sleep apnea, acute respiratory distress, foreign body aspiration

when breathing repeatedly stops and disrupts sleep, temporarily decreasing the amount of O2 and inc the amount of CO2 in the blood

sleep apnea

what are the 3 causes of sleep apnea

central sleep apnea, obstructive, mixed/complex

what is the most common kind of sleep apnea

obstructive sleep apnea

what causes central sleep apnea

occurs as primary medical condition or secondary to another medical condition (stroke, heart failure, meds like opioids, methadone)

central sleep apnea symptoms

frequent waking at night, daytime sleepiness, partners report periods of no breathing at night, NO snoring

what kind of sleep apnea is a major contributor to cardiovascular disease in adults and behavioral problems in kids

obstructive sleep apnea

obstructive sleep apnea symptoms

snoring, gasping, snorting while sleeping, daytime sleepiness, partners report significant noises while sleeping, thrashing movements while sleeping, frequent awakening while sleeping, difficulty maintaining alertness or involuntary periods of snoozing, dry mouth, recent weight gain, nocturnal heartburn, diaphoresis on chest and neck, nocturia, morning headaches, trouble concentrating, irritability, mood disturbances

what happens during inspiration in obstructive sleep apnea

intraluminal pharynheal pressure becomes negative and creates a suctioning force

how does the pharyngeal airway keep itself open

since it has no bone or cartilage it has to rely on pharyngeal dilator muscles to stay open. these are continuously activated when youre awake but relax more when asleep

what causes the “obstruction” in obstructive sleep apnea

muscular relaxation and lack of structural support leads to transient episodes on pharyngeal collapse or near collapse when sleeping. patient is partially woken by ventilatory compromise, which activates the muscles and the airway opens removing the obstruction

what are the common sites of collapse in obstructive sleep apnea

soft palate (most common), tongue base, lateral pharyneal walls, epiglottis

what is the biggest risk factor for obstructive sleep apnea

obesity (BMI over 30) increases risk 7x, as adipose in the laryngopharyngeal area narrows the upper airway and soft tissue weight reduces the chest wall compliance and lung volumes

other obstructive sleep apnea risk factors

male, smoking, family history, medical conditions (craniofacial and upper airway abnormalities, down syndrome, adenotonsillar hypertrophy, menopause, hypothyroidism

obstructive sleep apnea physical findings

small oropharynx w crowding from enlarged tongue, low lying soft palate, bulky uvula, large tonsils, high-arched palate, micro/retrognathia, hypertension, regional obesity (large waist and neck), maybe nasal polyps or septal deviation

gold standard definitive diagnostic for obstructive sleep apnea

overnight polysomnography

what is included on an overnight polysomnography

EEG, EKG, pulse ox, measurement of respiratory effort and airflow, electrooculography, electromyography

what would you see on a polysomnography for a pt w obstructive sleep apnea as their O2 sat falls

sinus bradycardia, sinus arrest, or atrioventricular block

what would you see on a polysomnography for a pt w obstructive sleep apnea as their ventilation returns

tachydysrhythmias like paroxysmal supraventricular tachycardia, a fib, ventricular tachycardia

what are the health consequences of obstructive sleep apnea

sleep fragmentation, cortical arousal and intermittent hypoxemia → inc BP, HTN, coronary disease, heart failure, arrhythmias, atherosclerosis, stroke, diabetes, depression, daytime sleepiness (2x likely workplace accidents and 2.5x likely car crashes)

obstructive sleep apnea treatment

weight loss, avoid alc, hypnotic meds, CPAP(does not allow tissue collapse), mechanical devices that hold the jaw anteriorly and prevent pharyngeal occlusion, uvulopalatopharyngoplasty (surgical resection of pharyngeal soft tissue and removal of uvula), nasal septoplasty (if caused by septal deformity), tracheostomy last line

what can cure obstructive sleep apnea

weight loss (loose 10-15% of body weight to reduce severity by 50%)

