Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 31 Sleep Apnea Figure 31-1. Obstructive sleep...

Copyright © 2006 by Mosby, Inc.Slide 1

Chapter 31Chapter 31 Sleep Apnea Sleep Apnea

Figure 31-1. Obstructive sleep apnea. When the genioglossus muscle fails to Figure 31-1. Obstructive sleep apnea. When the genioglossus muscle fails to oppose the force that tends to collapse the airway passage during inspiration, the oppose the force that tends to collapse the airway passage during inspiration, the

tongue moves into the oropharyngeal area and obstructs the airway.tongue moves into the oropharyngeal area and obstructs the airway.


Sleep ApneaSleep Apnea

Despite the fact that the clinical manifestations Despite the fact that the clinical manifestations of sleep apnea have be described for centuries, of sleep apnea have be described for centuries, it was not until the early 1980s that it became it was not until the early 1980s that it became acknowledged by the medical communityacknowledged by the medical community


Stages of Sleep and Characteristic Stages of Sleep and Characteristic Cardiopulmonary PatternsCardiopulmonary Patterns

Two major sleep stages during normal sleepTwo major sleep stages during normal sleep Non–rapid eye movement (non-REM) sleepNon–rapid eye movement (non-REM) sleep

• Quiet or slow-wave sleepQuiet or slow-wave sleep

Rapid eye movement (REM) sleepRapid eye movement (REM) sleep

• Active or dreaming sleepActive or dreaming sleep


Non-REM SleepNon-REM Sleep

Usually begins immediately after dozing off Usually begins immediately after dozing off

Four stages of non-REM sleep Four stages of non-REM sleep Each progressing into a deeper sleepEach progressing into a deeper sleep


Stages 1 and 2Stages 1 and 2

The ventilatory rate and tidal volume The ventilatory rate and tidal volume continually increase and decrease—brief continually increase and decrease—brief periods of apnea may occurperiods of apnea may occur

The ECG shows increased slow-wave activity The ECG shows increased slow-wave activity and loss of alpha rhythmand loss of alpha rhythm

Cheyne-Stokes respiration is common in Cheyne-Stokes respiration is common in older adult males, especially at high altitudesolder adult males, especially at high altitudes



Ventilation becomes slow and regularVentilation becomes slow and regular

Minute ventilation is commonly 1 to 2 L/min Minute ventilation is commonly 1 to 2 L/min less than during the quiet wakeful stateless than during the quiet wakeful state

Typically the:Typically the: PaCOPaCO22 levels are higher (4-8 mm Hg) levels are higher (4-8 mm Hg)

PaOPaO22 levels are lower (3-10 mm Hg) levels are lower (3-10 mm Hg)

pH is lower (0.03-0.05 unit)pH is lower (0.03-0.05 unit)



Normally, non-REM sleep lasts 60 to 90 minutes Normally, non-REM sleep lasts 60 to 90 minutes

Typically, an individual moves in and out of allTypically, an individual moves in and out of all4 stages during non-REM sleep4 stages during non-REM sleep Most of the time is spent in stage 2Most of the time is spent in stage 2



An individual may move into REM sleep, at An individual may move into REM sleep, at any time, directly, from any of the 4 non-REM any time, directly, from any of the 4 non-REM sleep stagessleep stages The lighter 1 and 2 stages, however, are the most The lighter 1 and 2 stages, however, are the most

common levels just before REM sleepcommon levels just before REM sleep


REM SleepREM Sleep

During this period, sudden burst of fast alpha During this period, sudden burst of fast alpha rhythmsrhythms

Ventilatory rate becomes rapid and shallowVentilatory rate becomes rapid and shallow

Sleep-related hypoventilation and apnea are Sleep-related hypoventilation and apnea are commonly seen during this periodcommonly seen during this period


REM SleepREM Sleep

In normal adults, apneic periods occur as In normal adults, apneic periods occur as often a five times per houroften a five times per hour

