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Obstructive sleep apnea

Highlights

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common sleep disorder. It occurs when tissues in the upper airways come too close to each other during sleep, temporarily blocking the inflow of air.

Who Is At Risk

Obstructive sleep apnea can develop in anyone at any age but most often occurs in people who are:

Sleep Apnea Symptoms

Symptoms of sleep apnea include:

Lifestyle Changes

Patients with sleep apnea may find these lifestyle changes helpful:

Treatment

The treatment of obstructive sleep apnea depends in part on the severity of the condition. Treatment options include:

Guidelines for Childhood Obstructive Sleep Apnea

Recent guidelines from the American Academy of Pediatrics (AAP) recommend:

Introduction

Obstructive sleep apnea (OSA) is a disorder in which a person temporarily stops breathing during the night, perhaps hundreds of times. These gaps in breathing are called apneas. The word apnea means absence of breath. An obstructive apnea episode is defined as the absence of airflow for at least 10 seconds.

Sleep apnea is usually accompanied by snoring, disturbed sleep, and daytime sleepiness. Many people with OSA do not even know they have the condition.

Obstructive sleep apnea (OSA) occurs when tissues in the upper throat relax and come together during sleep, temporarily blocking the passage of air. In general, OSA occurs as follows:

Obstructive sleep apnea is defined as five or more episodes of apnea or hypopnea per hour of sleep (called apnea-hypopnea index or AHI) in individuals who have excessive daytime sleepiness. Patients with 15 or more episodes of apnea or hypopnea per hour of sleep are considered to have moderate sleep apnea.

Causes

All of the muscles in the body relax during sleep. In people without obstructive sleep apnea, the throat muscles relax but do not block the airways. In patients with obstructive sleep apnea, the airways do become temporarily blocked or narrowed during sleep, reducing air pressure and preventing air from flowing normally into the lungs.

Certain physical characteristics of the face, skull, and neck can affect the size of the airway.

Large Neck. A large neck (17 inches or greater in men and 16 inches or greater in women) is a risk factor for sleep apnea. While some people’s necks are naturally larger than others, being overweight or obese can contribute to having a large neck.

Facial and Skull Characteristics. Structural abnormalities in the face and skull contribute to many cases of sleep apnea. These abnormalities include:

Soft Palate Characteristics. Some people have specific abnormalities in the soft area (palate) at the back of the mouth and throat that may lead to sleep apnea. These abnormalities include:

Muscle Weakness. Abnormalities or weakness in the muscles that surround the airway can also contribute to obstructive sleep apnea.

Sleep apnea occurs in about 2% of children and can occur even in very young children. The most likely causes include:

Risk Factors

Obstructive sleep apnea is more common in men than in women. Men tend to have larger necks and weigh more than women. However, women tend to gain weight and develop larger necks after menopause, which increases their risk of developing sleep apnea.

Sleep apnea is most common in adults ages 40 - 60 years old. Middle age is also when symptoms are worse. Nevertheless, sleep apnea can affect people of all ages.

African-Americans face a higher risk for sleep apnea than any other ethnic group in the United States. Other groups at increased risk include Pacific Islanders and Mexicans.

People with a family history of obstructive sleep apnea are at increased risk of developing the condition.

Being overweight or obese is a strong risk factor for sleep apnea in adolescents and children as well as adults. Excess weight can contribute to sleep apnea when fat deposits fill throat tissue.

Smoking. Smokers are at higher risk for apnea. Those who smoke more than two packs a day have a risk 40 times greater than nonsmokers.

Alcohol. Alcohol use may be associated with apnea. Patients diagnosed with sleep apnea are recommended not to drink alcohol before bedtime.

Diabetes. Diabetes is associated with sleep apnea and snoring. It is not clear if there is an independent relationship between the two conditions or whether obesity is the only common factor.

