Screening

Question 1

Is a positional element to AHI indicative of a better or poorer likelihood of success with OAT?

Answer 1

If the AHI is positional (supine), the OAT will have a much higher likelihood of success than in the patient with little or no difference between supine and lateral position.

Question 2

What effect does endothelial dysfunction have on coagulability?

Answer 2

Increased. This increases risk of stroke, myocardial infarction, etc.

Question 3

How does sleep apnea affect the endothelium and why? 17:10

Answer 3

Hypercapnia/hypoxia => bradycardia. Then sympathetic response. Hyperventilation, etc., then everything normalizes. Hypercapnia/hypoxia increase acidity of blood => damage endothelium => increased coagulability => vascular lumenal obliteration => vasoconstriction, smooth muscle hypertrophy, thrombosis, atherogenesis => CV complications

Question 4

Which drugs name ending indicates a beta blocker, and what do they do?

Answer 4

“-lol”
They lower BP and HR by interfering with the sympathetic response
Ultimately, they lower the oxygen demand of the heart

Question 5

What is the relationship between sympathetic activation and heart rhythm?

Answer 5

Hypoxia, hypercapnia, and intrathoracic pressure fluctuations lead to sympathetic response, which in turn leads to arrhythmia, especially atrial fibrillation.

Question 6

What is the odds ratio of OSA in afib patients?

Answer 6

Afib patients are 1.5 times more likely to have OSA – look for digitalis, coumadin, etc. as clues that the patient may have afib.

Question 7

What effect does treatment of OSA have on cardioversion in afib patients?

Answer 7

Cardioversion will often be maintained if the OSA is treated. This is because in many patients the OSA-induced hypoxia is the cause of the afib.

Question 8

What heart condition is snoring a causative factor in? 22:58

Answer 8

Carotid artery atherosclerosis. Increased severity (loudness) of snoring correlated directly with the amount of atherosclerosis in the carotid artery. The atherosclerosis was not found in the femoral artery (femur). This is because of the proximity of the carotid artery to the oropharynx – vibrations are transmitted into the artery.

Question 9

What are the potential sequelae of carotid artery atherosclerosis?

Answer 9

CA atherosclerosis can be caused by snoring alone. This can result in myocardial infarction or embolism.

Question 10

What is the effect of nitroglycerin on arteries?

Answer 10

Nitroglycerin is converted to nitric oxide. Nitric oxide is a vasodilator. In fact, it is found in higher levels in people who live at high altitudes as their bodies have adjusted for lower oxygen (increased dilation of pulmonary arterioles = increased oxygenation in spite of lower oxygen levels).
OSA patients produce less nitric oxide.

Question 11

Why is OSA a causative factor in CHF?

Answer 11

The sympathetic response that occurs at the end of an apneic episode results in increased peripheral resistance, which puts strain on the left ventricle which results in LV hypertrophy. Smaller lumen, less blood being pumped out of LV, buildup in the pulmonary side.

Question 12

What percentage of hypertensive patients have OSA?

Answer 12

40%-50%

Question 13

What percentage of CHF patients have OSA?

Answer 13

34%

Question 14

What percentage of COPD patients have OSA?

Answer 14

11%

Question 15

What percentage of coronary artery disease patients have OSA?

Answer 15

34%

Question 16

What percentage of fibromyalgia patients have OSA?

Answer 16

80%

Question 17

What percentage of DMII patients have OSA?

Answer 17

65%

Question 18

What percentage of end stage renal disease patients have OSA?

Answer 18

50%.

Why: hypertension, diabetes

Question 19

What percentage of ED patients have OSA?

Answer 19

50%

Why: OSA patients have less nitric oxide, which is a vasodilator.

Question 20

What is leptin?

Answer 20

Leptin is a hormone that suppresses appetite. Melatonin is a leptin agonist. In OSA patients, leptin levels are lower. So, OSA patients tend to gain weight. CPAP treatment => increased leptin levels.

Question 21

What is ghrelin?

