Sleep Related Breathing Disorders

Question 1

What does the Berlin Questionnaire evaluate for?

Answer 1

OSA

Question 2

What is Cor Pulmonale and what 3 conditions are most likely to cause it?

Answer 2

1. Right heart failure caused by pulmonary hypertension
2. COPD, Overlap syndrome (COPD + OSA) and OHS (Obesity Hypoventilation Syndrome)

Question 3

What is the diagnosis in a severely obese patient with LE edema and elevated daytime CO2?

Answer 3

Pt likely has cor pulmonale caused by hypoventilation. With an elevated daytime CO2, the diagnosis is OHS

Question 4

In men compared to women with OSA, which are more likely to have insomnia?

Answer 4

Women are more likely to have insomnia with OSA

Question 5

In men compared to women with OSA, which are more likely to have thyroid disease?

Answer 5

Women

Question 6

Compared to men, when will premenopausal women will have higher clusters of apneic episodes?

Answer 6

During REM sleep. This may be due to women having less compliant airways

Question 7

What are the ages for determining pediatric sleep disordered breathing?

Answer 7

< 18 years old but a sleep specialist can use 13 years old or younger

Question 8

Pediatric rules for scoring an apnea

Answer 8

• At least 90% drop in flow (thermistor) from baseline that lasts at least 90% of the specified time (obstructive, mixed, central)
• Duration
  
  • Obstructive at least 2 breaths
  • Central (at least 1 of the following)
    
    • At least 20 seconds
    • At least 2 breaths with 3% desaturation or an arousal
    • At least 2 breaths with a decrease in HR to below 50 bpm for 5 seconds or below 60 bpm for 15 seconds (less than 1 y/o)
  • Mixed
    
    • At least 2 breaths and…
    • Absence of respiratory effort for 1/2 and presence of respiratory effort for the other 1/2

Question 9

Unique features of pediatric OSA (4)

Answer 9

• Sleep architecture is usually normal
• Movement or autonomic arousals are more common than cortical arousals
• Obstructive events are more common in REM sleep
• Children have a faster respiratory rate and lower functional residual capacity than adults

Question 10

Criteria for diagnosis and treatment of OSA in children

Answer 10

No hard and fast rules since size from infant to adolescent is so great. One publication used this criteria:

• Mild
  
  • AHI < 1 to 4 without a drop in SaO2
  • Treat if daytime sequelae
• Moderate
  
  • AHI 5 to 10 and/or SaO2 < 85%
  • Most should receive treatment
• Severe
  
  • AHI > 10 with SaO2 < 85% and daytime sequelae
  • Treat

Question 11

Neck circumference in med and women that may be seen with patient’s with OSA

Answer 11

• Men: >/= 17 inches
• Women: >/= 15 inches

Question 12

PSG criteria for Cheyne Stokes Breathing

Answer 12

• Both need to be present
  
  • 3 or more consecutive central apneas/hypopneas separated by crescendo/descrescendo breathing with a cycle length of 40 seconds or greater
  • Central index of 5/hr or greater over at least 2 hours of sleep

Question 13

PSG criteria for periodic breathing in children (Cheyne-Stokes term not used in kids)

Answer 13

• >/= 3 episodes of central pauses in respiration (absent airflow and respiratory effort) lasting > 3 seconds separated by

Question 14

What percent of stroke patients are reported to have sleep disordered breathing (central or obstructive)?

Answer 14

50 to 70%

Obstructive

• Weakness of pharyngeal musculature

Central

• Increased drive to breathe resulting in central apneas

Question 15

Pauses in breathing are common in newborns. When is it a concern?

Answer 15

• If the pause is longer than 20 seconds

and

• Is associated with cyanosis, pallor, bradycardia or hypotonia

Question 16

Is home apnea monitoring recommended to reduce SIDS?

Answer 16

No. It has not been shown to reduce the death rate.

Question 17

When using PAP therapy, what would be considered an unacceptable mask leak?

Answer 17

Any unintentional mask leak > 25 L/min

Question 18

When is ASV contraindicated?

