Sleep Flashcards by Salem Thewodros

Definition OSA

Spectrum snoring to complete obstruction

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Symptoms OSA

Snoring or apnoeas
Sleep fragmentation
Daytime sleep or memory impairment or poor concentration
Low mood
Unrefreshed sleep
Choking in sleep

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Pathophysiology OSA

Small pharyngeal size
Neck compression
Large tonsil
Head shape
Submucosal tissue

Obesity or PCOS

Htn
DM
AF
Hypothyroid
Acromegaly
Asthma

——
Narrow airway
Collapse upper airway
Low o2 and high co2
Arousal
Reactivate respiratory centre
Correct ventilation

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Ddx OSA

MSA
Laryngeal damage
Arnold chiari malformation

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Hx OSA

Epworth and stop bang
Occupational inc driving class
Etoh
Smoking
Drug Hx
PMHx

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Dx OSA

Overnight pulse ox
Sats and HR
Apnoea reduction airflow with Sats less than 90% for more than 10s
Hypoapnoea reduction airflow more than 30% with 4% oxygen Desat

AHI apnoea percentage of total sleep
ODI drop Sats 3-4% from baseline

AHI
Less than 5 normal
5-14 mild
15-30 moderate
Above 30 severe
————
PSG involves eeg eog and emg

ABG t1 in osa and t2 in ohas/copd w osa
Cxr
ECG

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Management osa

Mild
Lifestyle inc diet ex stop smoking and min etoh

Mandibular advancement
indication good teeth no seizure and over 18

Pharyngeal sx

Sleepy CPAP
———————————-

Moderate or Severe
Lifestyle
Fixed CPAP +- mandibular device
T2RF then BIPAP
AutoCPAP don’t tolerate fixed but higher pressure at times
BMI over 35 then refer bariatric

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Surgery OSA

Tonsilar
Large tonsil and BMI less than 35

Oropharyngeal sx
Severe osa not tolerating cpap

Rhinitis
Nasal obs not tolerating cpap

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Sleep review

Epworth score
Pulse ox for AHI and ODI
Tolerance to tx inc mask fit/leak/ nasal issue/ insomnia or restless legs/ cleanliness
Telemonitor

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Obesity hypoventilation

BMI over 30
Pco2 over 6

Aetiology
-Resp system workload increased with increased ER and reduced ERV
- increased Resp drive but hypovent in REM
- OSA so obstruct so raised co2 and Resp depression so hypovent

PSG sleep hypoventilation with nocturnal Hypercapnia with or without osa events

Indication NIv
Ph less than 7.3 and paco2 more than 6.5
Nocturnal hypoxaemia

Acute ventilatory failure
NIV and once oh and co2 normal consider cpap

Mx
Weight loss
Stop smoking
DVLA guidance
Optimise BiPAP
Not acidosis and Hypercapnia can switch to cpap

CX pulmonary hypertension

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COPD-OHAS

VQ mismatch
- Gas exchange issue causes air trapping
and ventilatory overload
Sleep hypoV

Presentation
Am waking
Peripheral oedema
Hypoxia
Polycythaemia

Dx
ABG
Overnight pulse ox.

Higher risk
Hypoxia and Hypercapnia
Job heavy machinery
Pregnant
CVD

Mx
CPAP if paco2 less than 7
BiPAP if paco2 more than 7

LTOT if hypoxia despite optimisation

Follow up
Clinical assessment
Sleep
CBG

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Central sleep apnoea definition

Regular and symmetrical waxing and waning in the context LVF

BMI over 30
Raised paco2
Reduced ventilation in sleep with no mechanical obstruction

Presentation
Headache
Per oedema
Hypoxia
Polycythaemia

Mx CPAP first line

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Types CSA

Cheyenne’s stokes in heart failure
Fluctuations sleep without apnoea
Nocturnal hypoventilation

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Ix CSA

Epworth
ABG
Pulse ox apnoea but no abdominal movement
PSG

Other
Echo for hf
MRI brain medullary lesions

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Higher risk CSA

Paco2 over 7
Hypoxia
Respiratory failure
High risk occ
Com eg IHD

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CSA pathophysiology

Reduced ventilatory drive eg cva encephalitis SOL syringobulbia or polio
Ventilatory failure worse in sleep
Lung function Normal with no muscle weakness

Reduced ability chest wall to expand eg Copd
Worse prognosis when VC less than 1L

Unstable ventilatory control eg HF or altitude
LA dilation so J receptor stretched so hypoxia vent drive so reduce pco2 so hypoventilation so increase paco2 arousal then cycle maintained

Chronic hypoventilation eg Copd or NM weakness
Diurnal ventilatory failure especially when supine with VC falling 20% late sign
Awake use accessory but REM this is lost + metabolic ventilatory drive blunted progressively so reduced arousal/interrupted sleep

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Mx CSA

I’d and treat cause
Stop smoking
Reduce weight
No etoh

Hypoxia
LTOT+- CPAP

Severe CSA
BiPAP then once stable can switch to CPAP

Other
Phrenic nerve stimulation

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OSA and driving on symptom

Sleepy
Stop driving
Inform DVLA
Start CPAP
Symptom free 3m and mild start driving OR severe wait DVLA

Mild and not sleepy
Continue driving

Severe and not sleepy
Stop driving
Start CPAP

Review yearly G1 or 3y in G2

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OSA driving based on group

G1
Mild to moderate
No sleep continue
Sleepy stop /cpap /then reassess 3m if symptoms not controlled

Severe G1
Sleepy then stop notify cpap and reapply at 1y

—————-

Group 2
No sleep all grades drive

Sleepy
Mild stop driving/ cpap/ review 3m and notify if symptoms ongoing
Moderate stop inform CPAP then review 3m
Severe stop inform mx then reapply 3y

