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Pathophysiology 2 > Sleep Disordered Breathing > Flashcards

Sleep Disordered Breathing Flashcards

1
Q

Normal Sleep Cycle

A

There is two main stages of sleep

  • Non-Rapid Eye Movement (Non-REM)
    • Quiet or slow wave sleep
  • Rapid Eye Movement
    • Active or dreaming sleep
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2
Q

How are stages of sleep determined

A

Stages of sleep are determined through electrophysiological monitoring

EEG, EOG, EMG

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3
Q

Different Stages of Sleep

A

W: wakefulness

N1: non-REM 1

N2: non-REM 2

R: RE

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4
Q

NREM Sleep Sub Stages

A

N1

N2

N3- Has 2 levels

N1 and N2 are more chaotic whereas N3 is slower and more regular

Cycles of 60-90 minutes

Majority of the time in N2

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5
Q

NREM Sleep

A

Contributes to physical rest and may bolster the immune system and digestive system

Interruptions in these sleep stages (particularly N3) can interfere with normal growth patterns, healing, and immune response (especially in peds)

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6
Q

REM Sleep

A
  • Signified by an increase in EEG activity
  • Lasts 5-40 minutes
  • Lengthen as the sleep progresses
  • Contributes to psychological rest and long-term emotional and well-being
    • May bolster memory
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7
Q

REM Sleep and Sleep Disordered Breathing

A

Sleep related hypoventilation and apnea are frequent

Reduced response to hypoxia and hypocapnia

Profound atonia (muscle has lost its strength) affecting arms, legs intercostal and upper airway (does not affect diaphragm

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8
Q

Sleep Disordered Breathing

A

Describes a group of disorder that are characterized through abnormalities of the respiratory pattern (pauses of breathing) or the quantity of ventilation during sleep

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9
Q

Types of Sleep Apnea

A

Upper airway resistance syndrome (UARS)

Obstructive Sleep Apnea

Central sleep apnea

Mixed Sleep Apnea

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10
Q

Severity Progression From Snoring to Severe OSA

A

Snoring

Hypopnea

Mild Osa

Severe OSA

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11
Q

Hypopnea

A

A significant decrease in breathing without a complete cessation of airflow

Both the decreased SpO2 and/or the sleep arousal are the physiological significant features of hypopnea

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12
Q

Upper Airway Resistance Syndrome

A

Increased airway resistance results in an extra effort to breath

This can cause arousals and increases in blood pressure

Can also reduce arterial oxygenation

10 or more apneas lasting less than 10 seconds per hour

A person may or may not wake up

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13
Q

Sleep Apnea

A

Defined as the cessation of breathing

OSA requires apneas to be 10 seconds or longer (may exceed 100 seconds) until the brain reacts to overcome the problem

Sleep apnea is diagnosed when there is more than 5 apneas per hour occurring over a 6 hour period

Sleep apneas may appear in all age groups- In infants, it may play a role in SIDS

Individuals with sleep apnea had other chronic conditions. -Ex. Diabetes, hypertension, heart disease, and/or mood disorder

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14
Q

Obstructive Sleep Apnea (OSA)

A

The most common type of sleep apnea

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder that is characterized by intermittent closure of the upper airway associated with desaturation and arousal from sleep.

Approximately 25% of the Canadian population is at risk of OSA, but only about 5% have been diagnosed.

Caused by a small or unstable pharyngeal airway making them periodically struggling to breath as they are unable to inhale effectively as their airway has collapsed

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15
Q

Obstructive Sleep Apnea (OSA)

Anatomical Causes

A
  • Excess of soft tissue
  • Obesity
    • Though not all people with OSA are obese and a significant number of adults with normal BMI have a decreased tone causing airway collapse and sleep apnea
      • The cause of this is not well understood
  • Tonsillar hypertrophy (enlarged tonsils)
  • Mostly in peds
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16
Q

Obstructive Sleep Apnea (OSA)

Neurological Causes

A

Decreased muscle tone

While awake the pharyngeal tone is maintained through an increased activity of the airway dilator muscle

This is lost during sleep and the narrowing and/or closure of airway results

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17
Q

Obstructive Sleep Apnea (OSA)

Signs and Symptons

A

When asleep the patient will begin quiet and still which is followed by an increased effort to inhale and often resulting in “snorting”. This will end after an intense struggle

Hallmark symptom is excessive daytime sleepiness

Difficulty staying asleep (insomnia)

Awakening with dry mouth or sore throat

Morning headache

Nausea

Intellectual and personality changes

Depression

Nocturnal enuresis

Sexual impotence

Hypertension

Unexplained cardiac problems

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18
Q

Obstructive Sleep Apnea (OSA)

Signs and Symptons in Severe Cases

A

Suddenly awaken

Sit upright in bed

Gasp for air

Symptoms of sleep apnea are not always an indication of the severity of the sleep apnea!

