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Pulmonary > Obstructive Sleep Apnea > Flashcards

Obstructive Sleep Apnea Flashcards

1
Q

obstructive sleep apnea: definition + repetitive collapse of _________?

A

Definition:
- Recurrent episodes of partial or complete airway obstruction during sleep
- Caused by repetitive collapse of PHARYNX
- Results in recurrent awakenings/arousal = ↓ Quality of sleep

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2
Q

epidemiology of sleep apnea

A

Commonly:
- Sleep apnea does not pose any symptoms even with >5 events per hour

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3
Q

sleep apnea: risk factors

A

-Obesity**
-Older age
-ETOH or sedative drugs
-Nasal obstruction
-Smoking
-Craniofacial and upper airway soft tissue abnormalities
—–

sleep apnea: FAT old guy that loves smoking and drinking; who has messed up nose that snores lots

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4
Q

hypopnea vs apnea

A

HYPOPNEA- REDUCTION in airflow
-10s event with breathing BUT
- ventilation during sleep is REDUCED
-respiratory effort: at least 50% from baseline

APNEA: complete CESSATION of airflow
-10s event with cessation of airflow
-Obstructive apnea: no airflow but with continued respiratory EFFORT
-Central apnea: no airflow and no respiratory effort

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5
Q

pathophysiology of sleep apnea.irway occlusion is limited to ________.

A

pathophysiology: Narrowing of upper airway during sleep!!!
- Airway occlusion is LIMITED TO INSPIRATION**

OSAHS pts have smaller upper airway size due to:
-fat deposition
- facial bone structures
-Genetics

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6
Q

Sleep apnea comorbidities

A

Strong association with and potential cause of many medical conditions:
- Hypertension
- Pulmonary HTN/cor pulmonare
- cardiovascular disease
- Stroke
- Diabetes
- Depression
- Sleepiness-related accidents

Lots of cormorbid ds and can result in pul hypertension or cor pulmoare

Sleep apnea needs to be identified and treated

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7
Q

sleep apnea symptoms

A

-Sleepiness and daytime somnolence: MC*
-Poor concentration*
-snoring*
-Bed partners report: snoring, apneas, restless sleep, or irritability*

-Fatigue
-Unrefreshing sleep
-Nocturnal choking
-Nocturia: pee at night
-Depression and decreased libido

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8
Q

signs of sleep apnea

A

-Macroglossia, enlarged tonsils, nasal obstruction
-HTN common
-“crowded” upper airway
-Obesity
-Large NECK circumference ( >17 inch [males]; >16 inch [females])*
-Craniofacial abnormalities: retrognathia

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9
Q

cardinal symptoms of sleep apnea apnea

A
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10
Q

epworth sleepiness scale

A

Used to define whether someone is abnormally sleepy
A ESS Score > 12 is suggestive of Sleep Apnea

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11
Q

Sleep apnea: labs

A

-Secondary polycythemia: from hypoxia
-Some may have hypercapnea, lowP02
-Proteinuria
-Hypothyroidism

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12
Q

Sleep apnea: ekg

A

-Nocturnal cardiac arrhythmia
-Sinus bradycardia, sinus arrest or AV block
-SVT, A fib and VT may occur once airflow is re-established

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13
Q

dx of sleep apnea

A

Golden Standard = Polysomnography (AKA Sleep Study)
-There is night-to-night variability so first night negative test does NOT r/o sleep apnea

Apnea Hypopnea Index:
- 15 events/hr: asymptomatic
- 5 events/hr: symptomatic or with comorbidities

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14
Q

definitive dx: apnea hypopnea index (AHI) criteria

A

Apnea Hypopnea Index diagnosis criteria:
- 15 events /hr of sleep: asymptomatic
- 5 events/hr: symptomatic

SYMPTOMS (one or more)
-Excessive daytime sleepiness
-Choking or gasping from sleep
-Recurrent awakenings from sleep
-Feeling unrefreshed after sleep
-Daytime fatigue
-Poor concentration

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15
Q

severity of sleep apnea: AHI index

A

Mild:
- 5-14 events per hour of sleep
Moderate:
- 15-30 events per hour of sleep
Severe:
- >30 events per hour of sleep

just know vaguely

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16
Q

tx of sleep apnea

A
  • Weight loss **
  • AVOID EtOH & Hypnotics **
  • CPAP: Continuous Positive Airway Pressure
  • Oral Appliances: Recommended for more severe cases
  • Surgical Procedures: Indicated if only there is some surgical intervention (enlarged tonsils, etc)
  • Hypoglossal nerve stimulation (INSPIRE)
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17
Q

new sleep apnea tx- inspire

A

-Implantable upper airway stimulation device functions like a pacemaker
-sends regular electrical impulses to the hypoglossal nerve to maintain upper airway patency

Components:
- programmable neuro-stimulator placed in chest
- pressure sensing lead: detects patient’s breathing
- stimulator lead: stimulates hypoglossal nerve

