4B. Sleep Medicine Flashcards
OSA Treatment
ConHnuous PosiHve Airway Pressure Treatment (CPAP)
The first option to treat OSA is Continuous Positive Airway Pressure (CPAP)
This machine is essentially an air blower, which through a small hose and a small mask that covers either the face and the mouth or just the mouth or something small like nasal pillows (sp?) The machine blows air continuously, it ____ up the collapsing funnel. It creates a pneumatic or air cushion in your oropharynx in a way that prevents funnel collapse and keeps the airway open throughout the night regardless of the muscle relaxation around it.
Most of them can do adjustments ____ depending on your position, size, movementof night, stage of sleep etc. and are called ____
opens
automatically
autoCPAP
ConHnuous PosiHve Airway Pressure Treatment
• CPAP is highly effecFve in controlling OSA
• OpFmal CPAP seongs
• Main limitaFon is ____ of paFents to accept CPAP
• CPAP improves both objecFve and ____ sleepiness
• improve the quality of life of bed partners of paFents with OSA
• Reversal of ____ deficits acributed to untreated OSA has been difficult to prove conclusively
It is extremely effective (~95-100%) IF the patient is compliant.
The main limitation is that ppl dont like to sleep with a machine making noise next to them and a plastic thing in their face. However, when they see the results of waking up more awake, smarter, faster, stronger, then they buy it. The problematic pts are those that have severe sleep apnea but no ____, bc they see no noticeable difference but we still need to convince them to wear it for their health. Masks used to look horrible but they are smaller and more comfortable now.
CPAP improves objective and subjective sleepiness, reverses neurocognitive deficits, and is associated with ____ short term memory and improved concentration.
willingness
subjective
neurocognitive
symptoms
decreased
ConHnuous PosiHve Airway Pressure Treatment
Effect on Cardiovascular Disease
• CPAP treatment appears to acenuate the adverse effects of untreated OSA on dayFme and nocturnal systolic and diastolic b____ and on 24- hour mean blood pressure.
• Compared with placebo, sham CPAP, or supporFve therapy alone, CPAP treatment is associated with small (−1.8 to −3.0 mm Hg) but staFsFcally significant improvement in diurnal mean arterial systolic and diastolic ____
When you treat OSA with CPAP, there is a decrease in BP. The actual numbers may not seem like much (it is something like a decrease from 140 to 137 systolic), but this actually has long term ____ implications. This is especially true for those with moderate to severe OSA or with refractory hypertension and multiple medications.
*Relying on this treatment option is important bc oral appliances are good in the mild to moderate range but their effectiveness decreases significantly in the moderate to ____ range.
blood pressure
blood pressure
mortality/morbidity
severe
It is important to use CPAP ____ and throughout the night. Minimal benefit if it is used <4hrs/night. Benefits are significant with >____hrs of use/night.
consistently
4
He doesn’t think we know if treating mild OSA aside from symptomatic pts has any benefit to ____ disease.
HE’S REPEATED THIS LIKE 5 TIMES AND SAID HE MIGHT ASK A QUESTION ABOUT THIS: The benefit of treating sleep apnea in terms to cardiovascular disease pertains more to ____ sleep apnea
cardiovascular
severe
ORAL APPLIANCES
For Oral Appliances AKA Mandible Advancement Devices to be effective they need to be ____ made. They propel the jaw forward to sepparate the base of the tongue from the oropharynx and ____ the airway. There is now less chance for the tongue to migrate ____.
custom
widen
backwards
ORAL APLIANCES (MAD)
• Oral appliances are an accepted and reliable treatment opFon for paFents with snoring and obstrucFve sleep apnea–hypopnea syndrome
• Currently indicated for paFents with ____ OSAHS
• Most effecFve in ____, thinner paFents with mild to moderate OSAHS
• Mechanical advancement of the ____ is the primary mechanism of acFon of these devices
They are an accepted tx option for mild to moderate pts. Perfect for someone that is young, thin, has complete dentition, and they have positional sleep apnea (when the OSA depends on position duh). If you are sleeping on your back, gravity increases the chance of your tongue and anatomy from obstructing your airway.
mild to moderate
younger
mandible
ORAL APLIANCES
• Custom-made ____ devices offer superior treatment and a greater likelihood for successful therapy than other types of oral devices.
