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MS2 Respiratory > 9/25- Obstructive Sleep Apnea > Flashcards

9/25- Obstructive Sleep Apnea Flashcards

1
Q

What 2 main categories is sleep divided into? Subdivisions?

A

NREM: non-rapid eye movement sleep

  • 4 stages (1-4)
  • More sleep time is spent in stage 2
  • Respiration and muscle tone ~ awake

REM: rapid-eye movement sleep

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2
Q

When does REM begin? Recur?

A

REM begins 90 min after sleep onset and reoccurs every 90 min

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3
Q

Characteristics of REM sleep

  • Muscle tone
A
  • Loss of skeletal muscle tone (including the diaphragm and intercostal muscles)
  • Autonomic instability with fluctuations in BP and HR
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4
Q

What changes in ventilation occur during REM sleep?

A
  • Decrease in tidal volume with little change in respiratory rate (decreased minute ventilation)
  • Respirations are irregular
  • FRC decreases due to loss of muscle tone
  • These changes increase the vulnerability to develop respiratory problems and arterial desaturation
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5
Q

In supine sleep, what do sleep apnea patients experience in their upper airways?

A

Upper airway dilating muscles relax during sleep; in OSA, cannot overcome the negative inspiratory pressure in the airways

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6
Q

Define apnea

  • Obstructive apnea
  • Central apnea
  • Mixed apnea
A

> 10s pause in respiration during sleep; several types

  • Obstructive: occurs when respiratory effort is present without airflow; no air flow with continued effort
  • Central: lack of airflow and respiratory effort
  • Mixed: combo of obstructive and central
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7
Q

What does this polysomnogram show?

A

The tracings are:

  • Airflow
  • Respiratory channel (chest mvt)
  • Abdominal movement

From left to right, the sections are

  • Central apnea: no effort in RC/AB wtih apnea
  • Obstructive apnea: RC and AB function, but still apnea
  • Mixed apnea: no effort and then some effort in RC/AB but still apnea
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8
Q

Define hypopnea

A

Reduction of airflow accompanied by O2 desaturation of 4%+

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9
Q

What is:

  • Apnea Index?
  • Apnea Hypoxia Index?
  • Respiratory Distress Index?
A
  • Apnea Index = number of apneas per hour of sleep
  • Apnea Hypopnea Index (AHI) = number of apneas + hypopneas per hour
  • Respiratory Distress Index (RDI) = apnea + hypopneas + respiratory effort related arousal (RERA), which is a reduction in airflow (no cessation or desaturation) causing the brain to wake up at an EEG level to induce breathing
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10
Q

How much of the population is affected by obstructive sleep apnea?

  • Epidemiology
A
  • Estimated 2-4% (possibly > 25% if > 65 yo)
  • Contributes to > 38,000 cardiovascular deaths
  • Loss of productivity due to excessive daytime sleepiness
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11
Q

What are this risk factors for OSA?

A
  • Obesity/fat distribution (including neck thickness)
  • Age
  • Male > female
  • Familial/Genetic
  • Snoring (probably more symptom than RF)
  • Oral/facial abnormalities (short mandible or maxilla)
  • Hypothyroidism/acromegaly (soft tissue infiltration)
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12
Q

What is required for OSA diagnosis?

A
  • Unexplained excessive daytime sleepiness
  • (AHI > 5/hr) at least 5 obstructed breathing events per hour of sleep
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13
Q

What are indications for the evaluation of OSA?

A
  • Rule out apnea (for other conditions)
  • Sleepiness
  • Insomnia
  • Snoring
  • Sleepwalking
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14
Q

Typical phenotype of OSA pt?

A
  • Male (6-10x)
  • Middle-aged to elderly (apneas increase with age)
  • Overweight (80%) (>50% with BMI > 30 kg/m2)
  • Hypertensive (50-90%)
  • Presents with history of snoring and daytime sleepiness
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15
Q

How can an individual decrease their apea?

A

Weight loss

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16
Q

Snoring is a significant symptom in OSA, but most snorers doe NOT have OSA. What is snoring associated with?

