Presentations: Sleep Apnea, Vaping, & Long Covid

what is sleep apnea?

a disorder where breathing is repeatedly interrupted or paused during sleep

SA: pauses can last a few seconds to minutes and are long enough to (3)

- disrupt sleep

- decrease blood oxygen levels

- increase blood CO2 levels

SA: 3 types of sleep apnea

obstructive, central, complex

obstructive sleep apnea =

- Muscles in the throat relax causing the airway to narrow or close, not allowing enough air in.

- Briefly wakes up to reopen airways

- Most common type

central sleep apnea =

- less common

- brain fails to send signals to respiratory muscles

complex sleep apnea =

when obstructive sleep apnea becomes central sleep apnea

sleep apnea symptoms that happen while asleep (4)

- Breathing that starts and stops

- Frequent loud snoring (more common in men)

- Gasping for air

- Night Sweats

sleep apnea symptoms that may go unnoticed (5)

- Daytime sleepiness and tiredness

- Dry mouth

- Waking up often during the night to urinate

- Difficulty with concentration

- Mood changes

sleep apnea symptoms in women (3)

- fatigue

- headache

- insomnia

7 risk factors of sleep apnea

- Older age: > 40 years old

- Obesity

- Large tonsils narrowing the airways

- Family history and genetics

- Heart or kidney failure: increased fluid buildup in the neck

- Lifestyle habits: alcohol + smoking

- Sex: men more common than women

obstructive sleep apnea is present in what percentage of men and women?

- 33.9% men

- 17% women

obstructive sleep apnea affects 936 million adults between the ages of

30-69

obstructive sleep apnea is most common in what generation?

middle-aged and elderly

what nationalities is sleep apnea most seen in?

hispanics, africans, and asian

history of sleep apnea includes

- Frequent loud snoring, gasping for air /choking in sleep, daytime exhaustion, patient stopping/starting breathing multiple times during their sleep

- Greater than 4 obstructive breathing events in one hour classify pt for the possibility of sleep apnea

mild, moderate, severe sleep apnea =

- Mild: 5-15 events per hour of sleep

- Moderate: 15-30 events per hour of sleep

- Severe: greater than 30 events per hour of sleep

physical assessment of risk factors of sleep apnea =

narrowed airway, measure neck circumference, look for deviated septum

SA: home-based sleep studies pros and cons =

- Pros: cost effective, comfort

- Cons: technician doesn't place leads; thus, may be placed incorrectly,

what is the gold standard with diagnosing SA?

polysomnography

SA: polysomnography =

- Completed in a lab for at least 6 hours

- A minimum of 12 channels of recording electroencephalography, electrooculogram, electromyogram, oronasal airflow, chest wall effort, body position, snore microphone, ECG , and oxyhemoglobin saturation

- heart rate, respiratory abnormalities, gas exchange, heart rhythm, oxygen saturation and muscle tone and contraction are measured

- 1st half= monitoring patients sleeping

- 2nd half = given PAP machine and monitor effects to determine proper settings needed

sleep apnea can increase the risk of (9)

- AFIB

- Pulmonary Hypertension

- Cor pulmonale

- Stroke

- Heart failure

- Type 2 diabetes

- Obesity

- Metabolic syndrome

- Depression

SA: upper airway partially or completely collapses leading to

airflow blockage

- individual will continue to try to breathe despite air not being able to pass through

SA: hypoxia and hypercapnia, causing

- The brain wakes the body to reopen these airways

- This cycle repeats itself dozens of time per night

SA: the constant drops in oxygen supply activate the

sympathetic nervous system

- ↑ HR and ↑ BP

SA: one of the most significant consequences is the risk of Afib, because

- Constant changes in intrathoracic pressure and oxygen levels during apneic events stretch atrial walls and disrupt normal conduction (Leading to Atrial remodeling and arrhythmias)

SA: simple treatment =

lifestyle changes such as quitting smoking, change sleep positions, weight loss

SA: continuous positive airway pressure (CPAP) =

·Treats moderate to severe sleep apnea

·Worn during sleep to prevent apnea and snoring

oDelivers air pressure through mask to keep airways open

·Most people find this device uncomfortable to use: with practice, patients may learn to adjust the tensions on the straps to make it more comfortable

·Could get the Inspire Sleep Apnea Treatment that replaces CPAP

oImplanted device that monitors breathing patterns-> stimulates muscles of the airway during sleep

SA: other possible therapy treatments for sleep apnea

- auto CPAP

- BPAP

- oral appliances

SA: surgical treatments for sleep apnea =

- tissue removal

- tissue shrinkage

- jaw repositioning

- implants

- nerve stimulation

- tracheostomy

SA: PT involvement treatments include

- respiratory muscle training

- postural therapy

- orofacial exercises/myofunctional therapy

vaping associated lung injury (VALI) =

an acute or subacute respiratory illness in which a person's lungs become damaged from substances contained in e-cigarettes and vaping products

VALI: what is a e-cig/vape? how do they work?