Gastroesophageal Reflux Disease (GERD). GERD is a condition caused by acid backing up into the esophagus. It is a common cause of heartburn. GERD and sleep apnea often coincide. Research suggests that the backup of stomach acid in GERD may produce spasms in the vocal cords (larynx), thereby blocking the flow of air to the lungs and causing apnea. Apnea itself may also cause pressure changes that trigger GERD. Obesity is common in both conditions, and more research is needed to clarify the association.

Polycystic Ovary Syndrome (PCOS). Obstructive sleep apnea and excessive daytime sleepiness appear to be associated with polycystic ovary syndrome (PCOS), a female endocrine disorder. About half of patients with PCOS also have diabetes. Obesity and diabetes are associated with both sleep apnea and PCOS and may be the common factors.

Complications

Sleep apnea can lead to a number of complications, ranging from daytime sleepiness to possible increased risk of death. Sleep apnea has a strong association with several diseases, particularly those related to the heart and circulation.

Daytime sleepiness is the most noticeable, and one of the most serious, complications of sleep apnea. It interferes with mental alertness and quality of life. Daytime sleepiness can also increase the risk for accident-related injuries. Many studies have shown that people with sleep apnea have a significantly increased risk for drowsy driving and car accidents. Undertreated sleep apnea is a major risk factor for injury at factory and construction work sites.

Sleep-disordered breathing is very common among patients with heart problems such as high blood pressure, heart failure, stroke, heart attack, and atrial fibrillation. This link may be because both cardiovascular conditions and sleep apnea share a common risk factor of obesity. However, increasing evidence suggests that severe OSA is an independent risk factor that may cause or worsen a number of heart-related conditions.

High Blood Pressure. Moderate-to-severe sleep apnea definitely increases the risk for high blood pressure (hypertension) even when obesity is not a factor. Doctors are not certain whether treating OSA with CPAP reduces the risk for high blood pressure, but studies indicate that CPAP may help prevent or decrease high blood pressure.

Coronary Artery Disease and Heart Attack. Sleep apnea appears to be associated with heart disease regardless of the presence of high blood pressure or other heart risk factors. Studies suggest that patients with moderate-to-severe obstructive sleep apnea have a higher risk for heart attack.

Stroke. Sleep apnea may increase the risk of death in patients who have previously had a stroke.

Heart Failure. Up to a third of patients with heart failure also have sleep apnea. Central sleep apnea often results from heart failure. Obstructive sleep apnea can cause heart damage that worsens heart failure and increases the risk for death.

Atrial Fibrillation. Sleep apnea may be a cause of atrial fibrillation (irregular heartbeat).

Sleep apnea is associated with a higher incidence of many medical conditions, besides heart and circulation. The links between apneas and these conditions are unclear.

Studies report an association between severe apnea and psychological problems. The risk for depression rises with increasing severity of sleep apnea. Sleep-related breathing disorders can also worsen nightmares and post-traumatic stress disorder.

Because sleep apnea so often includes noisy snoring, the condition can adversely affect the sleep quality of the bed partner. Spouses or partners may also suffer from sleeplessness and fatigue. In some cases, the snoring can disrupt relationships. Diagnosis and treatment of sleep apnea in the patient can help eliminate these problems.

Failure to Thrive. Small children with undiagnosed sleep apnea may "fail to thrive," that is, they do not gain weight or grow at a normal rate and they have low levels of growth hormone. In severe cases, this may affect the heart and central nervous system.

Attention Deficits and Hyperactivity. Problems in attention and hyperactivity are common in children with sleep apnea. There is some evidence that such children may be misdiagnosed with attention-deficit hyperactivity disorder. Even children who snore and do not have sleep apnea may be at higher risk for poor concentration.

Symptoms

People with sleep apnea usually do not remember waking during the night.

Symptoms may include:

Sleep apnea occurs in about 2% of children. They may have symptoms that differ from adults, including:

Diagnosis

In diagnosing obstructive sleep apnea, the doctor will ask about your medical and sleep history, and conduct a physical exam. If symptoms suggest obstructive sleep apnea or another sleep disorder, further diagnostic testing may be performed. Your doctor may recommend you see a sleep specialist or have a sleep study (polysomnography) performed at a sleep disorders center.

