PULMONARY/CRITICAL CARE BOARD REVIEW WORKSHOP-3

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• PULMONARY/CRITICAL CARE BOARD REVIEW WORKSHOP-3
• J.Tavares,MD,FCCP,FAASM

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• A 60 y/o woman is evaluated 3 weeks after
  starting continuous positive airway
  pressure(CPAP) therapy for OSA.The patient was
  initially evaluated for excessive sleepiness,and
  obstructive sleep apnea was diagnosed based on
  the results of the polysomnogram. It was
  determined that CPAP at pressure of 14cm H20
  normalized respiration and 02

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• She was prescribed CPAP at this pressure along
  with heated humidification via a nasal mask.She
  has been using CPAP,but she is still often sleepy
  during the day.PE is unremarkable, except for BMI
  of 36.5.
• She does not smoke or drink alcohol.

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• Which of the following is the most appropriate
  next step in the management of this patient?
• A-Order a multiple sleep latency test
• B-Prescribe hormone replacement tx
• C-Prescribe modafinil
• D-Review CPAP compliance

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• A 20 y/o male college student is evaluated for a
  3-year history of persistent daytime
  sleepiness.He snores loudly but has had no
  witnessed apneas or cataplexy.He has occasional
  episodes of sleep paralysis in which he cannot
  move for about a minute after awakening from
  sleep. He typically goes to bed at 1130 PM on
  weekdays and at 1AM on weekends.He falls asleep
  easily,sleeps uneventfully,and awakens at

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• about 6AM on weekdays and 11AM on weekends.His
  medical history includes depression diagnosed 1
  year ago for which he takes a selective serotonin
  reuptake inhibitor. He drinks 3 to 4 caffeinated
  drinks a day.

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• Which of the following is the most appropriate
  management for this patient?
• A-Order thyroid function tests
• B-Perform multiple sleep latency test
• C-Prescribe modafinil
• D-Recommend longer nightime sleep
• E-Refer to polysomnography

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• 59 y/o woman with DOE, increase sleepiness and
  pedal edema.Her husband reports that she has
  episodes of funny breathing during sleep,but no
  snoring.
• She is 62 tall and weighs 150lbsAuscultation of
  the chest reveals bibasilar crackles.EF is 30.
• Which of the following is the most likely cause
  of this patients hypersomnolence.

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• A-Obstructive Sleep Apnea
• B-Cheyne-Stokes respiration
• C-Idiopathic central sleep apnea
• D-Obesity Hypoventilation syndrome
• E-Insomnia

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• A 65 y/o man is evaluated for daytime
  sleepiness.His wife says that he snores nightly
  and in all sleep positions and she has witnessed
  the patient having an apnea episode.The patient
  has repeated episodes of nightime awakenings when
  he feels sort of breath and has headaches and dry
  mouth on awakening in the morning.

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• He typically sleeps for about 8 hours each night
  but awakens unrefreshed.He does not smoke or
  drink alcohol,coffee,tea,or cola beverages.
• On physical examination,vital signs are
  normalBMI is 37. His neck circumference is 45.72
  cm(18 inches).Oxygen saturation is 90 with the
  patient breathing ambient air.

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• The patient is edentulous,and examination of his
  oropharynx reveals a low-lying palate,narrow
  pharyngeal wall,and a posterior displaced
  tongue.The rest of the physical examination is
  normal

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• Which of the following is the most appropriate
  management at this time?
• A)Continuous positive airway pressure
• B)Instructions on avoiding a supine position
• C)Oxygen therapy
• D)Referral for a mandibular repositioner
• E)Polysomnography

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• A 60 y/o woman is evaluated for a 2-year history
  of fatigue and daytime sleepiness and an 8 month
  history of dyspnea that occurs only on moderate
  exercise.She does not smoke cigarettes and works
  inside the home.She has hypertension,and her only
  medication is HCTZ.
• On physical examination,vital signs are normal.

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• The patient is obese(BMI 33)the neck is short
  and thick(circumference 50.8cm20 in),and
  posterior airway is crowded.Jugular venous
  distention cannot be adequately assessed.There is
  increased intensity of P2 with fixed splitting of
  S2 and a grade 1-2/6 holosystolic murmur that
  increases with inspiration heard best along left
  lower

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• sternal border.Chest radiograph is
  normal.Spirometry,plethysmography,and arterial
  blood gases on room air are normal.Transthoracic
  echocardiogram shows evidence of RVH and mild to
  moderate pulmonary hypertension.A
  ventilation/perfusion scan is normal.

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• Which of the following is the most appropriate
  management for this patient?
• A)Lung Transplantation
• B)Nocturnal CPAP therapy
• C)Polysomnography
• D)Right-heart catheterization

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Polysomnography
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Obstructive Sleep Apnea

• Clinical history snoring,witnessed
  apnea,excessive daytime sleepiness .
• Laboratory1-Apnea-cessation of airflow for at
  least 10 seconds,with chest and abdominal
  efforts.

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OSA

• Laboratory2-Hypopnea
• 30 reduction of airflow lasting at least 10
  seconds with a 4 oxyhemoglobin desaturation
• Apnea/Hypopnea Index(AHI)

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Pathophysiology of Apnea
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Positive Airway Pressure
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Oral Appliance Mechanics
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• A 63 y/o man with Parkinsons disease,has hx of
  violent behavior during his sleep for one yearHe
  has gotten out of bed,thrashed in bed,and even
  choked his wife these events occur between 3AM
  and 5AMHe is a Vietnam veteran.
• The sleep study(30 seconds epoch)

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Rem Sleep Behavior Disorder

• Dream-enactement disorder associated with LOSS of
  muscle atonia in REM sleep.
• Majority of patientsa)Parkinsonb)Dementia with
  Lewy Bodies and c)Multiple System Atrophy.

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RSBD

• DX 1-Elevated muscle tone during REM
• 2-Hx of dream enactement
  
• 3-Absence of EEG epileptiform activity
• Tx Avoid SSRIs. Give clonazepam qHS

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NARCOLEPSY

• Cataplexy
• Excessive daytime sleepiness
• Sleep paralysis
• Hypnogogic/Hypnopompic hallucinations

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NARCOLEPSY

• Loss of Hypocretin neurons of the lateral
  hypothalamus.
• CSF Hypocretin level lt110pcg/ml
• Laboratory Dx Multiple Sleep Latency Test

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NARCOLEPSY

• Treatment
• 1)Sleepiness Provigil Ritalindextroamphetamine
  Methamphetamine.
• 2)CataplexyTCAs SSRIs GHB(xyrem)