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Respiratory Medicine Exam II > Pulmonary HTN & Sleep Apnea > Flashcards

Pulmonary HTN & Sleep Apnea Flashcards

1
Q

Common causes of pulmonary HTN

A

Over 80% of cases are caused by conditions leading to elevation of left-sided heart filling pressures or pulmonary disease

Less commonly idiopathic [F>M]

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2
Q

With mild pulmonary hypertension, right ventricular function may be preserved and pts may be asymptomatic. As disease progresses, what are some symptoms the pt may report?

A 
Fatigue
Dyspnea on exertion
Palpitations
Chest pain
Syncope
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3
Q

What are some PE findings associated with pulmonary HTN?

A

Left parasternal lift

Augmented jugular A wave

Pulmonic component of S2 or a single S2

Murmurs of tricuspid regurgitation or pulmonic insufficiency

Right ventricular S3 or S4 gallops

Edema, ascites, hepatomegaly also possible

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4
Q

Pulmonary hypertension findings on imaging

A

Peripheral hypovascularity

Pulmonary artery enlargement

RV enlargement

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5
Q

PFT findings with pulmonary hypertension

A

Isolated reduction in DLCO

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6
Q

Possible ECG findings with pulmonary HTN

A

Right axis deviation

Right ventricular hypertrophy

Right atrial enlargement

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7
Q

A pt with pulmonary HTN may be similar to a pt with IHD in that both have exertional dyspnea and blood tests indicate elevated ____

A

BNP

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8
Q

How is diagnosis of pulmonary HTN confirmed?

A

Right heart catheterization and direct measurement of mean pulmonary artery pressure

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9
Q

Classifications of pulmonary HTN

A

Group 1 = idiopathic and CT disease (includes BMPR2, ALK1, endoglin with/without hereditary hemorrhagic telangiectasia; drug and toxin induced; scleroderma, HIV, portal HTN, congenital heart disease, schistosomiasis, chronic hemolytic anemia)

Group 2 = Heart (includes systolic dysfunction, diastolic dysfunction, valvular dz)

Group 3 = Lung (COPD, ILD, alveolar hypoventilation d/o, chronic high altitude exposure)

Group 4 = Pulmonary embolism

Group 5 = all others (include hematologic, systemic, metabolic, and other d/o)

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10
Q

What are some of the hematologic disorders included under group 5 pulmonary HTN?

A

Myeloproliferative disorders

Sickle cell dz

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11
Q

What are some of the systemic disorders included under group 5 pulmonary HTN

A

Sarcoidosis

Pulmonary langerhans histiocytosis

Vasculitis

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12
Q

What are some of the metabolic disorders included under group 5 pulmonary HTN?

A

Glycogen storage disease

Gaucher disease

Thyroid disorders

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13
Q

Why is pulmonary HTN separated into groups?

A

The group system is used because it gives a functional idea of what is causing the pulmonary HTN — which allows docs to better understand how to tx

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14
Q

How is pulmonary HTN treated?

A

Group 1 (idiopathic) — management is focused on vasodilator therapy

Group 2-5 — treat underlying cause; may include tx of heart failure, COPD, and/or OSA as well as O2 therapy

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15
Q

Symptoms of OSA

A

Impaired daytime attention and memory [significantly increased risk for MVA!!]

Habitual snoring

Nighttime awakening with gasping or choking

Insomnia

Nighttime diaphoresis

Erectile dysfunction

Daytime fatigue or sleepiness

Alterations in mood

Neurocognitive decline

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16
Q

Common physical findings in OSA

A 
Obesity
Large neck
Nasal obstruction
Enlarged tonsils
Narrow oropharynx
Macroglossia
Retro- or micrognathia
Systemic HTN
Decreased O2 sat
Nasal congestion
Wheezing
Accentuated pulmonic component of S2 or S3
17
Q

If OSA is left untreated, it can lead to the dangerous sequelae of _____ and _____

A

Heart failure; stroke

18
Q

Test of choice for OSA

A

Polysomnography

[often performed with EEG for sleep staging and assessment for other causes of apnea; CPAP titration may be done at the same time or separately]

19
Q

What is the purpose of polysomnography and what result confirms OSA?

A

Measures respiratory events and hours of sleep to derive apnea-hypopnea index (AHI), which is the average number of apnea and hypopnea events per hour

An AHI >5/hr confirms OSA

[the severity of OSA is based on AHI, degree of sleepiness, and presence or absence of CV problems]

20
Q

Less expensive test for sleep apnea that may allow more pts access, but it is overall less accurate than polysomnography; usually includes respiratory monitoring and oximetry

A

Reduced channel polysomnography

21
Q

T/F: overnight oximetry is not an accurate test for OSA

A

True

22
Q

What lab test should you always order in pts who present with weight gain and fatigue?

