Proportion Of Obstructive Sleep apneu (Osa) Risk in Stroke patients in General Hospital Sanglah Denpasar.
Proportion Of Obstructive Sleep apneu (Osa) Risk in Stroke patients in General Hospital
Sanglah Denpasar ***
Triatmoko, Indira Chadijah*, Buadiarsa, IGN **, Utami, DK Indrasari**, Widyadharma, Putu Eka **
Neurology Department, Faculty of Medicine, Udayana University/Sanglah General Hospital
Denpasar, Bali
ABSTRACT
BACKGROUND
Obstructive Sleep Apnea (OSA) has been associated with a number of diseases, which has
been associated with the incidence of stroke. The incidence of OSA in Indonesia is estimated to be
around 1-4% of the general population. Patients with cardiovascular disease have a high prevalence of
OSA, an estimated 50% of patients with acute stroke. Many hospitals in Indonesia do not yet have
sleep clinic therefor OSA diagnosis by polysomnography can not be established, including in Sanglah
Hospital. We used Berlin questionnaire to determine risk of OSA in patients with stroke that were
hospitalized in stroke unit.
PURPOSE
To determine the proportion risk of OSA in patients with stroke in General Hospital Sanglah
Denpasar.
METHOD
A descriptive study using primary data. Sampling was done by consecutive sampling method.
The research using Berlin Questionnaire for risk OSA. Data obtained from this study were analyzed
descriptively with SPSS 16.00 for windows.
RESULTS
Total Sample of 44 stroke patients were taken during the period of May 2015 with the
proportion of men is 32 people (72.7%) and women is 12 people (27,3%) with the mean age of
subjects 55,23+12,76 years old. Proportion of high risk OSA is 29 people (65,9%) and low risk is 15
people (34,1%).
CONCLUSION
This study finds a large proportion of high risk OSA in stroke patients.
Keywords: obstructive sleep apneu, stroke, stroke unit
==================================================================
*Resident of Neurology Department, Faculty of Medicine, Udayana University/ Sanglah General
Hospital Denpasar
**Lecturer of Neurology Department, Faculty of Medicine, Udayana University/ Sanglah General
Hospital Denpasar
*** Presented at KONAS PERDOSSI MAKASSAR, Augustus, 7-9th 2015
INTRODUCTION
Obstructive Sleep Apnea (OSA) is a form of abnormality that is a part of a complex sleep
disorder breathing syndrome. The symptoms of OSA are common but often they are not diagnosed
early in routine examination. Most people have experienced OSA but they are unaware of it and
don’ t really pay attention to the symptoms as these are considered as non-dangerous, with no adverse
effect.
The first article about OSA was published in 1956 by Sidney Burwell. The prevalence of
OSA in developed countries is estimated to be 2-4% in males and 1-2% in females. The prevalence of
OSA in males is 2-3 times higher than female. It hasn’ t been fully understood why OSA is less
common in females.1,3
The incidence of OSA is estimated to be 1– 4% in general population. Individuals with OSA
who have snoring habit usually have more frequent apnea, hipopnea and decreased oxyhemoglobin
saturation during sleep compared to those who don’ t snore. The frequency of OSA reaches its peak
at the fifth and sixth decade of life, and decreases after 60s. In general, however, the frequency of
OSA increases progressively with advancing age.1,2,3,4, 5
Patients with cardiovascular diseases have high rate of OSA. The prevalence is around 50% in
patients with hypertension, 50% in patients with atrial fibrillation that requires cardioversion, 33% in
patients with only atrial fibrillation, 33% in patients with coronary artery disease, 50% in patients with
acute stroke and 30-40% in patients with heart failure and systolic dysfunction. High OSA incidence
(45-90%) was found in stroke patients. The potential role of OSA in the pathogenesis of stroke among
others are through the process of atherosclerosis, hypertension, reduced cerebral perfusion due to
thickening of carotid artery, low heart output, increased intracranial pressure, increased coagulopathy
and increased risk of the formation of blood clot due to arrhythmia. Due to the high incidence of OSA
and its potential effect on morbidity and mortality, the examination to diagnose and manage OSA is
highly advised in patients with stroke.1
Obstructive sleep apnea is defined as the cessation of air flow in the nose and mouth during
sleep for more than 10 seconds followed by decreased oxygen for more than 4%, that happens
repetitively up to 20-60 times per hour. OSA is the most common breathing disorder found during
