Sleep Apnea Flashcards
How are breathing disorders characterized as?
A brief interruption of breathing during sleep
*apnea
*hypopnea
What are the 3 types of breathing disorders
- Central
- Obstructive
- Mixed
What do center and obstructive types of sleep related breathing disorders involve
Central (CNS causes RARE)
*ventilatory effort is absent for duration of episode
Obstructive
*brain says breathe but something is in the way
*most likely, the tissues in the throat
*ventilation effort continues but no airflow occurs
What is obstructive sleep apnea (OSA)
- Air cannot flow into or out of nose or mouth
*effort to breathe continues
Who has a higher risk for sleep apnea?
- Age
- Male sex
- obesity
- Family history
- Menopause
- Craniofacial abnormalities
- Certain health behaviors (cigarette smoking and alcohol use)
What are the risk factors for Obstructive Sleep Apnea (OSA)
- COPD (MC)
- Hypothyroidism
- Obesity
- Nasal obstruction
*VR
*rhinitis
What can precipitate or worsen OSA
- Smoking
- ETOH
- Sedatives
- Opioid use
What is the pathophysiology of OSA
- Upper airway obstruction while sleep due to
*pharyngeal muscles lose tone and collapse passively during inspirations
*diaphragm maintains tone
What are some anatomically conditions that may predispose someone to OSA
- Micrognathia (small mandibular jaw)
- Macroglassia
- Tonsillar hypertrophy
What happens during OSA
- Collapse of the upper pharyngeal airway
- Airflow is impeded
*effort to breathe continues - Progressive hypoxemia
- Arousal, patient awakens
- Upper airway opens, ventilation is restored
What is apnea?
- Cessation of airflow for >10 seconds
*OSA: apnea durations of 15-120 seconds
*may have 300-500 apneic episodes in a night
What is Hypopnea
- Reduction in tidal volume due to decrease in depth and rate of respiration
What is apnea/hypopnea index (AHI)
- Average apnea or hypopnea periods per hour of sleep
*AHI helps determine severity of OSA
What AHI will indicated OSA
> 5 AND excessive daytime sleepiness
What are the effects of hypoxemia?
Hypoxemia stimulates sympathetic nervous system
*will be systemic vasoconstriction, HTN
*bradycardia and dysrhythmias
What are the signs of OSA
- Almost always snoring between apneic episodes
*not everyone who snores has sleep apnea - Frequent interruptions of deep or restorative sleep
*morning headaches
*excessive daytime sleepiness - More common in obese, middle-aged males
What are the symptoms of OSA
- Daytime somnolence
- Weight gain
- Arterial HTN
- Morning sluggishness
- Inability to concentrate
- Depression
- Cognitive impairment
As a provider what can you ask the significant other about, if their partner may have OSA?
- Loud cyclic snoring
- Breathing cessation
- Witnessed apnea
- Restlessness
- Thrashing movements
- Irritability
- Personality changes
What will you find on the PE (OSA)
No significant findings
1. Weight BMI over 30
2. Appear sleepy
3. Abundant soft tissue in the neck and oral pharynx
4. Enlarged tonsils, large uvula or tongue
5. Deviated nasal septum, decreased nasal flow, nasal twang
6. Bull neck
7. Comorbidites
What are the Ddx of OSA
- Hypothyroidism
- Smoking
- Patient history
*alcohol use
*Drug of medication use - Seizure disorder
*narcolepsy - Depression
What are the laboratory / diagnostic tests to run
- Thyroid function tests
- Hbg / HCY erythrocytes is
- Depression screening
- Ent referral
Does the USPSTF recommend screening in an asymptomatic adult?
- No recommendation
What is the home nocturnal pulse oximetry
Screening and not diagnostic for OSA
1. Normal result = high negative predictive value
*will rule out significant episodes of apnea
What is the gold standard for OSA
Polysomnography (components are below)
1. Electroencephalography
2. Electro-oculography
3. Electro-myography
4. ECG
5. Pulse ox
6. Measure of respiratory effort, airflow
What will some of the findings be of the polysomnography be?
- Evidence or witnessed apneic upsides
- Fall in ox saturation
- Brady-dysrhythmias
- Tachy-dysrhythmias
*once airflow is re-established
what are the Brady dysrhythmias
*sinus bradycardia
*sinus arrest
*atrioventricular block
What are the tachy-dysrhythmias
- Paroxysmal supaventricular tachycardia
- Atrial fibrillation
- Ventricular tachycardia
What is essential for the diagnosis of OSA
- Daytime somnolence or fatigue
- History of loud snoring with witnessed apneic events
- Overnight polysomnography demonstrating apneic episodes with hypoxemia
What the treatment options for OSA (initial steps)
- Weight loss (if obese)
- Avoid alcohol, meds
- Improve sleep hygiene
- Devices that displaces the tongue and mandible forwards and prevent pharyngeal occlusion
What is the treatment for OSA (secondary steps)
- Nasal continuous positive airway pressure (nasal CPAP)
What are the components to a nasal CPAP device
Pressure will be determined by the polysomnography
1. Can be curative in many patients
*resolve obstructive apneic episodes, improves hypoxemia
What is the compliance rate of OSA
75% after 1 year
1. Compliant = at least 4 hours / night at least 70% of the total nights
2. Higher the AHI = more compliant
3. Decreased compliance = claustrophobia, self-conscious, reluctant to wear
What are the different types of CPAP masks
- Nasal pillow
- Full face
- Nasal
What to use for treatment if a patient cannot handle CPAP
- Use mandibular advancement (Repositioning device)
*mild/moderate OSA
Is supplemental oxygen recommended for OSA
No
*prolongs apneic episodes
When are surgical interventions used?
If the patient has
*large tonsils
*nasal polyps
What is uvulopalatopharyngoplasty?
- Resection of the pharyngeal soft tissue
*amputation of the soft palate and uvula
*helps 50% (eliminates snoring but not apneic episodes)
*laser surgery outpatient
What is tracheostomy
- Numerous adverse effects
*granuloma formation, speech issues, stoma infection
*reserved for those with most life threatening conditions when conservative treatment does not help
What are some complications of OSA
- Cardiac disease
- COPD exacerbations
- Hypoxemia during sleep
- Severe daytime somnolence
- Pulmonary HTN
What is the prognosis of OSA
- Excellent if treatment is instituted and followed
*untreated or unrecognized OSA can lead to serious or death
What should you educate a patient who has OSA about>
- Warn of the risk of driving
- Operating heavy machinery
- Engaging in other activities in which unintentional sleep episodes would be hazardous
What is obesity hypoventilation syndrome
- Applied to OSA and COPD
*if positive
*leads to increased M&M due to hypoxia
*intensifies the episodes of OSA
What can overlap syndrome lead to>
- OSA contributes to airway inflammation and worsen disease severity of COPD
*leads to pulmonary HTN, cor pulmonale, death