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19
Q

What is the common cause of most signs and symptons of OSA

A

These result from the continued stimulation of the sympathetic drive

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20
Q

Risk Factors for OSA

A
  • Excess weight
  • Neck size (16.5cm diameter or larger)
  • Hypertension
  • Anatomic narrowing of upper airway
  • Chronic nasal congestion
  • Diabetes
  • Family history of sleep apnea
  • Smoking or use of alcohol, sedatives, or tranquilizers
  • Age
    • Older than 65 years of age
  • Male sex
    • Though in post-menopausal women prevalence approaches men in same age range
  • CVD
  • DM
  • Mental illness
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21
Q

Consequences of Untreated OSA

A

HTN (50%)

Deterioration in QOL, family life

Job loss

Cardiovascular disease- Heart attacks, Stroke

Diabetes

Neurocognitive and performance deficits

Automotive accidents

People with untreated sleep apnea cost the healthcare system more than 2.5 times more than those without.

“Those with sleep apnea are 15 times more likely to be in a motor vehicle or work related accident due to sleepiness”.

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22
Q

Central Sleep Apnea

A
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23
Q

What Happends During the Sleep Apnea Period

A

With each episode of apnea blood oxygen levels will reduce (hypoxia), and sleep is disturbed as the sleeper must wake briefly in order to resume breathing

Because the sleeper will not become fully awake they will normally have no recollection of the awakening

This cycle is repeated throughout the night interfering with normal sleep pattern not allowing the patient to feel rested in the morning

Sleep disturbances and repeated reductions in blood oxygen levels result in excessive daytime sleepiness, reduced quality of life, and impaired cognitive function such as memory loss and poor concentration.

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24
Q

When do apneas occur during sleep

A

Apneas may occur in either non-REM or REM sleep

Apneas are more frequent and more severe in REM and when in a supine body position

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25
Q

% of Canadian diagnosed with sleep apnea

A

3% of Canadian adults 18 years and older will be diagnosed with sleep apnea

Out of those diagnosed with sleep apnea 4% reported symptoms and risk factors that are associated with a high risk of having or developing obstructive sleep apnea

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26
Q

Sleep Apnea Diagnosis

A

Many Canadians were diagnosed with sleep apnea without the benefit of sleep laboratory testing.

In order to be diagnosed with sleep apnea the Canadian Thoracic Society recommends that an individual undergo a polysomnography, but portable home monitoring devices are also sometimes used to test for sleep apnea

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27
Q

A high risk for obstructive sleep apnea is have three or more of the following (Canadian Community Health Survery)

A

Snoring loud enough to be heard through closed doors

Often feeling tired during the day

Having been observed stopping breathing in their sleep

Diagnosed with high blood pressure

Having a BMI >35

Being over 50

Being male

28
Q

Central Sleep Apnea

A

Patients with CSA will display a periodic breathing pattern where they periodically not breath or breathe so shallowly that oxygen intake is ineffectual

Waxing and waning or respiratory pattern

May show Cheyne Stokes breathing pattern

Occurs when respiratory centers of the medulla fail to send signals to the respiratory muscles

Characterized by cessation of airflow at the nose and mouth with absence of diaphragmatic excursions

29
Q

Cheyne-Stokes Breathing

A

Cheyne-Stokes is a severe type of periodic breathing that is often associated with CHF

Cheyne-Stokes breathing is shallow/under breathing that will alternate with a deep over breathing

30
Q

Clinical Disorders Associated with CSA

A
  • Congestive heart failure
    • Cheyne-Stokes respiration
  • Metabolic alkalosis
  • Idiopathic hypoventilation syndrome
  • Brain stem neoplasm or infarction
  • Bulbar poliomyelitis
  • Spinal surgery
  • Encephaslitis
  • Cervical cordotomy
  • Hypothyroidism
    • Will result in abnormalities in ventilatory control
31
Q

Bulbar Poliomyelitis

A

Infectious disease caused the poliovirus

A severe infection can extend into the brainstem and even into higher brain structures, resulting in polioencephalitis. This can affect breathing, swallowing, and other vital functions.

Bulbar polio leads to weakness of muscles innervated by cranial nerves.

32
Q

Encephalitis

A

Encephalitis is an acute inflammation (swelling) of the brain usually resulting from either a viral infection or due to the body’s own immune system mistakenly attacking brain tissue

33
Q

Cervical Cordotomy

A

Cordotomy is a surgical procedure that disables selected pain-conducting tracts in the spinal cord, in order to achieve loss of pain and temperature perception.

