Obstructive Sleep Apnea

Question 1

Common sites of Airway Collapse

Answer 1

1. **Soft Palate **(MOST COMMON)
2. Tongue base
3. Lateral pharyngeal walls
4. Epiglottis

LEST

Question 2

OSA may be most severe during

Answer 2

Rapid Eye Movement (REM) sleep
When neuromuscular output to the skeletal muscles is particularly low and in supine position due to gravitational forces

Question 3

Causes daytime sleepiness and impaired daily function

Answer 3

Obstructive sleep apnea

Question 4

Causes Hypertension and is strongly associated with cardiovascular disease in adults and behavioral problems in children

Answer 4

Obstructive sleep apnea

Question 5

Can occur as a primary condition (response to high altitude), or secondary to medical condition (e.g. heart failure) or medication (e.g. opioids)

Answer 5

Central sleep apnea

Question 6

Report frequent awakenings and daytime fatigue

Answer 6

Central Sleep Apnea

Question 7

Central Sleep Apnea is associated with increased risk for ______ (2)

Answer 7

Heart failure
Atrial fibrillation

Question 8

OSA is defined on the basis of ______ and ______ and sleep study findings

Answer 8

1. Nocturnal Breathing disturbances
   -snoring
   -snorting
   -gasping
   -breathing pauses
2. Daytime Sleepiness or Fatigue DESPITE sufficient opportunity to sleep

SLEEP STUDY FINDINGS
Five or more episodes of Apnea or Hypopnea per hour of sleep during sleep study

Question 9

OSA may be diagnosed in the absence of symptoms if the AHI is _____

Answer 9

≥15 episodes/hour

Question 10

Definition of APNEA

Answer 10

Cessation of airflow for ≥10 seconds during sleep, accompanied by:

OBSTRUCTIVE: Persistent respiratory effort
CENTRAL: Absence of respiratory effort

Question 11

Definition of HYPOPNEA

Answer 11

A ≥30% reduction in airflow for at least 10 s during sleep that is accompanied by either a ≥3% desaturation or an brain cortical arousal

Question 12

Partial obstruction that does not meet the criteria for hypopnea but provides evidence of increasing inspiratory effort (usually through pleural pressure monitoring) punctuated by an arousal

Answer 12

Respiratory effort–related arousal (RERA)

Question 13

A partially obstructed breath, typically within a hypopnea or RERA, identified by a flattened or scooped out inspiratory flow shape

Answer 13

Flow-limited breath

Question 14

Airway patency is dependent on the stabilizing influence of the _______-

Answer 14

Pharyngeal dilator muscles

Question 15

Airway lumen may be narrowed by enlargement of soft tissue structures (tongue, palate, uvula) due to ___ (3)

Answer 15

1. fat deposition
2. increased lymphoid tissue
3. genetic variation
   -mandibular retroposition
   -micrognathia

Question 16

___________ may trigger mouth opening during sleep, which breaks the seal between the tongue and the palate and allows the tongue to fall posteriorly and occlude the airway

Answer 16

High-level nasal resistance

Question 17

__________ during sleep results in central nervous system arousal

Answer 17

Increasing CO2 level

Question 18

This can preempt the CO2-mediated process of pharyngeal muscle compensation and prevent airway stabilization

Answer 18

A low arousal threshold

Question 19

May prevent appropriate termination of apneas, prolonging apnea duration and exacerbating oxyhemoglobin desaturation.

Answer 19

. A high arousal threshold

Question 20

Major risk factors for OSA

Answer 20

MOA
1. Obesity
2. Male sex
3. Older age

Additional risk factors:

-mandibular retrognathia
-micrognathia
-a positive family history of OSA
-sedentary lifestyle
-genetic syndromes that reduce upper airway patency (e.g., Down syndrome, Treacher-Collins syndrome)
-adenotonsillar hypertrophy (especially in children)
-menopause (in women)
-various endocrine syndromes (e.g., acromegaly, hypothyroidism)

Question 21

Approximately 40-60% of cases of OSA are attritutable to ___

Answer 21

Excess weight

Question 22

Obese individuals are at a ______ risk for OSA than their normal weight counterpart

Answer 22

fourfold or greater risk

Question 23

A 10% weight gain is associated with _____ increase in AHI

Answer 23

> 30%

Question 24

Prevalence of OSA is twofold higher among men than women. Factors that predispose men to OSA include ___ (2)

Answer 24

1. Android pattern of obesity
2. Relatively greater pharyngeal length, which increases collapsibility

Question 25

**TRUE OR FALSE** Premenopausal women are relatively protected from OSA by the **influence of sex hormones** on ventilatory drive.

