Sleep Apnea

Sleep apnea is a sleep disorder that is characterized by repetitive episodes of upper airway obstruction. While it can lead to daytime drowsiness and lethargy, it can be potentially life threatening if left untreated. Sleep apnea is a condition where the blockage of the airway prevents air from getting into the lungs. This leads to snoring at regular pace and short periods of time where the breathing ceases. Apnea is the lack of spontaneous breathing. The patient may become limp and lifeless, have a seizure or turn bluish.

This is followed by sudden attempts to breathe with a loud gasp and snort. Consequently this condition affects the sleep and the person is not well rested. Besides the oxygen levels remain low leading to drowsiness and tiredness. Severe sleep apnea is likely to cause pulmonary hypertension. A large neck or collar size can be one of the causes of obstructive sleep apnea. Sleep apnea can be potentially life threatening since it can cause heart attacks or strokes.

Prolonged apnea is called as respiratory arrest. In children, this can quickly lead to cardiac arrest in which the heart stops beating whereas in adults, cardiac arrest usually is the first to happen followed by respiratory arrest. In adults, common causes of apnea and respiratory arrest include choking, drug overdose, near-drowning, head injury and cardiac arrest. In children, the causes may be different - prematurity, swelling of the airways, choking on a foreign object, seizures, regurgitating food or near-drowning.

Obstructive sleep apnea: This is a condition where tissues of the body obstruct the airways during sleep. Obstructive Sleep apnea is common in obese men who sleep on their backs. Other factors include Smoking, heavy alcohol consumption, emphysema, and an inherited tendency toward a narrowed airway.

Diagnosis of sleep apnea

• ECG to show arrhythmia during sleep
  
  
• Echocardiogram to study the heart functioning
  
  
• Thyroid function tests
  
  
• Sleep studies
  
  

Sleep apnea treatment

Treatment for sleep apnea can range from lifestyle modification, medication to even surgery in some cases. Weight loss and avoiding smoking are some of the changes that may need to be introduced into the lifestyle to prevent episodes of sleep apnea.

The risk of obstructive sleep apnea choking can be reduced by avoiding alcohol, tobacco smoking, tranquilizers and sedatives before bed. There is a surgical procedure called as LAUP (Laser Assisted Uvula Palatoplasty) where removal of the offending tissue is done to allow for unobstructed airflow.

Sleep apnea is often treated with surgery that removes the cause of obstruction. Enlarged tonsils or adenoids are removed to cure sleep apnea. Another sleep apnea surgery is UPPP - Uvulopalatopharyngoplasty, which involves removal of excess tissue from the back of the throat. This is done to increase the size of the upper airway. Usually it involves removal of the soft palate that hangs down the back of the throat. Such sleep apnea surgery is performed under general anesthesia. These days it is done under local anesthesia with laser assistance. Nasal reconstruction surgery straightens the nasal septum and shrinks the nasal tissue, thereby improving nasal airway. Changing the bony structure in the upper airway allows air to move more freely, especially during sleep.

The CPAP (Continuous Positive Airway Pressure) mask uses air pressure to push the tongue forward. This opens the throat to air and reduces snoring and apnea. It does not cure sleep apnea but relieves the patient by preventing recurrent episodes. Personalized sleep apnea masks are created to fit exactly on your face, nose, cheeks, lips and forehead. The sleep apnea mask is secured well so that there are no leaks.

Fetal Surgery

Fetal surgery refers to the surgical treatment of the developing baby in the womb to rectify congenital defects. Surgery of the fetus is performed to fix the prenatally diagnosed anomalies. However fetal surgery is a complicated procedure and comes with lot of risks to both mother and the baby. Yet, doctors recommend fetal surgery, if the risks associated with continuing the pregnancy, without surgical intervention, outweighs the risks that come with fetal surgery. Certain abnormalities, if left to progress in the womb, may turn fatal and infant may die soon after the birth. However fetal intervention is initiated only after taking the safety of the mother into consideration. The common risks that are associated with fetal surgery are premature delivery, infection of the uterus, leaking of amniotic fluid through the membrane, potential infertility and the risk of anesthesia.

There are various techniques followed to diagnose fetal anomalies. The diagnostic method can be non invasive such as ultrasound, fetal echocardiography, MRI, Radiography, Measuring MSAFP (maternal serum alpha-fetoprotein) and Measuring maternal serum beta-human chorionic gonadotropin (HCG) or invasive procedure such as amniocentesis, Chorionic villus sampling and Percutaneous umbilical blood sampling (PUBS) are used to detect the birth defects.

Types of Fetal Surgery

Depending on the incision level, fetal surgery is classified into three types.

Open Fetal Surgery

Open fetal surgery is almost similar to cesarean section and involves a total opening of the uterus. In this type of surgery, a long incision is made in the mother's abdomen and then on the uterus to reach the fetes. Once the surgical correction is performed on the fetus to treat the birth defect, the uterus and abdominal is closed back leaving the fetus intact. Open fetal surgery is performed under general anesthesia. Surgery is performed using special instruments containing staples to prevent bleeding from uterus. During the operation, warm saline water is infused to maintain the position of placenta and umbilical cord and surgeon will keep a vigil on the pulse and heart rate of the baby with the help of the oximeter. After the surgery, the mother is hospitalized for close to a week to facilitate close monitoring. One should remember that, with open fetal surgery, mother will forgo the option of vaginal delivery for the present and future deliveries. She can deliver the baby only through C-section. She may be given some medication to avoid pre term labor. Open fetal surgery is followed for the conditions like chest mass, neck mass, spinbifida, myelomeningocele and Sacrococcygeal teratoma (SCT) (a tumor at the base of the child's tail bone).