34
Q

Mixed Sleep Apnea

A

Combination of obstructive and central sleep apnea

Usually begins as central sleep apnea, followed by:

Ventilatory efforts without airflow—OSA

Clinically, mixed sleep apnea is usually classified and treated as OSA

35
Q

Overlap Syndrome

A

When OSA and COPD co-exist

Worse prognosis

Worse ABG abnormalities than “simple” OSA

36
Q

STOP BANG Questionaire

A

High Risk: Answering yes to three for more items

Low Risk: Answering yes to less than three items

  • S = Snoring
  • T = Tiredness
  • O= Observed apneas/gasping
  • P = Pressure (as in high BP)
  • B = BMI
  • A = Age
  • N = Neck circumference
  • G = Gender
37
Q

STOP BANG Questionaire

Snoring

A

Do you snore loud enough to be heard through closed doors or louder than talking

38
Q

STOP BANG Questionaire

BMI

A

BMI more than 35 kg/m2 ?

39
Q

STOP BANG Questionaire

Age

A

Over 50

40
Q

STOP BANG Questionaire

Neck Circumference

A

Neck circumference greater than 40 cm?

41
Q

STOP BANG Questionaire

Gender

A

Are you male

42
Q

Epworth Sleepiness Scale

A
  • Used to measure excessive daytime sleepiness
    • Has patient rate how likely they are to fall asleep in different situations
  • Validated for OSA
  • Scores are added up
    • 0-9 is normal
    • 10-24 indicates need for expert medical advice
    • ≥ 16 indicates possibility of severe sleep apnea or nacolepsy
  • Can be repeated after beginning treatment with CPAP to see if symptoms have improved
43
Q

Who Intreprets Sleep Studies

A

Both studies read and interpreted by a specialist physician (usually a respirologist).

44
Q

Level 1 Sleep Study

A
  • Polysomnogram (PSG)
  • Done in a hospital or sleep lab
  • Diagnoses all sleep disorders
  • Able to stage sleep
  • Uses 16 channels to gather information:
    • SpO2, snoring, airflow, EMG, respiratory effort, limb movement, EOG, ECG, EEG
45
Q

Polysomnogram (PSG)

Obstructive Sleep Apnea

A
  • There will be a lack of airflow, but the presence of respirtory drive
  • There will be a paradoxical efforts of the rib cage and abdomen
  • Efforts will continue to increase until arousal and airflow returns
  • The arousal is shown on the EEG and results in the airway opening and resumption of airflow
46
Q

Polysomnogram (PSG)

Obstructive Hypopnea

A

There is a decrease (not total stop) of airflow at the same time as paradoxical efforts

There will be an increase in efforts until arousal occurs and airflow resumes

The arousal will result in complete airway opening and resumption of airflow

There will be a desaturation but to a lesser degree than OSA

47
Q

Polysomnogram (PSG)

UARS (Respirtory Effort Related Arousal

A

There will be no detectable decrease in airflow

Subtle paradoxical efforts are not unusual, but efforts will increase until arousal occurs

No desturataion is associated with the arousal

48
Q

Polysomnogram (PSG)

Central Sleep Apnea

A

There is a lack of airflow and a lack of respirtory efforts

There will be and arousal which is followed by a maximal respiratory effort

Desaturations are common

49
Q

Polysomnogram (PSG)

Mixed Sleep Apnea

A

There is a lack of airflow and respirtory efforts=Central Componenets

Respiratory Efforts resume without airflow= Obstructive Componenet

Arousal with increased respirtory efforts occur

Desaturations are common

50
Q

Level 3 Sleep Study (home or bedside)

A

Uses 6 channels to gather information:

SpO2, snoring, airflow, respiratory effort (optional), body position and heart rate

51
Q

Apnea-Hypopnea Index (AHI)

A
  • The apnea-hypopnea index is defined as the average number of apneas and hypopneas the patient has per hour of sleep.
  • The AHI score provides the following severity categories of sleep apnea:
    • Normal— < 5
    • Mild—5 to 15
    • Moderate—15 to 30
    • Severe—> 30
52
Q

Respiratory Disturbance Index (RDI)

A

RDI= (#of desats and resats events)/ Total monitoring time (hours)

This is calculated by the SnoreSat

53
Q

Apnea Hypopne Index Vs. Respirtory Disturbance Index

A

Like the AHI, an RDI > 15 is considered clinically significant and will be treated!

AHI ≠ RDI.

AHI is calculated from the “gold standard” PSG.

