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
Objectives
- 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
Background/Origin
Definition:
Apnea: cessation of airflow at the nose and mouth lasting at least 10 seconds
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
- Central – repeated episodes of apnea causes by temporary loss of respiratory effort during somnolence
- >10% of all apnea with numerous idiopathic presentations
Sleep Physiology
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
Synchronization of sleep-wake cycle
- Last 25 hours with 24-hour cycle imposed by earth’s rotation
Pathophysiology of OSA & CSA
OSA
- Disordered breathing during sleep
- Respiratory efforts with no airflow (upper airway obstruction)
CSA
- 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
- 12 million Americans
- OSA affects approximately 4% men and 2% women in U.S
- Prevalence in U.S children: 2%
- Male-to-Female ratio:
- Children: 1:1
- Adulthood: 2:1 or more
- African Americans and Hispanics >Whites
- African Americas are 3.5 times for likely to develop OSA
DSM-IV Classification of Sleep Disorders
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
Parasomnias
- Nightmare disorder
- Sleep terror disorder
- Sleepwalking disorder
- Parasomnias not otherwise specified
DSM-IV Classification of Sleep Disorders (cont’d)
Sleep Disorders Related to Another Mental Disorder
- Insomnia related to another mental disorder
- Hypersomnia related to another mental disorder
Other Sleep Disorder
- Sleep disorder due to a general medical condition
- Substance-induced sleep disorder
Risk Factors
- Morbidly obese (esp. neck size >17in)
- Anatomical disproportion (e.g. small jaw, large tongue)
- Men >40 years of age
- Postmenopausal women
- Family history of sleep apnea
- Smoking/Alcohol use
- Abnormalities in structure of upper airway
Signs and Symptoms of OSA
- Airway occlusionà lightened depth of sleep, arousal from sleep
- Repetitive bouts of hypoxia
- Heightened peripheral vascular constriction
- Tachycardic-bradycardic events during sleep
- Daytime symptoms (morning headache, poor memory, and irritability)
- High blood pressure and other cardiovascular complications
- Feelings of depression
- Reflux/Nocturia/Impotence
Diagnostic Tests
Polysomnography (standard for diagnosis)
- Overnight and during usual bedtime
- Gauge severity of OSA
- Inclusion in polysomnography:
- Electroculography
- Chin and leg surface electromyography
- Two EEG channels
- Breathing assessments (nasal/oral airflow sensor or pulse oximetry)
- 1 ECG channel (heart rate and rhythm)
- Others: seizure activity, esophageal ph measurements
Daytime nap studies (specific not sensitive)
Imaging Studies
- Anteroposterior and lateral neck radiography
- CINE MRI during sleep
Other tests
- CBC, multiple sleep latency test, MRI of brain and brainstem
Treatments for Sleep Apnea Medical Care
- Positional therapy (1.e., avoidance of sleeping on back)
- Encourage sleep in prone position
- Weight loss
- Oral appliances (aid with bringing lower jaw and tongue forward during sleep)à improvement of OSA
- Surgery: tonsillectomy and adenoidectomy (common in pediatric patients
- Continuous positive airway pressure (CPAP)
- Amount of CPAP
- Mainstay of therapy in most adults
- Over-the-counter disposable adhesive covered nasal strips
Treatments for Sleep Apnea Surgical Care
Adenotonsillectomy
- Curative in some instances
- Demonstrates improvement in neurocognitive function
Uvulopalatopharyngoplasty (UPPP)
- Removal of uvula, posterior margins of the soft palate, and lateral pharyngeal wall mucosa via scalpel or laser ablation
- Likely to resolve OSA is obstruction is localized to soft palate
- Successful reduction of apnea in 50% of patients and snoring in 90%
Tongue reduction procedures
- (midline partial glossectomy)
Trachectomy
- Effective for life-threatening obstructive apnea
Treatments for Sleep Apnea Pharmacological Interventions
OSA
- Avoidance of CNS depressants (i.e., alcohol, anxiolytics, hypnotics, narcotics)
- Protriptyline (mild OSA without hypercapnia)
- Dose: 10-30mg/day
- Anticholinergic side effects
- Fluoxetine
