OSA guidelines 2015 Flashcards
Clinical triad for Obstructive Sleep Apnea
- Chronic snoring
- Witnessed apneas
- Excessive daytime sleepiness
Symptom with greatest specificity for OSA
Witnessed apneas
Symptom that marks clinical intensity of OSA
Excessive daytime sleepiness
The clinically relevant OSA symptom most responsive to treatment.
Excessive daytime sleepiness
Its presence, unexplained by evident circumstances, is sufficient even in the absence of other symptoms or signs to carry out a sleep study for diagnosis.
Excessive daytime sleepiness
Patients at High Risk for Obstructive Sleep Apnea (OSA) who must be Evaluated for OSA Symptoms
- (Morbid) Obesity (BMI ≥ 35; *BMI ≥30 for Asians)
- Congestive heart failure or cardiac insufficiency Refractory hypertension
- Type 2 diabetes mellitus (T2DM)
- Nocturnal dysrhythmias or atrial fibrillation
- Stroke
- Pulmonary hypertension
- Individuals at high risk for accidents such as long haul drivers, pilots Preoperative for bariatric surgery
- Chronic respiratory diseases with greater hypoxemia or hypercarbia deterioration than (clinically) expected
Physical findings suggestive of the presence of OSA
- Increased neck circumference (M: >17 in., F >16) BMI ≥ 30 (*BMI ≥ 27.5 for Asians)
- Modified Mallampati score of 3 or 4
- Retrognathia
- Lateral peritonsillar narrowing
- Macroglossia
- Tonsillar hypertrophy/ elongated/enlarged uvula
- High arched/narrow hard palate
- Overjet defined as the extent of horizontal overlap of the maxillary central incisors over the mandibular central incisors)
- Nasal abnormalities such as septal deviation, nasal polyps, congestion or enlargement of turbinates
When should OSA screening be done?
- During routine health maintenance evaluation
- Routinely, among patients for pre-operative evaluation
- In populations where OSA poses a public health hazard (e.g. Public utility drivers, long haul drivers, pilots)
Questionnaire used in predicting risk for OSA
The Berlin Questionnaire
Questionnaire used for OSA screening in surgical patients
STOP-BANG
Questionnaire used for monitoring symptoms of excessive daytime sleepiness
Epworth Sleepiness Scale (ESS)
Gold standard for Diagnosing OSA
Polysomnogram
19-item questionnaire that quantifies subjective sleep quality over the past month
Pittsburgh Sleep Quality Index
Pittsburgh Sleep Quality Index score threshold for poor sleep quality
> 5
OSA screening tool in an elderly population
Multivariate Apnea Prediction Questionnaire
Most useful in predicting risk for OSA.
Berlin Questionnaire
Questionnaire with highest internal validity
STOP and STOP-Bang questionnaires
Alternative to Polysomnogram
The use of Portable Monitors (at least type 3) for diagnostic testing in patients suspected of OSA provided all of the following conditions are met:
High risk for moderate to severe OSA
Do not have serious co-morbidities
Other sleep disorders are not a consideration, and
With a prior comprehensive sleep evaluation by a sleep specialistx`
if excessive sleepiness continues despite optimal treatment, what test can be used for evaluation for possible narcolepsy
Multiple Sleep Latency Testing (MSLT)
Diagnosis of OSA using Polysomnogram
(GOLD STANDARD)
-
>5 obstructive events per hour in patients with
-symptoms
-comorbidities
OR
- >15 events/hour even in the absence of sleep related symptoms
Diagnosis of OSA using portable monitor
- >5 obstructive events per hour in patients with symptoms
- >15 events/hour even in the absence of sleep related symptoms
The sum of the 3 types of obstructive events that include apneas, hypopneas, and respiratory event related arousals (RERAs) divided by the total sleep time.
Respiratory Disturbance Index (RDI)
The sum of apneas and hypopneas divided by the total sleep time.
Apnea-Hypopnea Index (AHI)
Respiratory event where both of the following criteria are met
1. There is a drop in the peak signal excursion by ≥90% of pre-event baseline using an oronasal thermal sensor (diagnostic study), PAP device flow (titration study) or an alternative apnea sensor (diagnostic study).
2. The duration of the ≥90% drop in sensor signal is ≥10 seconds
Apnea
Type of respiratory event that meets ALL of the following:
- The peak signal excursions drop by **≥30% **of pre-event baseline using nasal pressure (diagnostic study), PAP device flow (titration study), or an alternative hypopnea sensor (diagnostic study).
- The duration of the ≥30% drop in signal excursion is ≥10 seconds.
- There is a ≥3% oxygen desaturation from pre-event baseline or the event is
associated with an arousal.
Hypopnea
A respiratory event recognized if there is a sequence of breaths lasting ≥10 seconds characterized by increasing respiratory effort leading to arousal from sleep when the sequence of breaths does not meet criteria for an apnea or
hypopnea. This can only be measured in the PSG.
Respiratory Effort-Related Arousal (RERA)
May be performed if an AHI> 40/hour is documented during 2 hours of a diagnostic study
Split-night study
Mild OSA
RDI/AHI 5-14/hour
Moderate OSA
RDI/AHI 15-30/hour
Severe OSA
RDI/AHI > 30/hour
Follow-up Polysomnogram is routinely done in what situation?
- For assessment of treatment results after surgical treatment for moderate to severe OSA
2.To assess treatment result on CPAP after substantial weight loss (10% of body weight);
substantial weight gain with return of symptoms while on CPAP
- When clinical response is insufficient or when symptoms recur despite good initial response to CPAP.
