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NYU Review > Obstructive sleep apnea > Flashcards

Obstructive sleep apnea Flashcards

Miloro 2015

1
Q

What defines Obstructive Sleep Apnea syndrome?

A

Complete or partial upper airway obstruction causing apneas or hyponeas during sleep.

“>10 apneas or hypopneas per hour”

Hyponea= reduction in airflow>10 secs (50% decrease of desaturation of 3%)
Apnea= cessation of airflow >10 seconds
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2
Q

Snoring is OSA?

A

No - but it can progress to OSA

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3
Q

Pickwickian Syndrome

A

Charles Dickens “joe the Fat Boy”

= obesity with hypoventilation

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4
Q

OSA prevalence

A

8:1 , M:F until menopause when women catch up

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5
Q

What are 3 types of OSA?

A

Central = CNS problem usually tumor or infarct of brainstem

tx with drugs or phrenic nerve pacemakers

Obstructive = Upper airway obstruction at level of pharynx = Most common
dx- with polysolmogram

Mixed

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6
Q

Patients with OSAS usually have all the following except:

a. snoring
b. excessive daytime sleepiness
c. lack of REM sleep
d. obesity

A

d. Obesity

Predisposing Factors
Male, Age >50, Smoking, Obesity, Max/Mand deficiency, Hypothyroidsm

Think STOP BANG

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7
Q

What are common comorbidities?

A

CAD, HTN, AFIB,CHF, STROKE, COPD, OBESITY, GERD, Renal disease

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8
Q

AHI

A

Apnea hyponea Index= (# apneas + hypopneas)/ total sleep time

<5 = normal
5-15 = mild
15-30 = moderate
>30 = severe
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9
Q

An RDI of 30 indicates:

a. normal
b. mild OSA
c. moderate OSA
d. severe OSA

A

C. moderate OSA
RDI = (# apneas + hypopneas + respiratory event related arousals) x 60 / total sleep time

Mild OSA =5-20
Moderate 20-40
Severe >40

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10
Q

Sher success Criteria?

A

Successful treatment is AHI <20 or 50% reduction in AHI preop

Cure = AHI <5

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11
Q

Which can be used to classify an airway in the Fujita system?

a. Epworth Sleep Scale
b. Polysomnography
c. Bed partner interview
D. Nasopharygoscopy

A

D. Nasopharyngoscopy

fujita = upper airway obstruction classification system

Type 1 = oropharnx obstruction
tx= UPPP, T and A removal, palatal surgery to remove excess

Type II = ORO and Hypopharynx obstruction - most common
Tx: Phase I: UPPP, geniohyoid advancmeent
Phase 2: MMA and tongue procedures

Type III = Hypopharynx obstruction
Tx: MMA, tongue procedures, advance hyiod bone

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12
Q

Surgery indications Stanford Protocol, RDI, ESS, LSAT?

A

RDI >20
LSAT <90
Epworth sleep scale >11

CPAP is gold standard treatment

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13
Q

How long do you wait after any treatment of OSA before moving toward another treatment?

A

Require repeat PSG at 6 months s/p initial tx

If unchanged or worsened consider cpap if not used prior or phase 2 tx

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14
Q

Stanford Protocol Phase 1 treatment consists of?

Success?

A

Nasal obstruction correction (turbinates, septum)

Pharyngeal obstruction correction (T and A, UPPP)

Hypopharyngeal obstruction (hyiod resuspension or genio advancement)

Success = 42-75%

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15
Q

Stanford phase 2 Protocol treatment consists of?

success?

A

MMA or tracheostomy

success >90%

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16
Q

Features of OSAS?

A

Nocturnal insomnia, Fatigeu, mornign headaches, snoring, sexual impotence, EDS = excessive daytime somnolence

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17
Q

How is OSAS diagnosed?

a. Intraoral exam
b. Cephalometric exam
c. Muellers maneuver
d. sleep study

A

d. sleep study

PSG is gold standard and quantifies severrtywith EMG, EEG, EKG, oronasal airflow, chest wall effort, body position, snore microphoen, O2 saturation, durations >6hours

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18
Q

Sleep histories are very important - what charactertics are indicative of OSAS?

A

BEARS acronym for sleep history

B = bedtime routine
E= EDS yes or no?
A = awakenings at night/early morning
R= duration of sleep/consistency
S = snoring
19
Q

REM makes up how much of total sleep?

A

20-25%

20
Q

Epworth Sleepiness Scale ?

A

subjective exam of 8 questions rated 0-3 evaluating EDS

Score 0-24 (24 = worst)

21
Q

Where is the most common source of obstruction in OSA?

A

soft palate and lateral pharyngeal walls

22
Q

What do the Mallampati, Brodsky, and friedman classifications measure?

What soft tissue needs to be evaluated?

A

Mallampati = soft tissues of oropharnx

Brodsky = tonsils

friedman = palatal position

Uvula, adenoids, tongue, soft palate.

23
Q

Patients with OSAS have:

a. increased Co-Pog
b. Increased posterior airway space
c. Increased hyiod-mandibular plane
d. Shortened length of soft palate

A

c. Increased hyoid-mandibular plane

lower and more posterior hyoid = increased distance between hyoid and mandible = steeper plane

In OSA SNA and SNB are both lower than normal

24
Q

what is Muellers manuever?

