Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

apnea > Sleep apnea > Flashcards

Sleep apnea Flashcards

study

1
Q

What are signs and symptoms of Sleep Apnea

A 
Sleepiness Breath-holding choking 
gasping 
observed snoring or gasping 
hypertension 
mood disorder 
cognitive dysfunction 
stroke 
coronary artery disease 
congestive failure 
atrial fibrillation 
diabetes mellitus
5 events per hour or 15 events per hour
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the frequency of overlap syndrome

A

1%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the prevalence of sleep apnea

A

OSA with sleepiness occurs in 3-7% of adult men

OSA with sleepiness occurs in 2-5% of adult women

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Using criteria of 5/h, what is the prevalence of sleep apnea

A

24% in man and 9% in women

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the proportion of sleep apnea attributed to body mass

A

60%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the genetic contribution to OSA

A

OSA Twice as frequent with family history

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What are the criteria for pediatric sleep apnea

A

Snoring
Labored paradoxical or obstructive breathing
Sleepiness
hyperactivity
behavioral or learning problems
Plus one obstructive apneas per hour sleep
Or
Hypoventilation 25% of total sleep time with hypercapnia greater than 50 mm associated with snoring pressure waveform flattening or paradoxical thoracoabdominal motion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the prevalence of obstructive apnea in pediatric population

A

1 to 4%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

When do arousals occur in Cheyne Stokes respiration

A

At peak respirations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Do apneas or hypopneas predominate in children.

A

Hypopneas predominate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are normal Gas concentrations

A 
pH	7.35–7.45	
pCO2	35–45 torr	4.5–6.0 kPa
pO2	>79 torr	>10.5 kPa
CO2	23-30 mmol/L	
Base excess/deficit	± 3 mEq/L	± 2 mmol/L
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How does oxygen saturation affect hypopneas

A

Reduces the number of hypopneas because hypopneas require oxygen saturation in the definition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What is normal serum bicarbonate

A

The normal range is 23 to 29 milliequivalents per liter (mEq/L) or 23 to 29 millimoles per liter (mmol/L).

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Is the PCO2 in Cheyne-Stokes respirations increased or decreased

A

Decreased

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is normal FEV1%.

A

80%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What FEV1% predisposes to sleep related hypoventilation

A

less than 60%
FEV1 greater than 80 percent of predicted is normal
FEV1 60 percent to 79 percent of predicted indicates mild obstruction
FEV1 40 percent to 59 percent of predicted indicates moderate obstruction
FEV1 less than 40 percent of predicted indicates severe obstruction

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are risk factors for obstructive sleep apnea

A

Untreated hypothyroidism
upper airway narrowing macroglossia
upper airway myopathy
impairment of ventilatory control systems

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are the guidelines for increasing CPAP pressure

A

CPAP pressure should be increased once 3 obstructive Hypopneas are observed 2 obstructive apneas or 5 respiratory effort related arousals

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What conditions lead to Infiltration of pharyngeal tissue

A

Obesity Prader Willi Cushing syndrome mucopolysaccharidosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

During sleep what happens to V/Q imbalance

A

V/Q imbalance becomes lower in the lung basis leading to more blood traversing the lungs unoxygeninated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What were the results of the CANPAP trial

A

CPAP reduced AHI and plasma catecholamines.

60 minute walk distance, nocturnal oxygenation,
and injection fraction improved.

No reduction in hospitalizations or mortality.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is idiopathic alveolar hypoventilation

A

Decreased responsiveness to CO2 and O2 levels with respiratory drive suppression

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is sleep related hypoxemia

A

sp02 less than or equal to 88% over 5 minutes if sleep-related hypoventilation is documented in the diagnosis of hypoventilation is made.

In the event characterized by an increase of PCO2 greater than 55 mg mercury for greater than 10 minutes maybe scored as hypoventilation.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is late onset hypoventilation with hypothalamic dysfunction.

