Treatment of Sleep Apnoea

Question 1

Why do we treat OSA?

Answer 1

• Relieve Symptoms
• Prevent Medical Complications like MI’s
• Improve QoL

Question 2

When do we treat OSA?

Answer 2

• Only for moderate-severe OSA

- or patients with mild OSA but symptomatic treatment is advised

Question 3

Benefits of treatment?

Answer 3

• Less sleep fragmentation
• Less lethargic and more alert
• Improves Sleep Quality leading to increased energy and decreased sleepiness
• Motivation to lose weight
• Reducing BMI

Question 4

Link with OSA and Hypertension?

Answer 4

• Difficult to establish bc of other factors

- BUT treatment of OSA with CPAP does improve BP

Question 5

What 4 treatment options are there?

Answer 5

• Behavioural/Conservative measures
• MRD Mandibular Repositioning Device
• Surgery
• CPAP

Question 6

What are first line treatments for MILD OSA?

Answer 6

• Lifestyle advise
• Obesity clinic
• Dietician
• Weight loss
• Postion therapy supine position
• Nasal Spray if obstruction refer to ENT (DEVIATED Septum)
• Smoking and Alcohol Cessation

Question 7

What MRD’s?

Answer 7

• Mandibular Repositioning Devices
• Dental devices which pull lower jaw forward during sleep
• Similar to a gumshiedl
• Crowded UA use Mallampati score to assess

Question 8

What are the 4 classes for Mallampati?

Answer 8

Class 1 = full visibility of tonsils, uvula and soft palate

Class 2 = Visibility of Hard and soft palate and base of the uvula

Class 3 = Soft and hard palate and base of the uvula are visible

Class 4 = Only hard Palate visible

Question 9

Advantages of MRD’s

Answer 9

• Less invasive

- Effecitve for simple snoring or mild OSA

Question 10

Disadvantages of MRD’s

Answer 10

• Rarely completely treat s moderate OSA
• Can cause pain
• Unsuitable for denture patients
• Not available on the NHS

Question 11

Surgical options?

Answer 11

• Paeds?
• Enlarged adenoids or tonsils can cause snoring
• Can remove these

Question 12

Surgical options for adults?

Answer 12

-Surgery In UA but if more than 1 area is affected surgery may not be effective and OSA will persist

Question 13

Which adults could benefit from Surgery?

Answer 13

Patients with craniofacial abnormalities or obvious UA congestion could benefit

Question 14

Downsides of having surgery?

Answer 14

Surgery is often painful and can reduce ultimate effectiveness of CPAP if surgery fails to solve problem

Question 15

What is UVPPP?

Answer 15

Removal of the excess soft palate tissue

Question 16

What is LAUP?

Answer 16

-Laser sculpt the soft palate

Question 17

What Nasal surgery is available?

Answer 17

• Straightening of Deviated septum

- Increasing size of nasal passages to improve airflow

Question 18

What are Nasal turbinates?

Answer 18

• Also known as conga due to shape

- Made up of Columnar ciliated epithelium with vascular erectile glandular tissue

Question 19

What are the 3 pair of nasal turbinates?

Answer 19

• Inferior
• Middle
• Superior

Question 20

What do inferior turbinates do?

Answer 20

• Majority of heating, filtering and humidification of air

Question 21

What do Middle turbinates do?

Answer 21

• Protect entrances of sinuses from pressurised air

Question 22

What do Superior turbinates do?

Answer 22

• Protect olfactory bulb

Question 23

What are adenoids AKA?

Answer 23

-Pharygeal tonsil

Question 24

Where are adenoids located?

Answer 24

• Roof of Nasopharynx

- Where nasal passage meets oropharynx

Question 25

What can occur to adenoids?

Answer 25

- Enlarge to size of golf balls causing airflow obstruction | - Removed with tonsils

Question 26

What tongue surgery is available?

Answer 26

- Advancement = Geniglossus muscle advanced preventing tongue base falling back - Tongue base reduction = removal of tongue mass to widen airway

Question 27

What is lower jaw advancement?

Answer 27

- Retrognathia is when upper/lower jaw is restricted - It mobilises upper and lower jaw and stabilise jaw with titanium plates - Can change facial appearance

Question 28

What is a tracheostomy?

Answer 28

- Making an opening in trachea bypassing upper airway - Not routine - Used to ventilate patients in ICU - Used when OSA is life threatening and CPAP is unavailable

Question 29

What is CPAP?

Answer 29

Continuous Positive Airway Pressure - Gold standard for treatment - Acts as Pneumatic splint using room air to support airway

Question 30

What are the indications for CPAP?

Answer 30

- Moderate/Severe OSA | - Mild OSA displaying symptoms

Question 31

What are the contraindications for CPAP?

Answer 31

- History of facial oral or skull trauma - Severe Epistaxis (nose bleeds) - Acute sinustitis - Pneumothorax - Cardiac arryhtmias (severe)

Question 32

What are the 3 types of CPAP

Answer 32

- Auto titrating CPAP - Fixed CPAP - Bi-Level

Question 33

What is APAP?

Answer 33

Auto-titrating CPAP (APAP) --> Variable pressure delivery

Question 34

What is Fixed CPAP?

Answer 34

Fixed CPAP -->Pressure set to fixed level for whole night -->Fixed pressure assessed using prediction formula, manual titration or trial with APAP device

Question 35

What is Bi-Level CPAP?

Answer 35

Bi-level -->2 pressure levels: IPAP and EPAP Used more in ‘complex OSA’ and respiratory failure

Question 36

What should be included when educating a person about CPAP?

Answer 36

- Information about OSA - How CPAP works? - Mask fitting - Care and Maintenance - DVLA regulations - Travelling - Available resources such as BLF

Question 37

How does Fixed CPAP work?

Answer 37

- Patient would have APAP for a trial period - Fixed CPAP is set to a Pressure that prevents events for 95% of the night - Calculates pressure using a prediction formula - Ramp Setting is for comfort to allow pressure to gradually rise

Question 38

Advantages of Fixed CPAP?

Answer 38

- Machine is cheaper as it isn't algorithm based

Question 39

Disadvantages of Fixed CPAP?

Answer 39

- Changes in weight - Body Position/Alcohol consumption not corrected for - Deliver too much Pressure sometimes

Question 40

How does the circuit work?

Answer 40

- Connects patient to CPAP - Masks generally nasal or nasal-oral (full face) - Must create a seal to ensure pressure is maintained - Variety of styles

Question 41

How can we monitor data?

Answer 41

Most CPAPs now provide compliance data -Monitor usage/pressure/AHI

Question 42

List some CPAP side-effects?

Answer 42

- Air Leak - Nasal problems - Skin Ulceration/Sensitivity - Claustrophobia - Aerophagy (swallowing air) - Noise of CPAP

Question 43

What can help troubleshoot nasal blockage?

Answer 43

- Nasal spray - Switch to full face mask - Add humidification to CPAP