Sleep Related Breathing Disorders Flashcards
What does the Berlin Questionnaire evaluate for?
OSA
What is Cor Pulmonale and what 3 conditions are most likely to cause it?
- Right heart failure caused by pulmonary hypertension
- COPD, Overlap syndrome (COPD + OSA) and OHS (Obesity Hypoventilation Syndrome)
What is the diagnosis in a severely obese patient with LE edema and elevated daytime CO2?
Pt likely has cor pulmonale caused by hypoventilation. With an elevated daytime CO2, the diagnosis is OHS
In men compared to women with OSA, which are more likely to have insomnia?
Women are more likely to have insomnia with OSA
In men compared to women with OSA, which are more likely to have thyroid disease?
Women
Compared to men, when will premenopausal women will have higher clusters of apneic episodes?
During REM sleep. This may be due to women having less compliant airways
What are the ages for determining pediatric sleep disordered breathing?
< 18 years old but a sleep specialist can use 13 years old or younger
Pediatric rules for scoring an apnea
- At least 90% drop in flow (thermistor) from baseline that lasts at least 90% of the specified time (obstructive, mixed, central)
- Duration
- Obstructive at least 2 breaths
- Central (at least 1 of the following)
- At least 20 seconds
- At least 2 breaths with 3% desaturation or an arousal
- At least 2 breaths with a decrease in HR to below 50 bpm for 5 seconds or below 60 bpm for 15 seconds (less than 1 y/o)
- Mixed
- At least 2 breaths and…
- Absence of respiratory effort for 1/2 and presence of respiratory effort for the other 1/2
Unique features of pediatric OSA (4)
- Sleep architecture is usually normal
- Movement or autonomic arousals are more common than cortical arousals
- Obstructive events are more common in REM sleep
- Children have a faster respiratory rate and lower functional residual capacity than adults
Criteria for diagnosis and treatment of OSA in children
No hard and fast rules since size from infant to adolescent is so great. One publication used this criteria:
- Mild
- AHI < 1 to 4 without a drop in SaO2
- Treat if daytime sequelae
- Moderate
- AHI 5 to 10 and/or SaO2 < 85%
- Most should receive treatment
- Severe
- AHI > 10 with SaO2 < 85% and daytime sequelae
- Treat
Neck circumference in med and women that may be seen with patient’s with OSA
- Men: >/= 17 inches
- Women: >/= 15 inches
PSG criteria for Cheyne Stokes Breathing
- Both need to be present
- 3 or more consecutive central apneas/hypopneas separated by crescendo/descrescendo breathing with a cycle length of 40 seconds or greater
- Central index of 5/hr or greater over at least 2 hours of sleep
PSG criteria for periodic breathing in children (Cheyne-Stokes term not used in kids)
- >/= 3 episodes of central pauses in respiration (absent airflow and respiratory effort) lasting > 3 seconds separated by
What percent of stroke patients are reported to have sleep disordered breathing (central or obstructive)?
50 to 70%
Obstructive
- Weakness of pharyngeal musculature
Central
- Increased drive to breathe resulting in central apneas
Pauses in breathing are common in newborns. When is it a concern?
- If the pause is longer than 20 seconds
and
- Is associated with cyanosis, pallor, bradycardia or hypotonia
Is home apnea monitoring recommended to reduce SIDS?
No. It has not been shown to reduce the death rate.
When using PAP therapy, what would be considered an unacceptable mask leak?
Any unintentional mask leak > 25 L/min
When is ASV contraindicated?
When LVEF is < 45%
Is OHS more common in men or women?
Women. This may be because morbid obesity is more common in women than men.
OHS is found in what percent of OSA patients?
10 to 20%
In Post Polio Syndrome patients with sleep-breathing problems and weak respiratory muscles, what is the best therapy?
Noninvasive ventilation. CPAP will only work if they have sleep apnea.
Patient is started on BiPAP therapy with an EPAP of 8 and a pressure support of 5. What is the IPAP?
13
What are the 2 diagnostic criteria for CCHS (Congenital Central Hypoventilation Syndrome)?
- Sleep related hypoventilation is present
- Mutation of the PHOX2B gene is present
What GI disorder do 10% to 20% of CCHS patients have?
Hirschsprung disease
What causes Hirschsprung disease in CCHS patients?
An aganglionic colon which leads to bowel distention and constipation.
What brain disorder can CCHS patients develop?
5% can develop neural crest tumors (e.g., neuroblastoma)
What is Biot breathing and what causes it?
- Apnea followed by hyperventilation in a repeating pattern
- It is caused by damage to the breathing centers in the medulla. This causes apnea which results in elevated CO2 which eventually causes hyperventilation
Which stage of REM sleep is the diaphram more resistant to, tonic or phasic?
Tonic. During phasic REM there is additional inhibition of the respiratory motor neurons which reduces the activity of the diaphram resulting in hypoventilation
Breathing is controlled by what 3 factors?
- State: Awake or asleep
- Metabolic factors (including blood gas changes)
- Lung function (like vagal inputs from pulmonary stretch receptors)
What functions do the carotid bodies and medullary central chemoreceptors play?
Carotid bodies
- Sense PaO2 and PCO2
Medullary central chemoreceptors
- Sense PCO2
Which will result in a higher concentration of oxygen in hemoglobin; a right shift or a left shift?
A left shift
Which will cause a faster arousal response; drop in SaO2 or increase in pCO2
Increase in pCO2
What were the study results in using CPAP to treat CSA according to the CAPNAP trial?
- Decreased AHI
- Increased EF
- Decreased plasma catecholamines
- No change in mortality or hospitalizations
Adenotonsillectomy can treat up to what % of sleep disordered breathing in pediatrics?
Up to 79%
What are the risk factors for CSR? (4)
- Decreased LV EF
- Male
- Relative daytime hypocapnea (PaCO2 < 38 mm Hg)
- Atrial fibrillation
What are the criteria for increasing CPAP pressure in adults?
- 2 obstructive apneas or
- 3 hypopneas or
- 5 RERAs or
- Greater than 3 min loud snoring
In what disorders can one see hypercapnic central sleep apnea?
Neuromuscular disorders (like MG) causing weakness in the neuromuscular aparatus or decresed chemoresponsiveness. It occurs because patients have reduced ventilation.
What are the indications to increase IPAP during BiPAP titration (3)?
Only 1 is needed
- 3 obstructive hypopneas
- 5 RERAs
- 3 min of snoring
What are the indications to increase IPAP and EPAP during BiPAP titration?
2 obstructive apneas are observed
What is the treatment protocol for primary CSA per the AASM?
- Positive airway pressure therapy
- Acetazolamide (causes mild metabolic acidosis )
- Zolpidem or triazolam (if no risk for respiratory depression)(by enhancing sleep stability, resulting in fewer arousals, which in turn would lessen oscillation in arterial CO2 and produce a decrease in central apnea/hypopnea events.)
