Pulmonary HTN & Sleep Apnea Flashcards
Common causes of pulmonary HTN
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]
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?
Fatigue Dyspnea on exertion Palpitations Chest pain Syncope
What are some PE findings associated with pulmonary HTN?
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
Pulmonary hypertension findings on imaging
Peripheral hypovascularity
Pulmonary artery enlargement
RV enlargement
PFT findings with pulmonary hypertension
Isolated reduction in DLCO
Possible ECG findings with pulmonary HTN
Right axis deviation
Right ventricular hypertrophy
Right atrial enlargement
A pt with pulmonary HTN may be similar to a pt with IHD in that both have exertional dyspnea and blood tests indicate elevated ____
BNP
How is diagnosis of pulmonary HTN confirmed?
Right heart catheterization and direct measurement of mean pulmonary artery pressure
Classifications of pulmonary HTN
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)
What are some of the hematologic disorders included under group 5 pulmonary HTN?
Myeloproliferative disorders
Sickle cell dz
What are some of the systemic disorders included under group 5 pulmonary HTN
Sarcoidosis
Pulmonary langerhans histiocytosis
Vasculitis
What are some of the metabolic disorders included under group 5 pulmonary HTN?
Glycogen storage disease
Gaucher disease
Thyroid disorders
Why is pulmonary HTN separated into groups?
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
How is pulmonary HTN treated?
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
Symptoms of OSA
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
Common physical findings in OSA
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
If OSA is left untreated, it can lead to the dangerous sequelae of _____ and _____
Heart failure; stroke
Test of choice for OSA
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]
What is the purpose of polysomnography and what result confirms OSA?
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]
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
Reduced channel polysomnography
T/F: overnight oximetry is not an accurate test for OSA
True
What lab test should you always order in pts who present with weight gain and fatigue?
Serum TSH
[note that TSH is elevated in 2-3% of pts with OSA]
It is important to order a CBC in OSA pts because ____________ can be a complication in severe cases with accompanying severe hypoxemia
Secondary erythrocytosis
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
CXR; ECG
_________ should be ordered on your OSA pt to look for hypercapnea and hypoxemia if obesity hypoventilation syndrome is suspected
Arterial blood gas
Differential diagnoses for OSA
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
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?
Polysomnography
In central sleep apnea, polysomnography shows absence of respiratory effort during apnea, distinguishing it from obstructive
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
Upper airway resistance syndrome
[symptoms and tx are the same as OSA]
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
Dialysis
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
Narcolepsy
Lifestyle changes recommended to OSA pts
Weight loss of at least 10% in obese pts
Avoid alcohol and sedatives 3-4 hrs before bed
Sleep in lateral position
Primar airway management strategies for OSA
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
Other than lifestyles changes, CPAP, and/or BiPAP, what are other options for OSA tx?
Oral devices
Upper airway surgical procedures (uvulopalatopharyngoplasty - UPPP)
Nasal glucocorticoids and decongestants
Mandibular advancement devices (only help in mild to moderate cases)
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
D. Group 4 pulmonary HTN
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
C. Obesity-hypoventilation syndrome
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. Polysomnography
