Sleep Disorders Flashcards
1) Is OSA (obstructive sleep apnea) common? Explain
2) What characterizes it?
1) Common; causes functional impairment & QOL
Up to 17% women and 34% men in USA
2) Reduction or cessation of breathing during sleep, resulting in intermittent hypoxemia, autonomic fluctuation, and sleep fragmentation
What are the 2 key findings of OSA (obstructive sleep apnea)?
1) Snoring – 80% of patients that snore have OSA
2) Obesity – 77% of patients with BMI > 30 have OSA
List things that increase morbidity and mortality assoc. with OSA
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1) Cardiovascular
2) Metabolic
3) Worse control of other chronic conditions, i.e., COPD, weight gain
List the risk factors for OSA
Obesity – especially neck
Sex (male)
Age over 40, but can affect any age
Structural abnormalities
Tonsillar hypertrophy
Family history
Alcohol and sedatives worsen symptoms (sleep aids)
Hypothyroidism
List the OLDCARTS for OSA
1) CC: fatigue
2) Onset, duration, timing: chronic
3) Location: pharynx
4) Character: impaired daytime function, falling asleep at inappropriate or dangerous situations
5) Aggravating: weight gain, alcohol, Rx sleep aids, position
6) Alleviating: position
7) Radiation: assoc. with CV and metabolic comorbidities
8) Associated symptoms: non-restorative sleep, day-time sleepiness, snoring, morning headaches, nocturnal chocking/gasping, nocturnal GERD, nocturia, impaired cognition, mood changes
What did the USPSTF say abt OSA screening in 2022?
Asymptomatic adults 18+ there’s insufficient evidence to assess the balance of benefits and harms of screening for OSA (rating)
1) AHA recommends assessing for OSA in what pts?
2) In patients you need to assess (i.e. w. clinical suspicion of OSA) what mnemonic do you use?
1) With poorly controlled HTN, HF, pulmonary HTN, recurring AF, nocturnal angina
2) STOP-BANG; others
1) What is STOP-BANG?
2) How is it scored?
1) 8 questions
Snore
Tired
Observed apnea
Pressure (HTN)
BMI > 35
Age > 50
Neck > 40 CM
Gender - male
2) Scoring: yes/no
-Less than 3 = low risk
-3+ = high risk
In patients with a pre-test probability of moderate to severe OSA, what do you do?
Describe each of the 2 options and when you should use each.
Polysomnography (sleep study):
1) Home-based study: for patient without significant CV, opioid, or other issues that preclude adequate home apnea study
2) Sleep lab-based study: gold standard, expensive
For patient with either significant medical issues or equivocal home test
Split-night protocol
Use if other than OSA is suspected (narcolepsy for example)
1) True or false: Insurance will often cover CPAP machine and or supplies for moderate or severe OSA
2) Objectively define apnea
3) Do the same for hypopnea
1) True
2) Not breathing for > 10 sec
3) Shallow breathing for > 10 sec
15
If above negative and still highly suspect OSA
If home test: PSG should be performed
If PSG: repeat PSG
Polysomnography, rather than home testing should be used in patients with significant CVA/Resp disease or chronic opioid use/hypoventilation or respiratory muscle weakness
Positive Airway Pressure device for OSA:
1) What does it improve?
2) What are the 2 kinds?
1) OSA severity, blood pressure, daytime sleepiness, and sleep related QOL
2) CPAP and BiPAP (Continuous Positive Airway Pressure; Bilevel PAP)
Positive Airway Pressure device for OSA:
1) What is first line therapy?
2) How is it indicated for?
3) What can be used unsupervised in patients at low risk and no comorbidities?
1) CPAP = first line therapy
2) Moderate to severe OSA (AHI > 15)
Mild OSA (AHI 5-15) + comorbidities
3) Auto-titrating CPAP
Positive Airway Pressure device for OSA: What are the 2 groups BiPAP is indicated for?
Obesity hypoventilation syndrome
OSA with restrictive lung disease
Oromandibular advancement device (sleeping appliance) can help who?
In patients with mild to moderate OSA, alternative to CPAP if unable to afford/tolerate/comply with PAP
Fitted by dentist
What 3 medical therapies are available for OSA?
1) All patients - weight loss (factor in 70% of cases), exercise, avoid alcohol & sedatives
2) Sleep in recliner (Positional therapy)
3) Nasal corticosteroids as adjunct
Describe surgery for OSA
Unproven: Uvulopalatopharyngoplasty (UPPP)
Inspire upper airway stimulation therapy for OSA:
1) What is it?
2) Indications?
3) Contrandications?
1) Surgically implanted device using pacemaker technology to stimulate the hypoglossal nerve during sleep
2) Mod-Severe OSA (AHI > 15)
-Failure or unable to tolerated PAP therapy
-BMI 32 or less
-Adults aged 18 or more
3) Anatomical: deviated nasal septum or enlarged tonsils
-Central or mixed apnea
What is a V-com?
V-Com fits between 2 hoses in the CPAP circuit
Describe a V-com
V-Com:
Lowers IPAP < EPAP
Softens IP and flow
CPAP more comfortable
Decreases:
Noise
Unintentional leaks
Need for chinstraps in many patients
Abdominal distension and dry mouth
Nasal symptoms
Use of full-face mask
