5/6- sleep disorders + dental related pulmonary disease

T/F: amount of oxygen consumed by the brain during sleep is the same as in the awake state

true

4 stages of sleep

1. NREM1

2. NREM2

3. NREM3: slow wave brain activity

4. REM: skeletal muscles in hypotonic state

what’s a polysomnogram

sleep study: uses EEG (brain activity), EOG (eye movement), EMG (muscle activty)

3 sleep disorders related to dentistry

1. insomnia

2. sleep bruxism

3. sleep apnea

definition of insomnia

inability to fall asleep or remain asleep at least 3x/week for longer than 1 month

3 types of insomnia

1. sleep onset: difficulty falling asleep

2. sleep maintenance: difficulty staying asleep characterized by spontaneous awakenings and difficulty in returning to sleep

3. terminal: early morning awakenings

4 sleep related breathing disorders (SRBD)

1. sleep apnea

2. sleep related hypoventilation disorders

3. sleep related hypoxemia

4. snoring

definition of apnea

• cessation of breathing for 10 seconds or longer

• 80-100% in airflow

• reduction in thoracoabdominal movement

definition of hypopnea

• a 30% decrease in airflow + thoracoabdominal movement

• for 10 seconds or longer

what’s needed to confirm an apnea/hypopnea diagnosis

4% drop in oxygen saturation

how is respiratory effort related arousals (RERAs) related to apnea/hypopnea

has 4% oxygen desaturation

how is upper airway resistance syndrome (UARS) different from SRBDs

lacks drop in oxygen levels

criteria of sleep apnea

1 of the following:

1. pt complains of unintentional sleep

2. pt awakes w/ breath holding, gasping, or choking

3. bed partner reports loud snoring, breathing interruptions

polysomnograph records the following:

1. 5+ scorable respiratory even per hr of sleep

2. evidence of respiratory effort during all or portion of each respiratory even

3 types of sleep apnea

1. obstructive: cessation of breathing 10+ sec

2. central: cessation of breathing 10+ sec and no effort to breath

3. mixed: both

obstructive sleep apnea (OSA) is usually due to an obstruction where

level of tongue or epiglottis

cause of central sleep apnea

malfunction in the neurological controls for breathing usually at the level of the brainstem

central sleep apnea can also present as which condition

Cheyne-Stokes respiration: pattern of deep/fast breathing followed by gradual decrease in breathing resulting in apnea, more prevalent at high altitudes

3 categories of apnea severity

1. mild: apnea-hypopnea index (AHI) of 5-15

2. moderate: AHI of 15-30

3. severe: AHI of >30

obstructive sleep apnea (OSA) affects more women or men

men

12 risk factors of obstructive sleep apnea (OSA)

1. obesity

2. chronic snoring

3. male gender, but females have increased risk post menopause

4. 50+ age

5. family hx

6. endocrine disorders

7. neurological disorders

8. alcohol use, eating near bedtime, smoking

9. chronic nasal congestion + inability to breathe through nose

10. increased neck circumference: 17+ in for men, 15.5+ in for women

11. waist above 40 in for men, 35 in for women

12. meds that relax the airway

7 anatomical risk factors of obstructive sleep apnea (OSA)

1. nasal obstruction

2. enlarged tonsils + adenoids (especially in children)

3. small nostrils

4. mandibular retrognathia

5. macroglossia

6. scalloping of the tongue

7. Mallampati score

which anatomical OSA risk factor is used by anesthesiologists to determine intubation difficulty

Mallampati score: class I-IV

6 medical conditions associated w/ obstructive sleep apnea (OSA)

1. CVD: atrial fibrillation, arrhythmias, stroke, CHD, congestive heart failure

2. HTN

3. type 2 diabetes

4. GERD

5. depression + anxiety

6. ADHD + ADD in children

3 consequences of obstructive sleep apnea (OSA)