  • Linked to what
A
  • Snoring = very prevalent

Associated with:

  • Decreased daytime alertness
  • Higher incidence of HTN, CVA and angina.

May be part of a continuum to the development of OSA

  • Likely to be older, overweight, males (same clinical profile as OSA)
17
Q

Sleepiness Facts (:

A
  • Sleepiness is a drive state like hunger or thirst.
  • Sleep occurs only if there is an underlying physiologic need to sleep.
  • Situations such as boredom do not cause sleep, they only permit sleep.
18
Q

What is the Epworth Sleepiness Scale?

A

How likely you are to doze off in certain situations in contrast to feeling tired. Score > 8 hours indicates… ?

19
Q

What is the DDx for excessive daytime sleepiness?

A
  • Insufficient sleep
  • Narcolepsy:
  • Idiopathic hyper-somnolence (long sleep periods)
  • Sleep-related periodic leg movements
  • Drugs: Sedatives, Stimulants, Alcohol
  • Endocrine disorders: Hypothyroidism
20
Q

Describe Narcolepsy

  • Prevalence compared to OSA
  • Typical age group affected
  • Symptoms
A
  • 50 x less common than OSA
  • Symptoms 10-30 years old (teens)
  • Cataplexy, sleep paralysis, sleep attacks
21
Q

How is OSA diagnosed?

A

Polysomnography (PSG)

22
Q

What is seen here?

A

Polysomnagraph

23
Q

Advantages/disadvantages of home sleep studies?

A

Advantages:

  • Lower cost/tes
  • Convenience
  • Study patients in home setting
  • This is becoming much more utilized!

Disadvantages:

  • Less complete
  • Inability to correct technical malfunction
  • Intervention (i.e. CPAP titration) limited
24
Q

What is the morbidity of OSA?

A
  • Restless sleep
  • Intellectual deterioration
  • Daytime sleepiness
  • Personality changes (some kids with OSA had tonsillectomy and their ADHD went away)
  • Chronic hypoventilation (problems including CO2 retention)
  • Pulmonary hypertension
  • Nocturnal arrhythmias (when O2sat is falling)
  • Right heart failure (due to repeated hypoxemias)
25
Q

Other consequences of OSA?

A

Cardiovascular

  • Hypertension
  • MI risk (increases 20%)

Cerebrovascular

  • CVA risk (increases 40%)

Diabetes

  • Increased insulin resistance; independent of obesity

Liver-increased steatosis and fibrosis independent of obesity

Anesthetic Risk-perioperative risk Accidents!

26
Q

Pathogenesis of Apnea/adverse consequences?

A

Apnea -> Asphyxia

  • Low oxygen levels
  • Loud snoring
  • Sleep disturbance
  • Increased heart rates
  • Increased blood pressure
27
Q

T/F: OSA causes increased mortality

A

True

  • Sleep-disordered breathing was associated with all-cause and cardiovascular disease–related mortality; association most apparent in men aged 40–70 y with severe disease (AHI>30 events/h).
28
Q

What is the indication for treatment with OSA?

A
  • EDS (Epworth > 11 or problems with driving/working) AND RDI > 15
  • Treatment improves symptoms, sleepiness, driving, cognition, mood, QOL and BP
  • RDI 5-15 AND EDS or impaired neurocognitive function, mood disorders, insomnia, cardiovascular disease of a history of stroke
  • Treatment improves symptoms
  • No EDS and SDB-?
  • No evidence for benefit of treatment
29
Q

What is the therapy for OSA?

  • General measures
  • Surgical
  • Others
A

General measures

  • Avoidance of alcohol, sedatives
  • Weight loss
  • Avoidance of supine sleeping position

Dental appliances (mandibular repositioning splint)/Oral devices

Nasal CPAP* or BiPAP (*Treatment of choice)

Surgical options

  • Uvulopalatopharyngoplasty (UPPP), LAUP
  • Tonsillectomy in children
  • Tracheostomy
  • Bariatric surgery
30
Q

Efficacy of positive airway pressure therapy (CPAP)?

