Test 3 Ch. 32 Sleep Apnea Flashcards
Sleep related breathing disorders are characterized by abnormal breathing patterns during sleep and include: (4)
- Obstructive Sleep Apnea (OSA) syndrome
- Central Sleep Apnea (CSA) syndrome
- Mixed Sleep Apnea
- Sleep- related hypoventilation and hypoxemia syndromes
According to the the American Academy of Sleep Medicine (AASM) sleep disorders can be classified into
eight major groups
Obstructive Sleep Apnea (OSA) is a common
sleep disorders that often requires lifelong care
OSA is when the ____________ muscles fails to oppose the forces that tend to collapse the airway passage during ____________, the tongue moves into the _________________ area and _________ the airway
genioglossus
inspiration
oropharyngeal
obstructs
Recurring collapse of the upper airway during sleep causes (3)
- obstructive apneas
- hypopneas
- respiratory effort-related arousals (RERA’s)
A sorting sound called _________ breathing maybe heard at the end of apneic periods
fricative
“The fat boy” who snored and had excessive daytime sleepiness, included features of what is now recognized as sleep apnea syndrome w/ hypercapnia or the obesity hypoventilation syndrome is called
Pickwickian syndorme
A disorder characterized by the repetitive stopping or reduction of both air flow and ventilatory effort during sleep.
Central sleep apnea (CSA)
CSA can be classified as: (2)
- primary central sleep apnea (idiopathic or unknown cause)
- secondary central sleep apnea
Examples of conditions associated w/ secondary CSA include (3)
- Cheyne Stokes breathing (CHF)
- medical conditions (spinal surgery, drug or substance abuse)
- high altitude periodic breathing
CSA is further categorized as (2)
- hyperventilation related CSA
- hypoventilation- related CSA
Which is this most common CSA
Hyperventilation- related CSA
Hyperventilation- related CSA includes primary
CSA and CSA associated w/ Cheyne- Stokes breathing pattern
Is a combination of both OSA and CSA
Mixed apnea
Mixed apnea is mostly treated as
OSA
Mixed apnea usually begins as
central apnea followed by the onset ventilatory effort w/o airflow (obstructive apnea)
Sleep- related Hypoventilation and hypoxemia syndrome (SRHHs) include a broad range of sleep disorders, some are quiet common such as
obesity hypoventilation syndrome (pickwickian syndrome) or coexisting w/ COPD the overlap syndrome
A specialized sleep test that monitors and records a number of physiologic parameters that occur during
Polysomnography (PSG)
That test result is called a
polysomnogram
This considered the gold- standard diagnostic test for OSA
full- night, attended, in- laboratory PSG
The diagnosis of OSA is establish during portion of study followed by a form of positive airway pressure treatment called a………
split night, attended, in- laboratory PSG
and
CPAP titration polysomnogram
During a polysomnogram, OSA is confirmed when either of the following conditions exists
- 15 or more apneas, hypopneas, or respiratory effort- related arousals (RERAs) per hour of sleep in asymptomatic pts. More than 75% of the apneas and hypopneas must be obstructive
- 5 or more apneas, hyponeas, RERA’s per hour of sleep or signs of disturbed sleep in pts with symptoms More than 75% of the apneas and hyponeas must be obstructive
What is AHI
apnea- hypopnea index
What is the calculation used for in-laboratory sleep study
AHI=Number of apnea and or plus hyponeas/ TST(hours)
Example of AHI
Pt went apneic 200 times, they had 40 hypopneas and 8hrs of sleep
200+40=240
240/8=30
AHI= 30
CSA is diagnosed when the majority of the respiratory events are
central apnea or hypopneas
On the PSG there is an absence of….
