POM I - Sleep Apnea - Exam 3

Hypopnea

-decrease in the flow of air through the upper airway for 10 seconds with a pathologic decrease in the O2 sat or abruption arousal from sleep

-AASM (3% SaO2 drop or arousal)

-Medicare (4% SaO2 drop)

Resp Disturbance Index

-a measure of the # of resp events per hour of sleep

-includes events that do not meet hypopnea definition but result in arousal, which causes increased resp efforts (Resp Effort Related Arousals (RERA)) per hour

->5 is dx of sleep apnea

Sleep Apnea

-episodes of complete (apnea) or partial collapse (hypopnea) of the upper airway with an associated decrease in O2sat or arousal from sleep

-this disturbance results in fragmented, nonrestorative sleep

-complete airflow obstruction through the upper airway for 10 seconds, with continued ventilatory effort

Obstructive Sleep Apnea

-airway is closing off while the body is trying to move air

Central Sleep Apnea

-airway may be open, but the body is not pulling for air

-usually d/t neurologic illness (often brainstem, stroke, opiates, or severe heart failure)

Cheyne-Stokes Resp

-periodic breathing

-cyclic brief apnea, followed by hyperpnea, then slows down again

-heart failure, neurologic damage, drugs

OSA - Incidence

-1 billion pts globally

-usually 30-69 y/o

-men > women

-increasing age

OSA - RF

-obesity

-male gender

-age

-craniofacial abnormalities

-enlarged tonsils/adenoids

OSA - S/S

-EDS (excessive daytime sleepiness)

-Mood d/os

-snoring, witnessed apneas

-nocturnal urination

-dry mouth in the morning

-morning HAs

-GERD

-HTN

-low testosterone

-sometimes noticed when pt gets sedation and apneas/hypopneas are more pronounced and frequent

-close call or accident d/t sleepiness

-memory problems/irritability

-daytime naps

OSA - etiology

relaxation of pharyngeal muscles during sleep --> airway collapse

OSA - anatomic factors

-micrognathia

-retrognathia

-facial elongation

-mandibular hypoplasia

-adenoid and tonsillar hypertrophy

-inferior displacement of hyoid

OSA - nonanatomic factors

-central fat distribution

-obesity

-advanced age

-male gender

-supine sleeping position

-pregnancy

OSA - additional factors

-alcohol use

-smoking

-use of sedatives and hypnotics

OSA - medical d/os

-endocrine d/os

-neuro d/os

-prader willi syndrome

-down syndrome

-CHF

-obesity

-a fib

-hypoventilation syndrome

in-lab polysomnogram

what is the gold standard dx for OSA?

Resp Event scoring - polysomnogram

-oronasal thermal sensor

-nasal air pressure transducer

-inductance plethysmography

-pulse ox

Apnea Scoring

-drop in peak signal excursion by >90% of pre-event baseline flow

-duration of the drop in flow is >10 seconds

Apnea-hypopnea index score

-apnea severity NL --> AHI <5

-apnea severity mild --> 5 < AHI < 15

-apnea severity mod --> 15 < AHI < 30

-apnea severity severe --> AHI >30

At-home PSG - indications

-no suspicion of another sleep-related dx

-adequate device available for at-home testing

-sleep expert is available to interpret the data

OSA - Complications

-neurocognitive and neuroaffective

-CV

-metabolic and endocrine

-obstetric and perinatal

-mortality

-pulmonary

-GI comp

-surgery comp

CPAP

-consistent, fixed pressure

-primarily used for OSA

BiPAP

-dual pressure (higher on inhalation, lower on exhalation)

-used for central sleep apnea and more complex resp conditions

Lifestyle Changes - SA

-weight loss decreases the severity of OSA in overwt or obese pts

-encourage 7-8 hr of sleep

Positional therapy - SA

-apnea more prominent on supine position

-can use positioning device to keep pt on their side

Meds and Medical conditions - sleep apnea

-avoid EtOH, benzos, opiates, some antidepressants

-nasal obstructions, tx with nasal steroids or surgery

-lung or heart dz optimize conditions

Oral Appliances - Sleep Apnea

-mandibular advancement device

-unable or unwilling to use CPAP or no electricity

-bring the jaw lower forward and relieve airway obstruction

-needs follow-up with dentist and follow-up with sleep testing

Uvulopalatopharyngoplasty (UPPP)

-surgical removal of the uvular and tissue from soft palate to create more space

-sleep apnea tx

Maxillomandibular advancement (MMA)

-requires both upper and lower jaws to be detached and surgically advanced anteriorly to increase space

-sleep apnea tx

hypoglossal nerve stimulator (HNS)

-stimulating the genioglossus (upper airway dilator muscle) during apneas, resulting in tongue protrusion

-sleep apnea tx

Positive airway pressure therapy

-the positive transmural pharyngeal pressure so that the upper airway remains patent as the intraluminal pressure exceeds the surrounding pressure

-Ex: CPAP, APAP, BiPAP

PAP therapy

what is the most common tx for sleep apnea?

4-6 wks

when should you see a sleep apnea patient back to evaluate compliance and troubleshoot?