32. Sleep Apnoea and Neuromuscular Respiratory Disorders Flashcards by Callum Anderson

What is Obstructive Sleep Apnoea Syndrome?

Recurrent episodes of upper airway obstruction leading to apnoea during sleep
Usually associated with heavy snoring
Typically unrefreshing sleep
Daytime somnolence /sleepiness
Poor daytime concentration

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What three things lead to repeated closure of the upper airway?

Muscle relaxation
Narrow Pharynx
Obesity

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What can repeated closure of upper airway lead to?

Snoring
Oxygen desaturation
Apnoeas and Hypopnoea

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What can apnoeas and hypopoeas lead to?

Frequent microarousals

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What does frequent microarousals cause?

Poor concentration

Daytime hypersomnolence

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What are some problems associated with OSAS?

Impaired quality of life
Marital dysharmony
Increased risk of RTA’s
Associated with hypertension, increased risk of stroke and probably increased risk of heart disease

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What is the prevalence of sleep apnoea?

2% adult men

1% adult women

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How is OSAS diagnosed?

Clinical history and examination
Epworth Questionnaire
Overnight sleep study
- pulse oximetry
- limited sleep studies
- full polysomnography

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What is involved in Polysomnography?

Oronasal airflow
Thoracoabdominal movement
Oximetry
Body position
EEG
(Audiovisual recording)
EOG
EMG (peripheral muscle)
ECG

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How is OSA Severity measure through desaturation rate/AHI?

0-5 Normal
5-15 Mild
15-30 Moderate
>30 Severe

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How is OSAS treated?

Identify exacerbating factors
weight reduction
avoidance of alcohol
diagnose and treat endocrine disorders e.g. hypothyroidism, acromegaly
Continuous positive airways pressure (CPAP)
Mandibular repositioning splint

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What are the effects of OSAS on driving?

Advise patients with sleep apnoea and excessive daytime somnolence not to drive or restrict driving and to inform DVLA of their condition

Once satisfactorily treated should be allowed to drive

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What are the facts about Narcolepsy?

Prevalence 0.05%
Familial
Associated with HLA - DRB11501 and HLA DQB1 0602

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What are the clinical features of Narcolepsy?

Cataplexy
Excessive daytime somnolence
Hypnagogic hallucinations
Sleep paralysis

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How is narcolepsy treated?

Modafinil
Clomipramine (for cataplexy)
Sodium Oxybate (Xyrem)

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What are the body conditions for Chronic Ventilatory Failure?

Elevated pCO2 (> 6.0 kPA)
pO2 < 8 kPA
Normal blood pH
Elevated bicarbonate

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What is the aetiology of CVF?

Airways disease
COPD
Bronchiectasis
OSA
Chest wall abnormalities
Kyphoscoliosis
Neuromuscular disease
Muscular dystrophy
Motor neurone disease (ALS)
Central Hypoventilation
Obesity hypoventilation syndrome
Central hypoventilation syndrome (Ondine’s curse)

What are the typical symptoms of CVF?

Breathlessness
Orthopnoea
Ankle swelling
Morning headache
Recurrent chest infections
Disturbed sleep

What should the examination findings of CVF be?

Reflects underlying disease
Particularly look for paradoxical abdominal wall motion in suspected neuromuscular disease
Ankle oedema (hypoxic cor pulmonale)

What are the investigations for neuromuscular disease?

Lung function
- Lying and standing VC
- Mouth pressures / SNIP
Assessment of Hypoventilation
- Early morning ABG
- Overnight oximetry
- transcutaneous CO2 monitoring
(Fluoroscopic screening of diaphragms)

What is the treatment for CVF?

Domicillary Non Invasive Ventilation (NIV)
Oxygen therapy
(t-IPPV)

What is the respiratory patterns in infants?

periodic/apneic before 36 weeks PCA

increased regular resp after 36 weeks

What is common sleeping patterns in Newborns?

16-18h asleep
sleep-wake states alternate in 3-4 h cycles
then start to adapt to light-dark/social cues

What is REM?

Rapid Eye Movement sleep

What percentage of a babies sleep is REM?

50% REM

What is common sleeping patterns for infants of 6 months?

14-15h asleep 2 longer sleep periods at night 1-2 daytime naps

What is common in an infants 2nd year

12h asleep | 1 daytime nap

What happens to the balance of REM and NREM sleep?

REM sleep decreases

What is common sleeping patterns in Prepubertal children?

highly efficient sleep

What is common sleeping patterns in Adolecense?

increased awakenings | need more/obtain less

How are sleeping patterns assessed?

``` Polysomnography Direct behavioural observation Time-lapse video Movement sensors in cot mattress Oxygen/CO2 monitoring ```

What is normal and what is abnormal?

Abnormal: Napping and enuresis after 3-5y 1y old sleeping 8h at night and not napping Unmedicated adult unrousable from sleep Normal: Sleep walking in toddlers

What are normal phenomena?

``` Sleep walking - middle childhood Sleep terrors - “look of fear” Hypnic jerks ```

What are the facts about sleeplessness?

``` Mainly behavioural problems - Infants 1+ arousal for 1-5 mins each night - “self-soothers” - “signalers” Medication Neurological disorders - melatonin ```

What are the facts about excessive sleepiness?

``` Insufficient sleep OSAS Narcolepsy - often not diagnosed in childhood - cataplexy - orexin deficiency ```

What is primary snoring?

``` Definition: - snoring without apnea, hypoventilation, hypoxia, hypercarbia, daytime symptoms Prevalence ~10% ? Progresses to OSAS ? Adenotonsillectomy ```

What is OSAS?

``` Commonest pre-school child (adenoids) Prevalence ~2% Morbidity - failure to thrive - neurocognitive defects/adhd - systemic hypertension - cor pulmonale ```

What are the differences between adult and childhood OSAS?

Daytime Sleepiness Adult - Main Symptom Child - Minority Obesity Adult - Majority Child - Minority Mouth breathing Adult - No Child - Common Gender Adult - M:F = 2:1 Child - M:F = 1:1 Enlarged tonsils Adult - Uncommon Child - Common Obstructive pattern Adult - Apnea Child - Hypoventilate

How is OSAS treated in children?

Adenotonsillectomy (CPAP) Weight loss Avoid environmental tobacco smoke

What are other respiratory disorders in children?

``` Chronic neonatal lung disease - hypoxaemia in REM sleep (similar COPD) - cardiac complications Cystic fibrosis - FEV1 30-60% associated with lowered SaO2 (~8%) - less REM/more awakenings Asthma ```

What are some neurologic disorders associated with children?

``` Cerebral palsy - fragmented sleep/delayed onset - melatonin Down syndrome - OSAS Prader-Willi syndrome - excessive daytime sleepiness Neuromuscular disease (Duchenne’s MD) - death due to respiratory failure - nocturnal desaturation associated with FVC <1litre - increasing quality of life/survival with BiPAP ```