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Sleep Apnea

Sleep Apnea. Everything You Never Wanted to Know About…. Case 1. 35 year old male with loud snoring. Spouse states she can’t sleep in the same room with him. Case 2. 46 year old obese male in for annual CPE observed by you to appear sleepy during the medical interview. Case 3.

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Sleep Apnea

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  1. Sleep Apnea Everything You Never Wanted to Know About… By: John J. Beneck MSPA, PA-C

  2. Case 1 • 35 year old male with loud snoring. Spouse states she can’t sleep in the same room with him.

  3. Case 2 • 46 year old obese male in for annual CPE observed by you to appear sleepy during the medical interview.

  4. Case 3 • In Hospital: Call at 0025 from RN that 42 year old female diabetic in with lower extremity cellulitis has oxygen saturation in the low 80s when checking vital signs. Awoke when stimulated and SaO2 improved.

  5. Objectives • Understand OSAH and CSAS in terms of the following: • Definition • Epidemiology • Pt. Presentation • Dx • Prevention • Tx • Prognosis

  6. CO2 – Carbon dioxide CPAP – Continuous positive airway pressure CPE – Comprehensive Physical Exam CSAS – Central sleep apnea syndrome CV – Cardiovascular D/t – due to Dx – Diagnosis Dz - Disease EEG – Electroencephalogram HF – Heart failure HTN – Hypertension LVEF – Left ventricular ejection fraction MVC – Motor vehicle crash N-CPAP – Nasal CPAP O2 - Oxygen OSAH – Obstructive sleep apnea hypopnea syndrome pCO2 – partial pressure of carbon dioxide pO2 – Partial pressure of oxygen REM – Rapid eye movement RN – Registered Nurse SaO2 – Oxygen saturation Tx – Treatment W/ - With Abbreviations

  7. Neuronal Respiratory Control • Neuronal Control • Rhythmic cycle of breath regulated by medullary neuron interaction • Efferent activity • Cranial nerves of upper airway • Chest wall muscle innervation

  8. Neuronal Control (cont.) • Medullary groups influenced by pontine & suprapontine descending pathways • These pathways influenced by sleep-wake cycle, particularly Reticular Activating System activity

  9. Obstructive Sleep Apnea Hypopnea - Definition • Episodes of airway obstruction during sleep resulting in recurrent arousals associated with: • Otherwise unexplained excessive daytime sleepiness AND...

  10. Definition (cont.) • …AND > 2 of the following • Loud disruptive snoring • Nocturnal choking/gasping/snort • Recurrent nocturnal awakening • Unrefreshed sleep • Daytime fatique • Impaired concentration • ...AND... • Documented overnight sleep monitoring • >5 episodes hypopnea and apnea per hour

  11. More Definitions • Apnea • <20% baseline airflow for  10 seconds in adults • Hypopnea •  30% baseline airflow •  10 seconds •  90% of duration of  airflow  30% baseline flow •  airflow accompanied by  4%  oxygen saturation

  12. Epidemiology • Overall 2-20% depending on sex and symptoms • Estimated 3 million men and 1.5 million women • M:F 2-4:1 • Daytime sleepiness 2-4% • (narcolepsy 0.02-0.06%) • Up to 85% in obese persons

  13. History • Charles Dickens - “The Postumous Papers of the Pickwick Club” • Pickwickian Syndrome • (Obesity Hypoventilation Syndrome) • Obesity • Hypersomnolence • Signs of Chronic Alveolar Hypoventilation • Polycythemia • Sleep apnea 1 - UpToDate, 2006

  14. Practical Predictors • HTN • History of habitual snoring • Observed reports of nocturnal choking or gasping • Neck size > 17 inches

  15. Airway Patency • Airway size - flow resistance • Anatomic traits • Neck size • Obesity • Crowded upper airway • Large tongue • Small chin • Nasopharyngeal tumors

  16. OSAH Etiology • Sleep affects respiratory control system • Reduced tonic input to upper airway muscles • Diminished reflexes that protect against airway collapse

  17. Etiology (cont) • Exaggerated inspiratory effort • Decreased gas exchange • Resolves with arousal or change in sleep state

  18. Recurrent Apnea • Instability of feedback control • Ventilation cycles instead of being maintained at a constant level

  19. Mechanism • Sleep… •  Upper airway tone... • Obstruction... • Apnea… •  pO2, pCO2…

  20. Mechanism (cont.) • …Arousal… •  Upper airway tone… • Resumption of breathing… • Hyperventilation… • Return to sleep… •  Upper airway tone… • This occurs HUNDREDS of times each night

  21. Etiology (cont) • Upper airway is destablilized • Partial or complete obstruction of nasopharynx, oropharynx, or both

  22. Presentation • Primarily relate to effects on pt’s sleep • Typically overweight men • Awaken unrested • Daytime somnolence • Disruptive snoring • 45% men & 30% women >65 yrs old snore

