Sleep Flashcards
Definition OSA
Spectrum snoring to complete obstruction
Symptoms OSA
Snoring or apnoeas
Sleep fragmentation
Daytime sleep or memory impairment or poor concentration
Low mood
Unrefreshed sleep
Choking in sleep
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
Ddx OSA
MSA
Laryngeal damage
Arnold chiari malformation
Hx OSA
Epworth and stop bang
Occupational inc driving class
Etoh
Smoking
Drug Hx
PMHx
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
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PSG involves eeg eog and emg
ABG t1 in osa and t2 in ohas/copd w osa
Cxr
ECG
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
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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
Surgery OSA
Tonsilar
Large tonsil and BMI less than 35
Oropharyngeal sx
Severe osa not tolerating cpap
Rhinitis
Nasal obs not tolerating cpap
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
Obesity hypoventilation
BMI over 30
Pco2 over 6
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
COPD-OHAS
Gas exchange issue causes air trapping
and ventilatory overload
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
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
Types CSA
Cheyenne’s stokes in heart failure
Fluctuations sleep without apnoea
Nocturnal hypoventilation
Ix CSA
Epworth
ABG
Pulse ox apnoea but no abdominal movement
PSG
Other
Echo for hf
MRI brain medullary lesions
Higher risk CSA
Paco2 over 7
Hypoxia
Respiratory failure
High risk occ
Com eg IHD
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
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
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
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
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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
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
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
17
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
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