1. orofacial pain disorders: myofascial pain, fibromyalgia, headaches

2. daytime sleepiness → accidents

3. decreased cognitive function

normal oxygen saturation % for adults + children

• adults: 88%+

• children: 90%+

gold standard for sleep apnea diagnosis

polysomnograph (PSG) performed in a hospital or a separate sleep testing facility

what does the home sleep test (HST) not measure compared to PSG

doesn’t define REM or NREM (sleep staging) + may not truly determine if the patient is actually asleep

3 management tx for sleep apnea

1. positive airway pressure (PAP) aka CPAP or BiPAP

2. oral appliances (OA)

3. surgery

which PAP is the gold standard

CPAP

oral appliances are recommended for which pts

for mild/moderate sleep apnea + cannot tolerate PAP devices

how oral appliances (OA) work

repositions mandible in an open (vertically) position and then advancing mandible forward to open airway + stabilize it during sleep, prevents tongue + mandible from collapsing backward + compromising airway

when is surgery recommended

1. severe OSA

2. PAP resistant

3. does not respond to OA

what surgery is used to treat OSA

MMA (Maxillomandibular Advancement): surgical advancement of maxilla + mandible

5 pulmonary diseases important to dentists

1. obstructive lung disease (asthma, emphysema)

2. upper airway diseases

3. restrictive lung disease

4. sleep apnea

5. tuberculosis

how is lung function measured

pulmonary function tests (PFTs):

1. spirometry (obstruction)

2. flow volume loop (upper airway, obstruction, restriction)

3. lung volume (restriction)

4. diffusion (gas exchange)

2 types of chronic obstructive pulmonary disease (COPD)

1. emphysema: abnormal + permanent enlargement of airspaces distal to the terminal bronchioles w/ destruction of their walls

2. chronic bronchitis: chronic cough for 3 months

signs to look for in COPD diagnosis

pts >40 years old w/

1. chronic cough

2. chronic sputum production

3. progressive dyspnea

4. history of exposures (>1 pack of cigs x 20 years)

5. obtain spirometry

obstructive disease (asthma + emphysema) manifests as what in PFTs

increased total lung capacity (TLC) due to hyperinflation of their lungs

T/F: behavioral counseling + pharmacotherapy are used together for greater efficacy when treating smoking cessation

true

asthma usually affects pts of what age

children, most diagnosed by age 7

restrictive pulmonary disease (pulmonary fibrosis) is characterized by what

decreased compliance + decreased TLC on PFTs

how can OSA lead to cardiovascular morbidity

OSA w/ repetitive upper airway obstruction + subsequent catecholamine surges → cardiovascular morbidity

how to differentiate latent vs. active Tb

• latent: positive skin test w/ no symptoms + normal x-ray

• active: positive/negative skin test w/ symptoms + abnormal x-ray

what’s the diagnosis?

50 year old woman presents with 1 year of increasing dyspnea & productive cough. She smoked 2packs/day for 35 years. On exam she uses accessory respiratory muscles to breathe. Respiratory rate is 24. Chest exam notable for poor air entry, expiratory wheezing, prolonged expiratory phase (I/E 1/5), positive Hoovers sign, and thoraco-abdominal paradox

emphysema

what’s the diagnosis?

35 year old woman presents with 2 months of coughing that was triggered by an upper respiratory infection. She denies smoking, but her parents smoked when she was a child. On exam she is not using accessory respiratory muscles to breathe. Respiratory rate is 20. Chest exam notable for good air entry and scattered expiratory wheezes. Cardiac exam + spirometry are normal.

asthma

What’s the diagnosis?

65 year old woman presents w/ 1 year of increasing dyspnea, fatigue & cough. She has a prior smoking history but quit 20 years ago. On exam her respiratory rate is 30. Chest exam is notable for velcro crackles posteriorly. Extremity exam reveals clubbing. Her O2 saturation by pulse oxymeter is 94% at rest, but drops to 88% with exertion.

pulmonary fibrosis (restrictive disease)