  23. Sleepiness(Of course we need to define sleepiness) • Mild • Sleep during times of rest • Incidental functional impairment • Moderate • Sleep during activities requiring some attention • Concerts • Meetings • Presentations

  24. Sleepiness (cont.) • Severe • Sleep during activities requiring at least moderate attention • Eating • Conversation • Walking • Driving • Marked functional impairment

  25. Differential Diagnosis of Sleepiness • Sleep restriction • Narcolepsy • Restless leg syndrome • Cardiovascular, respiratory, metabolic disturbances • Drug addiction • Depression

  26. OSAH Diagnosis-suspicion • Presentation as above • Witnessed apneic periods, nocturnal gasping or choking • >10 events per hr typical for symptomatic pts • Body habitus • HTN

  27. Diagnosis-definitive • Nocturnal Polysomnograph • EEG • Electromyelograph • Chin •  activity during REM • Limbs • checks non-respiratory causes of arousal • Electro-oculogram • Detects REM

  28. DDx (cont.) • Nasal/oral airflow • Thoracic/abdominal movement • Oxygen saturation • Cardiac rate & rhythm • Body position

  29. Split studies • Part 1 – Definitive diagnosis • Part 2 – Optimal CPAP level

  30. Terms of OSA Quantification • Apnea-hypopnea index (AHI) • Apnea Index (AI) • Respiratory Disturbance Index (RDI) • Respiratory Arousal Index (RAI)

  31. Apnea-Hypopnea Index (AHI) • # episodes apnea & hypopnea / # hrs sleep OSAH = AHI > 15 / hr

  32. Apnea Index • # apneic episodes / # hrs sleep

  33. Respiratory Disturbance Index (RDI) • # times per hour SaO2 drops > 3% • <5 - No OSA • 5-15 - Mild OSA • 16-30 - Moderate OSA • >30 - Severe OSA

  34. Respiratory Arousal Index (RAI) • Computed with EEG measurement • # inspiratory associated arousals per hour of sleep

  35. OSAH Complications • Sleepiness • Somnolence during activities • Impaired concentration • Systemic hypertension • Vascular disease

  36. OSAH and CV Disease • Arousals – bursts of sympathetic activity • Not good •  SaO2 /  SaO2 causes ischemia then reperfusion • Oxydative stress • Subsequent • HTN • Insulin resistance • Inflammation • Ultimately leading to… • CV endothelial dysfunction

  37. Other Potential Complications • Stroke • Cardiac arrhythmia • Pulmonary HTN • Morning head ache • Peri-operative complications • Impaired intubation • Impaired arousal from sedatives

  38. Prevention • Modifiable risk factors: • Obesity • Exacerbative medications • Inadequate sleep • Modifiable complications: • Machinery/motor vehicle operation • Inform Anesthesiologist before elective procedures

  39. Treatment - General • Depends on severity of disease • No Tx for < 15 events per hour • Behavioral Modifications

  40. Treatment - General (Cont.) • Weight loss • 5-10%  body weight may be effective • Nasal CPAP • Oral appliances

  41. Treatment - Medical • Vasoconstrictive sprays • Weight loss meds • Oxygen (select patients) • Chemical avoidance • Sedative hypnotics • Alchohol • Antihistamines

  42. Treatment - Surgical • Hyoplasty • Linguloplasty • Mandibular advancement • Uvulopalatopharyngoplasty • Tracheostomy

  43. Treatment - Surgical • For loud snoring: • Laser-assisted uvuloplasty • Radiofrequency tissue ablation • May  apnea and/or delay definitive treatment

  44. Prognosis • Natural history largely unknown • IF dz progresses, it does so slowly • Implications with death: • ?  in-hospital mortality d/t: • Cardiorespiratory failure • Pulmonary embolus • Case reports complications of anesthesia • Accidents • 2-7 times greater chance of MVC • Equipment operation

  45. Central Sleep Apnea Syndrome • > 10 second cessation of breathing in the absence of respiratory effort.

  46. Central Sleep Apnea Syndrome • Airflow stops without obstruction • Interruption of central respiratory drive • Airflow AND respiratory effort are absent • Disorder of Apneic Threshold • Relation to OSA (Mixed Apnea)

  47. Neural disorders Poliomyelitis Posterior fossa tumors Idiopathic failure of central breathing control Complication of OSAH Narcotic induced CSAS High altitude induced periodic breathing CSAS - Etiology

  48. CSAS – Etiology (Cont.) • Heart Failure • 37% of Pts with HF & LVEF < 45% have CSAS • 12% have OSAH

  49. CSAS - Presentation • Insomnia • Nocturnal awakenings • Nocturnal polysomnograph • No evidence of obstruction • No respiratory movement

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