These apneic periods may last 15 to 20 These apneic periods may last 15 to 20 seconds with no discernible effectsseconds with no discernible effects

In normal infants:In normal infants: Apneas are shorter—about 10 seconds longApneas are shorter—about 10 seconds long


REM SleepREM Sleep

A marked reduction occurs in the:A marked reduction occurs in the: Hypoxic ventilatory responseHypoxic ventilatory response

Hypercapnic ventilatory responseHypercapnic ventilatory response

The heart rate becomes irregularThe heart rate becomes irregular

The eyes move rapidly and dreaming occursThe eyes move rapidly and dreaming occurs


REM SleepREM Sleep

Paralysis of the skeletal muscles occursParalysis of the skeletal muscles occurs ArmsArms

LegsLegs

Intercostal and upper airway musclesIntercostal and upper airway muscles

The diaphragm is NOT affectedThe diaphragm is NOT affected


Muscle Paralysis during REM Sleep Muscle Paralysis during REM Sleep Affects Ventilation in Two WaysAffects Ventilation in Two Ways

1.1. Paradoxical motion of the rib cageParadoxical motion of the rib cage Causes in tissue to move inward during Causes in tissue to move inward during

inspirationinspiration

This causes the FRC to decreaseThis causes the FRC to decrease

2.2. Loss of muscle tone in the: Loss of muscle tone in the: Posterior muscles of the pharynxPosterior muscles of the pharynx

Genioglossus—protrudes the tongueGenioglossus—protrudes the tongue

Posterior cricoarytenoid—abducts the Posterior cricoarytenoid—abducts the vocal cordsvocal cords


Loss of Muscle Tone in the Upper Loss of Muscle Tone in the Upper Airway May Result in Airway Airway May Result in Airway

ObstructionObstruction

The negative pharyngeal pressure produced The negative pharyngeal pressure produced when the diaphragm contracts during when the diaphragm contracts during inspiration tends to:inspiration tends to: Bring the vocal cords togetherBring the vocal cords together

Collapse the pharyngeal wallCollapse the pharyngeal wall

Suck the tongue back into the oral pharyngeal Suck the tongue back into the oral pharyngeal cavity cavity


REM SleepREM Sleep

REM sleep lasts about 5 to 40 secondsREM sleep lasts about 5 to 40 seconds Recurs about every 60 to 90 minutesRecurs about every 60 to 90 minutes

REM sleep lengthens and becomes more REM sleep lengthens and becomes more frequent toward the end of a sleep periodfrequent toward the end of a sleep period


REM SleepREM Sleep

REM sleep constitutes about 20% to 25% of REM sleep constitutes about 20% to 25% of sleep timesleep time

It is usually more difficult to awaken a subject It is usually more difficult to awaken a subject during REM sleepduring REM sleep


Types of Sleep Apnea Types of Sleep Apnea


Types of Sleep ApneaTypes of Sleep Apnea

Apnea—the cessation of breathing for 10 Apnea—the cessation of breathing for 10 seconds or longerseconds or longer

Sleep apnea—more than five episodes of Sleep apnea—more than five episodes of apnea per hour apnea per hour May occur in either or both non-REM and REM May occur in either or both non-REM and REM

sleep, over a 6-hour periodsleep, over a 6-hour period



Generally, the episodes of apnea are more Generally, the episodes of apnea are more frequent and severe during REM sleep and in frequent and severe during REM sleep and in the supine body positionthe supine body position

Apnea periods last more than 10 seconds Apnea periods last more than 10 seconds and occasionally exceed 100 seconds in and occasionally exceed 100 seconds in lengthlength

In severe cases, as many as 500 apnea In severe cases, as many as 500 apnea periods per night may occurperiods per night may occur



Sleep apneas may appear in all age groupsSleep apneas may appear in all age groups

In infants, it may play a role in sudden infant In infants, it may play a role in sudden infant death syndrome (SIDS)death syndrome (SIDS)