Symptoms or signs that may indicate the need for a sleep study include:

To help determine the presence of obstructive sleep apnea, the doctor will ask the following questions:

The doctor will check for physical indications of sleep apnea, including:

The doctor will also consider conditions other than sleep apnea that may cause daytime sleepiness including:

Polysomnography is the technical term for an overnight sleep study that involves recording brain waves and other sleep-related activity. Polysomnography is typically performed at a sleep center. The patient sleeps in a room that resembles a hotel room but is equipped with a video camera and monitoring station.

The patient arrives about 2 hours before bedtime without having made any changes in daily habits. A trained technician places electrodes (similar to the sticky pads used for EKG’s) on the patient’s face and head, a sensor on the finger, and a sensor in the nose. Special belts are placed around the waist to monitor breathing activity. These devices are all painless. They are used to collect data on eye movements, brain activity, and oxygen levels. Wires attached to these devices transmit data to the technician in the monitoring room. The technician will score the sleep pattern data throughout the night as the patient passes through the various sleep stages. The patient is discharged in the morning. A sleep specialist doctor will later evaluate the data that was collected and send a report to your doctor.

If you show signs of moderate-to-severe sleep apnea during your sleep, the technician may wake you up during the night to perform a split-night polysomnography. In split-night polysomnography, during the second part of the night patients are fitted with a CPAP mask and receive a CPAP titration study to adjust the amount of air flow coming through the mask. In centers that do not do split-night polysomnography, patients may need to return for a second overnight sleep study to have CPAP titration performed.

Diagnostic testing at home with portable monitors may be an option for patients who appear, based on history and physical exam, to have a high likelihood of moderate-to-severe OSA but who do not have other major medical disorders or other sleep disorders, such as narcolepsy.

Portable monitors should only be used if the patient receives a comprehensive sleep evaluation by a board-certified sleep specialist. The monitors use nasal and respiratory sensors to record airflow, respiratory effort, and blood oxygen levels. The patient needs to be educated in how to use them by an experienced sleep technician.

Patients are shown how to use these devices and then sent home. Many of these devices are also capable of titrating CPAP levels (see Treatment section).

Lifestyle Changes

Body position greatly affects the number and severity of episodes of obstructive sleep apnea, with at least twice as many apneas occurring in people who lay on their back as in those who sleep on their side. This may be due to the effects of gravity, which cause the throat to narrow when a person lies on the back. (Indeed, astronauts show a marked reduction in apneas and snoring in the weightlessness of space.) Positional sleep apnea affects people of all ages, including young children.

As a first step in dealing with sleep apnea, the patient should simply try rolling over onto the side. Patients who sleep on their backs and have 50 - 80 apneas per hour can sometimes nearly eliminate them when they shift to one side or the other. (Changing positions is less effective the more overweight a person is, but it still helps.)

Here are some suggestions that can help maintain a low-risk sleeping position:

All patients with obstructive sleep apnea who are overweight should attempt a weight-reducing program. Weight loss reduces snoring and apnea/hypopnea episodes in many people, sometimes stopping it completely. It also improves sleep and significantly reduces daytime sleepiness.

Treatment

Treatment for sleep apnea depends on the severity of the problem. Given the data on the long-term complications of sleep apnea, it is important for patients to treat the problem as they would any chronic disease. Simply trying to treat snoring will not treat sleep apnea. (Remember that snoring does not necessarily indicate sleep apnea.) Because of its association with heart problems and stroke, sleep apnea that does not respond to lifestyle measures should be treated by a doctor, ideally a sleep disorders specialist.

The most effective treatment for sleep apnea is CPAP, a device that delivers slightly pressurized air to keep the throat open during the night.

The best treatment for obstructive sleep apnea is a system known as continuous positive airflow pressure (CPAP). It is safe and effective for people of all ages, including children. Patients with obstructive sleep apnea who use CPAP feel better rested, have less daytime sleepiness, and have improved concentration and memory. In addition, CPAP may potentially reduce the risks for heart problems such as high blood pressure. For maximum benefit, CPAP should be used for at least 6 - 7 hours each night.