Goals of therapy for OSA
1.To improve symptoms (excessive sleepiness, concentration, snoring, quality of life and sexual intimacy.)
2.To decrease AHI to <5, events/hour with no desaturations nor arousals
3.Improvement of associated comorbidities such as hypertension, arrhythmia, heart failure, stroke, and hyperglycemia.
4.To prevent or minimize the risk for cardiovascular events and traffic accidents.
CPAP results in OSA
- Modest improvement in blood pressure
- Improves LV ejective fraction
- Reduction recurrence in Atrial Fibrillation
- Improvement of Insulin Sensitivity
- Improved driver performance
Standard initial treatment for OSA
CPAP at a fixed pressure is the standard initial treatment of choice for OSA in adults.
Strongly recommended for Moderate to Severe AHI
CPAP should be used for _______ during sleep daily for optimal benefit.
at least 4 hours
Conservative Medical Therapy for Mild OSA
- Weight loss
- Positional therapy in patients with OSA in the supine position
- Nasal corticosteroids in patients with allergic rhinitis
Hierarchy of effectiveness of management of OSA
CPAP> Dental Appliance > Uvulopalatopharyngoplasty
What interface should be used with the CPAP?
The nasal airway is the preferred delivery route, however, alternatives may be tried to accommodate for comfort or difficulties
What measures can be used to increase CPAP compliance?
- The addition of heated humidification.
- Use of BiPAP is an option in CPAP-intolerant patients.
- Pressure waveform modification technologies
Definition of good adherence in CPAP
Use of the device for a minimum number of hours per night (~4 h in the literature) for 70% of the nights of the week.
Most important interventions to address compliance to CPAP use
- The addition of heated humidification to relieve nasal discomfort or irritation
- Use of pressure waveform modification technologies (i.e. pressure relief) to improve patient comfort
- The use of BiPAP as an option in CPAP-intolerant patients.
CPAP Problems and Possible Solutions
Claustrophobia
Use the mask an hour or 2 before bed to get used to it. Drugs can help if the anxiety gets too much but this is to be avoided if possible.
Try not to overtighten the straps on the mask
Nasal pillows
Setting the ―ramp time
CPAP Problems and Possible Solutions
nasal irritation and congestion
Heated humidifier
Nasal decongestant
CPAP Problems and Possible Solutions
Uncomfortable mask or pressure loss
Re-fit mask
Good hygiene and facial maintenance (beards, mustaches and other facial hair along with a dirty or oily face may prevent a proper air-tight seal)
CPAP Problems and Possible Solutions
Headaches & ear pressure
Nasal decongestant
CPAP Problems and Possible Solutions
Bloatedness
Try not to use pillows that are too high, this can cause the chin to tilt down and block off the airways
Lower CPAP pressure
CPAP Problems and Possible Solutions
Irritated eyes
Re-fit mask. Mask should not be set too high on the bridge
CPAP Problems and Possible Solutions
Skin irritation or sores
Use nasal pillows or mask that have inflatable cushion
CPAP Problems and Possible Solutions
Noise
Check the air filter if it is clean or not blocked Call your CPAP supplier
CPAP Problems and Possible Solutions
Tangled CPAP tubing at night
Try placing the tubing behind the head near the top of pillow, or positioned behind the headboard bed post.
OSA Outcomes that should be evaluated on follow up after interventions
Resolution of sleepiness
OSA specific quality of life measures Patient and spousal satisfaction
Adherence to therapy
Avoidance of factors worsening disease
Obtaining an adequate amount of sleep Practicing proper sleep hygiene
Weight loss for overweight/obese patients
Recommended as an alternative treatment to fixed CPAP for OSA in patients who are poorly tolerant of fixed CPAP, and those with position related and REM related OSA.
Auto-titrating CPAP
____ is associated with increased nocturnal oxygen desaturation in men more than in women and with exacerbation of SDB.
Alcohol use
Bedtime use of alcohol is associated with increased upper airway resistance particularly after the ____
first 2 hours of ingestion
Oxygen Supplementation
is NOT RECOMMENDED as a sole treatment for OSA
Adverse effects of Oxygen Supplementation
- Lengthens the apnea duration
- Increases the risk of hypercarbia
- Minimal to no effect on blood pressure and daytime sleepiness
Pharmacological therapy for OSA
There is no accepted pharmacological treatment for OSA
What is the role of oral appliance therapy in OSA?
The use of prefabricated non-custom, non-titratable oral appliance for OSA is NOT
RECOMMENDED for OSA.
Easy-to-learn breathing exercises that are performed daily by patients for OSA
Buteyko therapy
When is surgery indicated for Obstructive Sleep Apnea?
Generally, surgery is not recommended for OSA
Surgery is useful as adjunctive treatment to conservative and device-based therapies.
Which patients require urgent treatment for OSA?
- Any patient with known or suspected OSA with severe/unstable co-morbid conditions may benefit from a referral to a sleep specialist for evaluation and/or possible initiation of CPAP or non-invasive ventilation
- Among patients with suspected OSA, a definitive PSG is recommended after stabilization of co-morbid condition to confirm the diagnosis of OSA.
The CTS guidelines recommend laboratory evaluation within 4 weeks for patients with: _________
- unstable ischemic heart disease
- recent cerebrovascular disease
- congestive heart failure
- refractory systemic hypertension
- obstructive/restrictive lung disease
- pulmonary hypertension
- hypercapneic respiratory failure
- pregnancy
- safety-critical occupations
