Intro Lecture on Sleep Apnea

Lecture on Sleep Apnea


Abimbola
Farinde,PhD
11/15/15

Complete Powerpoint Intro Lecture_on_Sleep_Apnea – 28 Pages – Open Here

 

SUMMARY

Define and understand sleep apnea

Provide assessments and diagnosis for sleep apnea

Discuss the treatment options available for sleep apnea

Discuss a patient case presentation on sleep apnea

Lecture on Sleep Apnea
Abimbola Farinde,PhD
11/15/15

Objectives

Ø  Define and understand sleep apnea

Ø  Provide assessments and diagnosis for sleep apnea

Ø  Discuss the treatment options available for sleep apnea

Ø  Discuss a patient case presentation on sleep apnea

Background/Origin

 

Ø  Definition:

Ø      Apnea: cessation of airflow at the nose

               and mouth lasting at least 10 seconds

Ø       Classifications: obstructive or central apnea

                 Obstructive-episodic upper airway obstruction

                 during sleep

•      Complete or partial obstruction
•      Causation: obesity, polyps, enlarged tonsils)
•      Varying degree of O2 desaturation, hypercarbia, and sleep fragmentation

              Centralrepeated episodes of apnea causes by

                    temporary loss of respiratory effort during

                    somnolence

•      >10% of all apnea with numerous idiopathic presentations

Sleep Physiology

Ø Circadian rhythm

       Controlled by 2 oscillators with different period lengths

•      1st oscillator: biologic clock (suprahiasmic nucleus)

•      2nd oscillator: neurobiologic mechanism

•      Involvement of delta-sleep-inducing peptide and factor S

Ø Synchronization of sleep-wake cycle

•        Last 25 hours with 24-hour cycle imposed by earth’s

      rotation

  Pathophysiology  Of OSA & CSA

OSA

Ø  Disordered breathing during sleep

Ø  Respiratory efforts with no airflow (upper airway obstruction)

CSA

Ø   Interruption of both airflow /breathing efforts

Note: Mixed apneas can have both central and

         obstructive components.

         1st central apnea followed by 1 or more

         obstructed breaths

Epidemiology

Ø  12 million Americans

Ø  OSA affects approximately 4% men and 2% women in U.S

Ø  Prevalence in U.S children: 2%

Ø  Male-to-Female ratio:

      Children: 1:1

      Adulthood: 2:1 or more

Ø  African Americans and Hispanics >Whites

Ø  African Americas are 3.5 times for likely to develop OSA

DSM-IV Classification of Sleep
Disorders

Ø  Primary Sleep Disorders

      Dyssomnias

          Primary Insomnia

          Primary hyersomnia

          Breathing-related sleep disorders

          Narcolepsy

          Circadian rhythm sleep disorder

              Delayed sleep phase type

              Jet lag type

              Unspecified type

         Dyssomnias not otherwise specified

Ø  Parasomnias

          Nightmare disorder

          Sleep terror disorder

          Sleepwalking disorder

DSM-IV Classification of Sleep
Disorders (cont’d)

        Parasomnias not otherwise specified

Ø  Sleep disorders Related to Another Mental Disorder

     Insomnia related to another mental disorder

     Hypersomnia related to another mental disorder

Ø  Other Sleep Disorder

     Sleep disorder due to a general medical condition

    Substance-induced sleep disorder

 Risk Factors

Ø Morbidly obese (esp. neck size >17in)

Ø  Anatomical disproportion (e.g. small jaw, large tongue)

Ø  Men >40 years of age

Ø Postmenopausal women

Ø Family history of sleep apnea

Ø Smoking/Alcohol use

Ø Abnormalities in structure of upper airway

 Signs and Symptoms of OSA

Ø  Airway occlusionà lightened depth of sleep, arousal from sleep

Ø  Repetitive bouts of hypoxia

Ø  Heightened peripheral vascular constriction

Ø  Tachycardic-bradycardic events during sleep

Ø  Daytime symptoms (morning headache, poor memory, and irritability)

