10-2 Sleep Apnea CIS - Kinder

Question 1

What are the symptoms of sleep apnea?

Answer 1

—Loud, chronic snoring

—Excessive daytime somnolence

—Apneas witness by third parties

—Nocturnal choking/gasping

—Depression/Irritability

—Morning Dry Mouth

—Headache

—Nocturia

—

Question 2

In a general sense, what happens during an obstructive apnea event at night?

Answer 2

upper airway collapse

• person is still trying to breathe, inspiratory effort is there
• airway is partially (hypopnea) or completely collapsed (apnea) for at least 10 seconds
• SpO2 can decrease, sometimes into significant hypoxia
• brief arousal can sometimes occur
• increased release of catecholamines, SNS activity as a result

(Basically, OSA is choking when you sleep, with stress and crappy sleep as a result.)

Question 3

Why is morning headache a symptoms of OSA?

Answer 3

Intermittent nocturnal hypoxia = respiratory acidosis

acidosis = headache

Question 4

What are the signs of obstructive sleep apnea?

Answer 4

—Hypertension

—Polycythemia

—EKG:

• —RAD
• —RVH

—Cor Pulmonale

—Metabolic Alkalosis

Question 5

How is sleep apnea (of any kind) and/or sleep-disordered breathing diagnosed?

Answer 5

Polysomnography

Question 6

What is measured during a PSG?

Answer 6

—Polysomnography:

—Electroencephalography

—Electro-oculography

—Electrocardiography

—Leg and chin electromyography

—Respiratory effort

—Airflow

—Oxygen saturation

—End tidal carbon dioxide

Question 7

What is the diagnostic criteria for obstructive sleep apnea? At what amounts is sleep apnea pathological?

Answer 7

—Apnea-Hypopnea Index (AHI)

—Mild : 5-15/hour

—Moderate: 16-29/hour

—Severe: greater than 30/hour

Question 8

What is the ‘gold standard’ for treating obstructive sleep apnea?

Answer 8

CPAP - Continuous Positive Airway Pressure

Question 9

What are the beneficial effects of CPAP treatment?

Answer 9

—Lowers the apnea-hypopnea index

—Decreases daytime sleepiness

—Improves oxygen desaturation

—Decreases diurnal and nocturnal blood pressures

—Decreases pulmonary artery pressure

—Improves sleep efficiency

—Improves quality of life

—Improves executive mental function

Question 10

What is the insurance coverage for CPAP treatment?

Answer 10

—Must have 15 apnea or hypopnea events per hour (moderate - severe sleep apnea) or

—Have 5-14 apnea or hypopnea events per hour and one of the following symptoms or medical conditions

—Symptoms:

—Excessive daytime sleepiness

—Impaired cognition

—Mood disorders

—Insomnia

—Medical Conditions:

—Hypertension

—Ischemic Heart Disease

—History of Stroke

Question 11

Why is patient compliance with CPAP low?

Answer 11

Apparatus is too uncomfortable or bothersome to wear during sleep

air pressure is too difficult to get used to

patient is claustrophobic

patient is concerned about effect of CPAP on personal life, attractiveness

Question 12

Why does CPAP work for treating obstructive sleep apnea?

Answer 12

Continous airway pressure acts like a stent to keep airway open, so that airway is less likely to collapse during sleep

Question 13

Besides CPAP, what are some other treatments for OSA?

Answer 13

—Bilevel PAP

—Autotitrating PAP

—Supplemental Oxygen

—Weight Loss

—Oral Appliances

—Tracheostomy

Question 14

How do oral appliances work for treating OSA?

Answer 14

pulls jaw foreward and opens the airway, keeping tongue and soft palate from occluding the airway

Question 15

How can patient compliance with CPAP or other types of airway be support be monitored?

Answer 15

—Device compliance can be accurately monitored.

—Many insurances will not pay for the device if compliance is not demonstrated.

Question 16

Why is hypertension, and/or hypertension refractory to treatment, often a sign of OSA?

Answer 16

Obstructive apneic events produce spikes in SBP and DBP afterwards, increasing SNS activation and alterations in vascular function

Question 17

Why is polcythemia frequently a sign of OSA?

Answer 17

Intermittent hypoxia from apneas induces EPO release from kidneys

Question 18

Why does RAD and RVH result from OSA?

Answer 18

Hypertrophy of the right heart and subsequent right axis deviation are due to increased pulmonary arterial pressure and PHTN developing due to intermittent hypoxia, with associated pulmonary vascular remodeling

Question 19

Why is cor pulmonale a consequence of OSA?

Answer 19

Right sided heart failure is frequently a direct consequence of PHTN, and PHTN can be caused by intermittent hypoxia with OSA

Question 20

Why is metabolic alkalosis a frequent sign with OSA?

Answer 20

Nocturnal hypoxia will lead to a respiratory acidosis, due to a reduced ability to blow off CO2 and exchange gases

Kidneys will retain HCO3 as a result, which can result in a metabolic alkalosis

Question 21

In addition to the Epworth Sleepiness Scale, what other tool can be used in an office visit to determine suspected OSA?

Answer 21

STOPBANG

Snore - do you have a loud snore?

Tired - Do you often feel tired, fatigued or sleep?

Observed - has anyone observed you stop breathing when you sleep?

Pressure - do you have, or are being treated for, high blood pressure?

BMI - BMI more than 35?

Age - over 50 yo?

Neck- circumference >17” males or 16” females?

Gender - male?

Yes to 3 questions means high risk of OSA.

Question 22

—62 year old truck driver presents to his primary care physician with a chief complaint of feeling tired all of the time. He often falls asleep when sitting on his couch watching TV, and lately has had to pull over more often for rest while working. He sleeps through the night except for getting up once nightly to urinate. His wife says that he snores loudly and will often “stop breathing”. She also notes that he has been waking up with a headache for the last year and has had increasing difficulty remembering things.

—PMH –borderline hypertension

—PSH – appendectomy

—Family History – Father with CAD, DM, and hypertension

—Social History – 20 Pack year history of tobacco use, quit 3 years ago. Drinks 1-2 alcoholic drinks per night

What symptoms of OSA are present?

Answer 22

Excessive daytime somnolence

snores loudly

apneas witnessed by wife

morning headaches