CHAPTER 15: Sleep Apnea and Sleep Disorders

Question 1

The idea of obesity is written by Charles Dickens in…

Answer 1

The Posthumous Papers of the Pickwick Club (1837)

Question 2

Sound generated by the vibration of the pharyngeal soft tissues

Answer 2

Snoring

Question 3

TRUE or FALSE

Snoring is often louder during inspiration than expiration

Answer 3

TRUE

Question 4

A cessation of airflow for at least 10sec

Answer 4

Apnea

Question 5

A reduction in airflow (>30%) at least 10sec with >4% oxyhemoglobin desaturation

Answer 5

Hypopnea

Question 6

A reduction in airflow (>50%) at least 10sec with >3% oxyhemoglobin desaturation or an electroencephalogram (EEG) arousal

Answer 6

Hypopnea

Question 7

Sequence of breaths for at least 10sec with increasing respiratory effort or flattening of the nasal pressure waveform, leading to an arousal from sleep when the sequence of breaths does not meet the criteria of an apnea or a hypopnea

Answer 7

Respiratory effort-related arousal (RERA)

Question 8

Continued thoracoabdominal effort in the setting of partial or complete airfloe cessation

Answer 8

Obstructive

Question 9

The lack of thoracoabdominal effort in the setting of partial or complete cessation of airflow

Answer 9

Central

Question 10

A respiratory event with both obstructive and central features, with mixed events generally beginning as central events and ending with thoracoabdominal effort without airflow

Answer 10

Mixed

Question 11

Used to described patients who do not meet the criteria for OSA syndrome but who experience excessive daytime somnolence and other debilitating somatic complaints

Answer 11

Upper Airway Resistance Syndrome (UARS)

Question 12

Characterized by respiratory effort-related arousals

Answer 12

Upper Airway Resistance Syndrome

Question 13

Is detected by esophageal pressure manometry, which reveals a pattern of progressively increasing negative esophageal pressure followed by an arousal

Answer 13

Respiratory effort-related arousals

Question 14

Diagnostic criteria for OSA in adults requires a polysomnogram or home sleep apnes test (HSAT) that demostrates either…

Answer 14

1. 5 or more predominately obstructive respiratory events (obstructive and/or mixed apneas, hypopneas, or RERAs)
2. 15 or more predominately respiratory events per hour of sleep regardless of symptoms or comorbidities

Question 15

Symptoms related to OSA

Answer 15

1. Excessive daytime somnolence
2. Waking with gasping
3. Choking
4. Breath holding
5. Witnessed reports of apneas
6. Loud snoring

Question 16

Comorbidities include

Answer 16

1. Hypertension
2. Mood disorder
3. Congnitive dysfunction
4. Coronary artery disease
5. Stroke
6. Congestive heart failure
7. Atrial fibrillation
8. Type II DM

Question 17

Number of apneas per hour of total sleep time

Answer 17

Apnea index

Question 18

Number of hypopneas per hour of total sleep time

Answer 18

Hypopnea index

Question 19

Number of apneas and hypopneas per hour of total sleep time

Answer 19

Apnea-hypopnea index

Question 20

Number of RERAs per hour of total sleep time

Answer 20

Respiratory effort-related arousal index

Question 21

Number of apneas, hypopneas, and RERAs per hour of total sleep time

Answer 21

Respiratory disturbance index

Question 22

Number of central apneas per hour of total sleep time

Answer 22

Central apnea index

Question 23

Number of mixed apneas per hour of total sleep time

Answer 23

Mixed apnea index

Question 24

TRUE or FALSE

Diagnosis of OSA may be made on in-lab PSG or by HSAT

Answer 24

TRUE

Question 25

Symptoms of Sleep-Disordered Breathing

Answer 25

1. Restless sleep 2. Loud snoring 3. Observed apnea, choking, or gasping episodes 4. Excessive daytime sleepiness 5. Morning fatigue or irritability 6. Memory loss 7. Decreased cognitive function 8. Depression 9. Personality or mood changes 10. Decreased libido and impotence 11. Morning and nocturnal headaches 12. Nocturnal sweating 13. Nocturnal enuresis