RDI is calculated from the Snore Sat.

54
Q

Diagnosis of OSA

A
  • Level III device
  • Ares
    • Apnea risk evaluation system
    • Gives RDI and AHI.
  • PSG
    • Gives an “AHI” score
    • The gold standard
    • Will detect OSA that the ARES misses
55
Q

Lifestyle Monification for Treatment of Sleep Disordered Breathing

A

Weight loss/maintain healthy BMI

Good sleep hygiene

Avoidance of alcohol

Work with physician to change/alter schedule of sedatives

Avoid excessive fatigue

Smoking cessation

56
Q

Treatment of Sleep Disordered Breathing

Types of Positive Airway Pressure Devices

A

CPAP

APAP

AVAS/VPAP

BiPAP

57
Q

Treatment of Sleep Disordered Breathing

Positive Airway Pressure Devices-CPAP

A

Continuous positive airway pressure

Level determined by repeating sleep study while on CPAP

Pressurized air delivered through mask and tubing; designed to act as a pneumatic airway splint

CPAP usage of 4 hours/night on at least 70% of nights is generally considered the minimum required to see improvement in symptoms and quality of life

Established Outcomes

  • Decreased BP and MVA

When to use

  • Severe OSA
  • Mild-moderate PSA
  • Pt preference
58
Q

Treatment of Sleep Disordered Breathing

Positive Airway Pressure Devices-APAP

A

Auto-adjusting CPAP, within a set range

Thought to result in a lower failure rate

Special modes (“C-Flex”) may decrease the CPAP level during expiration to ease exhalation; “A-flex” does both inspiration and expiration

59
Q

Treatment of Sleep Disordered Breathing

Positive Airway Pressure Devices-AVAPS/VPAP

A

Allows volume-targeting and minimal minute volumes

Often used in when severe OSA or a central component

60
Q

Treatment of Sleep Disordered Breathing

Positive Airway Pressure Devices-BiPAP

A

Usually when there is a component of hypoventilation

61
Q

Treatment of Sleep Disordered Breathing

Oral Appliances

A
  • Tongue retaining device (TRD)
    • Holds tongue forward to prevent it from falling back and obstructing the airway
  • Mandibular advancement device (MAD)
    • Holds the lower jaw forward to maintain an open airway
    • Over-the-counter and custom made
    • May be used in conjunction with CPAP therapy (and allows reduced CPAP pressures to be used)
  • These typically used in treating snoring, UARS, intolerant of CPAP, and mild OSA
62
Q

Treatment of Sleep Disordered Breathing

Surgery

A

Nasal surgery (septoplasty, turbinate reduction…)

Tonsillectomy

uvulopalatopharyngoplasty

Genioglossal advancement

Mandibular advancement

Surgical interventions typically use a “phased” approach

63
Q

Treatment of Sleep Disordered Breathing

Positional Therapy

A
  • Devices used to “encourage” sleeping on the side (as snoring is typically worse when on their back)
  • Effective for those with positional SDB (i.e. only when supine)
  • Methods:
    • Specially designed shirt
    • “Tennis ball” technique
    • Backpack
64
Q

Treatment of Sleep Disordered Breathing

Other Treatment Options

A
  • Pharmaceutical
    • Area of current research
  • Neurostimulation
    • New surgery
    • For pt that cannot tolerate CPAP
    • Implant with a sensor that measures breath which sends a signal to the implant which will move the tongue
65
Q

Signs and Symptons for CSA vs OSA

A

The symptoms of central sleep apnea are for the most part the same as those of obstructive sleep apnea.

They include chronic fatigue, daytime sleepiness, morning headaches and restless sleep. But if the cause is a neurological disease

The CSA sufferer may also experience difficulty swallowing, voice changes, and an overall sense of weakness and numbness.

66
Q

Treatment for patient with suspected nocturnal hypoventilation

A

Patients with suspected nocturnal hypoventilation should not be started on therapy (including oxygen) outside of a monitored setting.

Such patients are at increased risk of worsening respiratory failure and should be referred for polysomographic titration of PAP therapy.

67
Q

When Deciding Which Treatment to Use

A
  • Patients with AHI or RDI ≥ 5 with daytime sleepiness or equivalent symptoms (fatigue, poor concentration)
    • CPAP or oral appliance therapy
  • Patients with severe OSA as defined by AHI or RDI
    • CPAP as first line therapy; oral appliance for patients who do not tolerate or refuse CPAP
  • Allpatients who are started on therapy should be clinically reassessed within 2-4 weeks to ensure that symptoms have improved and that OSA is adequately treated

Pathophysiology 2 (9 decks)

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