Answer 25

TRUE

Question 26

The contribution of skeletal features in OSA is most evident in _____

Answer 26

Non-obese patients

Question 27

For a first-degree relative of a patient with OSA, the odds of having OSA is approximately ______ than that of someone without an affected relative.

Answer 27

twofold higher

Question 28

OSA prevalence Middle-aged adults: ______ Elderly: _______

Answer 28

Middle aged adults: 5-15% Elderly: >20%

Question 29

Peak of **lymphoid hypertrophy** among

Answer 29

children between 3-8 years old

Question 30

Prevalence of OSA is high among the following patients (3)

Answer 30

**HAD** 1. Diabetes mellitus 2. Hypertension 3. Atrial fibrillation

Question 31

____ precipitates OSA symptoms

Answer 31

Weight gain

Question 32

Most common complaint in OSA

Answer 32

**Snoring** Note: absence does not exclude OSA

Question 33

______ distinguishes OSA from Paroxysmal Nocturnal Dyspnea, Nocturnal Asthma and Acid reflux with laryngospasm

Answer 33

Absence of Dyspnea

Question 34

Most common daytime symptom

Answer 34

**Excessive daytime sleepiness** (however many women report fatigue instead of sleepiness)

Question 35

**TRUE OR FALSE** OSA alone is thought to cause right-sided heart failure.

Answer 35

**FALSE** Evidence of cor pulmonale suggests a comorbid cardiopulmonary condition

Question 36

Gold standard for diagnosing OSA

Answer 36

Overnight Polysomnogram

Question 37

Causes of False-negative Sleep Study (3)

Answer 37

**LIN** 1. Night-to-night variation in OSA 2. Insufficient REM sleep 3. Less supine sleep during testing

Question 38

If there is a high prior probability of OSA, a negative home study should be followed by ___

Answer 38

Polysomnogram

Question 39

The key physiologic information collected during a sleep study for OSA assessment includes : (4)

Answer 39

**BB CO** 1. measurement of breathing (changes in airflow, respiratory excursion) 2. oxygenation (hemoglobin oxygen saturation) 3. body position 4. cardiac rhythm.

Question 40

Mild OSA

Answer 40

AHI 5-14 events/hour

Question 41

Moderate OSA

Answer 41

15-29 events/hour

Question 42

Severe OSA

Answer 42

≥30 events/hour

Question 43

Expected result of Overnight BP monitoring in OSA

Answer 43

**“nondipping” pattern** (absence of the typical 10% fall of blood pressure during sleep compared to wakefulness)

Question 44

ABG finding suggesting coexisting cardiopulmonary disease or hypoventilation syndromes.

Answer 44

Waking hypoxemia or hypercarbia

Question 45

Seen in patients with severe nocturnal hypoxemia

Answer 45

Elevated hemoglobin

Question 46

Useful test in **quantifying sleepiness** and helping to **distinguish OSA from narcolepsy**.

Answer 46

A **multiple sleep latency test** or a **maintenance of wakefulness test**

Question 47

OSA-related respiratory events stimulate sympathetic overactivity, leading to _____

Answer 47

1. Acute blood pressure surges during sleep and nocturnal 2. Daytime hypertension

Question 48

OSA-related hypoxemia also stimulates release of acute- phase proteins and reactive oxygen species that exacerbates ______

Answer 48

1. Insulin resistance and lipolysis a 2. Augmented prothrombotic and proinflammatory state

Question 49

Inspiratory effort against an occluded airway causes large intrathoracic negative pressure swings, altering ______

Answer 49

Cardiac preload and afterload and resulting in **cardiac remodeling** and **reduced cardiac function**

Question 50

Hypoxemia and sympathetic-parasympathetic imbalance also may ____

Answer 50

Cause **electrical remodeling of the heart and myocyte injury**

Question 51

Treatment of OSA with nocturnal continuous positive airway pressure (CPAP) has been shown to reduce 24-h ambulatory blood pressure by ____

Answer 51

2–4 mmHg

Question 52

**TRUE OR FALSE** OSA treatment with CPAP reduces cardiac event rates or prolongs survival.

Answer 52

FALSE

Question 53

**TRUE OR FALSE** Treatment of OSA has been shown to reduce several markers of cardiovascular risk and improve insulin resistance and, in uncontrolled studies, is associated with a decreased recurrence rate of atrial fibrillation.