A

Nasopharyngoscopy with valsalva maneuver

creates negative pressure to see collapse of soft tissue

25
Q

Medical tx of OSAS?

A

avoid EtOH and CNS depressants

Weight loss - if obese - Bariatric surgery also effective

CPAP - always initial therapy

Rx-Progesterone, Protriptyline

Oral appliances - sdjustable are better and can reduce snoring

tongue retaining vs anterior repositionign devices vs Klearway device (most common)

Postional therapy

26
Q 
The most effective treatment for OSAS is 
a weight loss
b LAUP
c CPAP
d MMA
A

c CPAP

continuous positive airway pressure 7-15 cm H2O
poor compliance

90-95% succes if compliance

BiPAP = Bilevel = changes with inspiration vs expirations = improved compliance

27
Q

Staging of treatment

A
  1. Presx eval = Physical exam, PSG, 3D CT, Nasopharyngoscop
  2. trial of CPAP- BiPAP or oral appliance
  3. Phase 1 stanford = 60% success
  4. PSG 6 months after
  5. Phase 2 = 90 % success= MMA
28
Q

Sx palatal procedure - retropalatal obstruction

A

ablative = good for snoring, poor success with OSA

Injection snoreplasty = sclerosing agent to Nasopharynx

CAPSO = scarring of soft palate

Radiofrequency ablation, Palatal implants
Laser assisted uvulplasty (LAUP) - usually recommended.

Expansion sphincter pharyngoplasty = better than UPPP

Z-palatopharyngoplasty + UPPP = good success

tonsillectomy = 40% success- may be good prior to CPAP

29
Q

UPPP what is it?

A

uvuloplatopharyngeoplasty

T and A, removes uvula, anterior pillar resection, lateral pharyngeal wall mucosa resection

50% of pts have 50% reduction in AHI

Overall it is not reliable - not recommend for moderate or severe OSA

30
Q

A 48 yo with OSAS and RDI of 110 presents with Pulmonary HTN, intermittent ventricular ectopy, and CHF. What surgical tx is indicated for this pt?

a. Septoplasty and turbinectomy
b. UPPP
c. tracheostomy
d. MMA

A

c. tracheostomy

100% cure rate but due to complications is a last resort

31
Q

Does Nasal surgery significantly improve OSAS?

A

No, minimal if any improvements.

It may improve snoring and CPAP compliance.

Septorhinoplasty may increase internal nasal valve

32
Q

Implanted Upper Airway Neurostimulation is recommend for who?

A

OSAS pts who have failed most other forms of therapy

Implant stimulate CN XIII/hypoglossal to activate and elevate tongue

33
Q

Keyhole procedure?

A

removal of medial and anterior portion of tongue for macroglossia

Radio frequency tongue ablation = scarring and contraction of posteior tongue.

Can suture from tongue base to screw in geniohyiod tuburcle.

Mixed success for both - recommend for mild to moderate OSA who wont use CPAP or oral appliances

34
Q

genioglossus advancement?

A

does not advance geniohyoid only the tongue.

Must advance 10-12mm of bony thickness ( make window - turn 90 degrees and fixate)

50-75% success, especially if combined with UPPP

risk of mandible fx

35
Q

Placement of inferior horizontal osteotomy of a rectangular osteotomy for genioglossus advancement for OSAS too inferiorly risks?

a. mandible fracture
b. mental nerve paresthesia
c. genioglossal detachment
d. mentalis detachment

A

a. mandible fracture

36
Q

What procedure would advance geniohyoid muscle and genioglossus?

A

BSSO advancement

genioplasty advancement

37
Q

Hyoid suspension procedures… how do they work?

A

Can suspend to mandible to move forward and superiorly

can suspend to thyroid cartilage to move anteriorly

better success to thyroid

38
Q

Transverse expansion help OSAS?

A

Yes! RME and SARPE both help dramatically

39
Q

how does MMA work?

A

Multilevel skeletal surgery designed to enlarge veloorohypopharyngeal airway without direction manipulation (nonablative) of soft tissues.

It advances the anterior pharyngeal tissues indirectly ( soft palate, tongue, suprahyoid muscles) that attach to the maxilla, mandible and hyoid bones.

It improves all three levels of upper airway (NP, OP, HP)

40
Q

what is MMA advancement

?

A

Goal = 10-12 mm of advancement

Poor success if <8mm of advancement

risk of esthetic defects/facial appearances.

90+% success

consider larger plates and screws

best alternative to TRACH and CPAP

41
Q

MMA indications?

LOOK at Neck- chin - throat angle!!! ( chin to chest = likely need this)

A

Severe OSAS

unwilling to use CPAP or oral appliance

Lower BMI, lower pre op AHI, younger age = better success

42
Q

how does MMA affect airway volume and turbulence?

A

increase airway volume

decreases turbulence

43
Q

Keys to OSAS treatment

A

What is severity of disease?
mild OSA = palatal sx or oral appliance

moderate-severe = consider MMA if CPAP non complaint

What treatments can patient tolerate (CPAP)?
CPAP is always intial tx

What is the level of obstruction?

NYU Review (8 decks)

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