CPAP works in the following way:

The standard CPAP machine delivers a fixed, constant flow of air. Variations on CPAP include:

CPAP works well but it can take some time to get used to, especially for the first few nights. Here are some tips to help you adjust:

In general, drugs are not very helpful except for specific situations. Medications that treat accompanying disorders associated with sleep apnea may be helpful. They include:

Note on Sedatives. Sedatives, narcotics, antidepressants, and anti-anxiety drugs can actually worsen the breathing disturbances and arousal conditions that occur with sleep apnea. These substances cause the soft tissues in the throat to sag and diminish the body's ability to inhale. Apnea sufferers should never use sleeping pills or tranquilizers. Apnea patients undergoing surgery should be sure that their surgeons, anesthesiologists, and other doctors are aware of their sleeping disorder in considering sedatives, anesthetics, and medications taken to relieve pain due to surgery.

Dental Devices

Oral appliances, also called dental appliances or devices, may be an option for patients who cannot tolerate CPAP. The American Academy of Sleep Medicine recommends dental devices for patients with mild-to-moderate obstructive sleep apnea who are not appropriate candidates for CPAP or who have not been helped by it. (CPAP should be used for patients with moderate-to-severe sleep apnea whenever possible.)

Several different dental devices are available. A trained dental professional such as a dentist or orthodontist should fit these devices. Devices include:

Patients fitted with one of these devices should have a check-up early on to see if it is working; short-term success usually predicts long-term benefits. It may need to be adjusted or replaced periodically.

Benefits of Dental Devices. Dental devices seem to offer the following benefits:

Disadvantages of Dental Devices. Dental devices are not as effective as CPAP therapy. The cost of these devices tends to be high. Side effects associated with dental devices include:

An orthodontic treatment called rapid maxillary expansion, in which a screw device is temporarily applied to the upper teeth and tightened regularly, may help patients with sleep apnea and a narrow upper jaw. This nonsurgical procedure helps to reduce nasal pressure and improve breathing.

Surgery

Surgery is sometimes recommended, usually by ear, nose, and throat specialists, for severe obstructive sleep apnea. A patient should be sure to seek a second opinion from a specialist in sleep disorders. Few randomized clinical trials, the gold standard of medical research, have been conducted to verify the long-term efficacy of sleep apnea surgery.

The Procedure. Surgery known as uvulopalatopharyngoplasty (UPPP) removes soft tissue on the back of the throat. Such tissue includes all or part of the uvula (the soft flap of tissue that hangs down at the back of the mouth) and parts of the soft palate and the throat tissue behind it. If tonsils and adenoids are present, they are removed. The surgery typically requires a stay in the hospital.

The Goal of Surgery. The goal of UPPP is threefold:

Success Rates. The American Academy of Sleep Medicine does not endorse UPPP as a sole procedure for treating OSA. The AASM recommends that patients considering this surgery first try CPAP or dental devices.

There is limited evidence as to the effectiveness of UPPP. Studies suggest that success rates for sleep apnea surgery are rarely higher than 65% and often deteriorate with time, averaging about 50% or less over the long term. Few studies have been conducted on which patients make the best candidates. Some studies suggest that surgery is best suited for patients with abnormalities in the soft palate. Results are poor if the problems involve other areas or the full palate. In such cases, CPAP is superior and should always be tried first. Many or most patients with moderate or severe sleep apnea will likely still require CPAP treatment after surgery.

Complications. Uvulopalatopharyngoplasty is among the most painful treatments for sleep apnea, and recovery takes several weeks. The procedure also has a number of potentially serious complications including:

In general, only a small percentage of patients experience serious complications. Many of these complications can be avoided with proper technique and experienced surgeon. A patient's health status, including presence of obesity and other health conditions, may also affect outcomes.

