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Respiration > Sleep Apnoea and Neuromuscular Respiratory Failure > Flashcards

Sleep Apnoea and Neuromuscular Respiratory Failure Flashcards

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1
Q

What is obstructive sleep apnoea?

A

Recurrent episodes of upper airway obstruction leading to apnoea (cessation of breathing) during sleep.

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2
Q

What are the common presentations of sleep apnoea?

A

Heavy snoring
Unrefreshing sleep
Daytime somnolence (sleepiness)
Poor daytime concentration

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3
Q

Where is the obstruction in sleep apnoea?

A

Between the base of the tongue/soft pallet and posterior pharyngeal wall

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4
Q

What are the causes of sleep apnoea?

A

Muscle relaxation
Narrow pharynx
Obesity

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5
Q

What is the pathophysiology of sleep apnoea?

A

Repeated closure of upper airways

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6
Q

What does recurrent closure of the airways lead to?

A

Oxygen desaturation
Snoring
Apnoea’s and hypopnea’s

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7
Q

What does apnoea’s and hypopnea’s lead to?

A

Frequent microarousals

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8
Q

What does frequent microarousals lead to?

A

Daytime hypersomnolence
Poor concentration

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9
Q

What is apnoea and hypopnoea?

A

Apnoea = obstructed for 10s or more
Hypopnoea = nearly obstructed for 10s or more

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10
Q

What is the importance of sleep apnoea?

A

Impaired QofL
Marital disharmony
Increased risk of RTA
Increased risk of stroke
Associated with hypertension
Probably increased risk of heart disease

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11
Q

What % of men/women are affected by sleep apnoea?

A

Men = 2%
Women = 1%

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12
Q

How do you diagnose sleep apnoea?

A

Clinical examination and history
Epworth questionnaire
Overnight sleep study

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13
Q

What are the 3 types of overnight sleep studies?

A

Pulse oximetry - basic
Limited sleep studies
Full polysomnography - most sophisticated

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14
Q

What is the Epworth questionnaire?

A

A questionnaire determining the level of sleepiness a patient experiences
Score of 11 or more = abnormal

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15
Q

What does overnight oximetry measure?

A

Records O2 sats and pulse rate while asleep

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16
Q

What is an indication of sleep apnoea on an overnight oximetry?

A

Repetitive desaturations
Pulse rate rises intermittently coinciding with O2 saturation

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17
Q

What does polysomnography measure?

A

Oronasal airflow
Thoracoabdominal movement
Body position
Oximetry
EEG (brain wave recordings)
Audio-visual recording
EOG (eye muscle movements)
EMG (peripheral muscle movements)
ECG (heart tracing)

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18
Q

How is severity of sleep apnoea measured?

A

Via desaturation index/apnoea hypopnoea index
0-5 = normal
5-15 = mild
15-30 = moderate
>30 = severe

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19
Q

What are the treatment options for sleep apnoea?

A

Identify exacerbating factors
Continuous positive airway pressure (CPAP)
Mandibular repositioning splint

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20
Q

What factors can exacerbate sleep apnoea?

A

Weight (90% of patients with SA are overweight)
Alcohol
Endocrine disorders

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21
Q

What does CPAP do?

A

Creates positive pressure within the throat and stops the tissue from being sucked together during inspiration.

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22
Q

How does mandibular repositioning splint work and when is it used?

A

Advances lower jaw forwards bringing base of tongue forwards and creating more space at the back of the throat.

Used if patient cannot tolerate CPAP.

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23
Q

How should patients be advised about driving?

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A

Advice those with excessive daytime somnolence NOT TO DRIVE or RESTRICT driving and inform DVLA of their condition

24
Q

What is narcolepsy?

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A

A chronic neurological disorder that affects the brain’s ability to control sleep-wake cycles