Ø  High blood pressure and other cardiovascular complications

Ø  Feelings of depression

Ø  Reflux/Nocturia/Impotence

Diagnostic Tests

Ø  Polysomnography (standard for diagnosis)

o              Overnight and during usual bedtime

o              Gauge severity of OSA

      Inclusion in  polysomnography:

o      Electroculography

o      Chin and leg surface electromyography

o      Two EEG channels

o      Breathing assessments (nasal/oral airflow sensor or pulse

     oximetry)

o     1 ECG channel (heart rate and rhythm)

o     Others: seizure activity, esophageal ph measurements

Ø   Daytime nap studies (specific not sensitive)

Ø  Imaging Studies

o      Anteroposterior and lateral neck radiography

o     CINE MRI during sleep

Diagnostic Tests

Ø Other tests

o      CBC, multiple sleep latency test, MRI of brain
      and brainstem

    Treatments for Sleep Apnea
Medical Care

Ø  Positional therapy (1.e., avoidance of sleeping on back)

               Encourage sleep in prone position

Ø  Weight loss

Ø  Oral appliances (aid with bringing lower jaw and tongue forward during sleep)à improvement of OSA

Ø  Surgery: tonsillectomy and adenoidectomy (common in pediatric patients

Ø  Continuous positive airway pressure (CPAP)

            Amount of CPAP

            Mainstay of therapy in most adults

Ø  Over-the-counter disposable adhesive covered nasal strips

          Treatments for Sleep Apnea
Surgical Care

Ø  Adenotonsillectomy

o    Curative in some instances
o     Demonstrates improvement in neurocognitive
     function

* Uvulopalatopharyngoplasty (UPPP)

o     removal of uvula, posterior margins of the soft
     palate, and lateral pharyngeal wall mucosa via
     scalpel or laser ablation
o     Likely to resolve OSA is obstruction is localized
     to soft palate
o     Successful reduction of apnea in 50% of patients
     and snoring in 90%

Ø  Tongue reduction procedures

                        (midline partial glossectomy)

Ø  Trachectomy

o      Effective for life-threatening obstructive apnea                

        Treatments for Sleep Apnea
Pharmacological Interventions

Ø OSA

o       Avoidance of CNS depressants (i.e., alcohol,

    anxiolytics, hypnotics, narcotics)

o     Protriptyline (mild OSA without hypercapnia)

             -Dose: 10-30mg/day

             -Anticholinergic side effects

o     Fluoxetine

             -Dose:20mg/day

             -Reduction of apnea in some patients

o      Respiratory stimulants: theophylline and

    clonidine(males)

o     Medroxyprogesterone

                -Dose: 60mg

                -Improvement of sleep apnea and obesity-

                  hypoventilation

         Treatments for Sleep Apnea
Pharmacological Interventions (cont’d)

Ø CSA

o     Hypercapnic CSA:

                -Ventillatory support with O2 and CPAP

                -Acetazolamide, theophylline, and

                 medroxyprogesterone

o      Non-hypercapnic CSA

      – Benzodiazepines (triazolam or temazepam)

      – Acetazolamide, CPAP, and O2

Patient Case: History of Present Illness

Ø  CC: “complaints of snoring, apneic episodes

    during sleep, disturbed sleep at night, daytime hypersomnolence and fatigue”

Ø   RB is a 79 year old African American male who currently admitted to 3J who received work-up for  “spells” from an inpatient sleep consult. Patient has had complaints for last few years but recently got worse.

Past Medical History

Ø Coronary artery disease

Ø Hypothyroidism

Ø Colonic Polyps

Ø Hematochezia

Ø Hypertension

Ø Hyperlipidemia

Social/Occupational/Military History

Ø Part time horse rancher

Ø >80 pack year history of smoking

Ø  Rarely smokes presently

Ø Lives with wife

Ø  3 children

Ø  Vietnam Veteran

           Review of Systems

Ø Vital Signs

   Temp: 96.7oF   BP: 123/66   R:16   P:95  Ht: 70in Wt:74.5KG(163.8lbs)