Obstructive Sleep ApneaObstructive Sleep Apnea(OSA)(OSA)

Most commonMost common

During periods of OSA, the:During periods of OSA, the: Patient, initially, appears quiet and stillPatient, initially, appears quiet and still

Followed by an increased effort to inhaleFollowed by an increased effort to inhale


Obstructive Sleep ApneaObstructive Sleep Apnea

OSA often ends only after an intense struggleOSA often ends only after an intense struggle

Snorting is often heard during periods of OSASnorting is often heard during periods of OSA Called “fricative breathing”Called “fricative breathing”

In severe cases, the patient may:In severe cases, the patient may: Suddenly awakenSuddenly awaken

Sit upright in bed, andSit upright in bed, and

Gasp for airGasp for air



OSA patients usually breathe normally during OSA patients usually breathe normally during wakeful periodswakeful periods

OSA seen more often in males than females OSA seen more often in males than females (8:1 ratio)(8:1 ratio)

Between 1% and 4% of male populationBetween 1% and 4% of male population

Commonly seen in obese people with short Commonly seen in obese people with short necksnecks


Pickwickian SyndromePickwickian Syndrome

Named after a character in Charles Dickens’ Named after a character in Charles Dickens’ The Posthumous Papers of the Pickwick ClubThe Posthumous Papers of the Pickwick Club (1837)(1837) Joe: the fat boy who snored and had excessive Joe: the fat boy who snored and had excessive

daytime sleepinessdaytime sleepiness

Charles Dickens’ description of Joe included Charles Dickens’ description of Joe included many of the classic features now recognized many of the classic features now recognized as OSAas OSA


Pickwickian SyndromePickwickian Syndrome

However, many patients with OSA are NOT However, many patients with OSA are NOT obese, thus clinical suspicion should not be obese, thus clinical suspicion should not be limited to this grouplimited to this group


Some Clinical Disorders Some Clinical Disorders Associated with OSAAssociated with OSA

ObesityObesity

Anatomic narrowing of the upper airwayAnatomic narrowing of the upper airway Excessive pharyngeal tissueExcessive pharyngeal tissue

Enlarged tonsils or adenoidsEnlarged tonsils or adenoids

Deviated nasal septumDeviated nasal septum

Laryngeal stenosis Laryngeal stenosis



Laryngeal webLaryngeal web

Pharyngeal neoplasmsPharyngeal neoplasms

MicrognathiaMicrognathia

MacroglossiaMacroglossia

GoiterGoiter

HypothyroidismHypothyroidism



Testosterone administrationTestosterone administration

Myotonic dystrophyMyotonic dystrophy

Shy-Drager syndromeShy-Drager syndrome

Down syndromeDown syndrome


General Clinical Manifestations General Clinical Manifestations Associated with OSAAssociated with OSA

Chronic loud snoringChronic loud snoring

HypertensionHypertension

Morning headachesMorning headaches

Systemic hypertensionSystemic hypertension

NauseaNausea

Dry mouth on awakeningDry mouth on awakening

Intellectual and personality changesIntellectual and personality changes


General Clinical Manifestations General Clinical Manifestations Associated with OSAAssociated with OSA

DepressionDepression

Sexual impotenceSexual impotence

Nocturnal enuresisNocturnal enuresis

Excessive daytime sleepinessExcessive daytime sleepiness

Car accidents or job malperformance Car accidents or job malperformance related to sleepinessrelated to sleepiness

Pulmonary hypertensionPulmonary hypertension


Polysomnographic Monitoring Polysomnographic Monitoring FindingsFindings

Apnea-related oxygen desaturationApnea-related oxygen desaturation

More than five obstructive apneas of more More than five obstructive apneas of more than 10 seconds per hour of sleep, and one than 10 seconds per hour of sleep, and one or more of the following:or more of the following: Frequent arousal from the apneasFrequent arousal from the apneas

