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
  • 1^st oscillator: biologic clock (suprahiasmic nucleus)
  • 2^nd 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. 1^st 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: 96.7^oF   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

Pertinent Laboratory Values  (cont’d)

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. 5^TH 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.