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Respiratory SCE > Sleep > Flashcards

Sleep Flashcards

1
Q

What is REM sleep?

A

Interesting and vivid dreams at their peak , usually associated muscle atonia and resultant paralysis to stop us acting our dreams

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2
Q

What is associated with REM Sleep Behaviour Disorder ?

A
  • SSRI initiation / cessation
  • Can arise in PD/ Narcolepsy
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3
Q

What is catharaemia

A

Groaning / moaning during expiration

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4
Q

What is Somniloquy?

A

Talking in sleep

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5
Q

What is Kleine Levin Syndrome

A

XS Sleep, XS eating , XS sex drive

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6
Q

What assessments do we use for OSA?

A

Epworth Sleepiness Scale and STOP-BANG

Do not use ESS alone , as not all patients with OSAHS are sleepy

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7
Q

Who are the patients prioritized for assessment w sleep study?

A

Vocational driving job
Vigilance critical to safety in job
Pregnant
Pre-Operatively
Unstable CDV risk
NAAION

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8
Q

How do we classify AHI results ?

A

<5 Normal
5-14 Mild
15-29Moderate
>30 Severe

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9
Q

What are the options if AHI 5-15?

A

MILD OSAHS

  • Tx not usually needed and lifestyle modifications usually effective
  • If significantly affecting QOL offer fixed level CPAP and lifestyle advice
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10
Q

Who can be offered auto CPAP?

A

High pressure needed for certain times of the night
OR
Unable to tolerate fixed level CPAP
OR
Telemetry can’t be used
OR
Auto CPAP is available at same /lower cost

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11
Q

Who can be offered mandibles advancement splint ?

A

If aged 18 years or over and have optimal dental and peridontal health

Useful for snoring and for mild OSA

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12
Q

What is the treatment for Moderate and Severe OSAHS

A

Mod (AHI 15-30 ) and Severe( AHI >30)
- fixed level CPAP and lifestyle measures

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13
Q

Who can you consider tonsillectomy in with OSAHS?

A

Large obstructive tonsils and BMI <35

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14
Q

What is obesity hypoventilation syndrome?

A

Obesity (BMI > 30) and Raised Arterial pCO2 and Apnoeas /Hypopneas when asleep or hypoventilating

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15
Q

What are the features of nocturnal hypoventilation?

A

Waking headaches
Peripheral oedema
Hypoxaemia
Unexplained polycythaemia

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16
Q

Who gets prioritised for OHS assessment ?

A

Severe hypercapnia >7 when awake
Hypoxaemia
Acute ventilatory failure
Vocational driving job
Hypervigilant job
Significant CDV or co-morbidity
Pregnancy
NAAION
Pre operative assessment

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17
Q

How can we diagnose OHS?

A

If pre-test probability is low can do a pre-test venous HCO3 and if <27 OHS is unlikely

Otherwise Resp Polygraphy to determine presence of OSAHS in those with OHS and consider adding transcutaneous CO2

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18
Q

What is the usual life style advice in OSAHS?

A

Stop smoking
Lose weight
DVLA guidance

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19
Q

What is the initial treatment for patients with OHS and severe OSAHS?

A

CPAP

20
Q

What is the treatment for OHS and OSAHS who sx not improving and hypercapnia persisting and AHI/ODI not reduced enough in CPAP?

A

NIV

21
Q

What is the treatment for OHS and nocturnal hypoxaemia ?

A

NIV

22
Q

What is the treatment for those with OHS and acute ventilatory failure ?

A

Offer NIV to ppl with OHS and ventilatory failure ; once resolved can go to CPAP and if relapses then back to NIV

23
Q

What is the first line treatment for COPD - OSAHS overlap?

A

CPAP first line if pCO2 < 7
NIV first line if pCO2 > 7

24
Q

What is the DVLA guidance if no somnolence?

A

No need to stop driving or inform

25
Q

What is the ESS threshold for a high risk driver (ie one with moderate to severe day time sleepiness)

A

17

26
Q

What is the advice for mild OSA?

A

GROUP 1:
Must not drive ; driving may resume only after satisfactory symptom control. If symptom control cannot be achieved in 3 months DVLA must be informed

GROUP 2 (Bus/Lorry)
Must not drive ; driving may resume only after satisfactory symptom control , if symptom control not achieved by 3 months DVLA must be informed

27
Q

What is the DVLA advice for Moderate to severe OSA?

A

Group 1
Must not drive and Must inform the DVLA

Subsequent licensing will require control of condition , improved sleepiness and tx adherence

DVLA will need confirmation of the above and must be reviewed every 3 years

Group 2
Must not drive and must notify DVLA

Subsequent licensing will require control of condition , improved sleepiness and tx adherence

DVLA will need confirmation of the above and must be reviewed every 3 years

28
Q

If patient excessively sleepy due to suspected OSA what is DVLA advice?