nasal or oral air flow and thoracoabdominal movements
Pts w/ CSA are elevated carefully for the presence of
cardiac disease and lesions involving the cerebral cortex and the brain stem
_________ _________ is associated w/ CSA
Atrial fibrillation (A-Fib)
The AASM endorses in- home unattended, portable motoring, commonly called a
home sleep test (HST)
HST is a reasonable cost effective alternative for pts who have a likelihood of either
moderate or severe OSA
Physical Examination for Sleep Apnea (2)
- Apnea or Hypopnea
- Cyanosis
Chest XRAY (2)
- Often normal
- Right or left sided heart failure
Cardiac Arrhythmias
- Brady- tachycardia syndrome
- Sinus arrhythmia
- Sinus Bradycardia
- sinus pauses
- Atrioventricular block (second degree)
- Premature ventricular contractions
- Supraventricular tachycardia
- Ventricular tachycardia
- Atrial fibrillation
- Sick sinus syndrome
Once the diagnosis of OSA is confirmed and the severity determine the pt should be
educated about the risk factors, natural history, and long term consequences of OSA
Help behavior modification areas includes:
- weight loss
- exercise
- changing sleep position
- abstaining from alcohol
- avoidance of certain medication
This is consider the first line of therapy for OSA
Positive airway pressure
Positive can be delivered as:
- CPAP
- BPAP
- APAP
- PEEP
The most common and the most effective treatment for OSA. This device provides positive airway pressure at level that remains constant throughout the ventilatory cycle in a spontaneous breathing pt
Continuous positive airway pressure (CPAP)
Provides both inspiratory and expiratory positive airway pressure. Used if ventilatory failure is involved
Bilevel positive airway pressure (BPAP)
Increases or decreases the level of positive airway pressure in response to change in airflow, change in circuit pressure, or vibratory snore
Autotitrating positive airway pressure (APAP)
Defined as positive pressure at the end of expiration during either spontaneous breathing or MV
Positive end- expiratory pressure (PEEP)
When PEEP is used for treating OSA, it can be achieved via a a disposal nasal device that permits unimpeded inspiration but
provides increases resistance on expiration
Most oral appliance fall under one of the following categories:
- A mandibular- repositioning device
- a tongue retains device
Designed to reposition the mandible forward or downward
Mandibular- reposition
Holds the tongue in a more anterior position
Tongue retaining device
Is the most effective in non obese pts who have OSA b/c of severe, surgically correctable, upper airway– obstructing lesion
Surgery
This is a reasonable approach in a pt w/ OSA caused by tonsillar hypertrophy, particularly in children but occasionally adults
Tonsillectomy
Is one of the most common procedure to treat snoring and sleep apnea
Uvulopalatopharyngoplasty (UPPP)
Device that stimulates the hypoglossal nerve (XII), which in turn activates the genioglossal muscle (the tongue) to contract and increase the latency of the upper airway
Implant able upper airway stimulator
HypERventilation- related CSA is the
most common
_______ has customarily been the first- line therapy for pts w/ hypERventilation- related CSA
CPAP
Pts who do not respond well to CPAP should receive a trial of
adaptive servoventilation (ASV) w/ the variable positive airway pressure adapt (VPAP Adapt)
_______ w/ a back up RR is the first line therapy for pts w/ hyPOventilation CSA
BPAP
B/c of hypoxemia- related cardiopulmonary complications of sleep apnea (arrhythmia and pulmonary hypertension)….
nocturnal low-flow oxygen therapy is sometimes used to offset or minimize the oxygen desaturation
In any pt who does not tolerate or benefit from positive airway pressure or supplement oxygen during sleep , a respiratory stimulant such as
acetazolamide or theophylline maybe tried pts w/ CSA
Questions from the back
What is (are) another name(s) for non- rapid eye movement (non REM) sleep?
- Slow- wave sleep
- Quiet sleep
During non-REM sleep, ventilation becomes slow and regular apnea-hypopnea index (AHI)
Stage N3
Moderate sleep apnea is said to be present when the apnea-hypopnea index (AHI) is
15-30 episodes per hour
During periods of apnea, the pt commonly demonstrates which of the following at the termination of apnea events
- Decreased cardiac output
- Transient pulmonary hypertension
Periods of severe apnea are commonly associated w/ which of the following?
- Ventricular tachycardia
- Sinus bradycardia
- Premature ventricular contraction
- Sinus arrhythmia
During REM sleep, there is paralysis of the:
- Arm muscles
- Upper airway muscles
- Leg muscles
- Intercostal muscles
Normally, REM sleep constitutes about what percentage of the total sleep time?
20% to 25%
Which of the following therapy modalities is therapeutic for OSA
CPAP
Which of the following has customarily been the first-line therapy for pts w/ hypERventilation- related CSA
CPAP
How long do normal periods of apnea during REM sleep last?
15 to 20 seconds
While a formal polysomnographic diagnosis of the precise type and severity of sleep apnea is being made (i.e obstructive, central, or mixed sleep apnea), which of the following respiratory care would be most safely used?
APAP
Mallampati classification
Class 1:
- Soft palate, fauces, uvula pillars are easily seen
Mallampati classification
Class 2:
- Soft palate, fauces, portion of uvula are seen
Mallampati classification
Class 3:
- Soft palate, only the base of the uvula are seen
Mallampati classification
Class 4:
- Only the hard palate can be seen
Sings and symptoms associated w/ OSA
- Loud snoring
- Abrupt awakenings accompanied by SOB
- Lack of concentration
- Memory impairment
- Nausea
- Insomnia
Mild OSA is defined as an
Pts are often
- AHI between 5 and 15 respiratory events per hour of sleep
- asymptomatic
Moderate OSA is defined as an
Pt is usually
- AHI between 15 and 30 respiratory events per hour of sleep
- aware of daytime sleepiness and feels the need to nap during the day
Severe OSA is defined as an
pts have
- AHI of more than 30 Respiratory events per hour and or SpO2 below 90% for more than 20% of the total sleep time
- significantly daytime sleepiness, and often fall asleep during the day