A

Associated with obesity
emotional disturbances
neural tumors
hypothalamic dysfunction.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

If a home study fails when is polysomnography indicated

A

If there is high suspicion of sleep apnea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

What are the complications of sleep apnea

A

Obstructive sleep apnea is associated with decreased SaO2 and PaO2, increased PaCO2, increased systemic and pulmonary artery pressures, decreased left and right ventricular output and increased vascular resistance because of sympathetic activity.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What is the definition of a hypopnea

A

30% drop in airflow from baseline lasting > 10 seconds and: Associated with > 3% oxygen desaturation or arousal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is the Respiratory Event Index (REI)

A

respiratory events per hour of monitoring time on Home Sleep Apnea Testing (HSAT)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is the Current Prevalence of OSA

A

AHI > 5/hr (30-70) Women 13 -17

AHI > 15/hr Men 9-13 women 4-6

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is the main finding of the Sleep Heart health study (SHHS)

A

There is a greater risk of CVD as RDI increases

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What is the finding of the Wisconsin Cohort study

A

AHI over 15 had 3x the odds of being diagnosed with hypertension than those with an AHI of zero.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What did Sleep Heart health study (SHHS) find regarding

hypertension

A

an AHI of 30 or more had 1.5 greater odds of being diagnosed with hypertension

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What did SHHS show regarding stroke and apnea

A

Sleep apnea seen in 50%–80% of acute stroke and TIA patients.

Sleep apnea improves in the sub acute phase, primarily central and Cheyne-stokes pattern, not OSA

Those with an AHI over 20 had a much higher likelihood of stroke

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What did SHHS show regarding Apnea and Arrhythmias

A

Most common is bradycardia cardiac slowing increases in proportion to the severity of hypoxemia

OSA increases the risk of developing A-fib.
an association of nocturnal cardiac death with worsening sleep apnea.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What is the relationship of OSA to Diabetes

A

up to 83% of patients with type 2 diabetes have unrecognized OSA

Insulin sensitivity improves after CPAP therapy
The greatest CPAP response on glucose metabolism is in the diabetic patient with a lower BMI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What is the relationship of OSA to GERD

A

54-76% of OSA patients have Gastroesophageal Reflux Disease (GERD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

What are physical exam findings in OSA

A 
Neck circumference  >17” men, >16” women 
Upper airway crowding
Lateral wall narrowing
High arched palate
Large tongue, high based
Large uvula and tonsils
High Modified Mallampati score
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

What is STOP-BANG

A

Score of ≥ 3 has >90% sensitivity to detect moderate to severe OSA
High positive predictive value (85%)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

What are the effects of CPAP in heart failure

A

CPAP reduces vascular and myocardial sympathetic activity

CPAP improves diastolic dysfunction

Treatment of OSA is associated with reduced readmission rate, health cost and mortality

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

What are Oral device predictors

A 
Lower initial AHI
Lower age
Lower BMI
Supine-dependent OSA
Certain cephalometric variables such as shorter soft palate or decreased distance between the mandibular plane and the hyoid bone
Low nasal resistance
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

What is the outcome for UPPP?

A

overall reduction in AHI of 33% (95 CI 23-42%).

Post-operative residual AHI remained elevated, averaging 29.8 events per hour

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

What is non hypercapnic central sleep apnea

A

Brief arousals accompanied by hyperventilation that decreases PaCO2 levels below apnea threshold causing central apneas

There is an increased ventilatory response to hypercapnia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

What causes Episodes of hyperventilation followed by low paCO2

A

Idiopathic central sleep apnea post arousal central sleep apnea congestive heart failure high altitudes CPAP pressure titration

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

When does an increase IPAP and EPAP occur

A

IPAP Should be increased if 3 obstructive hypopneas or 5 respiratory effort related arousals
IPAP and EPAP should be increased simultaneously if 2 obstructive apneas occur

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

What are the signs and symptoms of obesity hypoventilation syndrome

A

BMI greater than 30
waking hyper capnea greater than 45
Hypoxemia PaO2 less than 70

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

What is teatment emergent central sleep apnea

A

Obstructive sleep apnea with AHI or RDI greater than 5
On CPAP pressure that relieves obstructive events there is central apnea hypopneas index of greater than 5
50% of all events or central
Central sleep apnea is not explained by another disorder (Reduce CPAP by 1% and observed reemergence of obstructive events)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

What is Complex sleep apnea syndrome

A

Emergence of central apneic events during positive airway pressure titration for treatment of obstructive apnea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

Define Adult hypoventilation

A

PaCO2 greater than 55 mmHg lasting 10 minutes or longer

Increase in PaCO2 for 10 mmHg or more above baseline and reaching a level greater than 50 mmHg and lasting 10 minutes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

Define Child hypoventilation

A

PaCO2 greater than 50 mmHg for 25% of sleep or more

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Can Hypoxemia cause right heart failure in patients with obstructive sleep apnea

A

Yes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

What is Cheyne Stokes Criteria

A

3 central apneas or hypopneas consecutively separated by crescendo decrescendo breathing pattern of at least 40 seconds