sleep, marked by the presence of apnea and hipopnea caused by the obstruction of respiratory tract
during sleep.1
There are some diagnostic criteria in sleep disordered breathing (OSA) according to the
American Academy of sleep apnea. This condition is marked by the complaint of being sleepy in the
daytime that can’ t be described by other factors followed by 5 episodes or more of breathing
obstruction during sleep. Apnea-Hypopnea Index (AHI) is used to determine the degree of severity of
OSA. The definitive diagnosis of OSA can be established using polysomnography.1
The classification of severity of OSA is assessed by the scores of Apnea-Hypopnea Index
(AHI) using polysomnography. The degree of severity of OSA is divided to: 6,7
NO
Degree of OSA
Score of apnea-hypopnea index (AHI)
1
Mild
5-14
2
Moderate
15-29
3
Severe
> 30
Snoring is both social and health problem. Snoring might disturb sleeping partner, cause
disturbances in socialization, decrease productivity, increase the risk of traffic incidents and increase
the health spending in patients with OSA. People who snores severely are more prone to suffer from
hypertension, stroke, and heart disease compared to those who don’ t snore with same age and
weight.3
Based on the available study, snoring and OSA increases the risk of hypertension up to twice
and three times, and increase the risk of coronary artery disease or heart attack twice. Those who
snore and patients with OSA are also at risk on having stroke attack twice higher than those who
don’ t have OSA nor snore. Snoring and OSA are commonly found in adults, especially males,
middle age, and obese. Around 50 millions Americans snore, and 20 millions Americans have sleep
apnea syndrome.1,3
In Indonesia, there haven’ t been many centers established with sleep clinic, so the definite
diagnosis of OSA using polysomnography haven’ t been able to be properly established. This
includes Sanglah hospital, Denpasar, in which the sleep clinic is not yet available. The most common
approach is to use questionnaires to determine the presence or absence of the risk of OSA in patients
with stroke that are being hospitalized in the stroke unit. This research aimed at determining the
proportion of OSA risk in Sanglah General Hospital, Denpasar.
METHODS
This research is a descriptive research using primary data that were collected from all stroke
patients being hospitalized in stroke unit Sanglah General Hospital in May 2015. Samples in the
research were those stroke patients who were cooperative, and consented to participate in this
research. The sample was obtained consecutively. This research used Berlin questionnaire as the
measurement tool. The Berlin questionnaire was a questionnaire arranged by Netzer et al. in 1999,
which consists of development of interview results with patients with OSA. Berlin questionnaire
consists of 10 questions and is divided into three categories. Category one assesses the snoring factor
which is the presence or absence of snoring and the severity of snore. Category 2 assesses the factor
of fatigue and the feeling of being sleepy at noon. Category three assess the factor of blood pressure
and body mass index. Response for these questions were categorized in three groups, which was
category one positive if for questions 1 to 5 there are two or more positive responses. Category 2
positive was when questions 6 to 8 contains two or more positive response. Category 3 positive if
question 9 and 10 has one positive response. The end result were two categories of high risk for OSA
and low risk for OSA. High risk for OSA was when two or more categories were positive. Low risk
for OSA was when one or no category was positive. 8,9
Research in India testing the validity of Berlin questionnaire to identify patients who were at
risk for OSA, stated that this questionnaire was easier to use and more accurate due to its ability to
distinguish high risk from low risk OSA. In predicting high risk of OSA, Berlin questionnaire has
sensitivity of 86% and specificity of 95%. This questionnaire can be used in classifying risks of OSA
in general population.10
Ekasari et al. in 2014 conducted a research for testing the reliability of Berlin questionnaire in
Indonesian translation and showed that the value of Kappa Cohen coefficient in Berlin questionnaire
was 0.75 (p = 0.001) with very good agreement of interpretation. 11
Data that were gathered were then analyzed statistically using SPSS. Descriptive analysis was
conducted to determine the proportions of OSA risk. This would categorize OSA risk to high OSA
risk and low OSA risk.