There is one more variation to the open fetal surgery called the EXIT (Ex Utero Intrapartum Treatment) Procedure. EXIT surgery is performed at the end of the full term and just before the delivery. In this method the baby is partially delivered by bringing out only a part of the fetes from uterus and keeping rest of the fetes attached to placenta and umbilical cord to allow blood circulation. Once the defect is rectified, the baby is delivered fully. Exit procedure is essentially followed to correct the airway blockage in the baby.

Fetoscopic surgery

Fetoscopic surgery is minimally invasive and unlike open fetal surgery, fetes remains inside the uterus while operating. Surgeon uses special instruments such as laser and makes a small incision with the help of the fetoscope to correct the birth defects. Fetoscopic surgery has shown high success rate in conditions such as Twin-Twin Transfusion Syndrome (TTTS), Twin Reversed Arterial Perfusion (TRAP), Amniotic band syndrome, and Tracheal occlusion for CDH. Fetoscopic surgery does not pose a risk of pre term labor and also eliminates most of the risks associated with open fetal surgery. This is essentially why fetoscopic surgery is the preferred choice, yet one should note that few complicated birth defects can be corrected only through open fetal surgery.

Fetal image guided surgery

Fetal image guided surgery is the least invasive of all wherein surgery is performed with the guidance of images of fetus produced on the external screen by ultrasound. Very thin instruments are inserted through a small opening in the abdomen and the correction is made without any endoscopic view and the whole procedure is guided by the sonogram images.

Various congenital conditions treated through fetal intervention

Congenital diaphragmatic hernia (CDH): Congenital diaphragmatic hernia (CDH) refers to the opening in the diaphragm through which the contents of the abdomen enter the chest cavity leaving no space for the lungs to develop properly. This is a serious condition and may lead to respiratory failure after birth. This condition, depending upon its severity, is treated through fetal intervention.

Spina bifida: Spina bifida refers to a condition wherein spinal column of the baby does not close properly around the spinal cord and the nerves start to protrude through the opening. Spina bifida can range from mild to severe form, and the severe cases lead to serious neurological problems after the birth. Only the severe form of spina bifida like Meningocele and Myelomeningocele call for fetal intervention through open fetal surgery.

Neck masses: Neck masses are the tumors of the neck that may obstruct the airway and esophagus of the child and also increase the level of amniotic fluid surrounding the baby. Typically, tumors of any kind are treated after birth. In rare cases they grow very large and may even cause heart failure. In such cases fetal intervention becomes necessary to remove the tumors.

Lung lesions: Lung lesions refer to the abnormal growth of lung tissue and these lesions can be cystic (fluid filled) or solid. There are various types of lung lesions and treatment depends upon their size and location. During pregnancy, continuous monitoring is necessary to keep vigil on the size of the lesion. Most often lung lesions shrink and make way for normal development. Lesions of smaller and moderate size are best treated after delivery. But if the size of the lung tumor is abnormally huge and poses a risk of hydrops (excess accumulation of fluid in the fetus) fetal intervention is initiated. Cystic lesions are normally removed through needle aspiration under the constant guidance of ultrasound images, but solid lesions require more elaborate procedure such as EXIT.

Congenital heart diseases: Not all congenital heart defects call for fetal intervention. Sometimes the septum (wall separating the right and left side of the heart) of the heart develops a hole while in the womb. However septum defects are typically treated after the birth of the child and rarely require fetal surgery. But if the heart develops severe obstructive cardiac disorders such as aortic stenosis, pulmonary stenosis and coarctation of the aorta,a fetal image-guided procedure may be necessary to open or enlarge the narrowed valve. This procedure involves placing a balloon catheter by inserting it through the uterus and into the fetal’s heart.

Amniotic Band Syndrome: This is a condition where fetus is entrapped in fibrous amniotic bands in the womb, restricting blood flow to the affected portion of the fetes. It normally affects legs, arms, toes and fingers. In utero surgery may be performed to rectify the condition if there is risk of amputation of the limb after the birth.

Twin-to-twin transfusion syndrome (TTTS): TTTS is a condition that occurs in identical twins wherein unbalanced exchange of blood takes place between the twins. One receives higher amount of blood whereas the other receives less amount. The fetus with less blood supply may become anemic and the one with excess blood supply may suffer heart failure due to excess fluid. Fetal surgery through laser fetal intervention is the preferred option to correct the condition. This procedure involves inserting a laser along with small telescope into the uterus and separating the blood vessels on the placenta that are connected to both twins.

Congenital high airway obstruction syndrome (CHAOS): Congenital high airway obstruction syndrome (CHAOS) refers to the blocking of fetal airway resulting in enlarged lungs, windpipe and bronchial tube. A complete or near to complete blockage may lead to a heart failure. Though congenital high airway obstruction syndrome (CHAOS) is treated after birth, in severe cases where fetes is at high risk such as hydrops, fetal surgery is performed.

Tracheostomy

Tracheostomy is performed to create a direct airway into the windpipe. This incision is surgically created to aspirate any secretions from the airway or to create a bypass route to deliver oxygen to the lungs. In a Tracheostomy, an incision is made low in the neck of the patient and a Tracheostomy tube is inserted. Possible complications are neck scarring, disturbance to the vocal and swallowing functions, bleeding or infection.