- Dose:20mg/day
- Reduction of apnea in some patients
- Respiratory stimulants: theophylline and clonidine(males)
- Medroxyprogesterone
- Dose: 60mg
- Improvement of sleep apnea and obesity-hypoventilation
Treatments for Sleep Apnea Pharmacological Interventions (cont’d)
CSA
- Hypercapnic CSA:
- Ventillatory support with O2 and CPAP
- Acetazolamide, theophylline, and medroxyprogesterone
- Non-hypercapnic CSA
- Benzodiazepines (triazolam or temazepam)
- Acetazolamide, CPAP, and O2
Patient Case: History of Present Illness
- CC: “complaints of snoring, apneic episodes during sleep, disturbed sleep at night, daytime hypersomnolence and fatigue”
- 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
- Coronary artery disease
- Hypothyroidism
- Colonic Polyps
- Hematochezia
- Hypertension
- Hyperlipidemia
Social/Occupational/Military History
- Part time horse rancher
- >80 pack year history of smoking
- Rarely smokes presently
- Lives with wife
- 3 children
- Vietnam Veteran
Review of Systems
- Vital Signs
- Temp: 96.7oF BP: 123/66 R:16 P:95 Ht: 70in Wt:74.5KG(163.8lbs)
- HEAD: PERRLA, EOMI
- MOUTH: no lesions
- NECK: supple no lymph nodes palpable
- LUNGS: course breath sounds
- HEART: no murmurs
- ABDOMEN: soft mildly tender diffusely, no bowel sounds, nondistended
- EXTREMITIES: great toe with patchy heterogeneous flat multicolored dark lesion
- NEUROLOGICAL: delayed tendon reflex
Medications
- Clopidogrel 75mg daily to prevent blood clots
- Dilitiazem 240mg daily for blood pressure
- Etodolac 300mg at bedtime
- Levothyroxine 0.137mg daily for hypothyroidism
- Lisinopril 20mg/HCTZ 25MG every morning for blood pressure
- Metoprolol tartrate 25mg twice a day for blood pressure
- Simvastatin 20mg at bedtime for cholesterol
- Fluticasone nasal inh once daily in both nostrils for allergies
Pertinent Laboratory Values
Glucose | 102H | Anion gap | 9 |
BUN | 40H | Alkphos | 69 |
Creatinine | 1.6H | T.Protein | 6.7 |
Sodium | 136 | AST | 25 |
Potassium | 4.4 | ALT | 21 |
Chloride | 104 | T. Bilirubin | 0.8 |
CO2 | 29.0 | Urea Nitrogen | 40 |
Albumin | 3.7 | WBC | 6.9 |
TSH | RBC | 4.63L | |
Calcium | 9.8 | HGB | 11.9L |
Cholesterol | 157 | HCT | 36.4L |
Pertinent Laboratory Values (cont’d)
BUN | 40H |
HgA1C | 5.7 |
Plts | 234 |
LDL | 96 |
HDL | 35L |
TG | 130 |
INR-R/PT | 1.02/13.7 |
Assessment/Plan
- 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:
- Perform ECHO and full PFT
- Overnight sleep study and CPAP titration
- Advised patient to keep ideal body weight and avoid driving when sleepy
- Advised patient to follow sleep hygiene measures
- Avoid driving and operating dangerous equipment until elimination of daytime sleepiness
- Cautioned patient about exacerbations of sleep-related breathing problems: alcohol, sedatives, and hypnotics
- Scheduled for follow-up visit
Results of Pulmonary Function Test
- FVC = 3.13L or 75% predicted.
- FEV1 = 2.14L or 81% predicted.
- FEV1/FVC ratio 68
- FEF 25-75% = 1.56L/sec or 69% predicted.
- TLC = 10.00L or 146% predicted.
Results of Sleep Study
- Sleep efficiency (total sleep time/recording time):48% (normal >85%)
- Sleep onset latency: 62 minutes (normal 3-30 minutes)
- REM sleep latency: 108 minutes (normal 60-120 minutes)
- 101 obstructive apneas and 24 hypopneas) apnea-hyponea index of 41 events/hr (normal <5)
- Minimum o2 saturation by pulse oximetry: 92% and baseline oxygen saturation : 96%
- Mild Snoring during sleep study
- No EEG or EKG abnormalities
Final Impression: Obstructive Sleep Apnea Syndrome
References
- Dipiro, JT et al. Pharmacotherapy: A Pathophysiologic Approach. 5TH edition. New York: The McGraw-Hill Companies, Inc; 2005. p.1327-1328.
- Colin, Wayne & Duval, Susan. Surgical treatment of obstructive sleep apnea. AORN journal. Sept. 25, 2005.
- Steffan, Michael. Sleep Apnea. E-medicine from the WebMD. 2006
- Guilleminault, C. et al. Maxillomandibular expansion for the treatment of sleep-disordered breathing: preliminary result. Laryngoscope. 2004;114(5):893-6.
- 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.
- 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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