Sleep Apnea Flashcards by David Gordon

What brain wave patters accompany different stages of sleep and wakefulness

BATS Drink Blood
Beta waves= awake
alpha waves= falling asleep
Theta waves= stage 1
Sleep spindles= stage 2
Delta waves 20% of the time, slow waves= stage 3
Delta waves >50% of the time= stave 4
REM sleep

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How much time normally passes before the first REM cycle

45-60 min

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By the time you wake up after a full night of sleep what percentage of sleep is REM

20-25%

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How does the the time between NREM and REM sleep change over the course of a night

REM inc in length while NREM shortens

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What is the normal combined time to cycle through NREM and REM sleep

90-110 min

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Physiologic changes to breathing during sleep and their effects

Decreased cortical input= no higher brain stim to drive sleep
Decreased chemoreceptor sensitivity= CO2 inc and O2 dec
Decreased activation of respiratory motor neurons= breathing is less deep
Reduced alveolar ventilation with V/Q mismatches b/c of body postiion, CO, inc airway resistance, and dec breathing volumes

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What happens to PaCO2 while sleeping?

Does it change during REM vs NREM

Inc by 2-8 mmHg

Higher end during REM

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What happens to PaO2 during sleep

Decreases by 3-10 mmHg

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What happens to Oxygen demand during sleep

decreases by 15-25%

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What happens to SaO2 during sleep

dec by 2%

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Where are the chemo receptors

Central- Medulla

Peripheral- Carotid body, Aortic arch

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What does the central chemorecptor sense

PaCO2 (via pH)

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what do the peripheral chemoreceptors sense and what are they innervated by

PaO2 is the main stim but also respond to PaO2
Carotid body is innervated by CN IX
Aortic Arch is innervated by CN X

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Pulmonary sleep changes in Asthma

increased airway restriction= nocturnal bronchoconstriction

nocturnal cough

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Pulmonary and blood chemistry sleep changes in COPD

Hypercapnia and Hypoxemia are already problems in these patients
during sleep SaO2 may drop between 10 and 35%

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Pulmonary and blood chemistry sleep changes Diffusion problems ie ILD, CF

CO2 can diffuse fine by hypoxemia may be severe

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What are indications for non invasive positive pulmonary pressure ventilation in COPD

Severe COPD with hypercapnia (PaCO2 < 55) during the day OR
>2 hospitalizations for hypercapnic respiratory failure with PaCO2 of 50-55 OR
SaO2<88% for more than 5 min while on nasal oxygen

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What are indications for non invasive positive pulmonary pressure ventilation in restrictive lung dz or worsening neuromuscular dz

either with worsening symptoms
FEV < 50%
max inspiratory force < 60 cm H2O

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Pickwickian syndrome

Obesity Hypoventilation syndrome

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What is the pathology of Pickwikian syndrome

daytime hypoventilation b/c of obesity- chest mass limits chest wall excursion –> alveolar hypoventilation

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Symptoms of hypoventilation

Hypersomnelence
Dyspnea
Hypoxemia with cyanosis, polycythemia, and plethora

Complications of pickwickian syndrome

Cor pulmonlae- hypoxemia mediated

peripheral edema

Will CPAP help in Pickwikian syndrome

Definition of Apnea

Cessation of breathing for at least 10 seconds

Definition of hypopnea

30% dec in airflow for at least 10 seconds with 4% desaturation

what does RERA stand for

Respiratory associated Respiratory arousal

what is RERA

series of increased breathing with increased effort resulting in awakening

what is the respiratory disturbance index

Apnea's+ hypponeas's + RERA's/ night

AHI- what does it stand for | what is it, and what is it used for

Apnea - Hypopnea index Apnea's + Hypopnea's / night used to determine severity of sleep apnea

What is a normal AHI | what are the different stages of sleep apnea

normal: AHI30

what is polysomnography

sleep study

Why do you use do a sleep study

determine if sleep issues are behavioral or pathological | Allows for documentation of latency, efficiency, arousals/ awakenings, timing and quantification of stages based on EEG

What monitors are used

EEG EOG- REM vs NREM EMG's- muscle activity respiratory monitors- SaO2, EKG, airflow

What are the two main categories of sleep apnea

Obstructive sleep apnea vs central sleep apnea

What is the key difference between obstructive sleep apnea and central sleep apnea

EFFORT obstructive sleep apnea- want to breath but cant central sleep apnea- lose drive to breath

Definition of obstructive sleep apnea

intermittent obstruction of airflow resulting in apnea or hypopnea

where does the obstruction in obstructive sleep apnea normally occur

oropharynx

Risk factors for obstructive sleep apnea

``` obese enlarged neck African American Smoking Craniofacial abnormalities- large: tonsils, adenoids, uvula, soft palate, nasal polyps, tongue Retrognathia Diabetes Alcoholic Fam Hx Hypothyroidism ```

Signs and symptoms of obstructive sleep apnea

Snoring Excessive daytime sleepiness morning HA (arteries in brain expand to bring more blood in) personality changes respiratory acidosis from chronic hypercapnia

Diagnosis of sleep apnea

must be done with polysomnography | AHI>5 with hypersomnelence

Treatment of obstructive sleep apnea

behavioral changes- sleep hygiene- regulating bed time and duration, avoiding noise, drugs, and alcohol before bed. comfy bed avoid sleeping in a supine position weight loss CAPA uvulopalatopharyngoplasty, septoplasty, tubinoplasty- have varying success tongue base ablation in kids

Complications of obstructive sleep apnea

Cor pulmonale Secondary polycythemia systemic HTN arrhythmias

Central sleep apnea- definition

Repeated apneic efforts without respiratory muscle effort

Symptoms- of central sleep apnea

``` similar to OSA excessive daytime sleepiness morning HA personality changes respiratory acidosis ```

Risk Factors for central sleep apnea

general seen in sicker people, but have a normal BMI elderly men CHF Afib- smal emboli go to brain prior stroke endocrine abnomralities- acromegaly, hypothyroid Renal failure

Manifestations of central sleep apnea

Cheyne Stokes breathing

Describe Cheyne strokes breathing

apnea --> CO2 inc --> increasingly faster and deeper breathing --> CO2 dec --> lose respiratory drive --> apnea

pathophysiology of central sleep apnea

alveolar hypoventilation --> hypercapnia, hypoxemia, acidemia controller gain can magnify the response if it is from a neurologic abnormality the feedback system in the brain may not be working properly if CHF- feedback is delayed

what is controller gain central sleep apnea

compensatory release of catecholamines

diagnosis of central sleep apnea

same as obstructive

treatment of central sleep apnea

treat the underlying cuase reduce overshoot which causes sudden hyperventilation with NIPPV blunt control with benzos and narcotic O2 and CPAP dont work great for this