Pulmonary HTN & Sleep Apnea

Question 1

Common causes of pulmonary HTN

Answer 1

Over 80% of cases are caused by conditions leading to elevation of left-sided heart filling pressures or pulmonary disease

Less commonly idiopathic [F>M]

Question 2

With mild pulmonary hypertension, right ventricular function may be preserved and pts may be asymptomatic. As disease progresses, what are some symptoms the pt may report?

Answer 2

Fatigue
Dyspnea on exertion
Palpitations
Chest pain
Syncope

Question 3

What are some PE findings associated with pulmonary HTN?

Answer 3

Left parasternal lift

Augmented jugular A wave

Pulmonic component of S2 or a single S2

Murmurs of tricuspid regurgitation or pulmonic insufficiency

Right ventricular S3 or S4 gallops

Edema, ascites, hepatomegaly also possible

Question 4

Pulmonary hypertension findings on imaging

Answer 4

Peripheral hypovascularity

Pulmonary artery enlargement

RV enlargement

Question 5

PFT findings with pulmonary hypertension

Answer 5

Isolated reduction in DLCO

Question 6

Possible ECG findings with pulmonary HTN

Answer 6

Right axis deviation

Right ventricular hypertrophy

Right atrial enlargement

Question 7

A pt with pulmonary HTN may be similar to a pt with IHD in that both have exertional dyspnea and blood tests indicate elevated ____

Answer 7

BNP

Question 8

How is diagnosis of pulmonary HTN confirmed?

Answer 8

Right heart catheterization and direct measurement of mean pulmonary artery pressure

Question 9

Classifications of pulmonary HTN

Answer 9

Group 1 = idiopathic and CT disease (includes BMPR2, ALK1, endoglin with/without hereditary hemorrhagic telangiectasia; drug and toxin induced; scleroderma, HIV, portal HTN, congenital heart disease, schistosomiasis, chronic hemolytic anemia)

Group 2 = Heart (includes systolic dysfunction, diastolic dysfunction, valvular dz)

Group 3 = Lung (COPD, ILD, alveolar hypoventilation d/o, chronic high altitude exposure)

Group 4 = Pulmonary embolism

Group 5 = all others (include hematologic, systemic, metabolic, and other d/o)

Question 10

What are some of the hematologic disorders included under group 5 pulmonary HTN?

Answer 10

Myeloproliferative disorders

Sickle cell dz

Question 11

What are some of the systemic disorders included under group 5 pulmonary HTN

Answer 11

Sarcoidosis

Pulmonary langerhans histiocytosis

Vasculitis

Question 12

What are some of the metabolic disorders included under group 5 pulmonary HTN?

Answer 12

Glycogen storage disease

Gaucher disease

Thyroid disorders

Question 13

Why is pulmonary HTN separated into groups?

Answer 13

The group system is used because it gives a functional idea of what is causing the pulmonary HTN — which allows docs to better understand how to tx

Question 14

How is pulmonary HTN treated?

Answer 14

Group 1 (idiopathic) — management is focused on vasodilator therapy

Group 2-5 — treat underlying cause; may include tx of heart failure, COPD, and/or OSA as well as O2 therapy

Question 15

Symptoms of OSA

Answer 15

Impaired daytime attention and memory [significantly increased risk for MVA!!]

Habitual snoring

Nighttime awakening with gasping or choking

Insomnia

Nighttime diaphoresis

Erectile dysfunction

Daytime fatigue or sleepiness

Alterations in mood

Neurocognitive decline

Question 16

Common physical findings in OSA

Answer 16

Obesity
Large neck
Nasal obstruction
Enlarged tonsils
Narrow oropharynx
Macroglossia
Retro- or micrognathia
Systemic HTN
Decreased O2 sat
Nasal congestion
Wheezing
Accentuated pulmonic component of S2 or S3

Question 17

If OSA is left untreated, it can lead to the dangerous sequelae of _____ and _____

Answer 17

Heart failure; stroke

Question 18

Test of choice for OSA

Answer 18

Polysomnography

[often performed with EEG for sleep staging and assessment for other causes of apnea; CPAP titration may be done at the same time or separately]

Question 19

What is the purpose of polysomnography and what result confirms OSA?

Answer 19

Measures respiratory events and hours of sleep to derive apnea-hypopnea index (AHI), which is the average number of apnea and hypopnea events per hour

An AHI >5/hr confirms OSA

[the severity of OSA is based on AHI, degree of sleepiness, and presence or absence of CV problems]

Question 20

Less expensive test for sleep apnea that may allow more pts access, but it is overall less accurate than polysomnography; usually includes respiratory monitoring and oximetry

Answer 20

Reduced channel polysomnography

Question 21

T/F: overnight oximetry is not an accurate test for OSA

Answer 21

True

Question 22

What lab test should you always order in pts who present with weight gain and fatigue?