5 central apneas or hypopneas accompanied by crescendo decrescendo pattern four hours sleep

At least 2 hours of monitoring

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

What are pediatric sleep apnea rules

A

HIstory of labored paradoxical breathing during sleep and sleepiness, hyperactivity, behavior problems, or learning problems
PSG criteria include one or more obstructive apneas per hour sleep and hypoventilation with PaCO2 greater than 50 mmHg for at least 25% of total sleep time with snoring flattening of the nasal pressure waveform or paradoxical thoracoabdominal motion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

What type ventilation support is appropriate in neuromuscular disease at night

A

Bilevel spontaneously time mode is the most appropriate treatment and provides pressure support to treat the hypoventilation ST mode is appropriate for neuromuscular disease patients who may have trouble triggering the device

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

What therapies help high altitude central apnea or periodic breathing

A

acetazolamide
Theophylline
hypnotic agents

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

What percentage of sleep apnea patients have positional apnea

A

50%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

What is Central sleep apnea

A

Failure of ventilatory drive (idiopathic) secondary causes include congestive heart failure neurologic disorders

57
Q

Does snoring require increase in iPAP

A

If 3 minutes of snoring is observed iPAP may be increased

58
Q

What factors are associated with greater oxygen desaturation in sleep apnea

A

Lower baseline awake supine in sleep SaO2

Longer duration of apnea or hypopneas shorter duration of ventilation between periods of apnea

Increased percentage of sleep time with apneas or hypopneas

Lower functional residual capacity and expiratory reserve volume

Presence of comorbid lung disorder such as COPD

59
Q

What factors increased risk of developing central sleep apnea

A

High CO2 ventilatory drive
Male gender
age
High altitude

60
Q

Which disorders and establish cause of secondary non-hypercapnic central sleep apnea

A

Congestive heart failure
Idiopathic
Reduced lung volume
Circulatory impairment

61
Q

What factors contributed to increased arterial PC02 in obese individuals

A 
Decreased chest wall compliance
Decreased ventilation
decreased expiratory reserve volume
decreased tidal volume
increased dead space
increased response to elevated PaCO2
62
Q

What are Pediatric syndromes associated with OSA

A

Antlely-Bixl is associated with choanal atresia or stenosis

Apert syndrome Associated with small nasal passages a large jaw

Crouzon choanal atresia maxillary hypoplasia posterior displacement of the tongue and prolonged soft palate

Goldenhar syndrome is associated with mandibular hypoplasia

Down syndrome is associated with small nasal passages enlarged tongue maxillary hypoplasia in the short neck

63
Q

What is appropriate treatment for central sleep apnea

A

Positive airway pressure
Acetasolamide
Zolpidem and triazolam

64
Q

What Pediatric syndromes are associated with OSA

A

Antlely-Bixl is associated with choanal atresia or stenosis
Apert syndrome Associated with small nasal passages a large jaw
Crouzon choanal atresia or stenosis maxillary hypoplasia posterior displacement of the tongue and prolonged soft palate
Goldenhar syndrome is associated with mandibular hypoplasia
Down syndrome is associated with small nasal passages enlarged tongue maxillary hypoplasia in the short neck

65
Q

What is Idiopathic central alveolar hypoventilation

A

Diagnosis is made in the presence of sleep related hypoventilation whether is no known medical or neurologic cause

Sleep related hypoventilation in the adult may be scored during polysomnography if arterial PCO2 is greater than 55 mg mercury for at least 10 minutes

Alternatively sleep related hypoventilation may be scored up arterial PCO2 is greater than 50 mg mercury for at least 10 minutes and if this value is at least 10 mg higher than evaluated determined while awake and supine

66
Q

What is the effect of 10% weight gain on OSA

A

Increases odds of developing OSA by 6x, and increases AHI by 32%.

67
Q

What are effects of weight loss on OSA

A

10% weight loss associated with 26% decrease in AHI in moderate to severe OSA.

68
Q

What is the effect of a 10% weight gain on OSA

A

increases odds of developing OSA by 6x, and increases AHI by 32%.