A variation on UPPP called laser-assisted uvulopalatoplasty (LAUP) is being increasingly performed to reduce snoring. It removes less tissue at the back of the throat than UPPP and can be done in a doctor's office. At this time, however, long-term success rates in the treatment of obstructive sleep apnea with LAUP are very modest, particularly for reducing apneas. Some doctors, in fact, are concerned that if LAUP eliminates snoring, they may miss a diagnosis of apnea in patients who have the more serious condition.

More than half of patients complain of throat dryness after surgery. Throat narrowing and scarring have also been reported. In a minority of patients, snoring becomes worse afterward.

According to recent guidelines from the American Academy of Sleep Medicine (AASM), LAUP is not routinely recommended as treatment for obstructive sleep apnea. According to the AASM, this surgery generally does not help improve symptoms and may actually worsen the condition.

The pillar palatal implant is a noninvasive surgical treatment for mild-to-moderate sleep apnea and snoring. However, the main focus of the procedure is a reduction in snoring. The implant helps reduce the vibration and movement of the soft palate. In this procedure, a doctor inserts 3 short pieces of polyester string into the soft palate. The procedure can be performed in a doctor’s office and takes about 10 minutes. Unlike uvulopalatopharyngoplasty (UPPP), the pillar procedure requires only local anesthesia and has less pain and quicker recovery time. There is still not enough evidence to determine whether it is an effective treatment for obstructive sleep apnea.

Tracheostomy used to be the only treatment for sleep apnea. It is quite straightforward:

Today, this operation is performed rarely, usually only if sleep apnea is life threatening.

Other surgical procedures may be appropriate to correct facial abnormalities or obstructions that cause sleep apnea. They may be used alone or combined with each other or with UPPP. Most are invasive and reserved for patients with severe sleep apnea who fail to respond to or comply with CPAP. Overall, there is limited evidence as to their effectiveness in treating OSA. These procedures include:

Adenotonsillectomy, or surgical removal of the tonsils and adenoids, is a first-line treatment for children and adolescents with sleep apnea proven by sleep studies. It cures or improves the condition in most patients.

Complications include respiratory illness, which occurs in about 25% of children after the surgery. The highest risk for respiratory complications is associated with:

The procedure may fail to improve apnea in some patients, such as those with very severe disease. Such children are candidates for continuous positive airway pressure (CPAP) therapy.

Removal of the tonsils and adenoids alone is not an effective treatment for adults with sleep apnea, although the procedure may be effective when combined with UPPP surgery.

Resources

References

Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine, Epstein LJ, Kristo D, Strollo PJ Jr, Friedman N, Malhotra A, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009 Jun 15;5(3):263-76.

Aurora RN, Casey KR, Kristo D, Auerbach S, Bista SR, Chowdhuri S, et al. Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. Sleep. 2010 Oct;33(10):1408-13.

Ballard RD. Management of patients with obstructive sleep apnea. J Fam Pract. 2008 Aug;57(8 Suppl):S24-30.

Barbé F, Durán-Cantolla J, Sánchez-de-la-Torre M, Martínez-Alonso M, Carmona C, Barceló A, et al. Effect of continuous positive airway pressure on the incidence of hypertension and cardiovascular events in nonsleepy patients with obstructive sleep apnea: a randomized controlled trial. JAMA. 2012 May 23;307(20):2161-8.

Basner RC. Continuous positive airway pressure for obstructive sleep apnea. N Engl J Med. 2007 Apr 26;356(17):1751-8.

Bradley TD, Floras JS. Obstructive sleep apnoea and its cardiovascular consequences. Lancet. 2009 Jan 3;373(9657):82-93. Epub 2008 Dec 26.

Campos-Rodriguez F, Martinez-Garcia MA, de la Cruz-Moron I, Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Ann Intern Med. 2012 Jan 17;156(2):115-22.

Caples SM, Rowley JA, Prinsell JR, Pallanch JF, Elamin MB, Katz SG, et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep. 2010 Oct;33(10):1396-407.

Chan AS, Lee RW, Cistulli PA. Dental appliance treatment for obstructive sleep apnea. Chest. 2007 Aug;132(2):693-9.

