SLEEP DISORDERED breathing Flashcards by A B

•Flow through the upper airway during sleep can be predicted using a Starling resistor model, where flow through a tube is predicted by pressures and resistances upstream and downstream to the site of collapse. During an obstructive event, what is the relationship between the pressures at the site of airway collapse (Pcrit), upstream (Pus) to the site of collapse, and downstream (Pds) to the site of collapse?

A.Pus> Pcrit> Pds.
B.Pus> Pds> Pcrit.
C.Pcrit> Pus> Pds.
D.Pcrit> Pds > Pus.

answer = c

outside pressure causing collapse of the airway

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Primary muscles of sleep

1) muscles influencing hyoid position (geniohyoid/sternohyoid)
2) tongue muscles (genioglossus)
3) palate muscles (tensor palatini, levator palatini)

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Effect of obesity on airway

1) airway narrowed due to incr fatty tissue around neck
2) causes collapse of pharyngeal space
3) compensate by incr force of genioglossus muscle

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Physics of upper airway collapse

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Snoring

1) what proportion of people occassionally?
2) habitual in men vs women

universal

44% men, 28% women

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cheyne-stokes respiration

found in which patients?

what happens?

arounds occur when?

heart failure, storke

greater hypercaneic respiratory drive –> overshooting of PaCO2 below apneic threshold

1) CO2 = primary drive of breathe

2) CO2 in blood decr and delayed incr in resp neurons
(aortic and carotid bodies and medulla)

3) exaggerated response and overshoot target
blow down CO2 too low so long pause

when CO2 rise then breathe again

–> arousals occur at peak of ventilation

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•A 62 year old man presents to clinic with the chief complaint of daytime sleepiness for the past 6 months. He is unable to stay awoke while watching television in the evening and his wife is concerned about his driving. His wife also states that he struggles to breath during sleep. He has a history of hypertension and diabetes. His Body Mass Index is 38 and neck circumference is 56cm. Which of the following diagnostic tests would provide the definitive diagnosis for this patient?
A.Nocturnal oximetry
B.Serum TSH level
C.Multiple Sleep Latency Test
D.MRI of the head and neck
E.Polysomnography

answer = e

polysomnography

underlying co morbidity and postiive sleepiness –> high pre test probability

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Sleep apnea assoc with?

1) obesity
2) CV disease
3) MVC

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Consider what questions for sleep in patient?

Is the patient overweight or obese?
Is the patient retrognathic?

Does the patient complain of daytime sleepiness?

Does the patient snore?
Does the patient have hypertension?

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Assess which patients for OSA symptoms?

Morbidly obese- BMI >35
CHF
Atrial fibrillation
Treatment refractory hypertension
Type 2 diabetes
Nocturnal dysrhythmias
CVA
Pulmonary hypertension
High-risk driving populations
Preoperative for bariatric surgery

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Demographics of OSA
1) gender

2) age
3) race
4) PMH
5) FHx
6) SHx
7) meds

1) male more
2) prevalence incr until 60’s and 70’s
3) minorities
4) chronic rhinitis, acromegaly, neuromuscular disorder, amyloidosis, down
5) 1st degree relative with OSA
6) smoking, etoh abuse
7) sedative-hypnotics, opioids

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Features of sleep apnea

Morning headaches
Nonrestorative or unrefreshing sleep or naps
“Restless” sleep with frequent movements
Awakenings with a sensation of gasping or choking
Excessive body movements during sleep
Snoring
Witnessed apneas, gasping, or choking
Daytime sleepiness or fatigue
Decline in performance at work or school
Attention deficit (in children)
Hyperactivity (in children)
Impaired cognition (memory and concentration)
Impotence or diminished libido Insomnia
Nocturia or enuresis

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Physical exam

Mallampati

more crowding in posterior pharynx had incr risk during intubation

class 3 and class 4 are also incr risk of OSA

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Polysomnography

full night (diagnostic or therapeutic)

split night ( (diagnostic or therapeutic))

portable study ( (diagnostic or therapeutic))

when do you use portable study?

full night = diagnostic purpose only

split night = diagnostic (1/2 night) + therapeutic (1/2 night with CPAP) only

portable = diagnostic

high pre-test probability and no cardiopulm comorbidities

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•Which of the following surgical procedures is most likely to be definitively successful for the treatment of severe obstructive sleep apnea syndrome (OSAS) in an adult patient?
A.Uvulopalatopharyngoplasty
B.Tonsillectomy and adenoidectomy
C.Maxillomandibular advancement
D.Tracheostomy
●

answer = D

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Treatment of OSA

1) avoid sedatives, stop smoking (because incr inflamm of oropharynx and narrow arirway), treat underlying
2) weight reduction
3) position therapy, O2, pharmaco, positive airway
4) upper airway surgery
5) nerve stim

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Describe CPAP

Describe bi-level positive airway pressure

describe autotitrating positive airway pressure

describe nocturrnal noninvasive positive pressure ventilation

constant pressure throughout resp cycle

2 pressure levels - high during inspiration, lower during expiration (helps ventilation; if not only obstruction but also ventilation)

looks at breath to breath and augments pressure to ventilate well

ventilator for central or complex or mixed sleep apnea

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oral appliances for OSA

tongue retainer

when to use?

holds tongue forward

preferred for edentulous patients or those with no dentition

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oral appliances for OSA

mandibular repositioner

don’t use if (2)

advance mandible forward

1) don’t use if inadeq or broken teeth
2) don’t use if significant TMJ dysfunction

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surgical options for OSA

tracheostomy

used for?

tracheostomy

tracheal opening distal to pharynx to bypass upper airway obstruction

curative for severe sleepiness, cardiac arrhythmia, severe hypoxemia, hypoventilation, cor pulmonale

may still hypoventilate so still need additional ventilation

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surgical options for OSA

maxillomandibular advancement

goal

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maxillomandibular advancement

advance maxilla and mandible

enlarge retrolingual and retropalatal airway

surgical options

UPPP

more or less effective than CPAP

good long-term?