RESULTS
This research gathered 44 patients who were hospitalized in the stroke unit in Sanglah
General Hospital Denpasar in May 2015. Characteristics of the research subjects are presented in the
table.
A. Characteristics of the research subjects
Age
Sex
Table 1. Characteristics of Research Subjects
Variables
Numbers
%
Age (mean ± SB)
55.23 (±12.76)
Male
32
72.7
Female
12
27.3
Table 1 shows that research subjects consisted of 32 (72.7%) males and 12 (27.3%) females
with mean age of 55.23+12.76 years.
No
1
2
Table 2. Proportions of OSA risks in research subjects
OSA risk
Number
Percentage (%)
(Subjects)
High
29
65.9
Low
15
34.1
Total
44
100
Table 2 shows the proportion of high OSA risk was found in 29 (65.9%) subjects and low
OSA risk in 15 (34.1%) subjects.
DISCUSSIONS
Obstructive Sleep Apnea (OSA) is an abnormality that is a part of the complex sleep disorder
breathing syndrome. The symptoms of OSA often happen but many times they were not properly
diagnosed at early stage in routine examination. OSA strongly correlates to some diseases, including
the occurrence of stroke. The results of this research showed that the high OSA risk was prevalent in
the stroke patients being hospitalized in the stroke unit. This was in concordance with the data of
patients with cardiovascular diseases who have high prevalence of OSA, which is estimated to be
about 50% in patients with acute stroke.
There haven’ t been any previous studies assessing the proportion of high OSA risk in
patients with stroke being hospitalized in the stroke unit stroke unit Sanglah General Hospital
Denpasar. This research obtained high rate of high OSA risk in stroke patients. The result of this
research can be used as a basic data to conduct further research.
This descriptive research had some weaknesses. This research only assessed the proportion of
OSA risk in patients with stroke being hospitalized using a questionnaire without proper monitoring
of the value of Apneu-Hypopneu Index (AHI) and without the use of polysomnography.
CONCLUSION
This study finds a large proportion of high risk OSA in stroke patients in stroke unit Sanglah
General Hospital.
REFERENCES
1.
Febriani, Debi dkk. Hubungan Obstructive Sleep Apnea Dengan Kardiovaskular. Jurnal
Kardiologi Indonesia; 32:45-52. 2011.
2. Committee Advisory. Sleep Apnea-Assesment and Management of Obstructive Sleep Apnea in
Adult. 2005.
3. Rodriguez, Hector P. Berggren, Diana A-V. Biology and treatment of Sleep Apnea.
Otolaryngology chapter 6; 71-82. 2006.
4. Hormann, Karl. Verse, Thomas. Sleep Disordered Breathing. Surgery for Sleep Disordered
Breathing. Pg 1-10. 2005.
5. Antariksa, Budhi. Patogenesis, Diagnosis dan Patogenesis OSA (Obstructive sleep Apnea). Dept
pulmonologi dan Respirasi. FKUI. Jakarta.
6. Welch KC, Goldberg AN. Sleep disorders. Current diagnosis &treatment, otolaryngology head
and neck Surgery. 2nd ed. New York: McGraw-Hill Companies LANGE; 535-547. 2008.
7. Walker RP. Snoring and obstructive sleep apnea. In: Bailey JB, Johnson JT, editors. Head &
neck surgery-otolaryngology. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 645-664.
2006.
8. Ward F, Marlene A. Development of a Disease Specific Health Related Quality of Life
Questionnare for Sleep Apnea. Am J Respi Crit Care Med; 158 : 494-503. 1998.
9. James W, Craig Q et al. Identification by Primary Care Clinicians of Patients with Obstructive
Sleep Apneu. A Practice Based Research Network (PBRN) Study. J Am Board Fam Med; 24 :
138-145. 2011.
10. Sharma SK, Vasudev C, Sinha S, et al. Validation of the modified Berlin questionnaire to
identify patients at risk for the obstructive sleep apnoea syndrome.Indian J Med Res. 124 (3):
281-290. 2006.
11. Ekasari WN, Utami DKI, Budiarsa IGN. Uji Reliabilitas Kuesioner Berlin pada Penderita
Stroke Iskemik.Bagian/SMF Neurologi Fakultas Kedokteran Universitas Udayana. RSUP
Sanglah; Bali. 2014.
