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PSBIM Harrison 21st Edition > OSA guidelines 2015 > Flashcards

OSA guidelines 2015 Flashcards

1
Q

Clinical triad for Obstructive Sleep Apnea

A
  1. Chronic snoring
  2. Witnessed apneas
  3. Excessive daytime sleepiness
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2
Q

Symptom with greatest specificity for OSA

A

Witnessed apneas

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3
Q

Symptom that marks clinical intensity of OSA

A

Excessive daytime sleepiness

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4
Q

The clinically relevant OSA symptom most responsive to treatment.

A

Excessive daytime sleepiness

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5
Q

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.

A

Excessive daytime sleepiness

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6
Q

Patients at High Risk for Obstructive Sleep Apnea (OSA) who must be Evaluated for OSA Symptoms

A
  1. (Morbid) Obesity (BMI ≥ 35; *BMI ≥30 for Asians)
  2. Congestive heart failure or cardiac insufficiency Refractory hypertension
  3. Type 2 diabetes mellitus (T2DM)
  4. Nocturnal dysrhythmias or atrial fibrillation
  5. Stroke
  6. Pulmonary hypertension
  7. Individuals at high risk for accidents such as long haul drivers, pilots Preoperative for bariatric surgery
  8. Chronic respiratory diseases with greater hypoxemia or hypercarbia deterioration than (clinically) expected
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7
Q

Physical findings suggestive of the presence of OSA

A
  1. Increased neck circumference (M: >17 in., F >16) BMI ≥ 30 (*BMI ≥ 27.5 for Asians)
  2. Modified Mallampati score of 3 or 4
  3. Retrognathia
  4. Lateral peritonsillar narrowing
  5. Macroglossia
  6. Tonsillar hypertrophy/ elongated/enlarged uvula
  7. High arched/narrow hard palate
  8. Overjet defined as the extent of horizontal overlap of the maxillary central incisors over the mandibular central incisors)
  9. Nasal abnormalities such as septal deviation, nasal polyps, congestion or enlargement of turbinates
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8
Q

When should OSA screening be done?

A
  1. During routine health maintenance evaluation
  2. Routinely, among patients for pre-operative evaluation
  3. In populations where OSA poses a public health hazard (e.g. Public utility drivers, long haul drivers, pilots)
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9
Q

Questionnaire used in predicting risk for OSA

A

The Berlin Questionnaire

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10
Q

Questionnaire used for OSA screening in surgical patients

A

STOP-BANG

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11
Q

Questionnaire used for monitoring symptoms of excessive daytime sleepiness

A

Epworth Sleepiness Scale (ESS)

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12
Q

Gold standard for Diagnosing OSA

A

Polysomnogram

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13
Q

19-item questionnaire that quantifies subjective sleep quality over the past month

A

Pittsburgh Sleep Quality Index

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14
Q

Pittsburgh Sleep Quality Index score threshold for poor sleep quality

A

> 5

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15
Q

OSA screening tool in an elderly population

A

Multivariate Apnea Prediction Questionnaire

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16
Q

Most useful in predicting risk for OSA.

A

Berlin Questionnaire

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17
Q

Questionnaire with highest internal validity

A

STOP and STOP-Bang questionnaires

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18
Q

Alternative to Polysomnogram

A

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`

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19
Q

if excessive sleepiness continues despite optimal treatment, what test can be used for evaluation for possible narcolepsy

A

Multiple Sleep Latency Testing (MSLT)

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20
Q

Diagnosis of OSA using Polysomnogram
(GOLD STANDARD)

A
  1. >5 obstructive events per hour in patients with
    -symptoms
    -comorbidities

OR

  1. >15 events/hour even in the absence of sleep related symptoms
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21
Q

Diagnosis of OSA using portable monitor

A
  1. >5 obstructive events per hour in patients with symptoms
  2. >15 events/hour even in the absence of sleep related symptoms
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22
Q

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.

A

Respiratory Disturbance Index (RDI)

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23
Q

The sum of apneas and hypopneas divided by the total sleep time.

A

Apnea-Hypopnea Index (AHI)

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24
Q

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

A

Apnea

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25
Q

Type of respiratory event that meets ALL of the following:

  1. 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).
  2. The duration of the ≥30% drop in signal excursion is ≥10 seconds.
  3. There is a ≥3% oxygen desaturation from pre-event baseline or the event is
    associated with an arousal.
A

Hypopnea

26
Q

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.

A

Respiratory Effort-Related Arousal (RERA)

27
Q

May be performed if an AHI> 40/hour is documented during 2 hours of a diagnostic study

A

Split-night study

28
Q

Mild OSA

A

RDI/AHI 5-14/hour

29
Q

Moderate OSA

A

RDI/AHI 15-30/hour

30
Q

Severe OSA

A

RDI/AHI > 30/hour

31
Q

Follow-up Polysomnogram is routinely done in what situation?