Answer 21

Appetite stimulants hormone. There is an inverse relationship between sleep and ghrelin - i.e. poorer sleep, more ghrelin. Again, OSA tends to make weight control more difficult.
Ghrelin also stimulates growth hormone production.

Question 22

What are the limitations of the Epworth scale?

Answer 22

Does not account for patient age or medications

Question 23

What is the Epworth scale used for?

Answer 23

To screen for sleepiness and to subjectively monitor improvement with treatment.

Question 24

What are the three categories in the Berlin Quesionnaire?

Answer 24

Snoring, sleepiness/fatigue, hypertension

Question 25

What score range indicates further investigation on the Epworth scale?

Answer 25

10 or higher

Question 26

What score indicates further investigation with the Berlin Questionnaire?

Answer 26

2 or 3 categories positive = high risk
0 or 1 categories positive = low risk
2 positive answers in snoring and tiredness = positive category score
Hypertension or BMI >30 = positive hypertension category

Question 27

True or false: The Epworth, Berlin, and ARES scales have been validated.

Answer 27

True

Question 28

How should the sleep observer scale be used?

Answer 28

Get a pre-treatment baseline and then updates during followup. Filled out by spouse. Subjective.

Question 29

What are some of the inherent problems/limitations with the sleep scales?

Answer 29

Patients tend to normalize their symptoms (vastly underestimate true level of fatigue because they always feel that way)
They tend to disbelieve the diagnosis (everybody with kids or that is old, etc., is tired)
Symptoms poorly correlate with disease severity and are unreliable
There is a need for more objective assessment (PSG, HST, MSLT, MWT)

Question 30

What is the multiple sleep latency test (MSLT)?

Answer 30

4-5 20-minute naps at a 2-hour interval the morning after the PSG.
It measures the sleep latency (10 minutes is normal, 5-10 minutes concern, <5 is worse).

Question 31

What is the maintenance of wakefulness test (MWT)?

Answer 31

Strives to determination if a patient can maintain wakefulness.

Question 32

What is the relationship between increasing neck size and risk for OSA?

Answer 32

For every inch increase in neck size, the risk of OSA increases by 9.5%.

Question 33

What is the correlation between BMI and OSA incidence?

Answer 33

BMI ≥25 (overweight) = 2.5 times more likely to have OSA than normal BMI
BMI ≥30 = 3 times as likely to have OSA than normal BMI

Question 34

How much has the obesity rate among US adults changed in the last twenty years?

Answer 34

The rate of obesity in US adults has doubled in the last 20 years (1990-2010).

Question 35

How many traffic accidents have been attributed to OSA by the TSA?

Answer 35

10%-50%. This is more than drugs and alcohol combined. (2008 study).

Question 36

What is the medical guideline of CPAP compliance?

Answer 36

At least 4 hours per night, 70% of the nights (5 nights a week).

Question 37

What percentage of dental patients were found to be at risk of OSA?

Answer 37

Low risk: Almost 10% male and female
High risk: Almost 70% male, 30% of females
Total: 75% of males, 40% of females
(Sleep Breath February 2008)

Question 38

What is the STOP-BANG test?

Answer 38

1. Snoring: Do you snore loudly 2. Tired: Do you often feel tired, fatigued, or sleepy during the daytime? 3 Observed: Has anyone observed you stop breathing during your sleep? 4. Blood Pressure: Do you have or are you being treated for high blood pressure? 5. BMI: BMI > 35 kg/m2? (louder than talking or can be heard through closed doors)? 6. Age: Age > 50? 7. Neck circumference: Neck circumference > 40 cm? 8. Gender: male?

High risk of OSA High risk of OSA: answering yes to three or more items Low risk of OSA Low risk of OSA: answering yes to less than three items
(Anesthesiology 2008; 108:812–21)

Question 39

How does nasal congestion/chronic rhinitis impact one’s chances of success with OAT or CPAP?

Answer 39

Increased nasal obstruction is an independent risk factor for OAT and CPAP failure

Question 40

How does nasal congestion/chronic rhinitis impact one’s sleep?

Answer 40

Independent risk factor for:
habitual snoring
non-restorative sleep
daytime sleepiness
OSA