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Orthodontics > S2 - Obstructive sleep apnoea > Flashcards

S2 - Obstructive sleep apnoea Flashcards

1
Q

Describe sleep cycles

A

normally 5 sleep cycles every night

  1. First REM occurs 90min after falling asleep then every 90min, gets longer later 2. Then light sleep, lasts up to 7min, prone to twitches and hypnagogic jerks (stage 1) 3. Then deep sleep (what makes you feel well rested) REM cycles get longer and deepness of sleep gets less through the night (stage 2-4)
    - how much sleep is needed varies between individuals
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2
Q

Prevalence of OSA, how does age affect it

A

5% of population, incidence goes up with age (12% in over 45s), very rare in children

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3
Q

What are the sleep disorders: insomnia, parasomnia, sleep related breathing and movement disorders, narcolepsy and circadian rhythm sleep disorders

A

Insomnia: difficulty falling and/or staying asleep

Parasomnia: sleep walking, talking, abnormal movments, night terrors

Sleep related breathing disorders: snoring, CSA, OSA

Sleep related movement disorders: restless leg syndrome, nocturnal bruxism

Narcolepsy: overwhelming daytime drowsiness leading to sleeping (often associated w other sleep disorders)

Circadian rhythm sleep disorders: jet lag, shift work

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4
Q

Reasons for indirect financial costs to govt associated with sleep disorders and conditions attributed to them (3)

A
  • lost productivity
  • welfare benefits
  • car accidents
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5
Q

Which other health conditions are you at increased odds of with sleep apnoea (men)

A
  • heart failure
  • schizoprenia
  • heart attack
  • depression/anxiety
  • PTSD
  • angina
  • diabetes
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6
Q

How common is snoring? What causes it (adults vs children).

A

40% of adults (M>F)

results from vibration of loose soft tissues in airway as air passes over them

snoring in children - often due to enlarged tonsils or adenoids

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7
Q

T/F Snoring = sleep apnoea

A

F, not necessarily

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8
Q

Types of sleep apnoea

A
  1. CSA (central) = airflow ceases due to temporary lack of inspiration (CNS issue), causes include:
  • Polymyelitis
  • Spinal cord injury
  • Encephalitis
  • Brain tumours in children

(i. e. diseases affecting CNS)
2. OSA = airflow stops due to a physical obstruction
3. Complex (combination)

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9
Q

Apnoea vs Hypopnea

A

apnoea - total cessation of airflow for atleast 10s

hypopnea - reduced airflow for atleast 10s accompanied by arousal or drop in O2 sat

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10
Q

How is severity of sleep apnoea calculated?

A

apnoea-hypopnea index (AHI)

AHI = apnoea episodes + hypopnea episodes / sleep hours

more severe in children - so threshold lower

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11
Q

Pathophysiology of sleep apnoea

A

obstructive episode → increased breathing effort → muscles work harder → reduced O2 and increased CO2 in blood (signals brain) → wakes up → hyperventilation → reduced CO2 and increased O2 → return to sleep → upper airway occludes → so on…

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12
Q

Why might OSA cause someone to wake up tired?

A

takes about 25mins to get into deep stage of sleep (what makes you feel most rested) → if many apnotic episodes, you never rly get down to this level and keep going up to the lighter stages of sleep

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13
Q

Which part of the sleep cycle does OSA happen?

A

depends, some ppl its throughout, some ppl only in REM sleep and some in deep sleep

children more likely to have in REM sleep

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14
Q

**Symptoms of sleep apnoea

A
  • poor concentration
  • low mood
  • restless sleep
  • heartburn (decrease in inter-thoracic pressure causes liquid to come up oesophagus)
  • waking up w headache or dizzy
  • night sweats
  • insomnia
  • weight gain
  • excessive daytime fatigue
  • forgetfulness
  • irritability
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15
Q

*Risk factors for sleep apnoea in adults (modifiable and non-modifiable)

A
  • obesity (biggest)
  • smoking or alcohol (esp before bedtime, relaxes airway muscles, more likely to occlude)
  • upper airway collapsibility
  • male sex
  • older age
  • hereditary
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16
Q

*Dental risk factors for sleep apnoea

A
  • high narrow palate
  • narrow dental arches
  • increased anterior face height (long)
  • increased overjet
  • retrognathia
  • large tongue
  • tonsilar hypertrophy
17
Q

Risk factors for sleep apnoea in children. Why do they differ from adults?