A

Serum TSH

[note that TSH is elevated in 2-3% of pts with OSA]

23
Q

It is important to order a CBC in OSA pts because ____________ can be a complication in severe cases with accompanying severe hypoxemia

A

Secondary erythrocytosis

24
Q

A ______ and ______ should be ordered on your OSA patient if coexisting heart failure is suspected based on physical exam, as this can be a complication

A

CXR; ECG

25
Q

_________ should be ordered on your OSA pt to look for hypercapnea and hypoxemia if obesity hypoventilation syndrome is suspected

A

Arterial blood gas

26
Q

Differential diagnoses for OSA

A 
Central sleep apnea
Upper airway resistance syndrome
Periodic limb movements of sleep
Narcolepsy
Obstructive or restrictive lung dz
GERD
Sinusitis
Heart failure
Epilepsy
Sleep deprivation
Hypothyroidism
Acromegaly
Obesity-hypoventilation syndrome
27
Q

Central sleep apnea is most commonly seen in pts with heart failure and stroke, as well as use of opioid medications. What test can differentiate central vs. obstructive sleep apnea?

A

Polysomnography

In central sleep apnea, polysomnography shows absence of respiratory effort during apnea, distinguishing it from obstructive

28
Q

Condition most commonly seen in loud snorers who complain of excessive sleepiness and polysomnogram with EEG shows a normal AHI but increased respiratory effort causes frequent EEG interruptions during sleep

A

Upper airway resistance syndrome

[symptoms and tx are the same as OSA]

29
Q

Periodic limb movements of sleep are a neurologic disorder of unknown cause, characterized by frequent episodes of leg kicking during sleep; it is most common in pts on _______; limb movements are not associated with respiratory events on polysomnogram

A

Dialysis

30
Q

Severe excessive sleepiness and cataplexy with age of onset usually 15-25, and polysomnogram does not show OSA or periodic limb movements, but multiple sleep latency are abnormal

A

Narcolepsy

31
Q

Lifestyle changes recommended to OSA pts

A

Weight loss of at least 10% in obese pts

Avoid alcohol and sedatives 3-4 hrs before bed

Sleep in lateral position

32
Q

Primar airway management strategies for OSA

A

Continuous Airway Positive Pressure (CPAP) — pneumatically splints the entire airway, preventing collapse during sleep; raises intraluminal pressure in airway and increases FRC

Bi-level PAP (BiPAP) — while CPAP has one pressure leve, BiPAP has separate pressures for inspiratory and expiratory phases which may improve comfort and adherence

33
Q

Other than lifestyles changes, CPAP, and/or BiPAP, what are other options for OSA tx?

A

Oral devices

Upper airway surgical procedures (uvulopalatopharyngoplasty - UPPP)

Nasal glucocorticoids and decongestants

Mandibular advancement devices (only help in mild to moderate cases)

34
Q

A 53 y/o woman suffered multiple pulmonary emboli during the pregnancy with her second child. Subsequently, she has noticed limitations hiking in mountains she hadn’t noticed previously. Dyspnea slowly progressed so now she is dyspneic keeping her house and shopping. Her exam was normal except for accentuation of the second heart sound. Echocardiogram suggested pulmonary artery hypertension. What is the most likely diagnosis?

A. Group 1 pulmonary HTN
B. Group 2 pulmonary HTN
C. Group 3 pulmonary HTN
D. Group 4 pulmonary HTN
E. Group 5 pulmonary HTN
A

D. Group 4 pulmonary HTN

35
Q

A 62 y/o morbidly obese male presents with a history of chronic daytime hypersomnolence, loud snoring, choking during sleep, and impaired concentration. He is a lifelong nonsmoker and is employed as a machinest. He most likely has…

A. OSA
B. COPD
C. Obesity-hypoventilation syndrome
D. Ondine’s curse
E. Narcolepsy
A

C. Obesity-hypoventilation syndrome

36
Q

A 62 y/o morbidly obese male presents with a history of chronic daytime hypersomnolence, loud snoring, choking during sleep, and impaired concentration. He is a lifelong nonsmoker and is employed as a machinest. You suspect obesity-hypoventilation syndrome. The best diagnostic step is:

A. Polysomnography
B. Echocardiography
C. CXR
D. 6-minute walk test
E. Right heart catheterization
A

A. Polysomnography

Respiratory Medicine Exam II (11 decks)

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