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18
Q

obesity hypoventilation syndrome

A

Definition:
- presence of awake alveolar hypoventilation (PaCO2 ≥45 mmHg)
-pt is OBESE (BMI ≥30 kg/m2),
-Hypoventilation cannot be attributed to other conditions

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19
Q

obesity hypoventilation syndrome: clinical features of cns, respiratory, cardiovascular

A

CNS:
- decreased CENTRAL respiratory drive

Respiratory:
- restrictive chest physiology
- pulmonary HTN
- hypoxemia/hypercapnia
-severe airway obstruction
- obstructive sleep apnea

Cardiovascular:
- CAD
- CHF

20
Q

obesity hypoventilation syndrome: dx

A

DX:
- Chronic respiratory acidosis (PaCO2 ≥45 mmHg) with compensatory metabolic alkalosis
-must exclude other diseases that can cause or contribute to chronic alveolar hypoventilation or hypercapnia.

Work up:
-assess for common complications
-ex: pulmonary hypertension + cardiovascular disorders

21
Q

obesity hypoventilation syndrome: tx

A

Tx: CPAP therapy
- improves gas exchange, lung volumes, and sleep-disordered breathing
- reduces mortality

Crap im obese

22
Q

acute respiratory distress syndrome (ARDS)

A

Definition:
-Acute hypoxemic respiratory failure WITHOUT HF
- acute event caused by systemic or pulmonary insult (infection, trauma, sepsis)
-will have NORMAL pulmonary capillary wedge pressure (≤ 18 mm Hg) -> normal heart; no HF
-Bilateral, widespread pulmonary infiltrates on x-ray (“WHITE OUT”)

23
Q

ARDS PaO2/FIO2 ratio

A

-pt will have PaO2/FIO2 ratio <300: Arterial oxygen over concentration of oxygen being inhaled

so for ex, if PT has Pa02 of 60 while receiving 80% o2= 60/.8= 75.

24
Q

severity of ARDS

A

Based on PaO2/FIO2 ratio :
-Mild: 200-300 mm Hg
-Moderate: 100-200 mm Hg
-Severe: less than 100 mm Hg

PaO2/FIO2 ratio: tells you degree of hypoxemia
PaO2 = arterial O2
FIO2 = fraction of inspired oxygen (expressed as decimal)

25
Q

common risk factors for ARDS

A

-Sepsis (1/3 of pts)**
-Severe multiple trauma **
-large Aspiration of gastric contents **

-Shock
-Infection
-Lung contusion
-Nonthoracic trauma
-Toxic inhalation
-Near-drowning
-Multiple blood transfusions
-Drugs

all of these are the “systemic or pulmonary insults”

26
Q

ARDS pathophysiology

A

1) insult causes release of pro-inflammatory cytokines -> promotes tissue destruction + inflammation

Lung Inflammation causes:
- ↑ Vascular Permeability = Interstitial & Alveolar Edema + Bilateral Diffuse Infiltrates
- ↓ Alveolar Surfactants = Alveolar Collapse + Hypoxemia

27
Q

ARDS symptoms and signs

A

RAPID onset of really bad dyspnea:

-FROTHY RED OR PINK SPUTUM**
-Diffuse crackles everywhere
-Marked hypoxemia refractory to tx with supplemental oxygen ***
- Many pts demonstrate multiple organ failure

——-
-Labored breathing
-Tachypnea
-accessory inspiratory muscles

28
Q

ADRS: what must you r/o?

A

HEART FAILURE
- diffuse crackles
-multiple organ failure
- dyspnea
-cadiogenic pulmonary edema

29
Q

ARDS Chest radiography

A

Findings: “white out”
- May be normal at first
-BILATERAL infiltrates usually peripheral
- Air BRONCHOGRAMS * (80%) -> alveolar inflitrates

Normal:
-Heart size normal
- spares costophrenic angles: no pleural effusions

30
Q

ARDS tx

A

-Treatment of underlying precipitating or secondary conditions (ex: sepsis)
-Tracheal intubation
-PEEP: Positive End Expiratory Pressure = Keeps alveoli open
-Supplemental O2
- Fluid Management

basically: give PEEP and O2 but not too much for O2 toxicity and give fluids but not too much to cause HF

31
Q

ARDS: O2 + PEEP

A

PEEP: Positive End Expiratory Pressure = Keeps alveoli open
- Ideally keep PEEP ↓ and Supplemental O2 ↓ as possible

PEEP goal:
- PaO2 > 55 mmHg or SaO2 > 88%

O2 goal:
- Recommended FIO2 < 60% with <40% the safest
- avoid oxygen toxicity

Fraction of inspired oxygen (FIO2): percentage of O2 in the gas mixture that is inhaled
Oxygen saturation (SaO2): proportion of Hb that are saturation

32
Q

ARDS: fluid management

A
  • want to maintain pulmonary capillary wedge pressure at the LOWEST level compatible with adequate cardiac output
  • don’t want to fluid overload (HF)
33
Q