Sanglah Denpasar ***
Triatmoko, Indira Chadijah*, Buadiarsa, IGN **, Utami, DK Indrasari**, Widyadharma, Putu Eka **
Neurology Department, Faculty of Medicine, Udayana University/Sanglah General Hospital
Denpasar, Bali
ABSTRACT
BACKGROUND
Obstructive Sleep Apnea (OSA) has been associated with a number of diseases, which has
been associated with the incidence of stroke. The incidence of OSA in Indonesia is estimated to be
around 1-4% of the general population. Patients with cardiovascular disease have a high prevalence of
OSA, an estimated 50% of patients with acute stroke. Many hospitals in Indonesia do not yet have
sleep clinic therefor OSA diagnosis by polysomnography can not be established, including in Sanglah
Hospital. We used Berlin questionnaire to determine risk of OSA in patients with stroke that were
hospitalized in stroke unit.
PURPOSE
To determine the proportion risk of OSA in patients with stroke in General Hospital Sanglah
Denpasar.
METHOD
A descriptive study using primary data. Sampling was done by consecutive sampling method.
The research using Berlin Questionnaire for risk OSA. Data obtained from this study were analyzed
descriptively with SPSS 16.00 for windows.
RESULTS
Total Sample of 44 stroke patients were taken during the period of May 2015 with the
proportion of men is 32 people (72.7%) and women is 12 people (27,3%) with the mean age of
subjects 55,23+12,76 years old. Proportion of high risk OSA is 29 people (65,9%) and low risk is 15
people (34,1%).
CONCLUSION
This study finds a large proportion of high risk OSA in stroke patients.
Keywords: obstructive sleep apneu, stroke, stroke unit
==================================================================
*Resident of Neurology Department, Faculty of Medicine, Udayana University/ Sanglah General
Hospital Denpasar
**Lecturer of Neurology Department, Faculty of Medicine, Udayana University/ Sanglah General
Hospital Denpasar
*** Presented at KONAS PERDOSSI MAKASSAR, Augustus, 7-9th 2015
INTRODUCTION
Obstructive Sleep Apnea (OSA) is a form of abnormality that is a part of a complex sleep
disorder breathing syndrome. The symptoms of OSA are common but often they are not diagnosed
early in routine examination. Most people have experienced OSA but they are unaware of it and
don’ t really pay attention to the symptoms as these are considered as non-dangerous, with no adverse
effect.
The first article about OSA was published in 1956 by Sidney Burwell. The prevalence of
OSA in developed countries is estimated to be 2-4% in males and 1-2% in females. The prevalence of
OSA in males is 2-3 times higher than female. It hasn’ t been fully understood why OSA is less
common in females.1,3
The incidence of OSA is estimated to be 1– 4% in general population. Individuals with OSA
who have snoring habit usually have more frequent apnea, hipopnea and decreased oxyhemoglobin
saturation during sleep compared to those who don’ t snore. The frequency of OSA reaches its peak
at the fifth and sixth decade of life, and decreases after 60s. In general, however, the frequency of
OSA increases progressively with advancing age.1,2,3,4, 5
Patients with cardiovascular diseases have high rate of OSA. The prevalence is around 50% in
patients with hypertension, 50% in patients with atrial fibrillation that requires cardioversion, 33% in
patients with only atrial fibrillation, 33% in patients with coronary artery disease, 50% in patients with
acute stroke and 30-40% in patients with heart failure and systolic dysfunction. High OSA incidence
(45-90%) was found in stroke patients. The potential role of OSA in the pathogenesis of stroke among
others are through the process of atherosclerosis, hypertension, reduced cerebral perfusion due to
thickening of carotid artery, low heart output, increased intracranial pressure, increased coagulopathy
and increased risk of the formation of blood clot due to arrhythmia. Due to the high incidence of OSA
and its potential effect on morbidity and mortality, the examination to diagnose and manage OSA is
highly advised in patients with stroke.1
Obstructive sleep apnea is defined as the cessation of air flow in the nose and mouth during
sleep for more than 10 seconds followed by decreased oxygen for more than 4%, that happens
repetitively up to 20-60 times per hour. OSA is the most common breathing disorder found during
sleep, marked by the presence of apnea and hipopnea caused by the obstruction of respiratory tract
during sleep.1
There are some diagnostic criteria in sleep disordered breathing (OSA) according to the
