Week 9 Sleep Apnea in Primary Care

Question 1

Sleep Apnea

Definition

Answer 1

• A chronic syndrome characterized by repetitive episodes of complete or partial upper airway obstruction that occur during sleep, requiring lifelong multidisciplinary management.
• Most common sleep breathing related disorder

Question 2

OSA M <, >, or = risk?
What about in postmenopausal women?

Answer 2

M > W
Postmenopausal women = Older men

Question 3

OSA Pathophysiology
Pregnancy

Answer 3

• Velopharyngeal (includes the soft palate as well as the pharynx and the side and back walls of the throat)
• Disturbances in gas exchange (hypercapnia and hypoxemia) and fragmented sleep.
• Pregnancy CAUSES: airway narrowing, decreased nasal patency 2/2 hyperemia and mucosal edema, maternal blood volume increases leading to fluid displacement when sleeping

Question 4

OSA risk Factors

Answer 4

• Risk for OSA increases with increased BMI and the associated markers
  
  • W:H ratio (reliable measurement, regardless of sex assigned at birth
  • WC
  • Neck circumference [men, 17”, women 16”] males
• A 10% increase in weight a/w 6-fold increase in risk of OSA incidence. Wt up = risk up
  
  • In Class III obesity (BMI > 40kg/m2) + OSA —> increased risk for obesity hypoventilation syndrome (OHS)
• 10kg weight gain
  
  • Men = 5-fold risk of increasing severity of OSA
  • Women = 2.5-fold risk of increasing severity of OSA
• Weight loss reduces OSA severity

Question 5

Progression of Sleep Apnea

Answer 5

Question 6

Conditions a/w OSA

Answer 6

• Obesity hypoventilation syndrome
• CHF
• Afib [76-85%]
• Pulmonary HTN
• HTN (resistant) [73-82%]
• CVD
• ES kidney disease
• COPD, Asthma, Idiopathic pulmonary fibrosis
• Stroke [71%]/TIA
• Pregnancy (GDM/PIH)
• T2DM [65-85%]
• Acromegaly
• Hypothyroidism
• PCOS
• Parkinson’s disease
• Floppy eyelid syndrome
• Fibromyalgia
• Barret’s esophagus
• GERD
• Secondary polycythemia
• Down’s syndrome

Question 7

Major clinical features of OSA in adults

Answer 7

• Daytime sleepiness
• Loud snoring
• Witnessed apneas by partner
• Lack of concentration
• Cognitive deficits
• Changes in mood
• Morning headaches

Question 8

Other clinical features of OSA in adults

Answer 8

• Nonrestorative sleep
• Nocturnal choking/gasping
• Nocturnal restlessness
• Insomnia w/frequent awakenings
• Vivid, strange or threatening dreams
• GERD
• Nocturia

Question 9

Objective s/s of OSA

Answer 9

• Obesity
• Floppy eyelid
  Narrow or “crowded” airway
  Large neck circumference
  Systemic HTN
• Hypercapnia
  Polycythemia
• CVD
  Cerebrovascular disease
  Cardiac dysrhythmias
  Pulmonary HTN
  Cor pulmonale

Question 10

Screening in Diagnostic tools of OSA (chart)

Answer 10

Question 11

GOLD STANDARD for OSA DX

test and which symptoms?

Answer 11

• Polysomnogram
• Excessive daytime sleepiness on most days AND 2+ clinical features of OSA

Question 12

Who should be screened for OSA?

3 things

Answer 12

• BMI ≥35 kg/m2
• PMH comorbidity w/ OSA
• Risk of intubation difficulty

Question 13

Stop-Bang score for risk of OSA
Score interpretation?

Answer 13

• 3+ = increased risk of OSA
• 5-8 = HIGH RISK

Question 14

OSA event defined by two things

Answer 14

1. Apnea (complete cessation of airflow for at least 10sec)
2. Hypopnea (decreased airflow by 50% for 10sec)

Question 15

Apnea-Hypopnea Index

WHAT ARE THE QUALIFICATIONS FOR SEVERITY?

Answer 15

Sum of apneas and hypopnea per hr

AHI Events/hr.
< 5 = normal
5-14.9 = mild
15-29.9 = moderate
> 30 = severe
Diagnostic Criteria

Question 16

1st line tx for OSA

Answer 16

CPAP
Continuous positive airway pressure

Question 17

Goal of OSA

Answer 17

Improve QoL
Reduce morbidity/mortality
Decrease RF complications

Question 18

When to refer for OSA

Answer 18

If pregnancy - high risk obstetrics
If there needs to be behavioral modification