69
Q

When is positional therapy appropriate

A

May be beneficial in up to 75% with positional sleep apnea defined by AHI <5 in non-supine sleep

70
Q

What is effect of OSA on Atrial fibrillation

A

Patients with AF and untreated OSA are less likely to
maintain sinus rhythm after cardioversion
CPAP may reduce the occurrence of paroxysmal AF and
increase the success rate of cardioversion
Recurrence of AF after cardioversion with CPAP

71
Q

Ventricular arrhythmia

A

Frequency of PVCs during sleep by 58% with CPAP

72
Q

What is the incidence of Stroke in OSA

A

Patients with OSA twice as likely to suffer

stroke in 3.5 year follow up period

73
Q

What are AASM PAP titration guidelines

A

Optimal titration: reduces RDI <5 for at least a 15- min,
includes supine REM sleep at the selected pressure
• Good titration: reduces RDI ≤10 or by 50% if baseline RDI <15,
includes supine REM sleep at the selected pressure
• Adequate titration: does not reduce the RDI ≤10 but reduces
the RDI by 75% from baseline (especially in severe OSA
patients); or meets optimal or good with the exception that
supine REM sleep did not occur at the selected pressure

74
Q

What are contraindications for APAP

A

Congestive heart failure
Significant lung disease (COPD)
Expect nocturnal arterial oxyhemoglobin desaturation due to conditions other than OSA (e.g. OHS)
Patients who do not snore (either naturally or
as a result of palate surgery)
Central sleep apnea syndromes

75
Q

When is BiPAP appropriate in OSA

A 
– Optional with high pressures
– PAP intolerance
– Difficulty exhaling
– Co-existing hypoventilation
– Not shown to improve compliance
76
Q

What are Indications for BIPAP ASV

A
  • Complex sleep apnea, CPAP emergent central sleep apnea, central sleep apnea with EF >45%
  • Shown to improve AHI versus CPAP and BiPAP in complex sleep apnea
  • About ½ report improvement in sleep quality
77
Q

What is the effect of Supplemental oxygen

A

Supplemental O2 alone may reduce nocturnal hypoxemia

May prolong apneas (due to prolonged time to arousal after airway occlusion) and worsen nocturnal hypercapnia

78
Q

What is Pediatric apnea scoring rules

A

A drop occurs in the PK signal by greater than 90% of the preevent baseline using apnea sensor Device flow titration or alternative apnea since or

The drop last at least the minimum duration

Event meets respiratory effort criteria for obstructive central or mixed apnea

79
Q

What is pediatric obstructive apnea rule

A

Obstructive apnea meets apnea criteria for at least 2 breaths during baseline breathing and is associated with respiratory effort throughout the entire period of absent airflow

80
Q

What is Pediatric mixed apnea rule

A

Score a respiratory event as mixed if it makes apnea criteria for at least the duration 2 breaths during breathing and is associated with absent respiratory effort during one portion of the event and inspiratory effort is present in another portion

81
Q

What is Central apnea

A

The event last 20 seconds are longer

The event last the duration of 2 breaths during baseline breathing associated with a 3% anxious due to saturation

In infants younger than one age if the event last the duration of 2 breaths during baseline breathing and is associated with a heart rate 50 beats or less for 5 seconds or less or 60 beats a minute for 15 seconds

82
Q

What is Obstructive Hypopneas rule

A

Peak signal excursion drops by greater than 30% of predicted event baseline using nasal pressure or PAP Device flow signal

Snoring during the event

Increased inspiratory flattening of the nasal pressure or PAP Device flow signal

83
Q

What is the RERA rule

A

Sequence of breast last greater than 2 breaths when the breathing sequences characterized by increasing respiratory effort, flattening of the inspiratory portion of the nasal pressure, Device flow waveform, snoring or an elevation of the end tidal PCO2 leading to an arousal from sleep when the sequence of breaths does not meet criteria for apnea or hypoxia

84
Q

Define Pediatric hypoventilation

A

Greater than 25% of the total sleep time as a manager either by arterial PCO2 or surrogate is spent with greater than 50 mmHg PCO2

85
Q

What is pediatric periodic

breathing

A

Greater than 3 episodes of central apnea lasting 3 seconds separated by 20 seconds of normal breathing

86
Q

What is Adult hypoventilation

A

Score hypoventilation if there is an increase in arterial PCO2 to evaluate greater than 55 mmHg for 10 minutes

Score hypoventilation if there is a 10 mmHg increase in arterial PCO2 during sleep compared to value during wake and exceeding 50 mmHg for greater than 10 minutes

87
Q

List APAP Contraindications

A

Patients with congestive heart failure

significant lung disease such as chronic obstructive pulmonary disease

patients expected to have nocturnal arterial oxyhemoglobin desaturation due to conditions other than OSA (e.g., obesity hypoventilation syndrome),

patients who do not snore (either naturally or as a result of palate surgery)

patients who have central sleep apnea syndromes are not currently candidates
for APAP titration or treatment.