American Academy of sleep apnea. This condition is marked by the complaint of being sleepy in the
daytime that can’ t be described by other factors followed by 5 episodes or more of breathing
obstruction during sleep. Apnea-Hypopnea Index (AHI) is used to determine the degree of severity of
OSA. The definitive diagnosis of OSA can be established using polysomnography.1
The classification of severity of OSA is assessed by the scores of Apnea-Hypopnea Index
(AHI) using polysomnography. The degree of severity of OSA is divided to: 6,7
NO
Degree of OSA
Score of apnea-hypopnea index (AHI)
1
Mild
5-14
2
Moderate
15-29
3
Severe
> 30
Snoring is both social and health problem. Snoring might disturb sleeping partner, cause
disturbances in socialization, decrease productivity, increase the risk of traffic incidents and increase
the health spending in patients with OSA. People who snores severely are more prone to suffer from
hypertension, stroke, and heart disease compared to those who don’ t snore with same age and
weight.3
Based on the available study, snoring and OSA increases the risk of hypertension up to twice
and three times, and increase the risk of coronary artery disease or heart attack twice. Those who
snore and patients with OSA are also at risk on having stroke attack twice higher than those who
don’ t have OSA nor snore. Snoring and OSA are commonly found in adults, especially males,
middle age, and obese. Around 50 millions Americans snore, and 20 millions Americans have sleep
apnea syndrome.1,3
In Indonesia, there haven’ t been many centers established with sleep clinic, so the definite
diagnosis of OSA using polysomnography haven’ t been able to be properly established. This
includes Sanglah hospital, Denpasar, in which the sleep clinic is not yet available. The most common
approach is to use questionnaires to determine the presence or absence of the risk of OSA in patients
with stroke that are being hospitalized in the stroke unit. This research aimed at determining the
proportion of OSA risk in Sanglah General Hospital, Denpasar.
METHODS
This research is a descriptive research using primary data that were collected from all stroke
patients being hospitalized in stroke unit Sanglah General Hospital in May 2015. Samples in the
research were those stroke patients who were cooperative, and consented to participate in this
research. The sample was obtained consecutively. This research used Berlin questionnaire as the
measurement tool. The Berlin questionnaire was a questionnaire arranged by Netzer et al. in 1999,
which consists of development of interview results with patients with OSA. Berlin questionnaire
consists of 10 questions and is divided into three categories. Category one assesses the snoring factor
which is the presence or absence of snoring and the severity of snore. Category 2 assesses the factor
of fatigue and the feeling of being sleepy at noon. Category three assess the factor of blood pressure
and body mass index. Response for these questions were categorized in three groups, which was
category one positive if for questions 1 to 5 there are two or more positive responses. Category 2
positive was when questions 6 to 8 contains two or more positive response. Category 3 positive if
question 9 and 10 has one positive response. The end result were two categories of high risk for OSA
and low risk for OSA. High risk for OSA was when two or more categories were positive. Low risk
for OSA was when one or no category was positive. 8,9
Research in India testing the validity of Berlin questionnaire to identify patients who were at
risk for OSA, stated that this questionnaire was easier to use and more accurate due to its ability to
distinguish high risk from low risk OSA. In predicting high risk of OSA, Berlin questionnaire has
sensitivity of 86% and specificity of 95%. This questionnaire can be used in classifying risks of OSA
in general population.10
Ekasari et al. in 2014 conducted a research for testing the reliability of Berlin questionnaire in
Indonesian translation and showed that the value of Kappa Cohen coefficient in Berlin questionnaire
was 0.75 (p = 0.001) with very good agreement of interpretation. 11
Data that were gathered were then analyzed statistically using SPSS. Descriptive analysis was
conducted to determine the proportions of OSA risk. This would categorize OSA risk to high OSA
risk and low OSA risk.
RESULTS
This research gathered 44 patients who were hospitalized in the stroke unit in Sanglah
General Hospital Denpasar in May 2015. Characteristics of the research subjects are presented in the
table.