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UvuloPalatoPharyngoPlasty

excision of uvula, posterior soft palate, tonsils

less effective than CPAP

recurrence of snoring or OSA after initial benefit

Surgical options for OSA
tonsillectomy and adenoidectomy

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remove tonsils/adenoids

effective in children with OSA

nerve stimulation for OSA

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for mild OSA not want CPAP

implanted into skin and insert into genioglossus and intercostal muscle so when do respiratory effort, sends signal to genioglossus to contract and move it out of oropharynx

Most common cause of OSA is \_\_\_\_ Related to this is:

periodic collapse of pharyngeal soft tissue during sleep 1) obesity 2) anatomically small pharyngeal airway 3) loss of tone of pharyngeal or genioglossus 4) unstable respiratory control system 5) low arousal threshold 6) changes in lung volume/loss of coordination of airway

Patients with OSA have a reduced ____ due to XS soft tissue (fat) or a higly compliant airway

upper airway

Patients with OSA have a reduced upper airway due to (2)

1) XS soft tissue (fat) 2) highly complaint airway

What can result in partial or complete upper airway collapse in OSA

1) reduced airway size 2) diminished neural input to upper airway muscles

What determines the tendency of upper airway to collapse?

Critical closing pressure (Pcrit)

Apneas occur when ___ is less than the threshold for inspiratory muscle activation to maintain upper airway patency during sleep If an overshoot in ventilation decr CO2, what happens to respiratory drive Thus, the next apnea results from \_\_\_

respiratory drive fall below the threhsold for inspiration to occur overcompensation for prior apnea

Apneas occur when respiratory drive is less than \_\_\_

threshold for inspiratory muscle activation and maintaining airway patency during sleep

Prevalence of apnea what % of adults at risk for apnea if the prevalence is defined as an apnea hypopnea index \>5 events per hour (asymptomatic) if the prevalence is defined as an apnea hypopnea index \>5 events per hour + at least one symptom known to respond to treatment (daytime sleepiness)

26% 20% 2-9% therefore, common to be asymptomatic

how does OSA prevalence change with age and gender and race

incr from 18-45 then plateaus at 55-65 more common in african americans \< 35 compared to whites and common in Asians males more than women due to higher apnea hypopnea during adulthood (little difference beyond 60's)

if a patient says that they are feeling sleepy or falling asleep in boring or passive situations, this could imply \_\_\_

daytime sleepiness

if a patient snores 9common in OSA), what else could they also likely have?

excessive daytime sleepiness

what are common symptoms in OSA?

1) XS daytime sleepiness 2) restless sleep 3) silence, then loud snoring 4) poor concentration 5) waking up gasping, choking

each apnea event results in arterial ___ and \_\_\_

hypoxemia and hypercarbia d

what do arterial hypoxemia and hypercapnia in OSA cause?

1) sympathetic hyperexcitation 2) incr peripheral vascular resistance 3) TRANSIENT SYSTEMIC HYPERTENSION 4) precapillary pulmonary vasoconstriction --\> pulmonary hypertension 5) vagal tone via carotid body hypoxic stim --\> bradycardia

why do patients with OSA have pulm hypertension

due to precapillary pulmonary vasoconstriction

what causes the bradycardia that occurs in OSA during an apneic episode

carotid body hypoxic stim (breath holding)

what happens when the patient wakes up from an apneic episode?

1) aroused 2) pharyngeal patency 3) hyperventilate 4) blood gas back to normal

what are treatment plan for apnea

1) CPAP --\> good for sleepiness, cog function 1) lifestyle mod = weight loss, exercise 2) sleep position (cervicomandibular support, pillow) 3) mandibular repositioning and tongue retaining 4) CNS stim 5) surgery

what are surgical procedures for OSA

1) oral/oropharyngeal/nasopharyngeal procedures 2) hypopharyngeal procedures 3) airway 4) laryngeal procedures

Paradigm of checking for OSA

1) clinical probability of positive test for sleep apnea 2) low neck circumference --\> daytime symptoms = conservatve if none to mild polysomnography = moderate to severe 3) large neck --\> polysomnography if polysomnography not available use portable monitor

what happens to airway during sleep? how does this affect neck muscle motor activity?

when in deep sleep, motor activity of neck decr significantly

how does airway resistance change with sleep

1) airway narrowed 2) incr resistance 3) body compensates by incr pull of muscles to open airway 4) chronically incr baseline EMG activity due to incr force

how does sitting and standing affect airway size what happens with OSA

airway size decr with supine due to tongue falling back to neck in sleep apnea, start with smaller airway and more compromise with supine

Describe Zone 3

best situation because pressure in upper airway \> lower airway \> Pcrit so airway always open

Describe Zone 2

snoring prssure upper airway \> P crit \> pressure lower airway upper still greater than lower so air goes downstream but due to narrowing from P crit, create snoring

Describe zone 1

P crit \> P upstream \> P downstream obstructive sleep apnea collapse of the straw in all situations causing incr turbulence and obstructed airflwo

SLEEP DISORDERED breathing Flashcards

(50 cards)