25
What are the clinical features of narcolepsy?
Cataplexy Excessive daytime somnolence Hypnagogic/hypnopompic hallucination Sleep paralysis
26
What is cataplexy?
Where person will suddenly collapse during the day appearing to be asleep but is vaguely aware of what's going on around them.
27
What are hypnagogic/hypnopompic hallucinations?
Hallucinations that occur just at the onset of sleep or just at the end of sleep. They are visual and often quite frightening
28
What investigations would you perform for narcolepsy?
Polysomnography MSLT (multi sleep latency test) Low CSF orexin
29
What is MSLT?
Patient is asked to try fall asleep in a dark silent room. Their brain waves and time to fall asleep are recorded. If time to sleep is less than 6mins then significantly abnormal. >1 SOREM and mean sleep latency <8 mins
30
What does low CSF orexin show?
Orexin = neuropeptide involved in controlling wakefulness. Typically see low levels in narcolepsy patients
31
What are the treatment options for narcolepsy?
No cures - have to take drugs to continuously control illness - Modafinil - Dexamphetamine - Venlafaxine - Sodium Oxybate (Xyrem)
32
What does modafinil do?
General stimulant taken at morning and lunch Counteracts excessive somnolence
33
What does dexamphetamine do?
Is a 2nd line drug used to counteract somnolence
34
What is venlafaxine for?
Cataplexy
35
What is sodium oxybate for?
2nd line drug for somnolence and cataplexy
36
What type of ventilatory failure is chronic ventilatory failure?
Type 2
37
What are the defining perimeters on ABG for chronic ventilatory failure?
Elevated pCO2 pO2 < 8kPa Normal blood pH Elevated bicarbonate in blood
38
How does chronic ventilatory failure differ from acute?
Acute = rises in pCo2 Acute = Low pH
39
What is blood pH proportional to?
Concentration of bicarbonate dived by pCO2
40
What happens in the body when pCO2 rises and how is this managed in chronic situations?
Rise in pCO2 = blood pH falls In chronic situation body attempts to compensate for this acidity by retaining the week buffer bicarbonate from the kidneys
41
What is the aetiology of chronic ventilatory failure?
Airway disease Chest wall abnormalities Respiratory muscle weakness Central hypoventilation
42
What airways diseases can cause chronic ventilatory failure?
COPD Bronchiectasis
43
Give an example of a chest wall abnormality causing chronic ventilatory failure?
Kyphoscoliosis
44
What respiratory muscle weakness can bring about chronic ventilatory failure?
Diaphragm, intercostal, abdominal muscles Motor neurone disease (ALS) Muscular dystrophy Glycogen storage disease (Pompe's disease)
45
What can cause central hypoventilation?
Obesity hypoventilation syndrome Congenital central hypoventilation syndrome (Ondine's curse) - Presents in newborns with ventilatory failure - Used to be fatal but children can now sometimes survive to adulthood
46
What are the typical symptoms of chronic ventilatory failure?
Breathlessness Orthopnoea Ankle swelling Morning headaches Recurrent chest infections Disturbed sleep
47
What is orthopnoea?
Breathlessness while lying flat
48
Why do you get ankle swelling in chronic ventilatory failure?
Chronic low pO2 results in hypoxic vasoconstriction within pulmonary vasculature, resulting in elevated pressure within right heart, transferred to venous system, fluid can leak out of veins and cause swelling = cor pulmonale.
49
Why do you get morning headaches in chronic ventilatory failure?
When pCO2 rises in blood at night, excess CO2 acts a vasodilator in cerebral blood vessels, this can result in headache.
50
What would you expect to find on examination of a chronic ventilatory failure patient?
Paradoxical abdominal wall motion in suspected neuromuscular disease. Ankle oedema (hypoxic cor pulmonale).
51
Why does paradoxical abdominal wall motion come about and what is it?
Due to a weakness of the diaphragm. Breath in diaphragm descends creating -ve intrathoracic pressure drawing air into the lungs. When sitting upright it has help of gravity, when lying flat no gravity to help descend. If significant weakness diaphragm wont contract properly/descend, opposite may happen and diaphragm is drawn up into the chest. Abdominal wall will move up/out normally, but with diaphragm weakness it moves down during inspiration.
52
What investigations do you do with chronic ventilatory failure?
Lung function Assessment of hypoventilation If suspected weekended diaphragm = fluoroscopic screening of diaphragm
53
What do you look at with lung function tests and what would you expect to find?
Spirometry when lying and standing = measure VC: - VC will be lower when lying than sitting/standing Mouth pressure/SNIP - Measure pressure person can generate breathing in/out as hard as possible - SNIP = sniff in/out as hard as possible
54
What tests are done in assessment of hypoventilation?
Early morning ABG - Results reflect physiology of what happened during sleep Overnight oximetry Transcutaneous CO2 monitoring - Looking for elevated CO2 during sleep
55
What would be the expected results of a pulmonary function test for a patient with chronic ventilatory failure?
Reduced FEV1 and FVC Ratio of FEV1/FVC is high Characteristic of restrictive ventilatory pattern Supine FVC is significantly lower than standing FVC
56
What are the treatment options for someone with chronic ventilatory failure?
Not curable unless the underlying cause is curable. Non-invasive ventilation (NIV) Oxygen therapy Tracheostomy ventilation (t-IPPV)

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