Sleep Apnea

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Sleep Apnea

• Dr. Jones

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Stages of Sleep

• Stage 1 (Awake (active mental concentration-
  beta, eyes closed alpha)) theta activity 5
• Stage 2 (Eyes closed) sleep spindle and
  K-complexes 50
• Stage 3 4 (Delta sleep) large complexes
  15-20
• REM sawtooth waves looks like beta 20-25
• Penile/clitoral tumescence
• Tonic REM
• Phasic REM
• Stage 4 GH secretion
• Ruffies (Rohypnol) elevates GH and prolongs
  stage ¾ sleep (knocks you out)

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Definitions

• Apnea no breathing for at least 10 seconds
• Hypopnea less than 70 of effort to breathe
• Sleep Apnea repetitive episodes of upper
  respiratory airway obstruction that occurs during
  sleep
• usually a/w a decrease in blood O2 saturation
• This causes an elevated BP which may carry over
  to cause HTN during daytime

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Definitions

• Upper Airway Resistance Patients upper airways
  are more narrow than normal
• Pickwickian Syndrome (Obesity-Hypoventilation
  Syndrome) a syndrome of obesity, somnolence,
  hypoventilation, and erythrocytosis

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Sleep Apnea Prevalence

• Males gt Females

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Effort of Sleepiness Scale (ESS)

• Refer to handout (Sleep Tendency Scale)
• Bottom Scale
• NCnormal control PSprimary snorer SAsleep
  apnea NAnarcolepsy IHidiopathic
  hypersomnolence INH PLMSperiodic leg
  movement syndrome

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Signs Symptoms

• Sleepiness
• Snoring
• Apneic episodes spouse observation
• Choking/gasping
• Nocturia
• Fatigue upon wakening
• AM headaches are sometimes present

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Features of Excess Sleepiness

• MVA
• Work-related injuries
• Impaired school/work performance
• Social embarrassments
• Marital problems
• Memory/concentration problems
• Depression
• Impaired quality of life

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Obstructive SA Syndrome

• Features in child
• Hyperactive or excess sleepiness (ADHD)
• Noisy breathing during sleep
• Irregular body position with sleep
• Rib cage retractions
• Flaring of ribs
• No. 1 cause is tonsillar hypertrophy

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Predisposing Factors

• Age 40-60 years
• Obesity BMI
• Gender MalegtFemale

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Exam Findings

• Short, fat neck
• Obesity causes narrowing of pharynx
• Upper airway narrowing large tonsils/adenoids,
  enlarged uvula, long soft palate
• Micrognathia/retrognathia

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Associated Disorders

• Hypothyroidism
• Acromegaly
• Marfans Syndrome
• Amyloidosis

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Physiologic Consequence

• Asphyxia
• Hypoxemia
• Hypercapnia
• Acidosis
• Sleep fragmentation

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Pathophysiology
SA

• Obesity Pharyngeal obstruction
• Reduced pharyngeal muscle tone
• Sleep deprivation

Snoring
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Polysomnography

• Sleep test
• staging, respiratory measures, ECG, O2
  saturation, limb movement activity, position
  monitoring, video monitoring, end-tidal CO2
  measurements

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Typical Polysomnography Test Result for SA

• Repetitive apnea
• Terminates with arousal
• Destroyed sleep continuity
• Usually 30 episodes per hour
• Reduced stage 3 4, REM
• Apnea often gt50 of sleep time

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SA Treatment

• Continuous Positive Airway Pressure (CPAP)
• Behavioral Tx
• Medical Tx

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Behavioral Treatment

• Ideal body wt.
• Sleep on side
• Avoid sedative meds prior to sleep
• Avoid sleep deprivation
• Avoid EtOH prior to sleep
• Elevate head during sleep
• Promptly treat colds allergies
• Avoid large meals prior to sleep
• Smoking cessation

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Medical Treatment

• Weight loss
• Pharmacotherapy
• O2
• Nasopharyngeal intubation
• Nasal CPAP
• Bilevel CPAP
• Automatic CPAP
• Oral appliances to maintain airway

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Exam Emphasis

• Predisposition to SA
• Common patient complaints
• Recognition of patients with SA in clinical
  setting