A
  1. 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

  1. When clinical response is insufficient or when symptoms recur despite good initial response to CPAP.
32
Q

Goals of therapy for OSA

A

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.

33
Q

CPAP results in OSA

A
  1. Modest improvement in blood pressure
  2. Improves LV ejective fraction
  3. Reduction recurrence in Atrial Fibrillation
  4. Improvement of Insulin Sensitivity
  5. Improved driver performance
34
Q

Standard initial treatment for OSA

A

CPAP at a fixed pressure is the standard initial treatment of choice for OSA in adults.

Strongly recommended for Moderate to Severe AHI

35
Q

CPAP should be used for _______ during sleep daily for optimal benefit.

A

at least 4 hours

36
Q

Conservative Medical Therapy for Mild OSA

A
  1. Weight loss
  2. Positional therapy in patients with OSA in the supine position
  3. Nasal corticosteroids in patients with allergic rhinitis
37
Q

Hierarchy of effectiveness of management of OSA

A

CPAP> Dental Appliance > Uvulopalatopharyngoplasty

38
Q

What interface should be used with the CPAP?

A

The nasal airway is the preferred delivery route, however, alternatives may be tried to accommodate for comfort or difficulties

39
Q

What measures can be used to increase CPAP compliance?

A
  1. The addition of heated humidification.
  2. Use of BiPAP is an option in CPAP-intolerant patients.
  3. Pressure waveform modification technologies
40
Q

Definition of good adherence in CPAP

A

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.

41
Q

Most important interventions to address compliance to CPAP use

A
  1. The addition of heated humidification to relieve nasal discomfort or irritation
  2. Use of pressure waveform modification technologies (i.e. pressure relief) to improve patient comfort
  3. The use of BiPAP as an option in CPAP-intolerant patients.
42
Q

CPAP Problems and Possible Solutions

Claustrophobia

A

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

43
Q

CPAP Problems and Possible Solutions

nasal irritation and congestion

A

Heated humidifier
Nasal decongestant

44
Q

CPAP Problems and Possible Solutions

Uncomfortable mask or pressure loss

A

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)

45
Q

CPAP Problems and Possible Solutions

Headaches & ear pressure

A

Nasal decongestant

46
Q

CPAP Problems and Possible Solutions

Bloatedness

A

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

47
Q

CPAP Problems and Possible Solutions

Irritated eyes

A

Re-fit mask. Mask should not be set too high on the bridge

48
Q

CPAP Problems and Possible Solutions

Skin irritation or sores

A

Use nasal pillows or mask that have inflatable cushion

49
Q

CPAP Problems and Possible Solutions

Noise

A

Check the air filter if it is clean or not blocked Call your CPAP supplier

50
Q

CPAP Problems and Possible Solutions

Tangled CPAP tubing at night

A

Try placing the tubing behind the head near the top of pillow, or positioned behind the headboard bed post.

51
Q

OSA Outcomes that should be evaluated on follow up after interventions

A

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

52
Q

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.

A

Auto-titrating CPAP

53
Q

____ is associated with increased nocturnal oxygen desaturation in men more than in women and with exacerbation of SDB.

A

Alcohol use

54
Q

Bedtime use of alcohol is associated with increased upper airway resistance particularly after the ____

A

first 2 hours of ingestion

55
Q

Oxygen Supplementation

A

is NOT RECOMMENDED as a sole treatment for OSA

56
Q

Adverse effects of Oxygen Supplementation

A
  1. Lengthens the apnea duration
  2. Increases the risk of hypercarbia
  3. Minimal to no effect on blood pressure and daytime sleepiness
57
Q

Pharmacological therapy for OSA

A

There is no accepted pharmacological treatment for OSA

58
Q

What is the role of oral appliance therapy in OSA?

A

The use of prefabricated non-custom, non-titratable oral appliance for OSA is NOT
RECOMMENDED for OSA.

59
Q

Easy-to-learn breathing exercises that are performed daily by patients for OSA

A

Buteyko therapy

60
Q

When is surgery indicated for Obstructive Sleep Apnea?

A

Generally, surgery is not recommended for OSA

Surgery is useful as adjunctive treatment to conservative and device-based therapies.

61
Q

Which patients require urgent treatment for OSA?

A
  1. 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
  2. Among patients with suspected OSA, a definitive PSG is recommended after stabilization of co-morbid condition to confirm the diagnosis of OSA.
62
Q

The CTS guidelines recommend laboratory evaluation within 4 weeks for patients with: _________

A
  1. unstable ischemic heart disease
  2. recent cerebrovascular disease
  3. congestive heart failure
  4. refractory systemic hypertension
  5. obstructive/restrictive lung disease
  6. pulmonary hypertension
  7. hypercapneic respiratory failure
  8. pregnancy
  9. safety-critical occupations

PSBIM Harrison 21st Edition (15 decks)

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