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MND

Presentation
Muscle weakness
Speech or swallow difficulties
Fatigue
Muscle issue
SOB or T2RF
Cognitive impairment

Ax
Bloods
Cxr
ABG
NCS or EMG
Tumour marker and CTCAP
Restrictive lung function with reduced MIP

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Mx MND

Riluzole
LRTI mx secretions saliva
Avoid opioids and benzo
Respiratory support
Cough assist

Indications NIV
Confusion bulbar tired
Paco2 over 6
Respiratory effort
Cognitive impairment

Pre NIV
Escalation
Review
Feeding
Care lsecretions
Cough
Trache

Stop
Patient and NOK wishes
Legal ACP

Prioritise sleep study

Vocational driving
Security
Pregnant
Pre op
Unstable cv disease

Priority OHS
Co2 above 7
Hypoxaemia
Acute ventilatory failure
Vocational driving
Security
CVD
Pregnancy
Pre op

Auto CPAP

Higher pressure for certain times night

Unable to tolerate fixed

Telemetry can’t be used

Lower cost

Nocturnal hypoventilation

Waking headache
Peripheral oedema
Hypoxia
Unexplained Polycythaemia.

ESS threshold for high risk driver

REM sleep muscle

Diaphragm

Cheyenne’s stokes with altitude

Acute hypoxia Increased ventilation so Resp alkalosis Sleep onset reduces ventilatory drive so hypoventilation and apnoea Reduced Sats and increased paco2 Arousal Larger Resp alkalosis the greater risk hypoventilation sleep Mx Pre acclimatisation acetazolamjde produces met acidosis O2 fixes issue

CSA sleep studies

Fall in Sats with hypoventilation No osa Sats oscillation like sine wave

OSA moderate CV risk

2-3x

OSA ep 30-60

4% men 2% women

PSG

Nasal airflow Thoraco abdominal bands Snore vibration sensor Pulse ox

Narcolepsy Dx

Multiple sleep latency test less than 8m and rapid eye movement tests x2 Others limited psg with transition rem less than 10m

NIV in MND

Breathlessness Daytime sleepiness Hypercapnia more than 6 Nocturnal Desat 94% Reduced FVC 50% predicted or 80% with symptoms SNIP less than 40 (or symptoms with less than 65 men and less than 55 women) Postural VC drop 20%

Catathrenia

Moaning in sleep PSG Mx cpap

REM sleep disorder

Intense sleep Antonia Paralysis Risk factor PD, neurodivergent or narcolepsy Ix PSG Mx SSRI Clomazepam Melatonin

Periodic limb movement disorder mx

Ropinerole

Sleep stages

4-5 cycles Non rem is 75% REM 25% diaphragm spared so risk hypoventilation

Diseases increase respiratory muscle load

COPD due to hyperinflation so diaphragm can’t contract Obesity due to upper airway obstruction + ER increased and airway closure early — reduced muscle strength and reduced ERV Neuromuscular due to bulbar urt weak/slutum/ reduced chest wall compliance

ODI

4% oxygen desaturation per hour Helps grade OSA 5-14 mild 15-29 moderate Over 30 severe

Copd and hypoventilation on pulse ox

Gas shows Hypercapnia Mx NIV

OSA w hypoventilation pulse ox

Baseline variation within 4% then periods severe hypoxia

Acute decompression T2RF due to cold exac

Medical mx with controlled oxygen/nebs/pred Abx diuretics secretion Still pH less than 7.35 with pco2 over 6 then NIV Rv where and escalation

Benefits NIV in aCOPD

Reduces invasive ventilation Reduced LOS Reduces mortality

Use acute circuits for ACOPD

NIPY4 Starting 14+4 BUR 18 Ti 0.8 Trouble shooting Interface size, facial anatomy and strap tightness so leak review synchrony consider trigger setting change Review pressure area

ORRF obesity related respiratory failure

May need EPAP over 10 Increase Ti to offset issue with increased ER IE should be 1:1 Consider volume targeted mode to achieve TV

Causes neuroM or chest wall disease

Muscular dystrophy Myotonic dystrophy CMT MND or SMA GBS Chest wall ——————— Presentation FVC reduced and tachypnoea without Acidaemia ——————————— Secretion mx Cough assist Swallow and feeding Communication aids Escalation and MDT

Weaning acute NIV

First 24 hours max use and optimise settings D2 wean to self ventilation in day and nocturnal D3 if able trial without nocturnal NIV Documents pre discharge ABG ————— COPD old fe in 2-4 weeks with ABG Obesity RF with persistent Hypercapnia —) better outcomes with PAP on discharge NMD or chest wall all refer to specialist ventilation service pre discharge

Obesity related respiratory failure

BMI over 30 Sleep disordered breathing with AHI over 5 events per hour Daytime Hypercapnia pco2 over 6 *** no other cause for hypoventilation eg NM/mechanical/metabolic ——————- OSA overnight pulse ox looks like artefact Hypoventilation Pc02 rises —————— Mx OSA with pcos less than 7 — only cpap then ACPAP Mixed with pco2 over 7 — NIVto auto titrating NIV Pure OHS straight line w hypoventilation and ODI less than 15– NIV first line

Duchenne MD

Most common NMD X linked recessive Wheelchair at 10, death 20 Ix VC fall 30% in rem COD 70% Resp failure -1 year life expectancy post Resp failure 10% CM Mx NIV PEG CM treatment Positive tx ITU

Timing of NIV

Daytime respiratory failure Nocturnal rise co2 Pre op

Long term trache

Type and size Cuff or non cuff Subglotic port Vent MIE Esc Inform PT and ITU -PT burden secretions - freq and who performs Appropriate place to transfer