Question 26

Mild OSA

Answer 26

5-15 events per hour

Question 27

Moderate OSA

Answer 27

15-30 events per hour

Question 28

Severe OSA

Answer 28

30 events or more

Question 29

4 key traits or phenotypes that contribute to OSA

Answer 29

1. Impaired upper airway anatomy that is narrow or collapsible 2. Low respirtory arousal threshold 3. Inadequate responsiveness of upper airway dilator muscles during sleep 4. Unstable or overly sensitive respiratory control, a concept referred to as high loop gain

Question 30

TRUE or FALSE Obesity, soft tissue hypertrophy, and craniofacial characteristics such as retrognathia contribute to the upper airway anatomy by increasing the extraluminal tissue pressures surrounding the upper airway

Answer 30

TRUE

Question 31

TRUED or FALSE | Patients without anatomic abnormalities may also have OSA

Answer 31

TRUE

Question 32

3 major areas of obstruction

Answer 32

1. Nose 2. Palate 3. Hypopharynx

Question 33

Classification of patterns of obstruction by anatomic location: Type I

Answer 33

Collapse in the retropalatal region only

Question 34

Classification of patterns of obstruction by anatomic location: Type II

Answer 34

Collapse in both retropalatal and retrolingual regions

Question 35

Classification of patterns of obstruction by anatomic location: Type III

Answer 35

Collapse in the retrolingual region only

Question 36

Major risk factor for OSA

Answer 36

Obesity

Question 37

TRUE or FALSE The increase fat deposition around the neck and parapharyngeal spaces is postulated to narrow and compress the upper airway and may offset the effects if dilator muscles that maintain airway patency

Answer 37

TRUE

Question 38

TRUE or FALSE Obesity contribute to OSA through its deleterious effects on metabolism, ventilation, and lung volume, resulting in a mismatch between alveolar ventilation and pulmoary perfusion

Answer 38

TRUE

Question 39

Changes in lung volume significantly reduce pharyngeal upper airway size through the mechanical effect of tracheal and thoracic traction

Answer 39

Tracheal tug

Question 40

Major cause of OSA in children

Answer 40

Adenotonsillar hypertrophy

Question 41

Craniofacial variations that have been associated with OSA

Answer 41

1. Increased distance of the hyoid bone from the mandibular plane 2. Decreased mandibular and maxillary projection 3. Downward and posterior rotation of mandibular and maxillary growth 4. Increased vertical facial length 5. Increased vertical length of the posterior airway 6. Increased cervical angulation

Question 42

TRUE or FALSE To quantify the functional collapsibility of the upper airway, the passive criticla closing pressure (Pcrit) is measured using a mask attached to a device that can deliver both positive and negative airway pressure

Answer 42

TRUE

Question 43

Is the luminal pressure at which the upper airway collapses after a prolonged period of therapeutic positive pressure, such that there is minimal recruitment of the pharyngeal dilator muscles when airway pressures are suddenly reduced

Answer 43

Passive critical closing pressure (Pcrit)

Question 44

Pcrit of individuals with OSA

Answer 44

Pcrit above atmospheric pressure

Question 45

Pcrit of individuals without OSA

Answer 45

Pcrit below -5 cm H2O

Question 46

TRUE or FALSE | Neuromuscular tone contributes to the patency of the upper airway

Answer 46

TRUE

Question 47

Considered to be the most important muscle in maintaining airway patency in OSA

Answer 47

Genioglossus

Question 48

The sensitivity of the respiratory control system to perturbations in CO2 level

Answer 48

Concept of loop gain

Question 49

Indicates an unstable respiratory control system that is prone to overcompensation, resulting in excessive changes in ventilation