Answer 22

Serum TSH

[note that TSH is elevated in 2-3% of pts with OSA]

Question 23

It is important to order a CBC in OSA pts because ____________ can be a complication in severe cases with accompanying severe hypoxemia

Answer 23

Secondary erythrocytosis

Question 24

A ______ and ______ should be ordered on your OSA patient if coexisting heart failure is suspected based on physical exam, as this can be a complication

Answer 24

CXR; ECG

Question 25

_________ should be ordered on your OSA pt to look for hypercapnea and hypoxemia if obesity hypoventilation syndrome is suspected

Answer 25

Arterial blood gas

Question 26

Differential diagnoses for OSA

Answer 26

``` Central sleep apnea Upper airway resistance syndrome Periodic limb movements of sleep Narcolepsy Obstructive or restrictive lung dz GERD Sinusitis Heart failure Epilepsy Sleep deprivation Hypothyroidism Acromegaly Obesity-hypoventilation syndrome ```

Question 27

Central sleep apnea is most commonly seen in pts with heart failure and stroke, as well as use of opioid medications. What test can differentiate central vs. obstructive sleep apnea?

Answer 27

Polysomnography In central sleep apnea, polysomnography shows absence of respiratory effort during apnea, distinguishing it from obstructive

Question 28

Condition most commonly seen in loud snorers who complain of excessive sleepiness and polysomnogram with EEG shows a normal AHI but increased respiratory effort causes frequent EEG interruptions during sleep

Answer 28

Upper airway resistance syndrome [symptoms and tx are the same as OSA]

Question 29

Periodic limb movements of sleep are a neurologic disorder of unknown cause, characterized by frequent episodes of leg kicking during sleep; it is most common in pts on _______; limb movements are not associated with respiratory events on polysomnogram

Answer 29

Dialysis

Question 30

Severe excessive sleepiness and cataplexy with age of onset usually 15-25, and polysomnogram does not show OSA or periodic limb movements, but multiple sleep latency are abnormal

Answer 30

Narcolepsy

Question 31

Lifestyle changes recommended to OSA pts

Answer 31

Weight loss of at least 10% in obese pts Avoid alcohol and sedatives 3-4 hrs before bed Sleep in lateral position

Question 32

Primar airway management strategies for OSA

Answer 32

Continuous Airway Positive Pressure (CPAP) — pneumatically splints the entire airway, preventing collapse during sleep; raises intraluminal pressure in airway and increases FRC Bi-level PAP (BiPAP) — while CPAP has one pressure leve, BiPAP has separate pressures for inspiratory and expiratory phases which may improve comfort and adherence

Question 33

Other than lifestyles changes, CPAP, and/or BiPAP, what are other options for OSA tx?

Answer 33

Oral devices Upper airway surgical procedures (uvulopalatopharyngoplasty - UPPP) Nasal glucocorticoids and decongestants Mandibular advancement devices (only help in mild to moderate cases)

Question 34

A 53 y/o woman suffered multiple pulmonary emboli during the pregnancy with her second child. Subsequently, she has noticed limitations hiking in mountains she hadn’t noticed previously. Dyspnea slowly progressed so now she is dyspneic keeping her house and shopping. Her exam was normal except for accentuation of the second heart sound. Echocardiogram suggested pulmonary artery hypertension. What is the most likely diagnosis? ``` A. Group 1 pulmonary HTN B. Group 2 pulmonary HTN C. Group 3 pulmonary HTN D. Group 4 pulmonary HTN E. Group 5 pulmonary HTN ```

Answer 34

D. Group 4 pulmonary HTN

Question 35

A 62 y/o morbidly obese male presents with a history of chronic daytime hypersomnolence, loud snoring, choking during sleep, and impaired concentration. He is a lifelong nonsmoker and is employed as a machinest. He most likely has... ``` A. OSA B. COPD C. Obesity-hypoventilation syndrome D. Ondine’s curse E. Narcolepsy ```

Answer 35

C. Obesity-hypoventilation syndrome

Question 36

A 62 y/o morbidly obese male presents with a history of chronic daytime hypersomnolence, loud snoring, choking during sleep, and impaired concentration. He is a lifelong nonsmoker and is employed as a machinest. You suspect obesity-hypoventilation syndrome. The best diagnostic step is: ``` A. Polysomnography B. Echocardiography C. CXR D. 6-minute walk test E. Right heart catheterization ```

Answer 36

A. Polysomnography