88
Q

What are Indications for APAP

A

Certain APAP devices may be initiated and used in the self-adjusting mode for unattended treatment of patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea
syndromes, or hypoventilation syndromes).

Certain APAP devices may be used in an unattended way to determine a fixed CPAP treatment pressure for patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea
syndromes, or hypoventilation syndromes).

89
Q

What are starting pressures

A

The recommended minimum starting CPAP should be 4 cm H2O for pediatric and adult patients, and the recommended minimum starting IPAP and EPAP should be 8 cm H2O and 4 cm H2O, respectively, for pediatric and adult patients on BIPAP

90
Q

What are the highest pressures for CPAP and BIPAP

A

The recommended maximum CPAP should be 15 cm H2O (or recommended maximum IPAP of 20 cm H2O if on BPAP) for patients <12 years, and 20 cm H2O (or recommended maximum IPAP of 30 cm H2O if on BPAP) for patients ≥12 years.

91
Q

What is the IPAP EPAP differential

A

The recommended minimum IPAP-EPAP differential is 4 cm H2O and the recommended maximum IPAP-EPAP differential is 10 cm H2O

92
Q

What are criteria for raising PAP pressures

A

CPAP (IPAP and/or EPAP for patients on BPAP depending on the type of event) should be increased by at least 1 cm H2O with an interval no shorter than 5 min, with the goal of eliminating obstructive respiratory events.

93
Q

If there are obstructive apneas, how are pressures raised

A

CPAP (IPAP and EPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 obstructive apnea is observed for patients <12 years, or if at least 2 obstructive apneas are observed forpatients ≥12 years.

94
Q

If there are hypopneas, how are pressures raised

A

CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 1 hypopnea is observed for patients <12 years, or if at least 3 hypopneas are observed for patients ≥12 years.

95
Q

How do you raise the pressure raise for RERAs

A

CPAP (IPAP for patients on BPAP) should be increased from any CPAP (or IPAP) level if at least 3 RERAs are observed for patients <12 years, or if at least 5 RERAs are observed for patients ≥12 years.

96
Q

What are pressure increase for snoring

A

CPAP (IPAP for patients on BPAP) may be increased from any CPAP (or IPAP) level if at least 1 min of loud or unambiguous snoring is observed for patients <12 years, or if at least 3 min of loud or unambiguous snoring are observed for patients ≥12 years.

97
Q

When do you switch from CPAP to BIPAP

A

If there are continued obstructive respiratory events at 15 cm H2O of CPAP during the titration study, the patient may be switched to BPAP.

98
Q

How are titrations graded

A

An optimal titration reduces RDI <5 for at least a 15-min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings.

A good titration reduces RDI ≤10 or by 50% if the baseline RDI <15 and should include supine REM sleep that is not continually interrupted by spontaneous arousals or awakenings at the selected pressure.

An adequate titration does not reduce the RDI ≤10 but reduces the RDI by 75% from baseline (especially in severe OSA patients), or one in which the titration grading criteria for optimal or good are met with the exception that supine REM sleep did not occur at the selected pressure.

99
Q

what are treatments for What are signs and symptoms of CSAS in CHF

A

CPAP therapy targeted to normalize the apnea hypopnea index (AHI) is indicated for the initial treatment of CSAS related to CHF.

BPAP therapy in a spontaneous timed (ST) mode targeted to normalize the apnea hypopnea index (AHI) may be considered for the treatment of CSAS related to CHF only if there is no response to adequate trials of CPAP, ASV, and oxygen therapies.

Nocturnal oxygen therapy is indicated for the treatment of CSAS related to CHF.

100
Q

CSAS in Renal Disease

A

The following possible treatment options for CSAS related to end stage renal disease may be considered: CPAP, supplemental oxygen, bicarbonate buffer use during dialysis, and nocturnal dialysis.

101
Q

Define treatment of CSAS in Renal Disease

A

The following possible treatment options for CSAS related to end stage renal disease may be considered: CPAP, supplemental oxygen, bicarbonate buffer use during dialysis, and nocturnal dialysis.

102
Q

What are the effects of elevation breathing

A

Approximately 25% of people examining periodic breathing at 8000 feet 100% of people demonstrate periodic breathing at 13,000 feet
Some people show periodic breathing at 5000 feet.

