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Intro 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

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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