Collop NA, Anderson WM, Boehlecke B, Claman D, Goldberg R, Gottlieb DJ, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2007 Dec 15;3(7):737-47.

Franklin, KA, Anttila H, Axelsson S, Gislason T, Maasilta P, Myhre K I, et al. Effects and side-effects of surgery for snoring and obstructive sleep apnea--a systematic review. Sleep. 2009 Jan 1; 32(1): 27-36.

Friedman M, Schalch P. Surgery of the palate and oropharynx. Otolaryngol Clin North Am. 2007 Aug;40(4):829-43.

Hirshkowitz M. The clinical consequences of obstructive sleep apnea and associated excessive sleepiness. J Fam Pract. 2008 Aug;57(8 Suppl):S9-16.

Kasai T, Bradley TD. Obstructive sleep apnea and heart failure: pathophysiologic and therapeutic implications. J Am Coll Cardiol. 2011 Jan 11;57(2):119-27.

Marcus CL, Brooks LJ, Draper KA, Gozal D, Halbower AC, Jones J, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012 Sep;130(3):576-84. Epub 2012 Aug 27.

Marcus CL, Moore RH, Rosen CL, Giordani B, Garetz SL, Taylor HG, et al. A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013 Jun 20;368(25):2366-76. Epub 2013 May 21.

Marin JM, Agusti A, Villar I, Forner M, Nieto D, Carrizo SJ, et al Association between treated and untreated obstructive sleep apnea and risk of hypertension. JAMA. 2012 May 23;307(20):2169-76.

Marshall NS, Wong KK, Liu PY, Cullen SR, Knuiman MW, Grunstein RR. Sleep apnea as an independent risk factor for all-cause mortality: the Busselton Health Study. Sleep. 2008 Aug 1;31(8):1079-85.

Morgenthaler T, Alessi C, Friedman L, Owens J, Kapur V, Boehlecke B, et al. Practice parameters for the use of actigraphy in the assessment of sleep and sleep disorders: an update for 2007. Sleep. 2007 Apr 1;30(4):519-29.

Morgenthaler TI, Aurora RN, Brown T, Zak R, Alessi C, Boehlecke B, et al. Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007. An American Academy of Sleep Medicine report. Sleep. 2008 Jan 1;31(1):141-7.

Morgenthaler TI, Kapen S, Lee-Chiong T, Alessi C, Boehlecke B, Brown T, Coleman J, et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep. 2006 Aug 1;29(8):1031-5.

Patel NP, Ahmed M, Rosen I. Split-night polysomnography. Chest. 2007 Nov;132(5):1664-71.

Patil SP, Schneider H, Schwartz AR, Smith PL. Adult obstructive sleep apnea: pathophysiology and diagnosis. Chest. 2007 Jul;132(1):325-37.

Powell S, Kubba H, O'Brien C, Tremlett M. Paediatric obstructive sleep apnoea. BMJ. 2010 Apr 14;340:c1918.

Somers VK. Sleep apnea and cardiovascular disease. In: Bonow RO, Mann DL, Zipes DP, Libby P, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. Saunders; 2011:chap 79.

Somers VK, White DP, Amin R, Abraham WT, Costa F, Culebras A, et al. Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008 Aug 19;52(8):686-717.

Strohl KP, Brown DB, Collop N, George C, Grunstein R, Han F, et al. An official American Thoracic Society Clinical Practice Guideline: sleep apnea, sleepiness, and driving risk in noncommercial drivers. An update of a 1994 Statement. Am J Respir Crit Care Med. 2013 Jun 1;187(11):1259-66.

Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, et al. Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep. 2008 Aug 1;31(8):1071-8.



Review Date: 9/23/2013
Reviewed By: Harvey Simon, MD, Editor-in-Chief, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.
The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition. A licensed medical professional should be consulted for diagnosis and treatment of any and all medical conditions. Links to other sites are provided for information only -- they do not constitute endorsements of those other sites. © 1997- A.D.A.M., Inc. Any duplication or distribution of the information contained herein is strictly prohibited.
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