Answer 49

High loop gain

Question 50

Indicates a more stable respiratory control system where responses to perturbation are less prone to overcompensation, resulting in a more rapid return to homeostasis

Answer 50

Low loop gain

Question 51

TRUE or FALSE High loop gain can contribute to OSA by causing rapid increases in respiratory drive in response to small increases in CO2, resulting in large negative luminal negative pressures and increasing the likelihood of airway collapse

Answer 51

TRUE

Question 52

Negative health effects attributed to untreated OSA

Answer 52

1. Increased mortality 2. Increase in cardiovascular disease 3. Neurocognitive difficulties

Question 53

Independent risk factor for insulin resistance

Answer 53

Untreated OSA

Question 54

Most common symptoms of OSA

Answer 54

1. Loud snoring 2. Restles sleep 3. Daytime hypersomnolence

Question 55

Most common finding in patient with OSA

Answer 55

Obesity

Question 56

Widely used tool that assesses daytime sleepiness

Answer 56

Epworth Sleepiness Scale

Question 57

TRUE or FALSE | OSA may be suspected in patients with an ESS score greater than 10

Answer 57

TRUE

Question 58

STOP-BANG

Answer 58

``` S- snor T- tired O- observed you stop breathing P- high blood pressure B- BMI A- age (50) N- neck circumference (>40 cm/female, >43 cm/male) G- gender (male) ```

Question 59

Physical examination findings: Nasal obstruction

Answer 59

1. Septal deviation 2. Turbinate hypertrophy 3. Nasal valve collapse 4. Adenoid hypertrophy 5. Nasal tumors or polyps

Question 60

Physical examination findings: Oropharyngeal obstruction

Answer 60

1. Large soft palate 2. Palatine tonsillar hypertrophy 3. Posterior pharyngeal wall banding 4. Macroglossia 5. Large mandibular tori 6. Narrow skeletal arch

Question 61

Physical examination findings: Hypopharyngeal obstruction

Answer 61

1. Lateral pharyngeal wall collpase 2. Omega-shaped epiglottis 3. Hypopharyngeal tumor 4. Lingual tonsillar hypertrophy 5. Retrognathia and micrognathia

Question 62

Physical examination findings: Laryngeal obstruction

Answer 62

1. True vocal cord paralysis | 2. Laryngeal tumor

Question 63

Physical examination findings: General neck obstruction

Answer 63

1. Increased neck circumference | 2. Redundant cervical adipose tissue

Question 64

Physical examination findings: General body habitus

Answer 64

1. Obesity 2. Achondroplasia 3. Chest wall deformity 4. Marfan syndrome

Question 65

Physical examination findings: Cardiovascular signs

Answer 65

1. Arterial hypertension, especially morning hypertension | 2. Peripheral edema

Question 66

Is performed in an awake patient, who generates negative pressure buy inhaling against a closed glottis with the nose and mouth closed to trigger airway collapse

Answer 66

Muller maneuver

Question 67

Agent for sedation for DISE for adults

Answer 67

Midazolam and profopol

Question 68

Agents for seadtion of DISE in children

Answer 68

Dexmedetomidine

Question 69

A proposed method of standardizing DISE findings

Answer 69

V- velum O- oropharynx T- tongue base E- epiglottis

Question 70

Radiologic technique used to aid in the identification of the site and severity of upper airway obstruction or collapse in OSA

Answer 70

Cephalometric radigraph

Question 71

TRUE or FALSE The differences between OSA and non-OSA patients noted on cephalometry have not been significant enough to allow for the use of lateral cephalograms as a sole diagnostic tool

Answer 71

TRUE

Question 72

Provides good anatomic detail of the bone and soft tissue

Answer 72

Awake CT

Question 73

Primary advantage of CT

Answer 73

Highn anatomic resolution of dynamic airway movement during sleep without the presence of an endoscope that might potentially alter inflow

Question 74

Provided excellent soft tissue differentiation and does not require radiation exposure

Answer 74

MRI