- A battery-operated device which heats up an e-liquid within the cartridge

- Liquid is converted to an aerosol

- The aerosol is inhaled/"smoked"/"vaped" by users

VALI: what substances are in vape liquid

- Nicotine

- Propylene glycol

- Formaldehyde - known carcinogen

- Acrolein - herbicide

- Diacetyl

- Diethylene glycol - used in antifreeze

- Heavy metals - nickel, tin, and lead

- Cadmium - metal found also in regular cigarettes

- Benzene - found in car exhaust

VALI: what other complications can happen due to chemical compounds being inhaled?

COPD, bronchiolitis obliterans

VALI: has been found in those who

use a variety of different vaping devices and liquids

- nicotine, THC, CBD

VALI: potentially harmful substances present in vapes include

- Vitamin E acetate (VEA)

- Flavorants

- Volatile organic compounds

- Heavy metals

VALI: what has been highly linked to VALI?

VEA (vitamin E acetate)

VALI: symptoms

SOB, fatigue, fever, cough, vomiting, diarrhea, headaches, dizziness, tachycardia, chest pain, fever, chills, tachypnea, or weight loss

VALI: oxygen saturation will be less than

95%

VALI: patient history =

- use of e-cig devices within the last 90 days

- worsened symptoms over days to weeks prior to seeking care

- decreased exercise tolerance

- predominantly younger male adults - median age being 21

VALI: what type of diagnosis?

exclusion

- ruling out other diagnoses

VALI: what imaging could be used?

- CXR

- computed tomography (CT)

- pulmonary infiltrates can be found on CXR or CT scan within 90 days of e-cig use

VALI: labs show what?

- increased WBC can be found on a lab test of someone with VALI

- blood oxygen levels - low levels indicated lung damage

VALI: what will you see in a CT scan?

- Ground glass opacities

- Consolidation

- Septal thickening

- Provides a sensitive to detection of EVALI

VALI: less common findings in a CT scan

- Subpleural sparing (lung tissue closest to the chest wall is normal but abnormalities are present further in)

- Pleural effusions

- Centrilobular nodularity (a pattern of small white spots signifying underlying lung disease)

VALI: treatment

- cessation of vaping

- rule out other pathologies with antibiotics or antivirals

- corticosteroids - decrease inflammation

- supplemental oxygen

VALI: poor prognosis indicators =

- Age > 35 yo

- Comorbidities compromising pulmonary reserve

- Resting SpO2 >95%

- Continued vaping following admission to the hospital & counseling

VALI: patients can rapidly deteriorate and develop

ARDS

long covid =

patients who have a history of symptoms consistent with or were diagnosed with COVID-19 with symptoms continuing for more than 2 months

- do not fully recover

LC: causes/etiology =

multiple factors

- psychosocial, immune response, post-traumatic stress, complication

LC: physiological effects on cardiopulmonary system =

- increased HR, blood pressure, pain, anxiety

- orthostatic and perfusion issues

LC: symptoms

- Shortness of breath, dyspnea, headache, chest pain, cough, fatigue, cognitive dysfunction

- Affect productivity and ADLs

- Flare-up and go away

LC: medical management =

- medications

- physical therapy

LC: medications adress

specific symptoms/physiologic changes

LC: physical therapy includes

respiratory therapy, aerobic training, strength training

LC: long-term effects on the respiratory system include

Pulmonary fibrosis, hypoxemia, chronic cough, asthma, chronic pulmonary hypertension

LC: long-term effects on the neurologic/neuropsychiatric system include

- Anxiety/panic disorders, depression, attention deficit disorder, OCD, PTSD

- Cognition

LC: long-term effects on the multisystem system include

chronic fatigue syndrome

LC: functional implications include

- Physical activity limitations

- Vision, hearing, and speech

POTS =

A disorder of the autonomic nervous system that affects heart rate, blood pressure, sweating, and body temperature

POTS: characterized by

An increase in heart rate (at least 30 bpm in adults and 40 bpm in adolescents) when transitioning from sitting or lying to standing

- Decreased blood circulation

- Excessive pooling of blood below level of the heart

- Elevated hormones (epinephrine & norepinephrine)

POTS: diagnosis can be done by what 2 tests?

10 minute standing test, head-up tilt test

POTS: associated with a very specific cluster of symptoms that a patient will experience when?

mostly when they are in the upright position

POTS: symptoms

- A heart rate increase of at least 30-40 bpm depending on the age of the patient measured within 10 minutes of the person standing

- Lightheadedness or fainting, palpitations

- Brain fog

- Fatigue

- Exercise intolerance/tremor

- Headache/blurry vision/nausea

POTS: treatments

Diet changes

-Lots of fluids and salty foods

-Avoid alcohol and caffeine

Medications

-Improve blood volume and reduce heart rate

-Improve vessel constriction

-Help kidneys retain sodium

Physical Therapy

-Graded exercise (retrain autonomic nervous system)

-Aquatic therapy

POTS: known to be caused by

numerous types of conditions

LC/POTS: PT considerations

- endurance training (critical early on)

- resistance training

- physical countermeasures to prevent orthostatic intolerance and syncope

- education

- start low, go slow

- monitor vitals and symptoms

- patient safety is key