ARDS prognosis

A

-30-40% Mortality Rate
-90% Mortality with Sepsis
-Median Survival Time ~ 2 weeks
- If pts survive: will have SIGNIFICANT respiratory impairments

34
Q

pulmonary aspiration syndromes definition and causes

A

Definition: Aspiration of material

Causes: Impaired deglutition
- Secondary to Altered Consciousness
- Secondary to Esophageal Dysfunction

35
Q

Different types of aspirations

A

-Aspiration of Inert Material

-Aspiration of Toxic Material

-“Café Coronary”

-Retention of Aspirated FB

-Chronic Aspiration of Gastric Contents

-Acute Aspiration of Gastric contents

36
Q

aspiration of inert material

A

Inert Material: non-hazardous = No serious sequelae
- Aspiration of particular matter or large volumes of fluid
- May present with asphyxia if amount aspirated is MASSIVE

–
ex: waterboarding

37
Q

aspiration of toxic material - what does it cause, sx, tx

A

May cause hydrocarbon pneumonitis**: aspiration of ingested petroleum distillates:
-Gasoline, kerosene, furniture polish
- occurs in suicide attempt or child accidentally ingesting toxic material
-Lung injury: mainly from vomiting and aspiration

Symptoms:
- vomiting, coughing
- respiratory distress
- cyanosis
- fever

Tx: supportive care

“toxicpeople go low and hide in the middle, they are initially normal and then get worse at night”

38
Q

aspiration of toxic material - chest xray + tx

A

CXR: initially be normal -> significantly progress over the next 12 hours.

Patchy airspace consolidation particularly in:
- LOWER lobes
- medial basal segments

Tx: supportive

“toxic ppl:
- go low and hide in the medial base
- initially normal and can get worse at night (12 h)”

39
Q

lipoid pneumonia

A

Chronic syndrome due to REPEATED aspiration of oily materials
- Mineral oil, cod liver oil, and oily nose drops
-Can cause pneumonia and fibrosis
- MC: Elderly patients with impaired swallowing
-Cough is present

Dx: lipid laden alveolar macrophages
- sputum sample or bronchial washings with + lipid-laden alveolar macrophages

“Lipoid = Oily Fat People”
- can cause Fibrosis and Pneumonia
- chronic ingestion of oily substances
- Oily: Old ppl with impaired swallowing -> cough a lot

40
Q

Cafe coronary + risk factors

A

Definition: ACUTE obstruction of the upper airway by FOOD

Associated with:
-Difficulty swallowing
-Old age
-Dental problems that impair chewing
-Use of alcohol and sedative drugs

Tx: Heimlich procedure

41
Q

Retention of Aspirated Foreign Body: what does it cause

A

May be acute, chronic, or asymptomatic: these are what it can cause:

“foreign Body -> Being HAPA is a foreign body”
- Bronchiectasis
- Hyperinflation
- Abscess (lung)
- Pneumonia (recurrent)
- Atelectasis”

-recurrent pneumonia
-Bronchiectasis
-Lung abscess
-Atelectasis
-Postobstructive hyperinflation

42
Q

Retention of Aspirated Foreign Body imaging

A

CXR:
- usually suggests the site of the foreign body

Golden Standard = Bronchoscopy
- Establishes Dx & Removal of FB

“foreign BOdy = BrONchoscopy -> BB”

43
Q

chronic aspiration of gastric contents

A

Result from primary disorder of larynx or esophagus:
-Untreated asthma
-esophageal stricture
-achalasia
-scleroderma
-chronic reflux

it can cause:
- Bronchial asthma
- pulmonary fibrosis
- bronchiectasis

44
Q

chronic aspiration of gastric contents: dx and tx

A

Dx: “swallowing disorders”
- EGD
- barium swallow

Tx:
- EGD Dilate
- PPI
- H2 Blocker
- Metoclopramide: increase gastric emptying

45
Q

acute aspiration of gastric contents def+ what can it cause?

A

Catastrophic event!! -> response depends on how much was aspirated
-more acidic + more quantity = WORSE chemical pneumonitis
-Aspiration of pure gastric acid (pH < 2.5) -> ARDS

What can it cause: “HEbP = HELP!!”
-Hemorrhage: bleeding in lungs
-Extensive desquamation of the bronchial epithelium
-Bronchiolitis
-Pulmonary edema

46
Q

acute aspiration of gastric contents: chest xray

A

-Patchy alveolar infiltrates in dependent lung zones
-Appear within few hours and progresses
- If particular food matter = Obstruction may be observed

47
Q

acute aspiration of gastric contents: treatment

A

ABCs:
-Maintain the airway
-Supplemental oxygen
- mechanical ventilation if ARDS

Supportive:
-Fluids for hypotension
-Treatment of superinfection -> prevent secondary infection

“ACUTE= ABCs
- airway: maintain airway
- Breathing: ventilate if respiratory failure (ARDS); O2
- Circulation: fluids for hypotension + treat superinfections”

Pulmonary (23 decks)

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