PVCsPVCs

Profound bradycardia and/or asystoleProfound bradycardia and/or asystole

Shortened sleep latencyShortened sleep latency


Central Sleep ApneaCentral Sleep Apnea

Occurs when respiratory centers of the Occurs when respiratory centers of the medulla fail to send signals to the respiratory medulla fail to send signals to the respiratory musclesmuscles

Characterized by cessation of airflow at the Characterized by cessation of airflow at the nose and mouth with absence of nose and mouth with absence of diaphragmatic excursionsdiaphragmatic excursions

Associated with cardiovascular, metabolic, or Associated with cardiovascular, metabolic, or central nervous system disorderscentral nervous system disorders


Central Sleep ApneaCentral Sleep Apnea

Diagnosed when the frequency of apnea Diagnosed when the frequency of apnea episodes is more than 30 in a 6-hour periodepisodes is more than 30 in a 6-hour period


Clinical Disorders Associated with Clinical Disorders Associated with Central Sleep ApneaCentral Sleep Apnea

Congestive heart failureCongestive heart failure

Metabolic alkalosisMetabolic alkalosis

Idiopathic hypoventilation syndromeIdiopathic hypoventilation syndrome

EncephalitisEncephalitis

Brainstem neoplasmBrainstem neoplasm

Brainstem infarctionBrainstem infarction

Bulbar poliomyelitisBulbar poliomyelitis

Cervical cordotomyCervical cordotomy

Spinal surgerySpinal surgery

HypothyroidismHypothyroidism


General Noncardiopulmonary Clinical General Noncardiopulmonary Clinical Manifestations Manifestations

Tendency to be of normal weightTendency to be of normal weight

Mild snoringMild snoring

InsomniaInsomnia

Some of the following may also occurSome of the following may also occur Daytime fatigueDaytime fatigue

DepressionDepression

Sexual dysfunctionSexual dysfunction


Mixed Sleep ApneaMixed Sleep Apnea

Combination of obstructive and central Combination of obstructive and central sleep apneasleep apnea

Usually begins as central sleep apnea, Usually begins as central sleep apnea, followed by:followed by: Ventilatory efforts without airflow—OSAVentilatory efforts without airflow—OSA

Clinically, mixed sleep apnea is usually Clinically, mixed sleep apnea is usually classified and treated as OSAclassified and treated as OSA


Figure 31-2. Patterns of airflow, respiratory efforts (reflected through the esophageal pressure), Figure 31-2. Patterns of airflow, respiratory efforts (reflected through the esophageal pressure), and arterial oxygen saturation produced by central, obstructive, and mixed apneas.and arterial oxygen saturation produced by central, obstructive, and mixed apneas.


DiagnosisDiagnosis Begins with a careful historyBegins with a careful history

Noting presence of snoring, sleep disturbance, and Noting presence of snoring, sleep disturbance, and daytime sleepinessdaytime sleepiness

Followed by examination of upper airway and Followed by examination of upper airway and PFT to determine presence of upper airway PFT to determine presence of upper airway obstructionobstruction

Blood evaluationBlood evaluation PolycythemiaPolycythemia

Thyroid functionThyroid function

ABGsABGs


DiagnosisDiagnosis

Chest radiographChest radiograph

Electrocardiogram to determine:Electrocardiogram to determine: Presence of pulmonary hypertensionPresence of pulmonary hypertension

State of right and left ventricular compensationState of right and left ventricular compensation

Presence of any other cardiopulmonary diseasePresence of any other cardiopulmonary disease


Diagnosis and Type of ApneaDiagnosis and Type of Apnea

Confirmed with the following:Confirmed with the following: Polysomnographic sleep studies, which Polysomnographic sleep studies, which

include:include: EEG and EOG—to identify sleep stagesEEG and EOG—to identify sleep stages

Airflow monitorAirflow monitor

ECGECG

Monitor of patient’s ventilatory rate and effort Monitor of patient’s ventilatory rate and effort

Oximetry Oximetry

CT scanCT scan


Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Clinical Manifestations

Associated Associated with SLEEP APNEAwith SLEEP APNEA


Clinical Data Obtained at theClinical Data Obtained at the Patient’s Bedside Patient’s Bedside

CyanosisCyanosis


Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings


Arterial Blood GasesArterial Blood Gases

Severe Sleep ApneaSevere Sleep Apnea

Chronic ventilatory failure with hypoxemiaChronic ventilatory failure with hypoxemia

pH PapH PaCOCO22 HCO HCO33-- Pa PaOO2 2

Normal Normal (Significantly)(Significantly)


Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.

