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Respiration > Sleep Apnoea and Neuromuscular Respiratory Failure > Flashcards

Sleep Apnoea and Neuromuscular Respiratory Failure Flashcards

1
Q

What is obstructive sleep apnoea?

A

Recurrent episodes of upper airway obstruction leading to apnoea (cessation of breathing) during sleep.

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2
Q

What are the common presentations of sleep apnoea?

A

Heavy snoring
Unrefreshing sleep
Daytime somnolence (sleepiness)
Poor daytime concentration

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3
Q

Where is the obstruction in sleep apnoea?

A

Between the base of the tongue/soft pallet and posterior pharyngeal wall

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4
Q

What are the causes of sleep apnoea?

A

Muscle relaxation
Narrow pharynx
Obesity

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5
Q

What is the pathophysiology of sleep apnoea?

A

Repeated closure of upper airways

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6
Q

What does recurrent closure of the airways lead to?

A

Oxygen desaturation
Snoring
Apnoea’s and hypopnea’s

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7
Q

What does apnoea’s and hypopnea’s lead to?

A

Frequent microarousals

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8
Q

What does frequent microarousals lead to?

A

Daytime hypersomnolence
Poor concentration

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9
Q

What is apnoea and hypopnoea?

A

Apnoea = obstructed for 10s or more
Hypopnoea = nearly obstructed for 10s or more

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10
Q

What is the importance of sleep apnoea?

A

Impaired QofL
Marital disharmony
Increased risk of RTA
Increased risk of stroke
Associated with hypertension
Probably increased risk of heart disease

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11
Q

What % of men/women are affected by sleep apnoea?

A

Men = 2%
Women = 1%

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12
Q

How do you diagnose sleep apnoea?

A

Clinical examination and history
Epworth questionnaire
Overnight sleep study

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13
Q

What are the 3 types of overnight sleep studies?

A

Pulse oximetry - basic
Limited sleep studies
Full polysomnography - most sophisticated

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14
Q

What is the Epworth questionnaire?

A

A questionnaire determining the level of sleepiness a patient experiences
Score of 11 or more = abnormal

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15
Q

What does overnight oximetry measure?

A

Records O2 sats and pulse rate while asleep

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16
Q

What is an indication of sleep apnoea on an overnight oximetry?

A

Repetitive desaturations
Pulse rate rises intermittently coinciding with O2 saturation

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17
Q

What does polysomnography measure?

A

Oronasal airflow
Thoracoabdominal movement
Body position
Oximetry
EEG (brain wave recordings)
Audio-visual recording
EOG (eye muscle movements)
EMG (peripheral muscle movements)
ECG (heart tracing)

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18
Q

How is severity of sleep apnoea measured?

A

Via desaturation index/apnoea hypopnoea index
0-5 = normal
5-15 = mild
15-30 = moderate
>30 = severe

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19
Q

What are the treatment options for sleep apnoea?

A

Identify exacerbating factors
Continuous positive airway pressure (CPAP)
Mandibular repositioning splint

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20
Q

What factors can exacerbate sleep apnoea?

A

Weight (90% of patients with SA are overweight)
Alcohol
Endocrine disorders

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21
Q

What does CPAP do?

A

Creates positive pressure within the throat and stops the tissue from being sucked together during inspiration.

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22
Q

How does mandibular repositioning splint work and when is it used?

A

Advances lower jaw forwards bringing base of tongue forwards and creating more space at the back of the throat.

Used if patient cannot tolerate CPAP.

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23
Q

How should patients be advised about driving?

A

Advice those with excessive daytime somnolence NOT TO DRIVE or RESTRICT driving and inform DVLA of their condition

24
Q

What is narcolepsy?

A

A chronic neurological disorder that affects the brain’s ability to control sleep-wake cycles

25
Q

What are the clinical features of narcolepsy?

A

Cataplexy
Excessive daytime somnolence
Hypnagogic/hypnopompic hallucination
Sleep paralysis

26
Q

What is cataplexy?

A

Where person will suddenly collapse during the day appearing to be asleep but is vaguely aware of what’s going on around them.

27
Q

What are hypnagogic/hypnopompic hallucinations?

A

Hallucinations that occur just at the onset of sleep or just at the end of sleep.
They are visual and often quite frightening

28
Q

What investigations would you perform for narcolepsy?

A

Polysomnography
MSLT (multi sleep latency test)
Low CSF orexin

29
Q

What is MSLT?

A

Patient is asked to try fall asleep in a dark silent room.
Their brain waves and time to fall asleep are recorded.
If time to sleep is less than 6mins then significantly abnormal.

> 1 SOREM and mean sleep latency <8 mins

30
Q

What does low CSF orexin show?

A

Orexin = neuropeptide involved in controlling wakefulness.
Typically see low levels in narcolepsy patients

31
Q

What are the treatment options for narcolepsy?