A

Must not drive ; only once satisfactory control

29
Q

What is central sleep apnoea?

A

Actual apnoea referred to as Cheney Stoke’s breathing when there is regular and symmetrical waxing and waning usually in the context of left ventricular failure

30
Q

Outline absent or reduced ventilatory drive accounting for Central Sleep Apnoea

A

Brain stem involvement from strokes /tumours etc ; presents with unexplained ventilatory failure much worse during sleep

Lung function usually normal with no evidence of resp muscle weakness

Often maintain adequate or near adequate ventilation when awake as non metabolic drive and then during Non REM sleep this awake drive is most and ventilation is dependent on PaO2 and PaCO2 , during REM slightly better as awake like drive

31
Q

Outline neuromuscular inspiratory weakness

A

Diurnal ventilatory failure

Particularly when supine VC falls below 20% predicted (often late sign tho)

Accessory muscles become very important , when during REM sleep these are lost with physiological paralysis then profound hypoventilation

Metabolic ventilatory drive is maintained and therefore this will result in arousal and interrupted sleep; but this gets progressively blunted

32
Q

Outline chest wall restrictive diseases

A

Scoliosis or post thoracoplasty , muscles not weak

Worry when VC <1L

33
Q

In REM sleep what is the resp muscle working?

A

Diaphragm is the only resp muscle working as all other muscles are profoundly hypotonic ; if diaphragm paralysed then REM sleep is very vulnerable

34
Q

Outline Cheyne Stoke’s breathing associated with heart failure

A

Raised left atrial pressure of the left heart which increases ventilatory drive through stimulating the J receptors this in addition to ventilatory stimulation from hypoxaemia from pulmonary oedema

This ventilatory stimulation reduces the awake pCO2 causing resp alkalosis (and use of diuretics may cause it s metabolic alkalosis)

J receptor ventilatory stimulations reduces at sleep onset and this together with loss of the awake ventilatory drive allows central hypoventilation

This hypoventilation / apnoea will continue until PaCO2 increases driving ventilation again or reduces pO2 provoking arousal(may cause patient to awaken)

Cycle maintained

35
Q

Outline Cheyne Stoke’s breathing associated with r altitude

A

Acute hypoxia following ascent to altitude provokes increased ventilation (degree variable) ; sleep onset lessening of hypoxic drive and removal of the awake drive and uncomplicated alkalosis will allow hypoventilation and apnoea , get arousals due to reduced sats or increased paCO2 ; sleep is fragmented

The larger the resp alkalosis the greater the tendency to sleep hypoventilate

Two tx approaches : Pre-acclimatise with acetazolamide which produces mild metabolic acidosis or hypnotics

O2 would abolish the problem

36
Q

What does pCO2 normal and raised HCO3 indicate?

A

Nocturnal hypoventilation and incipient resp failure

HCO3 is the HbA1c of PaCO2 !!

37
Q

For CSA what do we see on sleep study?

A

Fall in sats with associated hypoventilation but no evidence of OSA and no snoring

Oscillation in sats more sinusoidal than in OSA

38
Q

If moderate sleep apnoea is left untreated , what is the risk of cardiovascular mortality ?

A

2-3 fold increase

39
Q

What is an apnoea?

A

> 90% reduction of airflow (measured by nasal monitor) lasting 10 seconds with or without desaturation

40
Q

What is a hypopnoea?

A

10 seconds reduction in airflow of >30% with 4% oxygen desaturation

41
Q

How common is OSA syndrome ?

A

4% of men and 2% of women aged 30-60 years

42
Q

How common is OSA? (On sleep study but without day time symptoms)

A

20%

43
Q

Does ODI derived from overnight oximetry correlate with AHI derived from polysomnography?

A

Yes

44
Q

What is included in limited PSG?

A

Nasal airflow
Thoracic-abdominal bands
Snore vibration sensor
Pulse oximeter

45
Q

What is OHS?

A

BMI > 30 , sleep disordered breathing and daytime pCO2 >6kpa

PSG will show sleep hypoventilation with nocturnal hypercapnia with or without obstructive sleep apnoea /hyponea eventd

OHS strongly associated with pulmonary HTN

46
Q

How do you diagnose narcolepsy?

A

A multiple sleep latency test <8minutes and two or more sleep onset rapid eye movements (SOREMs)

47
Q

What are the indications for NIV in motor neuron disease ?

A
  • Breathlessness, particularly orthopnea
  • Daytime sleepiness
  • Daytime hypercapnia >6 req urgent referral
  • Nocturnal desaturation or daytime saturation <94%
  • Reduced FVC <50% predicted (or <80% and signs/symptoms)
  • SNIP < 40 or a SNIP < 65 in men and <55 in women plus any resp sx
  • Postural VC drop

Respiratory SCE (15 decks)

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