A. Characteristics of the research subjects
Age
Sex
Table 1. Characteristics of Research Subjects
Variables
Numbers
%
Age (mean ± SB)
55.23 (±12.76)
Male
32
72.7
Female
12
27.3
Table 1 shows that research subjects consisted of 32 (72.7%) males and 12 (27.3%) females
with mean age of 55.23+12.76 years.
No
1
2
Table 2. Proportions of OSA risks in research subjects
OSA risk
Number
Percentage (%)
(Subjects)
High
29
65.9
Low
15
34.1
Total
44
100
Table 2 shows the proportion of high OSA risk was found in 29 (65.9%) subjects and low
OSA risk in 15 (34.1%) subjects.
DISCUSSIONS
Obstructive Sleep Apnea (OSA) is an abnormality that is a part of the complex sleep disorder
breathing syndrome. The symptoms of OSA often happen but many times they were not properly
diagnosed at early stage in routine examination. OSA strongly correlates to some diseases, including
the occurrence of stroke. The results of this research showed that the high OSA risk was prevalent in
the stroke patients being hospitalized in the stroke unit. This was in concordance with the data of
patients with cardiovascular diseases who have high prevalence of OSA, which is estimated to be
about 50% in patients with acute stroke.
There haven’ t been any previous studies assessing the proportion of high OSA risk in
patients with stroke being hospitalized in the stroke unit stroke unit Sanglah General Hospital
Denpasar. This research obtained high rate of high OSA risk in stroke patients. The result of this
research can be used as a basic data to conduct further research.
This descriptive research had some weaknesses. This research only assessed the proportion of
OSA risk in patients with stroke being hospitalized using a questionnaire without proper monitoring
of the value of Apneu-Hypopneu Index (AHI) and without the use of polysomnography.
CONCLUSION
This study finds a large proportion of high risk OSA in stroke patients in stroke unit Sanglah
General Hospital.
REFERENCES
1.
Febriani, Debi dkk. Hubungan Obstructive Sleep Apnea Dengan Kardiovaskular. Jurnal
Kardiologi Indonesia; 32:45-52. 2011.
2. Committee Advisory. Sleep Apnea-Assesment and Management of Obstructive Sleep Apnea in
Adult. 2005.
3. Rodriguez, Hector P. Berggren, Diana A-V. Biology and treatment of Sleep Apnea.
Otolaryngology chapter 6; 71-82. 2006.
4. Hormann, Karl. Verse, Thomas. Sleep Disordered Breathing. Surgery for Sleep Disordered
Breathing. Pg 1-10. 2005.
5. Antariksa, Budhi. Patogenesis, Diagnosis dan Patogenesis OSA (Obstructive sleep Apnea). Dept
pulmonologi dan Respirasi. FKUI. Jakarta.
6. Welch KC, Goldberg AN. Sleep disorders. Current diagnosis &treatment, otolaryngology head
and neck Surgery. 2nd ed. New York: McGraw-Hill Companies LANGE; 535-547. 2008.
7. Walker RP. Snoring and obstructive sleep apnea. In: Bailey JB, Johnson JT, editors. Head &
neck surgery-otolaryngology. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 645-664.
2006.
8. Ward F, Marlene A. Development of a Disease Specific Health Related Quality of Life
Questionnare for Sleep Apnea. Am J Respi Crit Care Med; 158 : 494-503. 1998.
9. James W, Craig Q et al. Identification by Primary Care Clinicians of Patients with Obstructive
Sleep Apneu. A Practice Based Research Network (PBRN) Study. J Am Board Fam Med; 24 :
138-145. 2011.
10. Sharma SK, Vasudev C, Sinha S, et al. Validation of the modified Berlin questionnaire to
identify patients at risk for the obstructive sleep apnoea syndrome.Indian J Med Res. 124 (3):
281-290. 2006.
11. Ekasari WN, Utami DKI, Budiarsa IGN. Uji Reliabilitas Kuesioner Berlin pada Penderita
Stroke Iskemik.Bagian/SMF Neurologi Fakultas Kedokteran Universitas Udayana. RSUP
Sanglah; Bali. 2014.