OSA/OHS Flashcards
Obstructive Sleep Apnea
general
Characterized by episodes of partial (hypopnea) or complete (apnea) collapse of the airway with an associated decrease in oxygen saturation or arousal from sleep
Significant implications for cardiovascular health, mental illness, quality of life, and driving safety
Obstructive Sleep apnea (OSA)
Epidemiology
Adults
Most common sleep-related breathing disorder
Prevalence increases with age; plateau in the 7th decade
Obesity (BMI ≥ 30 kg/m2) correlates strongly with OSA
African Americans are more likely to develop OSA
Children
Occurs most commonly between 2-6 years of age
OSA affects ~25% of adults in the United States
OSA
RF
Obesity
Congenitalor acquired craniofacial abnormalities:
Abnormalities of the jaw (micrognathiaorretrognathia)
Tonsillarhyperplasia
Macroglossia
Neckcircumference
> 43 cm (17 in.) in men and > 38 cm (15 in.) in women
Previousairwaysurgery
Nasal polyps
Septal deviation
Hypertrophiedpharyngeal muscles
Advanced age:> 65 years
Use of sedatives/alcohol
Poormuscle tone due tobraininjury or neuromuscular disease
Hypothyroidism and acromegaly
OSA
patho
During sleep patient experience hypopneic and apneic episodes due to:
Loss of the wakefulness drive to breathe
Decreasedmotoroutput to respiratory muscles
Decreased upperairway(UA) size due to anatomical structures
Increased UAresistance
OSA
Apneic and hypopneic episodes →
Apneic and hypopneic episodes → ↑ arterial carbon dioxide (CO2) levels (hypercapnia) → stimulates respiratory efforts against the narrowed upperairwayuntil the individual is awakened
- Hypercapnia→ respiratoryacidosis
- Increased respiratory efforts are achieved by sympathetic effects → secondary tachycardia and hypertension
- Reduced airflow results in pulmonaryhypoxiawhich triggers pulmonary vasoconstriction →pulmonary hypertension→cor pulmonale
OSA
Most important muscles for dilating the upper airway:
Most important muscles for dilating the upper airway: genioglossus and geniohyoid muscles; these muscle are innervated by the hypoglossal nerve (CN XII) and the first cervical nerve, respectively
Common sites of collapse: velum and base of the tongue, although lateral pharyngeal wall, epiglottic, nasal, and multilevel obstruction can occur
OSA
Clin Man
Nocturnal restlessness
Vivid, strange, or threatening dreams
Interruptedsleep, frequent awakenings
Snoring, choking, or gasping while asleep
Diminished ability to concentrate
Cognitive deficits
Irritability and other changes in mood
Nocturia
Morning headaches
Dry mouth or throat on awakening
Daytime sleepiness
OSA
PE findings
Obesity
Measure waist circumference
Calculate BMI
Measure neck circumference
ENT assessment
Low-lying palate
Size of the tonsils
Size of the tongue
Mallampati score
OSA
Mallampati score
-The amount of mouth opening to the size of the tongue
Patient sitting in Fowler’s position, mouth open and tongue maximally protruded, without speaking or saying “ahh”
OSA
Dx
Testing is usually guided and monitored by an expert insleepmedicine
Questionnaires for OSA
Nocturnal polysomnography(PSG)
GOLD STANDARD
Epworth Sleepiness Scale (ESS)
Preliminary, quantitative assessment for sleepiness
Scores range from 0-24
≥ 10 points indicates the presence of excessive daytime sleepiness and additional assessment is required
OSA
STOP-BANG Questionnaire
Common screening tool
Used to determine if high probability of moderate-severe disease is present
Interpretation:
Low risk ofOSA: Yes to 0–2 questions
Intermediate risk ofOSA: Yes to 3–4 questions
High risk ofOSA:Yes to 5–8 questions
int/high needs referral
Nocturnal polysomnography(PSG)
Gold standard test for the diagnosis of OSA
Patient monitoring
Electroencephalogram (EEG)
Pulse oximetry
Temperature and pressure sensors to detect nasal and oral airflow
Respiratory impedance plethysmography belts around the chest and abdomen to detect motion
Electrocardiogram(ECG)
Electromyography (EMG) to detectmusclecontraction inthe chin, chest, and legs
The severity ofOSAcan be determined from the apnea/hypopnea index (AHI), which is calculated as the number of apneic episodes per hour ofsleepduring asleepstudy
AHI ≥ 5 = mildOSA
AHI ≥ 15 = moderateOSA
AHI > 30 = severeOSA
OSA
Tx-lifestyle mods
Lifestyle modification
Weight loss
Cessation of consumption of sedatives/alcohol
Smokingcessation
Posturalsleephabits (lateral decubitus rather than supine sleeping)
Sleephygiene, such as:
Keepregularsleephours (minimum of 7-8 hours per night)
Ensure suitable sleeping environment
Avoid certain activities before bed (intense physical exertion, mental concentration)
Regulate napping
Avoid activities other than sleeping in bed
OSA
Devices for Tx
Positional modifiers to preventpatientsfrom sleepingin a supine position
Oral appliances or splints duringsleepto preventairwaycollapse/obstruction
Mandibular repositioning appliances
Tongue-retaining devices
Custom devices are preferred over non-custom devices
Avoid inpatientswith:
Generalized tonic-clonic seizures
Temporomandibular joint (TMJ) disorders
OSA
Surgery Tx & indications
Indications
Major upperairwayabnormality
Meeting criteria forbariatric surgery
Intolerance or inadequate adherence to PAP therapy
Uvulopalatopharyngoplasty (UPPP)
Surgically removes the uvula and tissue from the soft palate to create more space in the oropharynx
Can be done in conjunction with a tonsillectomy and adenoidectomy
Central sleep apnea (CSA)
general
Characterized by a lack of drive to breathe during sleep, resulting in repetitive periods of insufficient ventilation and compromised gas exchange
Less common than OSA
Occurs in patients with:
Problems that affect the brainstem (brain infection, stroke, or conditions of the cervical spine)
Certain medicines (narcotics)
OHS
Leptin
Peptide hormone
Released from adipose tissue
Amount of leptin in the blood is directly proportional to the amount of adipose tissue
Functions
Regulation of appetite
Energy homeostasis
Stimulatory effect on ventilatory response to CO2
OHS
Patient have higher levels of leptin in the blood (hyperleptinemia), but also have leptin insensitivity or resistancelikely due to diminished transport or down-regulation in the CNS