103
Q

What are the symptoms of altitude sickness

A

The increase and ventilation attacks associated with hypoxemia causes hypocarbia-Alkalosis. The low PaCO2 causes a loss or reduction respiratory drive resulting in central apnea or hypoxia. The greater than ventilatory response to hypoxia, the greater than fallen PaCO2 PSG findings demonstrate recurrent central apneas with cycle time of less than 40 seconds. There is more prevalent in NREM sleep than in REM sleep

104
Q

Which of the following is recommended to address sleepiness in myotonic dystrophy?

A

stimulants
naps
Treating obstructive and/or central sleep apnea

105
Q

68-year-old patient with systolic heart failure, with LVEF of 35%, was diagnosed with severe central sleep apnea. He tried CPAP and BPAP S/T but struggled with its use and does not wish to continue. On the most recent ECHO, his estimated pulmonary artery systolic pressure is 30 mmHg. On the PSG, his mean oxygen saturation was 89% on room air.

When considering nocturnal supplemental oxygen therapy for this patient, which of the following is true?

A

Treatment guideline recommends supplemental oxygen

106
Q

What are the Stop bang questions

A

Snoring
Tired
Observed
Pressure

BMI
Age
Neck
Gender

107
Q

calculate the AA gradient

A

A- Alveolar pO2
a-Arterial pO2
A= 150-1.2(pCO2)

Normal A-a gradient:
– Age dependent and increases with age
– Normal 5 -10 mm Hg in young adults
– Increases by 1 mm Hg for each decade of life

108
Q

Acid-base equations

A

Metabolic acidosis decreased pH decreased PaCO2 decreased bicarbonate
Metabolic alkalosis increased pH increased bicarbonate increased PaCO2
Respiratory acidosis decreased pH increased PaCO2 increased bicarbonate
Respiratory alkalosis increased pH decreased PaCO2 decreased bicarbonate

109
Q

How do you tell acute from chronic acid-base

A

Acute vs Chronic

Acute: ph change of 0.08 for every PaCO2 change of 10 mm Hg

Chronic: ph change of 0.03 for every PaCO2
change of 10 mm Hg

110
Q

Define hypoventilation

A

Hypoventilation is scored if either of the following occur:
– Increase of PCO2 or surrogate to value > 55 mm Hg for ≥ 10 minutes or
– Increase of PCO2 or surrogate during sleep (in comparison to awake
supine value) to a value > 50 mm HG for ≥ 10 minutes
• Other things to know:
– Persistent oxygen desaturation alone is not sufficient
– Duration of event not defined

111
Q

How is breathing controlled

A

Cortex (conscious control of breathing)
Pons (adjusts breathing rate)
Medulla (controls breathing
rhythm)

112
Q

Where do Problems with the Ventilatory Pump originate

A

Organ System or Anatomic Site Entities Associated with Ventilatory Pump Dysfunction

Brain, Brain Stem and Central Chemoreceptors
Brain stem stroke, Central Congenital Hypoventilation
Syndrome (CCHS), multiple sclerosis, Medications
(narcotics)

Spinal Cord Cervical spine injury Phrenic Nerves Phrenic nerve injury, Peripheral nerve diseases such as
ALS, Gullian Barre disease and Myasthenia gravis

Diaphragms Muscular dystrophy

Lungs and Chest wall Chronic obstructive lung disease, kyphosis and scoliosis compromise ability of lungs to expand

113
Q

Obesity Hypoventilation Syndrome (OHS)

A

Diagnostic Criteria: ICSD 3
• Diagnostic Criteria: All must be met
– Presence of hypoventilation during wakefulness (PaCO2 > 45 mm Hg) as measured by arterial PCO2
, end-tidal PCO2 or
transcutaneous PCO2
– Presence of obesity
• BMI > 30 kg/m2
• BMI > 95 percentile for age and sex for children
– Hypoventilation is not primarily due to other etiologies
• Lung disease, chest wall disorders (other than mass loading from obesity), medication use, neurologic disorders, muscle weakness, congenital disease, or idiopathic central alveolar hypoventilation
syndrome

114
Q

Role of oxygen treatment

A

No role as primary therapy
– May worsen hypercapnea
• Add oxygen to PAP therapy when hypoxemia persists in the following settings:
– Resolution of OSA (AHI < 10)
– Improvement/resolution of hypoventilation
– Intolerance to higher PAP pressures
• Remember:
– CMS requires resolution of OSA on PAP (AHI < 10) to
qualify for oxygen
– Reassess need for oxygen therapy based on clinical
improvement