A

enlarged tonsils and/or adenoids are most common risk factor in children

(lymphoid tissues enlarged in childhood, peaks 9-12, goes down in teens)

unlike adults, obesity is not the main risk factor but 50% of obese children present with OSA vs 1-4% of general paediatric population

but some kids underweight; failure to thrive

18
Q

Differences between adults and children OSA summary

A

AHI > 5 defines OSA in adults wheres >1 for kids

19
Q

Management of adults with OSA (5)

A
  1. weight management
  2. smoking, alcohol cessation (in evenings)
  3. sleeping position (not supine)
  4. CPAP-Continuous Positive Airway Pressure - forces air down and opens obstruction - only 50% compliance rate, dries airway (if everything else fails)
20
Q

What to tell patients to use as guide when losing weight for OSA

A

BMI (body mass index)

weight in kg/height^2

(kg/m^2)

21
Q

Management of children with OSA. What is the biggest concern.

A
  1. Referral to ENT for adenotonsillectomy (to check if needed) - mainstay
  2. pharmacological agents to reduce lymphoid tissue (dont rly do anything so might be better to just remove)
  3. weight loss if obese
  4. CPAP → maxillary retrusion, class III (backward pressure on nose & mx, failure to grow fwd)

failure to thrive is biggest concern (physically, intellectually, mentally, emotionally)

22
Q

Implications of OSA for dentist/ortho

A
  • under diagnosed and under reported
  • dentists are in unique position as they see pt’s regularly
  • dentists can also have role in mgt through provision of md advancement appliances (for pts who cant tolerate CPAP → should be done under GUIDANCE and mgt of specialist sleep physician
23
Q

How to screen adults for OSA

A
  • Mallampati score: class 1)complete visualisation of soft palate, 2) complete uvula 3) base of uvula 4) soft palate not visible at all → 3 & 4 more risk
  • Scalloped tongue - tongue presses during teeth in sleep, 70% diagnostic for OSA, also sign of nocturnal bruxism (or both)
  • STOP-BANG Questionnaire: (>3 suggestive of OSA, higher score = higher risk)

*if pt has bruxism, enquire about OSA

24
Q

STOP-BANG Questionnaire

A
  • snoring
  • tiredness
  • observed apnoeas
  • hypertension
  • BMI>35kg/m2
  • age>50
  • neck circumference>40cm
  • gender - male

score >3 suggestive of OSA, higher score = higher risk

25
Q

How to screen children for OSA. Name 2 skeletal risk factors.

A
  1. Enlarged tonsils (Brodksy scale - see pic)
  2. history of snoring, daytime sleepiness, difficulty concentrating, ADHD* may be suggestive
  3. paediatric sleep questionnaire
  4. Epworth sleepiness scale for children
  5. retrognathic md, narrow mx

*sometimes OSA misdiagnosed as ADHD

26
Q

How is OSA diagnosed?

A

polysomnography i.e. sleep study (not done by dentist)

sleep at clinic or hospital

  • machine monitors things like brain activity, airflow, thoracic and abdominal movement, O2/CO2 sat, infrared camera watches pt

after apnoeic episode → increase inventilation, reduction in thoracic movement but increase in abdominal

before ep → O2 desaturation and increase HR just before

27
Q

Therapeutic guidelines for dentists

A
  • diagnosis of retrognathia and construction of mandibular advanacement splints
  • some pts with OSA can be tx w md advancement splints, MUST be done in conjunction w team led by specialist respiratory physician
  • snoring may or may not be sign of OSA, impossible to dx cause of snoring w/o medical examination and sleep lab investigation - use of oral devices to treat snoring w/o is INNAPROPRIATE → refer
  • pts with OSA are at increased risk of respiratory arrest from sedation and GA!!! should be undertaken in hospital w anaesthetist present
  • skeletal problems causing malocclusion should still be corrected (functional appliance, RME, OGS) there may some improvement in airway as side effect
  • insufficient evidence that ortho appliances in children without skeletal problems are effective
  • md advancement splints can be used in adults with mild-moderate OSA who dont tolerate CPAP
28
Q

T/F Md advancement devices are effective in severe OSA cases as much as mild-moderate

A

F, less effective in severe cases

29
Q

Advantage (1) and disadvantages (2) of Md advancement devices/splints.

A
  • better tolerated than CPAP
  • can cause changes in occlusion over time (proclination of lowers, retro of upper and tendency to develop class III)
  • adults need to be dentate for appliances
30
Q

How does md advancement device/splint work?

A

pushes md fwd opens airway

31
Q

What tx may be done as last resort if all other tx’s have been attempted and failed

A

orthgnathic surgery for mx/md advancements

(better w both jawd, unless class II just md)

32
Q

T/F functional appliances, RMEs can be used to treat OSA in children

A

ONLY if associated malocclusion needs it, useless otherwise

33
Q

Which functional appliances are md advancement splints/devices similar to?

A

Twin blocks or Herbst appliances

(both push md fwd to fix class II)

34
Q

Studies claim that RME and functional appliances increase airway volume. T or F?

A

RME - no

functional appliance - yes

Orthodontics (15 decks)

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