what is first line tx for obstructive sleep apnea

cpap

central sleep apnea treatment

treat underlying disease, ACETAZOLAMIDE (diuretic that creates mild metabolic acidosis which stimulates the lungs to compensate by breathing more), CPAP

when an obese patient has awake hypoventilation

obesity hypoventilation syndrome

what is a common comorbidity of obesity hypoventilation syndrome

90% of patients have concurrent obstructive sleep apnea

when not enough air entering alveoli with each breathe eventually leads to hypercapnia and hypoxia

obesity hypoventilation syndrome (pathophys like obstructive sleep apnea)

what criteria do you need to meet for obesity hypoventilation syndrome

BMI 30 or more, CO2 45 or more in the absence of other known causes

what is the possible hormone relationship with obesity hypoventilation syndrome

leptin resistance (a protein produced by adipose which stimulates ventilation, shown to be elevated in obese pts. theory is that body is trying to compensate for leptin resistance by making more, which leads to obesity)

reduced chest wall compliance in pts w obesity hypoventilation syndrome leads to

low lung volumes of air

obesity hypoventilation syndrome risk factors

BMI over 30 required for diagnosis, BMI over 50 has a 50% prevalence rate

severe symptoms of obesity hypoventilation syndrome

severe hypoxemic hypercapnic respiratory failure, right sided heart failure from pulmonary HTN, dyspnea on exertion, elevated jugular vein pressure, hepatomegaly, pedal edema, polycythemia

obesity hypoventilation syndrome diagnostics

CO2 over 45 and bicarb over 27 (respiratory acidosis with renal compensation), frequent O2 below 70% with a normal A-a gradient, polycythemia, PFT/spirometry will be either normal or show restrictive pattern due to obesity

obesity hypoventilation syndrome treatment

cpap or bipap first line, avoid alc/sedatives, weight loss (bariatric surgery and meds), tracheostomy last line

an acute, diffuse, inflammatory lung injury associated from a variety of etiologies

acute respiratory distress syndrome

acute respiratory distress syndrome risk factors

sepsis, aspiration pneumonitis, pneumonia, pulmonary contusion, toxic inhalation, near drowning, multiple blood transfusions, pancreatitis, heroin/coke use, covid19

acute respiratory distress syndrome diagnostic criteria

must have ALL 3: severe dyspnea of rapid onset within 7 days of clinical insult to lungs, hypoxemia, diffuse pulmonary infiltrates leading to respiratory failure AND infiltrates or other symptoms not explained by other causes

what are the 3 phases of acute respiratory distress syndrome

exudative, proliferative, fibrotic

what is happening in the exudative phase of acute respiratory distress syndrome

increased inflammation from pro-inflammatoy cytokines, alveolar capillary cells and type 1 pneumocytes are injured → alveolar capillary barrier is damaged and increased vascular permeability, inc protein rich edema accumulates in the interstitial and alveolar spaces. surfactant is lost causing alveoli to collapse, patient will require intubation and ventilation

when does the exudative phase of acute respiratory distress syndrome happen

days 1-7

when does the proliferative phase of acute respiratory distress syndrome happen

days 7-21

when does the fibrotic phase of acute respiratory distress syndrome happen (if it happens at all)

21+ days

what is happening in the proliferative phase of acute respiratory distress syndrome

type 2 pneumocytes proliferate along alveolar basement membranes and synthesize new pulmonary surfactant. most pts recover rapidly and are removed from mechanical ventilation, but dyspnea, tachypnea and hypoxemia are still experienced despite improvement

what happens in the fibrotic phase of acute respiratory distress syndrome (if pt enters this phase)

alveolar edema and inflammatory exudates cover to extensive alveolar and interstitial fibrosis which leads to an inc risk of pneumothrorax and reduction in lung compliance

acute respiratory distress syndrome symptoms

labored breathing, tachypnea, tachy cardia, intercostal retractions, crackles/rales, dec oxygenation

what would you se on a chest xray for acute respiratory distress syndrome

diffuse or patchy bilateral infiltrates (looks very whited out)

what happens when you lay a pt w acute respiratory distress syndrome down on their back