Answer 53

TRUE

Question 54

Patients with OSA has ____ increase in occupational accidents

Answer 54

twofold increase

Question 55

Management of OSA

Answer 55

1. Reduce weight 2. Optimize sleep duration (7–9 h) 3. Regulate sleep schedules (with similar bedtimes and wake times across the week) 3. Encourage the patient to avoid sleeping in the supine position 4. Treat nasal allergies 5. Increase physical activity 6. Eliminate alcohol ingestion (which impairs pharyngeal muscle activity) within 3 h of bedtime 7. Minimize use of opiate medications

Question 56

OSA: standard medical therapy with the highest level of evidence for efficacy.

Answer 56

Continuous Positive Airway Pressure (**CPAP**) CPAP works as a mechanical splint to hold the airway open, thus maintaining airway patency during sleep.

Question 57

Specific treatment for **nasal congestion**

Answer 57

Provide heated humidification, administer saline/steroid nasal sprays

Question 58

Specific treatment for **Claustrophobia**

Answer 58

Change mask interface (e.g., to nasal prongs), promote habituation (i.e., practice breathing on CPAP while awake)

Question 59

Specific treatment for **Difficulty exhaling**

Answer 59

Temporarily reduce pressure, provide bilevel positive airway pressure

Question 60

Specific treatment for **Bruised nasal ridge**

Answer 60

Change mask interface, provide protective padding

Question 61

Specific treatment for **Aerophagia**

Answer 61

Administer antacids

Question 62

Oral appliances are most often used for treating patients with ______

Answer 62

1. Mild/moderate OSA 2. Do not tolerate CPAP

Question 63

Upper airway surgery for OSA is less efficacious than CPAP and is mostly reserved for the treatment of patients ___

Answer 63

1. Snoring 2. Mild OSA 3. Cannot tolerate CPAP

Question 64

Most commonly performed surgery for OSA

Answer 64

Uvulopalatopharyngoplasty

Question 65

Indications of Upper Airway Neurostimulation (alternative treatment for OSA)

Answer 65

1. Moderate to Severe OSA (AHI 15–65) 2. BMI <32 kg/m2 3. **Absence of complete concentric collapse at the level of the velum documented by awake and drug-induced endoscopy** (a predictor of response to surgery).

Question 66

Predictor of response of Upper airway neurostimulation

Answer 66

**Absence of complete concentric collapse** at the level of the **velum** documented by awake and drug-induced endoscopy

Question 67

**TRUE OR FALSE** In OSA, Supplemental oxygen can **improve oxygen saturation**, but there is **little evidence** that it improves OSA symptoms or the AHI in unselected patients.

Answer 67

TRUE

Question 68

Caused by an **increased sensitivity to pCO2**, which leads to an unstable breathing pattern that manifests as **hyperventilation alternating with apnea**.

Answer 68

Central sleep apnea

Question 69

With prolonged circulation delay, there is a crescendo-decrescendo breathing pattern known as

Answer 69

Cheyne-Stokes breathing

Question 70

Risk factors for Central Sleep Apnea

Answer 70

1. Congestive Heart failure 2. Opioid (Dose-dependent) 3. Hypoxia

Question 71

CPAP—particularly at high pressures—seems to induce central apnea; this condition is referred to as

Answer 71

**Complex sleep apnea** or **treatment-emergent central sleep apnea**

Question 72

An independent risk factor for the development of both heart failure and atrial fibrillation

Answer 72

Central Sleep Apnea

Question 73

Early marker of subclinical myocardial infarction

Answer 73

Central Sleep Apnea

Question 74

**TRUE OR FALSE** Supplemental oxygen can reduce the frequency of central apneas, particularly in patients with hypoxemia.

Answer 74

TRUE