115
Q

Define Congenital Central Alveolar Hypoventilation Syndrome (CCHS)

A

• ICSD 3 diagnostic criteria:
– Presence of sleep related hypoventilation
– Mutation of the PHOX2B gene is present
• Autosomal dominant
• Poly-alanine repeat expansion mutations (PARMs)

116
Q

What are characteristics of CCHS

A

Typically presents at birth or in early childhood with sleep related hypoventilation
• Severity of illness determined by PHOX2B mutation type:
– More poly-alanine repeats = More severe disease
• May present in adulthood with respiratory failure after anesthesia or a respiratory illness
– Typically due to a mild mutation of the PHOX2B gene
• Associated with Hirschspung’s disease, neural crest tumors and autonomic dysfunction
• Increased risk for neuroblastoma
• Treatment:
– Ventilatory support at night
– Case reports of diaphragmatic pacing

117
Q

Late-Onset Central Hypoventilation with

Hypothalamic Dysfunction

A

• Diagnostic Criteria:
– Presence of sleep related hypoventilation
– Symptoms absent during the first few years of life
– At least 2 of the following:
• Obesity
• Endocrine abnormalities of hypothalamic origin
• Severe emotional and behavioral disturbances
• Tumor of neural origin
– 40% with neural crest tumors
– Mutation of PHOX2B is not present
– Not better explained by other disorders
• Also known as ROHHAD:
– Rapid-onset obesity with hypothalamic dysfunction, hypoventilation,
and autonomic dysregulation
• Treatment: Ventilatory support

118
Q

Idiopathic Central Alveolar Hypoventilation

A

• ICSD 3 diagnostic criteria:
– Sleep related hypoventilation is present
– Not better explained by other disorders
• Rare disease: Prevalence not known
• Often presents in adolescence or early adulthood
• Slowly progresses to respiratory failure
• Treatment: Ventilatory suppor

119
Q

Obstructive Lung Disease and Alveolar Hypoventilation

A
  • COPD
  • Bronchiectasis
  • Cystic fibrosis
120
Q

Restrictive Lung Disease and Alveolar Hypoventilation

A
  • Pulmonary fibrosis (end stage)

* Chest wall disease (kyphoscoliosis)

121
Q

Neuromuscular Weakness and Alveolar Hypoventilation

A 
• Muscular dystrophies
• Myotonic dystrophy
• ALS
• Guillian Barre syndrome
• Myasthenia gravis
ALS:
• Riluzole is the only medication that affects survival. Best for patient with less severe disease 
• NPPV may improve survival
122
Q

What are possible consequences of carotid body resection and
Myxedema

A

Some Alveolar Hypoventilation

123
Q

Chronic Obstructive Pulmonary Disease (COPD) Definition:

A

– Chronic obstructive lung disease

– Post bronchodilator FEV1/FVC < 70%

124
Q

Mechanisms Sleep Related Hypoxemia in COPD

A

• Hypoventilation
– Most important mechanism Decreased minute ventilation and tidal volume
• REM > NREM > Wake
• Decreased response to CO2 and hypoxemia
– REM > NREM > Wake
• Increase in upper airway resistance
• Reduction in FRC associated with sleep and supine position
• V/Q mismatch
Determinants of Hypoxemia
• ↓ SaO2 during wakefulness

125
Q

Determinants of Hypoxemia Sleep Related Hypoxemia in COPD

A 
– Major predictor of mean and lowest sats during sleep in COPD
• ↑ PaCO2 during wakefulness
• ↑ Duration of REM sleep
• ↑ Severity of obstruction
• ↑ Respiratory muscle dysfunction
• ↑ BMI
• Co-existence of OSA
126
Q

What are the benefits COPD Treatment: Oxygen

A

• Improves survival in patients with resting hypoxemia (PaO2 < 60
mm Hg)
– More (duration) = Better outcomes
• Nocturnal Oxygen Therapy Trial (NOTT)
• Medical Research Council (MRC) Trial
• No data to support improved survival in patients with normal resting oxygen saturations

127
Q

What is Overlap Syndrome

A

• Coexistence of COPD and OSA
• Prevalence of OSA similar to general population
• Associated with lower nocturnal mean oxygen saturations and lower oxygen desaturations compared to COPD patients without OSA
• Increased risk of death and severe COPD exacerbation leading to hospitalization if OSA untreated compared to group without concomitant OSA
• Risks of death or hospitalization reduced with CPAP treatment
– Outcomes no different than COPD group alone
– Improved CPAP adherence = Better survival
– Older age associated with reduced survival

