Miscellaneous Pulm Disorders

obstructive sleep apnea, high altitude pulmonary edema

obstructive sleep apnea

recurrent upper airway collapse during sleep that involves cessation of airflow in the presence of breathing 

snoring, sleepiness during the day, significant other reports episodes

what are the 3 cardinal symptoms of OSA?

enlarged tongue, tonsils & lateral pharyngeal walls, long soft palate, abnormal positioning of the maxilla and mandible

what anatomic factors of OSA decrease the pharyngeal wall space?

risk patients have an exaggeration of the normal decrease in reflex respiratory activity that occurs during sleep, results in decrease of motor output to upper airway muscles, leads to soft tissue collapse at the level of the soft palate or tongue

neuromuscular factors of OSA that contribute are?

obesity, retrognathia, micrognathia, macroglossia, adenoid or tonsillar hyperplasia, pierre robin syndrome, downs, marfans, hypothyroidism, acromegaly

what are some structural risk factors of OSA?

retrognathia

receding chin 

micrognathia

lower jaw is smaller than usual

macroglossia

unusually large tongue

pierre robin syndrome

congenital birth defect characterized by an underdeveloped jaw, backward displacement of tongue and upper airway obstruction

male sex, advanced age, alcohol and sedative use, tobacco

what are some nonstructural risk factors of OSA?

insidiously and may be present for years

symptoms of OSA begin how?

gasping and choking sensations 

people with OSA feel what sensations that result in restless sleep with frequent arousals?

supine

OSA is worse in what position?

excessive daytime sleepiness

what aspect of OSA can be very debilitating?

obesity 

what is the #1 documented risk factor for OSA?

large neck circumference, enlarged “kissing” tonsils, retrognathia, micrognathia, high mallpati score

on physical exam what are the risk factors aside from obesity?

kissing tonsils

polysomnography (sleep study) 

what is the study of choice for OSA?

sleep stages recorded via EEG, electroculogram, EMG, oxygen, heart rhythm, leg movements, air flow and chest wall movement, breathing pattern

what is analyzed/monitored during a polymnosography?

cessation of airflow for 10 seconds with persistent respiratory effort

what is considered OSA according to polysomnography?

cessation of airflow for 10 seconds with no respiratory effort 

what is considered OSA according to polysomongraphy?

weight loss avoidance of alcohol, sleeping in non-supine position

what is the conservative management of OSA? 

nasal CPAP

what is the treatment of choice for OSA?

only if noninvasive methods fail

when is surgery indicated for OSA?

uvulopalatopharyngoplasty (UPPP) 

what is the surgery we do if noninvasive methods fail for OSA?

uvulopalatopharyngoplasty (UPPP)

resection of the uvula, soft palate, tonsils and adenoids

tracheostomy

what may patients require in the post op period after their UPPP for their OSA?

nocturnal dysrhythmias, systemic HTN, CAD, pulmonary HTN, cor pulmonale, stroke, DM

what are the complications of OSA?

midnight and 6am

with nocturnal dysrhythmias there is an increase incidence of sudden death between what times? 

CPAP

the incidence of complications of OSA is reduced by the use of what?

excellent with use of CPAP

short term outlook of OSA?

unknown

long term prognosis of OSA?

MI and VCA

untreated severe sleep apnea is a significant risk factor for….

MVA due to excessive daytime sleepiness

OSA increases the incidence of what?

high altitude pulmonary edema 

form of non-cardiogenic edema that results from high altitude illness resulting from short-term exposure to altitudes >2500 

acute mountain sickness, cerebral edema

what is the spectrum of high altitude illnesses?

altitude, rate of ascent, physical activity, individual susceptibility factors

severity of HAPE is influenced by?

reduced 

the ambient inspired oxygen concentration is ______ at higher altitudes 

increasing their minute ventilation

natives of high-altitude areas compensate long term by doing what?

acute hypoxia resulting in increased capillary permeability and ARDS

non-natives of high altitude areas develop…

young, physically fit patients 

HAPE usually occurs in who?

height and rapidity of ascent, physical exertion at high altitude, cold weather, underlying respiratory infection, alcohol & respiratory depressant use

risk factors of OSA?

fatigue, generalized weakness, lightheadedness, headache, nausea, cough & DOE, symptoms more severe at night

what might the history look like in someone who has HAPE?

progressive dyspnea, hypoxia, altered mental status, frothy sputum 

untreated disease of HAPE results in….

hangover

early symptoms of HAPE may mimic…

general - respiratory distress, cyanosis

vitals - tachycardia, tachypnea, low O2

lungs - bilateral rales

no evidence of cardiogenic pulmonary edema

what might one find on the physical exam of someone with HAPE?

bilateral thoracic infiltrates 

what are the expected chest xray findings of HAPE?

high pH, low pCO2, low HCO3?????

what would be the patient’s expected acid-base findings of HAPE?

descent

what is the most important therapy for HAPE?

2500

HAPE is exposure to altitudes > ______ m 

noncardiogenic pulmonary edema

what does the cxr reveal with HAPE?