Answer 18

When LVEF is < 45%

Question 19

Is OHS more common in men or women?

Answer 19

Women. This may be because morbid obesity is more common in women than men.

Question 20

OHS is found in what percent of OSA patients?

Answer 20

10 to 20%

Question 21

In Post Polio Syndrome patients with sleep-breathing problems and weak respiratory muscles, what is the best therapy?

Answer 21

Noninvasive ventilation. CPAP will only work if they have sleep apnea.

Question 22

Patient is started on BiPAP therapy with an EPAP of 8 and a pressure support of 5. What is the IPAP?

Answer 22

13

Question 23

What are the 2 diagnostic criteria for CCHS (Congenital Central Hypoventilation Syndrome)?

Answer 23

1. Sleep related hypoventilation is present
2. Mutation of the PHOX2B gene is present

Question 24

What GI disorder do 10% to 20% of CCHS patients have?

Answer 24

Hirschsprung disease

Question 25

What causes Hirschsprung disease in CCHS patients?

Answer 25

An aganglionic colon which leads to bowel distention and constipation.

Question 26

What brain disorder can CCHS patients develop?

Answer 26

5% can develop neural crest tumors (e.g., neuroblastoma)

Question 27

What is Biot breathing and what causes it?

Answer 27

• Apnea followed by hyperventilation in a repeating pattern
• It is caused by damage to the breathing centers in the medulla. This causes apnea which results in elevated CO2 which eventually causes hyperventilation

Question 28

Which stage of REM sleep is the diaphram more resistant to, tonic or phasic?

Answer 28

Tonic. During phasic REM there is additional inhibition of the respiratory motor neurons which reduces the activity of the diaphram resulting in hypoventilation

Question 29

Breathing is controlled by what 3 factors?

Answer 29

1. State: Awake or asleep
2. Metabolic factors (including blood gas changes)
3. Lung function (like vagal inputs from pulmonary stretch receptors)

Question 30

What functions do the carotid bodies and medullary central chemoreceptors play?

Answer 30

Carotid bodies

• Sense PaO2 and PCO2

Medullary central chemoreceptors

• Sense PCO2

Question 31

Which will result in a higher concentration of oxygen in hemoglobin; a right shift or a left shift?

Answer 31

A left shift

Question 32

Which will cause a faster arousal response; drop in SaO2 or increase in pCO2

Answer 32

Increase in pCO2

Question 33

What were the study results in using CPAP to treat CSA according to the CAPNAP trial?

Answer 33

• Decreased AHI
• Increased EF
• Decreased plasma catecholamines
• No change in mortality or hospitalizations

Question 34

Adenotonsillectomy can treat up to what % of sleep disordered breathing in pediatrics?

Answer 34

Up to 79%

Question 35

What are the risk factors for CSR? (4)

Answer 35

• Decreased LV EF
• Male
• Relative daytime hypocapnea (PaCO2 < 38 mm Hg)
• Atrial fibrillation

Question 36

What are the criteria for increasing CPAP pressure in adults?

Answer 36

• 2 obstructive apneas or
• 3 hypopneas or
• 5 RERAs or
• Greater than 3 min loud snoring

Question 37

In what disorders can one see hypercapnic central sleep apnea?

Answer 37

Neuromuscular disorders (like MG) causing weakness in the neuromuscular aparatus or decresed chemoresponsiveness. It occurs because patients have reduced ventilation.

Question 38

What are the indications to increase IPAP during BiPAP titration (3)?

Answer 38

Only 1 is needed

• 3 obstructive hypopneas
• 5 RERAs
• 3 min of snoring

Question 39

What are the indications to increase IPAP and EPAP during BiPAP titration?

Answer 39

2 obstructive apneas are observed

Question 40

What is the treatment protocol for primary CSA per the AASM?

Answer 40

1. Positive airway pressure therapy
2. Acetazolamide (causes mild metabolic acidosis )
3. Zolpidem or triazolam (if no risk for respiratory depression)(by enhancing sleep stability, resulting in fewer arousals, which in turn would lessen oscillation in arterial CO2 and produce a decrease in central apnea/hypopnea events.)