blood flows posteriorly and on a CT looks totally whited out

why do we lay a pt w acute respiratory distress syndrome down on their stomach

so blood flows forward and improves their O2/CO2 exchange

what may accompany acute respiratory distress syndrome

multi organ failure, esp w kidneys, liver, intestines, central nervous system and cardiovasc system

how do we treat acute respiratory distress syndrome

treat underlying cause, intubate, positive pressure mechanical ventilation, lay them on their stomach, restrict fluid intake and diuresis

what is the prognosis for acute respiratory distress syndrome with treatment

still bad, mild 35% die, severe 46% die

what is the urgency status of a pediatric foreign body aspiration in the upper airway

immediate life threatening hazard

what is the urgency status of a pediatric foreign body aspiration in the lower airway

immediate life threatening hazard or long term hazard

what are the most common items aspirated by infants and toddlers

food items (esp peanuts)

what are other non fod items commonly aspirated in pediatrics

coins, paper clips, pins, pen caps (esp in older children)

what are dangerous characteristics of items for foreign body aspiration in pediatrics

roundness, failure to break apart easily, compressibility, smooth slippery surface (balls, marbles)

what are the most common objects removed in fatal pediatric aspirations

toy balloons or similar stuff like inflated gloves

where do the majority of of aspirated items end up in

the right mainstem bronchus/right lung

how would a pediatric patient w a foreign body aspiration in the laryngotracheal region present

stridor, wheezing, salivation, dyspnea, hoarseness/voice change, absense of all dependent breath sounds, acute respiratory distress and failure

how would a pediatric patient w a foreign body aspiration in the main bronchi present

coughing and wheezing, hemoptysis, dyspnea, maybe: respiratory distress, focal decreased breath sounds, fever, cyanosis

when should we suspect a peds airway obstruction

time missing away from adult supervision, wheezing, stridor, regional variation in breath sounds

how do we diagnose a foreign body aspiration

chest xray, chest CT (100% sensitivity) and diagnostic bronchoscopy (100% sensitivity)

what tool can we potentially use to remove a foreign object in pediatric foreign body aspiration

magill forceps

how do we treat a complete airway obstruction in pediatric foreign body aspiration

dislodgment using back blows and chest compressions in infants, heimlich maneuver in older kids, once unconscious begin CPR, NO blind sweeps

how do we treat an incomplete airway obstruction in pediatric foreign body aspiration

RIGID bronchoscopy to remove it

whats a good rule of thumb to prevent pediatric foreign body aspiration

if a toy can fit inside a TP roll its a chocking hazard and too small

when does death from foreign body aspiration peak in adults

85yo

what items do you typically see in adult foreign body aspiration

food with incomplete chewing to accidentally inhaling something while being held in the mouth (holding nails in mouth while working)

a fatal or near fatal aspiration of incompletely chewed meat that inhibits the vagal nerve response to the heart and the heart stops

cafe coronary

what symptoms would a pt w cafe coronary have

NO chocking sx, looks like theyre having a heart attack

how do adults typically present w foreign body aspiration

rarely full airway obstruction, often suspected aspiration, 80% present w a cough

symptoms of adult foreign body aspiration

cough, fever, hemoptysis, foul smelling sputum, chest pain, wheezing

how do we diagnose an adult foreign body aspiration

chest or neck xray, chest CT for high suspicion even if xrays are normal bc higher sensitivity, FLEXIBLE BRONCHOSCOPY is diagnostic of choice

how do we treat an adult full obstruction foreign body aspiration

attempt to remove w magill forceps, heimlich maneuver followed by CPR once unconscious, NO blind sweeps

how do we treat an adult partial obstruction foreign body aspiration

FLEXIBLE BRONCHOSCOPY

what age group gets rigid bronchoscopy

kids

what age group gets flexible bronchoscopy

adults

what kind of bronchoscopy can be done w conscious sedation

flexible

what bronchoscopy has larger pieces of equipment that can only access the proximal airways

rigid

what bronchoscopy can remove smaller objects from lower airways

flexible