Sindrome delle apnee ostruttive nel sonno (OSAS)
Table of Contents
Definizione
La sindrome delle apnee ostruttive nel sonno, nota anche con l’acronimo OSAS (Obstructive Sleep Apnea Syndrome), è caratterizzata da pause nella respirazione durante il sonno. Le apnee notturne sono definite come flusso aereo assente o ridotto di oltre il 90% rispetto al periodo preapnoico (riduzione parziale del flusso respiratorio).
L’ipopnea è la riduzione del flusso respiratorio di almeno il 50%, per almeno 10 secondi, associata a caduta della saturazione ossiemoglobinica.
Epidemiologia
La prevalenza di apnea notturna nella popolazione adulta è di circa 4% negli uomini e 2% nelle donne; aumenta con l’età fino alla sesta decade, poi si stabilizza o diminuisce in età avanzata. L’OSAS è spesso associata all’obesità. L’associazione con laBPCOè definita “overlap syndrome“. In pazienti con insufficienza cardiaca o renale, influenza negativamente la prognosi. Inoltre l’ OSAS è spesso associata a endocrinopatie (diabete mellito, acromegalia,ipotiroidismo) in parte a causa della coesistenza obesità.
Sintomi
Il paziente tipico è un uomo di mezza età, sovrappeso o obeso, che riferisce il russamento intenso e intermittente, interruzioni del respiro durante il sonno, con sensazione di soffocamento e/o insonnia. I sintomi sono:
- cefalea o sonno poco riposantecon senso di stanchezza al risveglio
- pause respiratorie nel sonno (riferite dal partner)
- deficit di concentrazione e di memoria
- depressione
- disfunzione erettile
- nicturia, frequente, ma in età avanzata è poco specifica per le frequenti comorbilità (ipertrofia prostatica, incontinenza urinaria).
- sonnolenza diurnache può causare incidente stradali.
E’ consigliabile la valutazione otorinolaringoiatrica nei pazienti OSAS, è importante studiare il metabolismo glucidico e lipidico nonchè gli enzimi epatici. Il monitoraggio della pressione arteriosa nelle 24 ore, l’ecocardiogramma sono utili per evidenziare rispettivamente l’ipertensione notturna o la disfunzione del ventricolo sinistro.
Sindrome delle apnee ostruttive nel sonno e patologia cardiovascolare
L’ OSAS è associata ad aumentato rischio di patologie cardiovascolari quali:
- ipertensione arteriosa
- cardiopatia ischemica
- fibrillazione atriale
- ictus cerebrale
Nonostante l’obesità sia un importante fattore confondente, è stato definitivamente dimostrato che l’OSAS se non trattata aumenta il rischio di ipertensione arteriosa. Studi osservazionali evidenziano un alto rischio per eventi cardiovascolari nei 10 anni successivi alla diagnosi nei pazienti con OSAS grave non trattata, specie se giovani o di media età, mentre negli anziani un rischio sembra ridursi. Nonostante le apnee ostruttive esercitino tali effetti negativi sulla funzione cardiaca, il ruolo dell’ OSAS nella patogenesi nell’insufficienza cardiaca è incerto. Invece, in pazienti con scompenso cardiaco, se non trattata aumenta la mortalità.
Diagnosi
La registrazione degli eventi respiratori durante il sonnoè indispensabile per la diagnosi di OSAS. Lapolisonnografia(PSG) in laboratorio include la registrazione delle variabili sia nel sonno (EEG, movimenti oculari, elettromiogramma), sia respiratorie (movimenti addominali e toracici, flusso aereo chiuso aereo SaO2). La polisonnografia è costosa e inadeguata alla gestione ordinaria di una patologia frequente come l’OSAS. Più spesso si usa ilmonitoraggio poligrafico cardiorespiratorio(PG) che registra i segnali sopra descritti ad eccezione dell’EEG, dei movimenti oculari ed è uno strumento diagnostico affidabile in pazienti con alta probabilità clinica di OSAS.
Criteri per la diagnosi di OSAS:
- Eccessiva sonnolenza diurnanon spiegata da altri fattori
- Due o più dei seguenti sintomi clinici:
- sensazione di soffocamento durante il sonno
- risvegli ricorrenti
- sonno poco ristoratore
- astemia durante il giorno
- deficit di concentrazione
- presenza di 5 o più eventi ostruttivi respiratori/ ora di sonno alla registrazione strumentale notturna.
Terapia
E’ consigliabileevitare l’assunzione serale di alcolici o sedativi, ridurre il peso corporeo e praticareattività fisica regolare,anche se tali interventi sullo stile di vita migliorano, ma raramente normalizzano, la respirazione durante il sonno. Nei casi con obesità severa, lachirurgia bariatricaè il trattamento più efficace per ottenere una significativa riduzione ponderale. La terapia posizionale è consigliata ai pazienti con OSAS lieve e apnee soltanto in posizione supina. Sono in commercio apparecchi elettronici che producono una vibrazione quando il paziente è supino, provocandoarousalse cambiamento di posizione; la loro efficacia nel singolo paziente dovrebbe essere verificata mediante PG o PSG.
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