A

No cures - have to take drugs to continuously control illness
- Modafinil
- Dexamphetamine
- Venlafaxine
- Sodium Oxybate (Xyrem)

32
Q

What does modafinil do?

A

General stimulant taken at morning and lunch
Counteracts excessive somnolence

33
Q

What does dexamphetamine do?

A

Is a 2nd line drug used to counteract somnolence

34
Q

What is venlafaxine for?

A

Cataplexy

35
Q

What is sodium oxybate for?

A

2nd line drug for somnolence and cataplexy

36
Q

What type of ventilatory failure is chronic ventilatory failure?

A

Type 2

37
Q

What are the defining perimeters on ABG for chronic ventilatory failure?

A

Elevated pCO2
pO2 < 8kPa
Normal blood pH
Elevated bicarbonate in blood

38
Q

How does chronic ventilatory failure differ from acute?

A

Acute = rises in pCo2
Acute = Low pH

39
Q

What is blood pH proportional to?

A

Concentration of bicarbonate dived by pCO2

40
Q

What happens in the body when pCO2 rises and how is this managed in chronic situations?

A

Rise in pCO2 = blood pH falls

In chronic situation body attempts to compensate for this acidity by retaining the week buffer bicarbonate from the kidneys

41
Q

What is the aetiology of chronic ventilatory failure?

A

Airway disease
Chest wall abnormalities
Respiratory muscle weakness
Central hypoventilation

42
Q

What airways diseases can cause chronic ventilatory failure?

A

COPD
Bronchiectasis

43
Q

Give an example of a chest wall abnormality causing chronic ventilatory failure?

A

Kyphoscoliosis

44
Q

What respiratory muscle weakness can bring about chronic ventilatory failure?

A

Diaphragm, intercostal, abdominal muscles

Motor neurone disease (ALS)
Muscular dystrophy
Glycogen storage disease (Pompe’s disease)

45
Q

What can cause central hypoventilation?

A

Obesity hypoventilation syndrome
Congenital central hypoventilation syndrome (Ondine’s curse)
- Presents in newborns with ventilatory failure
- Used to be fatal but children can now sometimes survive to adulthood

46
Q

What are the typical symptoms of chronic ventilatory failure?

A

Breathlessness
Orthopnoea
Ankle swelling
Morning headaches
Recurrent chest infections
Disturbed sleep

47
Q

What is orthopnoea?

A

Breathlessness while lying flat

48
Q

Why do you get ankle swelling in chronic ventilatory failure?

A

Chronic low pO2 results in hypoxic vasoconstriction within pulmonary vasculature, resulting in elevated pressure within right heart, transferred to venous system, fluid can leak out of veins and cause swelling = cor pulmonale.

49
Q

Why do you get morning headaches in chronic ventilatory failure?

A

When pCO2 rises in blood at night, excess CO2 acts a vasodilator in cerebral blood vessels, this can result in headache.

50
Q

What would you expect to find on examination of a chronic ventilatory failure patient?

A

Paradoxical abdominal wall motion in suspected neuromuscular disease.
Ankle oedema (hypoxic cor pulmonale).

51
Q

Why does paradoxical abdominal wall motion come about and what is it?

A

Due to a weakness of the diaphragm.
Breath in diaphragm descends creating -ve intrathoracic pressure drawing air into the lungs.
When sitting upright it has help of gravity, when lying flat no gravity to help descend.
If significant weakness diaphragm wont contract properly/descend, opposite may happen and diaphragm is drawn up into the chest.
Abdominal wall will move up/out normally, but with diaphragm weakness it moves down during inspiration.

52
Q

What investigations do you do with chronic ventilatory failure?

A

Lung function
Assessment of hypoventilation
If suspected weekended diaphragm = fluoroscopic screening of diaphragm

53
Q

What do you look at with lung function tests and what would you expect to find?

A

Spirometry when lying and standing = measure VC:
- VC will be lower when lying than sitting/standing
Mouth pressure/SNIP
- Measure pressure person can generate breathing in/out as hard as possible
- SNIP = sniff in/out as hard as possible

54
Q

What tests are done in assessment of hypoventilation?

A

Early morning ABG
- Results reflect physiology of what happened during sleep
Overnight oximetry
Transcutaneous CO2 monitoring
- Looking for elevated CO2 during sleep

55
Q

What would be the expected results of a pulmonary function test for a patient with chronic ventilatory failure?

A

Reduced FEV1 and FVC
Ratio of FEV1/FVC is high
Characteristic of restrictive ventilatory pattern
Supine FVC is significantly lower than standing FVC

56
Q

What are the treatment options for someone with chronic ventilatory failure?

A

Not curable unless the underlying cause is curable.
Non-invasive ventilation (NIV)
Oxygen therapy
Tracheostomy ventilation (t-IPPV)

Respiration (27 decks)

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