Treatment of Sleep Apnoea Flashcards
Why do we treat OSA?
- Relieve Symptoms
- Prevent Medical Complications like MI’s
- Improve QoL
When do we treat OSA?
- Only for moderate-severe OSA
- or patients with mild OSA but symptomatic treatment is advised
Benefits of treatment?
- Less sleep fragmentation
- Less lethargic and more alert
- Improves Sleep Quality leading to increased energy and decreased sleepiness
- Motivation to lose weight
- Reducing BMI
Link with OSA and Hypertension?
- Difficult to establish bc of other factors
- BUT treatment of OSA with CPAP does improve BP
What 4 treatment options are there?
- Behavioural/Conservative measures
- MRD Mandibular Repositioning Device
- Surgery
- CPAP
What are first line treatments for MILD OSA?
- Lifestyle advise
- Obesity clinic
- Dietician
- Weight loss
- Postion therapy supine position
- Nasal Spray if obstruction refer to ENT (DEVIATED Septum)
- Smoking and Alcohol Cessation
What MRD’s?
- Mandibular Repositioning Devices
- Dental devices which pull lower jaw forward during sleep
- Similar to a gumshiedl
- Crowded UA use Mallampati score to assess
What are the 4 classes for Mallampati?
Class 1 = full visibility of tonsils, uvula and soft palate
Class 2 = Visibility of Hard and soft palate and base of the uvula
Class 3 = Soft and hard palate and base of the uvula are visible
Class 4 = Only hard Palate visible
Advantages of MRD’s
- Less invasive
- Effecitve for simple snoring or mild OSA
Disadvantages of MRD’s
- Rarely completely treat s moderate OSA
- Can cause pain
- Unsuitable for denture patients
- Not available on the NHS
Surgical options?
- Paeds?
- Enlarged adenoids or tonsils can cause snoring
- Can remove these
Surgical options for adults?
-Surgery In UA but if more than 1 area is affected surgery may not be effective and OSA will persist
Which adults could benefit from Surgery?
Patients with craniofacial abnormalities or obvious UA congestion could benefit
Downsides of having surgery?
Surgery is often painful and can reduce ultimate effectiveness of CPAP if surgery fails to solve problem
What is UVPPP?
Removal of the excess soft palate tissue
What is LAUP?
-Laser sculpt the soft palate
What Nasal surgery is available?
- Straightening of Deviated septum
- Increasing size of nasal passages to improve airflow
What are Nasal turbinates?
- Also known as conga due to shape
- Made up of Columnar ciliated epithelium with vascular erectile glandular tissue
What are the 3 pair of nasal turbinates?
- Inferior
- Middle
- Superior
What do inferior turbinates do?
- Majority of heating, filtering and humidification of air
What do Middle turbinates do?
- Protect entrances of sinuses from pressurised air
What do Superior turbinates do?
- Protect olfactory bulb
What are adenoids AKA?
-Pharygeal tonsil
Where are adenoids located?
- Roof of Nasopharynx
- Where nasal passage meets oropharynx
What can occur to adenoids?
- Enlarge to size of golf balls causing airflow obstruction
- Removed with tonsils
What tongue surgery is available?
- Advancement = Geniglossus muscle advanced preventing tongue base falling back
- Tongue base reduction = removal of tongue mass to widen airway
What is lower jaw advancement?
- Retrognathia is when upper/lower jaw is restricted
- It mobilises upper and lower jaw and stabilise jaw with titanium plates
- Can change facial appearance
What is a tracheostomy?
- Making an opening in trachea bypassing upper airway
- Not routine
- Used to ventilate patients in ICU
- Used when OSA is life threatening and CPAP is unavailable
What is CPAP?
Continuous Positive Airway Pressure
- Gold standard for treatment
- Acts as Pneumatic splint using room air to support airway
What are the indications for CPAP?
- Moderate/Severe OSA
- Mild OSA displaying symptoms
What are the contraindications for CPAP?
- History of facial oral or skull trauma
- Severe Epistaxis (nose bleeds)
- Acute sinustitis
- Pneumothorax
- Cardiac arryhtmias (severe)
What are the 3 types of CPAP
- Auto titrating CPAP
- Fixed CPAP
- Bi-Level
What is APAP?
Auto-titrating CPAP (APAP)
–> Variable pressure delivery
What is Fixed CPAP?
Fixed CPAP
–>Pressure set to fixed level for whole night
–>Fixed pressure assessed using prediction formula, manual titration or trial with APAP device
What is Bi-Level CPAP?
Bi-level
–>2 pressure levels: IPAP and EPAP
Used more in ‘complex OSA’ and respiratory failure
What should be included when educating a person about CPAP?
- Information about OSA
- How CPAP works?
- Mask fitting
- Care and Maintenance
- DVLA regulations
- Travelling
- Available resources such as BLF
How does Fixed CPAP work?
- Patient would have APAP for a trial period
- Fixed CPAP is set to a Pressure that prevents events for 95% of the night
- Calculates pressure using a prediction formula
- Ramp Setting is for comfort to allow pressure to gradually rise
Advantages of Fixed CPAP?
- Machine is cheaper as it isn’t algorithm based
Disadvantages of Fixed CPAP?
- Changes in weight
- Body Position/Alcohol consumption not corrected for
- Deliver too much Pressure sometimes
How does the circuit work?
- Connects patient to CPAP
- Masks generally nasal or nasal-oral (full face)
- Must create a seal to ensure pressure is maintained
- Variety of styles
How can we monitor data?
Most CPAPs now provide compliance data
-Monitor usage/pressure/AHI
List some CPAP side-effects?
- Air Leak
- Nasal problems
- Skin Ulceration/Sensitivity
- Claustrophobia
- Aerophagy (swallowing air)
- Noise of CPAP
What can help troubleshoot nasal blockage?
- Nasal spray
- Switch to full face mask
- Add humidification to CPAP
