10-2 Sleep Apnea CIS - Kinder Flashcards
What are the symptoms of sleep apnea?
Loud, chronic snoring
Excessive daytime somnolence
Apneas witness by third parties
Nocturnal choking/gasping
Depression/Irritability
Morning Dry Mouth
Headache
Nocturia
In a general sense, what happens during an obstructive apnea event at night?
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.)
Why is morning headache a symptoms of OSA?
Intermittent nocturnal hypoxia = respiratory acidosis
acidosis = headache
What are the signs of obstructive sleep apnea?
Hypertension
Polycythemia
EKG:
- RAD
- RVH
Cor Pulmonale
Metabolic Alkalosis
How is sleep apnea (of any kind) and/or sleep-disordered breathing diagnosed?
Polysomnography
What is measured during a PSG?
Polysomnography:
Electroencephalography
Electro-oculography
Electrocardiography
Leg and chin electromyography
Respiratory effort
Airflow
Oxygen saturation
End tidal carbon dioxide
What is the diagnostic criteria for obstructive sleep apnea? At what amounts is sleep apnea pathological?
Apnea-Hypopnea Index (AHI)
Mild : 5-15/hour
Moderate: 16-29/hour
Severe: greater than 30/hour
What is the ‘gold standard’ for treating obstructive sleep apnea?
CPAP - Continuous Positive Airway Pressure
What are the beneficial effects of CPAP treatment?
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
What is the insurance coverage for CPAP treatment?
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
Why is patient compliance with CPAP low?
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
Why does CPAP work for treating obstructive sleep apnea?
Continous airway pressure acts like a stent to keep airway open, so that airway is less likely to collapse during sleep
Besides CPAP, what are some other treatments for OSA?
Bilevel PAP
Autotitrating PAP
Supplemental Oxygen
Weight Loss
Oral Appliances
Tracheostomy
How do oral appliances work for treating OSA?
pulls jaw foreward and opens the airway, keeping tongue and soft palate from occluding the airway
How can patient compliance with CPAP or other types of airway be support be monitored?
Device compliance can be accurately monitored.
Many insurances will not pay for the device if compliance is not demonstrated.
Why is hypertension, and/or hypertension refractory to treatment, often a sign of OSA?
Obstructive apneic events produce spikes in SBP and DBP afterwards, increasing SNS activation and alterations in vascular function
Why is polcythemia frequently a sign of OSA?
Intermittent hypoxia from apneas induces EPO release from kidneys
Why does RAD and RVH result from OSA?
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
Why is cor pulmonale a consequence of OSA?
Right sided heart failure is frequently a direct consequence of PHTN, and PHTN can be caused by intermittent hypoxia with OSA
Why is metabolic alkalosis a frequent sign with OSA?
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
In addition to the Epworth Sleepiness Scale, what other tool can be used in an office visit to determine suspected OSA?
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.
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?
Excessive daytime somnolence
snores loudly
apneas witnessed by wife
morning headaches