128
Q

Not APAP Candidates (AASM Standard)

A 
– Congestive heart failure
– COPD and chronic lung disease
– Obesity hypoventilation syndrome
– Other hypoventilation syndromes
– Lack of snoring
129
Q

Nocturnal NIPPV May Improve Survival in Stable Hypercapnic COPD

A

• Methods:
– 195 patients with stable GOLD stage IV,
– PCO2 > 52 mm Hg and ph > 7.35
– NIV targeted to reduce PCO2 by 20% or < 48 mm Hg
– Randomized to NIPPV or medical therapy
– Outcome: 12 month all-cause mortality
• Results: Mortality reduced in NIPPV group – Mortality 12% in NIPPV group vs 33% in control group
– HR = 0.24 (p = 0.0004)
• Conclusions:
– The addition of long-term NIPPV to standard treatment improves survival of patients with hypercapnic, stable COPD when NIPPV is targeted to reduce hypercapnia
– NIV plus oxygen may prolong the time to readmission or death within 12 months of a COPD exacerbation in patients with persistent hypercapnea

No role for patients without hypercapnea

130
Q

COPD: The Bottom Line

A

• Hypoventilation is the most important mechanism responsible for sleep related hypoxemia
• Oxygenation during wakefulness is the major predictor of mean and lowest oxygen saturation during sleep in COPD
• Consider PSG for concomitant OSA
• Nocturnal treatments and outcomes:
– Oxygen improves survival in COPD with resting hypoxemia
– CPAP improves survival and decreases exacerbations and hospitalizations in those with the overlap syndrome
• Better outcomes associated with greater CPAP adherence
– NIPPV targeted to reduce PaCO2 may improve survival in patients with stable COPD and hypercapnea (PaCO2 > 52 mm Hg)

131
Q

Sleep Related Hypoventilation due to Medication or Substance

A

• Opioids
– Long acting narcotics are the most common medication associated with hypoventilation
– Both in normal individuals and for patients with comorbid diseases
– May cause OSA, CSA, and or hypoventilation

• Benzodiazepines for patients with comorbid diseases that may affect respiratory drive:
– COPD
– OHS
– Neuromuscular weakness
– CVA
– In combination with opioids
132
Q

Oxygen Therapy for the Boards: The Bottom Line

A

• OSA:
– Role of oxygen on outcomes is not clear and not recommended as primary therapy
– CPAP is better than oxygen for BP control in short term studies
– Add oxygen if hypoxemia persists after OSA is resolved with PAP therapy

• CSA syndromes:
– Useful for reducing CSA and symptoms in high altitude CSA
– Role of oxygen for other forms of CSA not clear

• COPD:
– Nocturnal and 24 hour oxygen therapy improves survival in patients with resting hypoxemia while awake
– Role in other groups not clear

• Hypoventilation syndromes:
– Be careful in patients with chronic hypercapnea who’s main respiratory drive is based on hypoxemia

133
Q

What are blood gases like in CCHS

A

Arterial blood gases may be normal during wakefulness will be abnormal and obtained from an arterial line during sleep. Decompensated respiratory acidosis may be present pulmonary hypertension may be present.

134
Q

What are the characteristics of ROHAD

A

Patients require ventilatory support during sleep. They breathe adequately during wakefulness. Hypoventilation persisted even at the patient’s lose weight. Hormones may be increased or decreased and resulted in the following conditions: Diabetes insipidus, inappropriate IADH, precocious. Puberty, hypogonadism, hyperprolactinemia, hypothyroidism, and decreased growth hormone secretion. Mood and behavior disorders occur. Developmental delay may occur.

135
Q

What is Antlely-Bixl

A

Antlely-Bixl is associated with choanal atresia or stenosis

136
Q

What is Apert syndrome

A

Apert syndrome Associated with small nasal passages a large jaw

137
Q

What crouzon syndrome

A

Crouzon choanal atresia or stenosis maxillary hypoplasia posterior displacement of the tongue and prolonged soft palate

138
Q

What is goldenhar syndrome

A

Goldenhar syndrome is associated with mandibular hypoplasia

139
Q

What are features of Down’s syndrome

A

Down syndrome is associated with small nasal passages enlarged tongue maxillary hypoplasia in the short neck

apnea (2 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions