.000 moving on to the last question of today's session that is what 471 00:37:34.000 --> 00:37:38.700 are the alternative treatment options for patient who are intolerant to CPAP 472 00:37:38.700 --> 00:37:43.700 therapy? Yes. So as we already discussed so 473 00:37:43.700 --> 00:37:49.900 first of all the most important thing which I always suggest 474 00:37:49.900 --> 00:37:54.800 my patients to lose weight first and most important thing. Okay. Whenever 475 00:37:54.800 --> 00:37:59.900 the patient loses weight definitely there is a better tolerance to their 476 00:37:59.900 --> 00:38:04.700 CPAP devices and also the requirement of pressures in the CPAP comes 477 00:38:04.700 --> 00:38:09.600 down if you lose weight. So weight loss strategies second most important 478 00:38:09.600 --> 00:38:14.800 thing which I have already discussed is the sleep hygiene. Okay. 479 00:38:15.000 --> 00:38:20.400 They should maintain their proper sleep cycle, proper bedtime, proper awakening. 480 00:38:20.600 --> 00:38:25.100 They should avoid the evening time exercises and all those things, stimulants, 481 00:38:25.200 --> 00:38:30.700 reduce screen time everything. And there are certain therapies 482 00:38:30.700 --> 00:38:35.400 which are called intraoral devices which can help in maintaining the upper 483 00:38:35.400 --> 00:38:39.700 airway patency which I have already showed you. So intraoral devices and 484 00:38:39.700 --> 00:38:44.900 positionals obstructive sleep apnea POSA P O S A that 485 00:38:44.900 --> 00:38:49.100 is the patient is getting sleep apnea only during some position. Okay. 486 00:38:49.100 --> 00:38:54.000 This can also be seen in your sleep study report. For example 487 00:38:54.000 --> 00:38:57.900 a patient is having during supine. So the you should ask him 488 00:38:57.900 --> 00:39:01.200 to lie on the right lateral or the left lateral side to 489 00:39:01.200 --> 00:39:06.100 avoid this sleep apnea during his sleep. So generally how this is 490 00:39:06.100 --> 00:39:09.800 maintained because whenever we sleep we tend to move in all directions. 491 00:39:09.800 --> 00:39:14.800 Right. So the traditional method of doing 492 00:39:14.800 --> 00:39:20.800 this is they will stitch some I mean four to five balls 493 00:39:21.500 --> 00:39:25.600 and they keep in their back and aligned to the spine so 494 00:39:25.600 --> 00:39:29.700 that they can't sleep supine. So they have to fall asleep on 495 00:39:29.700 --> 00:39:33.500 the right or left. So this is one of the method if 496 00:39:33.500 --> 00:39:37.600 really the patient is unable to take CPAP and he has positional 497 00:39:37.600 --> 00:39:42.600 sleep apnea this also you can try. And surgical options. 498 00:39:42.800 --> 00:39:47.900 ENT colleagues are really wonderful in doing these procedures. If 499 00:39:47.900 --> 00:39:52.000 at all you want to correct the anatomy. Okay. You can correct 500 00:39:52.000 --> 00:39:56.500 the anatomy and you can just free up the obstructive space and 501 00:39:56.500 --> 00:40:00.100 the most important thing which you should tell your patient that even 502 00:40:00.100 --> 00:40:04.800 though they have surgery even though they get the surgery done still 503 00:40:04.800 --> 00:40:08.100 they may need to have they may need to use the CPAP 504 00:40:08.100 --> 00:40:13.200 in future. Your surgery is not 100% curable in all patients. Some 505 00:40:13.200 --> 00:40:17.200 patients may also need to use the CPAP on a long on 506 00:40:17.200 --> 00:40:21.800 a longer run although they underwent surgery. So these are some options 507 00:40:21.900 --> 00:40:26.900 along with the CPAP. All right sir. So with this I 508 00:40:26.900 --> 00:40:29.500 would like to thank you so much for taking out time and 509 00:40:29.500 --> 00:40:33.100 delivering such a wonderful and insightful session for all of us. I'm 510 00:40:33.100 --> 00:40:37.600 sure all our attendees would love to extract bits and parts of 511 00:40:37.600 --> 00:40:41.500 this session and we are really looking forward to have you again 512 00:40:41.500 --> 00:40:45.000 with more such amazing and insightful session in your future. Thank you 513 00:40:45.000 --> 00:40:45.600 so much sir.