• Successful therapy is more likely to be achieved by performing an at-home ____ FtraFon using a custom-made Ftratable device.
They need to be custom made and titratable. Titration is tricky because:
CPAPs: the machine is able to get ____ in real time every night and sense if it is treating the sleep apnea. The data is uploaded automatically to a network available to the insurance company, the medical equipment company, and treating provider.
Oral Appliances: we need to do more sleep studies to measure their effect. We either manage their ____ (they are snoring less), or we repeat a portable ____ while they are wearing the oral appliance.
titratable progressive titration data symptoms sleep study
ORAL APLIANCES
• Oral appliances are not as effecFve as ____ devices for reducing the apnea- hypopnea index and other sleep measures
• Short- and long-term improvements in dayFme somnolence, quality of life, neurocogniFve funcFon, and cardiovascular outcomes (primarily blood pressure) appear to be ____ with both treatments
Not as effective as CPAPs.
They are well tolerated but can develop ____
CPAP
similar
malocclusion
OA Cardiovascular Outcomes
• OAs were found to ____ the systolic, diastolic,
and mean blood pressure
• Results from three randomized trials suggest that OAs are as effecFve as ____ in reducing blood pressure measures
• Studies are largely limited to ____-made, Ftratable devices
Cardiovascular outcomes are good for mild and moderate cases
lower
PAP
custom
- Among paFents with obstrucFve sleep apnea, both CPAP and MADs were associated with reducFons in ____
- Metaanalysis did not idenFfy a staFsFcally significant difference between the BP outcomes associated with these therapies
Metaanalysis showing that they fall in the same category and are pretty decent for those (again, don’t know what he means)
BP
OA PaHent and Device SelecHon IndicaHons and ContraindicaHons
• In general, ____, thinner paFents with ____ OSA and an overall ____ AHI appear to be the preferred candidates for OA therapy.
• No clear selecFon criteria
• Rely on ____ judgment and the paFent’s preference
It is unclear what the long term benefits are for treating mild-moderate cases of sleep apnea, but we should continue treating until we get more data.
Reads rest of this slide.
HE SAYS TO REMEMBER THIS SENTENCE HINT:
Younger, thinner patients with positional OSA and overall lower AHI are preferred candidates for oral appliance therapy.
younger
positional
lower
clinical
OA PaHent and Device SelecHon
• Sufficient number and locaFon of healthy teeth to retain the device and to promote mandibular advancement.
• Minimum of ____ teeth in the upper jaw and in the lower jaw, with at least ____ teeth in each quadrant
• The paFent should have the ability to protrude the ____ forward
You need to have a min of 8 teeth in upper and lower jaw and a min of 2 teeth per quadrant. You should have a functional ____
eight
two
mandible
TMJ
OA PaHent and Device SelecHon
- PAP affords a more ____ iniFaFon of therapy
- Major clinical limitaFon :c ircumstances in which there is an imperaFve to start ____ treatment (inherent delays to acaining opFmal therapy) such as severe symptomaFc OSA (e.g., concern about ____ risk or profound dayFme impairments) and coexistent medical comorbidiFes, such as ____disease
You can always ____ CPAP with OA (oral appliances)
With OA you are looking at a more delayed process since you need to design it, build it, recheck to see if it is effective.
With severe pts, apart from OAs being less effective they may not be fast enough to implement since these pts have comorbidities that need to be addressed sooner rather than later.
prompt immediate driving ischemic heart mix
OA PaHent and Device SelecHon • Absolute dental contraindicaHons: -- FuncFonal restricFons of the \_\_\_\_ -- Insufficient denFFon with \_\_\_\_ aspects -- Insufficient \_\_\_\_
Relative contraindications include (these were on his slide but don’t appear on this one. I wrote them below word for word):
• Other ____ disorders (e.g. parasomnias)
• Previous invasive ____ surgery for sleep-disordered breathing (uvulopalatopharyngoplasty,
palatal implants, maxillomandibular advancement, suspension or resection of the tongue
base, hyoid suspension, genioglossus advancement)
• Genetic disorders with ____ and/or UA anomalies
• Use of ____(s) and/or antidepressant(s)
• Prior history of ____ disease (including alcoholism)
With regards to the last point, alcoholics are tricky situations since you don’t know if they will have ____ in the middle of the night and aspirate.
TMJ
pathological
retention
sleeping UA craniofacial benzodiazepines psychiatric