Ø  HEAD: PERRLA, EOMI

Ø  MOUTH: no lesions

Ø  NECK: supple no lymph nodes palpable

Ø  LUNGS: course breath sounds

Ø  HEART: no murmurs

Ø  ABDOMEN: soft mildly tender diffusely, no bowel sounds, nondistended

Ø  EXTREMITIES: great toe with patchy heterogeneous flat multicolored dark lesion

Ø  NEUROLOGICAL: delayed tendon reflex

Medications

Ø  Clopidogrel 75mg daily to prevent blood clots

Ø  Dilitiazem 240mg daily for blood pressure

Ø  Etodolac 300mg at bedtime

Ø  Levothyroxine 0.137mg daily for hypothyroidism

Ø  Lisinopril 20mg/HCTZ 25MG every morning for  blood pressure

Ø  Metoprolol tartrate  25mg twice a day for blood pressure

Ø  Simvastatin 20mg at bedtime for cholesterol

Ø  Fluticasone nasal inh once daily in both nostrils for allergies

       Pertinent Laboratory Values

Pertinent Laboratory Values  (cont’d)

Assessment/Plan

Ø Assessment: clinical features suggestive of obstructive sleep apnea syndrome. Episodes of “spells” need not be secondary to sleep-related breathing disorder. History is indicative of central sleep apnea

  Assessment/Plan (cont’d)

Plan:

 

Ø  Perform ECHO and  full PFT

Ø  Overnight sleep study and CPAP titration

Ø   Advised patient to keep ideal body weight and avoid driving when sleepy

Ø  Advised patient to follow sleep hygiene measures

Ø  Avoid  driving and operating dangerous equipment until elimination of daytime sleepiness

Ø  Cautioned patient about exacerbations of sleep-related breathing problems: alcohol, sedatives, and hypnotics

Ø  Scheduled for follow-up visit

 Results of Pulmonary Function Test

Ø FVC = 3.13L or 75% predicted.

Ø FEV1 = 2.14L or 81% predicted.

Ø FEV1/FVC ratio 68

Ø FEF 25-75% = 1.56L/sec or 69% predicted.

Ø TLC = 10.00L or 146% predicted.

      Results of Sleep Study

 

Ø  Sleep  efficiency (total sleep time/recording time):48%  (normal >85%)

 

Ø   Sleep onset latency: 62 minutes (normal 3-30  

      minutes)

 

Ø   REM sleep latency: 108 minutes (normal 60-120 minutes)

 

Ø   101 obstructive apneas and 24 hypopneas)

      apnea-hyponea index of 41 events/hr (normal <5)

 

Ø   Minimum o2 saturation by pulse oximetry: 92% and baseline    

      oxygen saturation : 96%

 

Ø  Mild Snoring during sleep study

 

Ø  No EEG or EKG abnormalities

 

   Final Impression: Obstructive Sleep Apnea Syndrome

 

 

 

References

Ø  Dipiro, JT et al. Pharmacotherapy: A Pathophysiologic Approach. 5TH edition. New York: The McGraw-Hill Companies, Inc; 2005. p.1327-1328.

Ø  Colin, Wayne & Duval, Susan. Surgical treatment of obstructive sleep apnea. AORN journal. Sept. 25, 2005.

Ø  Steffan, Michael. Sleep Apnea. E-medicine from the WebMD. 2006

Ø  Guilleminault, C. et al. Maxillomandibular expansion for the treatment of sleep-disordered breathing: preliminary result. Laryngoscope. 2004;114(5):893-6.

Ø  Young, T, Peppard, PE, Gottlieb, DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165(9):1217-39.

Ø  Paje, Dama  T. & Kremer, Michael. The Perioperative Implications of Obstructive Sleep Apnea. Orthopaedic Nursing. 2006;25(5):291-297.

 

 

Abimbola Farinde, PharmD is a healthcare professional who has gained experience in the field and practice of psychopharmacology/mental health, and geriatric pharmacy. She has worked with active duty soldiers with dual diagnoses of a traumatic brain injury and a psychiatric disorder providing medication therapy management and disease state management. Dr. Farinde has also worked with mentally impaired and developmentally disabled individuals. Dr. Farinde always strives to maintain a commitment towards achieving professional growth as she transitions from one phase of her career to the next.

 

 

 

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