A
  • Proven in randomized placebo-controlled trials to improve breathing during sleep, sleep quality, EDS, BP, vigilance and cognition
  • Proven to improve metabolic syndrome in patients with OSA
  • Titration required to determine ideal pressure for patient
31
Q

Describe Central Apnea again

A

Pause in effective respiration secondary to the absence of respiratory effort (lack of central drive to ventilatory muscles)

32
Q

What are hallmarks of central apnea

  • Expiratory flow
  • Effort
  • Etiology
A
  • Flat line on expiratory flow (i.e., apnea), plus:
  • No respiratory effort on chest wall/abdominal strain gauges Etiology, usually seen in:
  • Cardiac failure (CHF): thought to be due to dilation of aorta and reduced baroreceptor feedback?
  • CNS disease (post CVA, tumors, etc.)
33
Q

What is the treatment for central apnea?

A
  • Management of underlying pathophysiology (i.e. CHF)
  • CPAP
  • Respiratory stimulants rarely work.
  • O2 relieves desaturation, but may prolong the apnea
  • If severe, may require nocturnal mechanical ventilatory assistance
34
Q

What are Periodic Limb Movement in Sleep (PLMS)?

  • Definition
  • Prevalence
  • Treatment
A

Recurring muscle contraction of the extremities which may or may not result in sleep disruption/arousal

  • Fragmented sleep leads to EDS
  • Found in 13% c/o insomnia, 6% c/o sleepiness

Treatment:

  • Dopaminergic agents (carbidopa/levodopa)
  • Opioids/benzodiazepines
  • Anticonvulsants (carbamazepine, valproate sodium)
  • Clonidine
35
Q

What is Restless Leg Syndrome?

  • Define
  • Symptoms
  • Timing
  • Rule out what?
  • Treatment
A

Sensorimotor disorder with irresistable urge to move legs

  • Creepy-crawling sensaion in legs
  • Worse in evening or night
  • Interferes with inablity to fall asleep
  • Sx appear with inactivity and improve with movement

Rule out iron deficiency

Treatment with dopaminergic drugs

36
Q

What is the tetrad of narcolepsy?

A
  1. Excessive daytime sleepiness
  2. Muscle atonia during wakefulness (cataplexy)
  3. Hypnagogic or hypnopompic hallucinations
  4. Sleep paralysis (It’s like REM sleep induced during awakening)
37
Q

Describe narcolepsy

  • Age affected
  • Diagnosis
  • Treatment
A
  • Symptoms commonly in 2nd decade
  • Diagnoses with PSG followed by multiple sleep latency test (MSLT)

Treatment is symptomatic:

  • Modafinil; Methylphenidate; Dextroamphetamine for EDS
  • Tricyclic antidepressants or GHB for cataplexy
38
Q

What is REM Behavior Disorder?

  • Symptoms
  • Treatment
A

Normal muscle atonia seen during REM stage is lost

  • Pts describe symptoms of acting out their vivid dreams

Treatment is Clonzepam

(Not sleep walking; sleep walking is considered a non-REM behavior (walking, talking, eating, not acting out dreams)

39
Q

Summary: - Normal sleep is divided into NREM and REM sleep stages - Sleep apnea is cessation of airflow during sleep. - Obstructive sleep apnea is when apnea occurs despite chest and abdominal respiratory efforts and is due to airway obstruction - Central sleep apnea is when apnea occurs due to absence of respiratory efforts - OSA under recognized disorder and prevalence numbers likely underestimate the magnitude of disorder. Obesity epidemic contributing - Excessive daytime sleepiness and snoring are the two most common presenting symptoms of OSA - The apnea/hypopnea index (AHI) is the number of apneas or hypopneas per hour of sleep - For the diagnosis of sleep apnea, the AHI should be ≥ 5. - Obstructive sleep apnea(OSA) can lead to many comorbidities including HTN, stroke and death - Treatment of sleep apnea consists of sleep hygiene, weight loss and PAP (positive airway pressure) therapy

A

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MS2 Respiratory (26 decks)

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