Time and Progression of DiseaseTime and Progression of Disease

100100

5050

3030

80

0

PaO2

1010

2020

4040

Alveolar HyperventilationAlveolar Hyperventilation

6060

7070

9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

Point at which PaO2 declines enough to stimulate peripheral oxygen receptors

PaCO 2

Chronic Ventilatory Failure Chronic Ventilatory FailureDisease OnsetDisease Onset

Point at which disease becomes severe and patient begins to become fatigued

Point at which disease becomes severe and patient begins to become fatigued

Pa0

2 o

r P

aC0 2

Pa0

2 o

r P

aC0 2


Acute Ventilatory Changes on Acute Ventilatory Changes on Chronic Ventilatory FailureChronic Ventilatory Failure

Acute alveolar hyperventilation on chronic Acute alveolar hyperventilation on chronic ventilatory failureventilatory failure

Acute ventilatory failure on chronic ventilatory Acute ventilatory failure on chronic ventilatory failure failure


Oxygenation IndicesOxygenation Indices

QS/QT DO2 VO2 C(a-v)O2

Normal Normal

O2ER SvO2

QS/QT DO2 VO2 C(a-v)O2

Normal Normal

O2ER SvO2


Hemodynamic Indices Hemodynamic Indices (Severe)(Severe)

CVP CVP RAPRAP PAPA PCWPPCWP

COCO SVSV SVISVI CICI

RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR


Radiologic FindingsRadiologic Findings

Chest radiographChest radiograph

Right- or left-sided heart failureRight- or left-sided heart failure


Cardiac ArrhythmiasCardiac Arrhythmias

Sinus arrhythmiaSinus arrhythmia

Sinus bradycardiaSinus bradycardia

Sinus pausesSinus pauses

Atrioventricular blockAtrioventricular block

Premature ventricular contractionsPremature ventricular contractions

Ventricular tachycardiaVentricular tachycardia


General Management of General Management of Sleep ApneaSleep Apnea

Weight reductionWeight reduction

Sleep positionSleep position

Oxygen therapyOxygen therapy

Drug therapyDrug therapy REM inhibitorsREM inhibitors

• Protriptyline (Vivactil)Protriptyline (Vivactil)

Acetazolamide (Diamox)Acetazolamide (Diamox)

Protriptyline hydrochlorideProtriptyline hydrochloride



SurgerySurgery UvulopalatopharyngoplastyUvulopalatopharyngoplasty

Laser-assisted uvulopalatoplastyLaser-assisted uvulopalatoplasty

Nasal surgeryNasal surgery

TracheostomyTracheostomy

Mandibular advancementMandibular advancement



Mechanical ventilationMechanical ventilation Continuous positive airway pressureContinuous positive airway pressure

Continuous mechanical ventilationContinuous mechanical ventilation

Negative-pressure ventilationNegative-pressure ventilation


Figure 31-3. Figure 31-3. A, Normal airway. B, Obstructed airway during sleep. C, Nasal CPAP A, Normal airway. B, Obstructed airway during sleep. C, Nasal CPAP generates a positive pressure and holds the airway open during sleep.generates a positive pressure and holds the airway open during sleep.



Phrenic nerve pacemakerPhrenic nerve pacemaker



Medical devicesMedical devices Neck collarNeck collar


Classroom DiscussionClassroom DiscussionCase Study: Case Study:


Copyright © 2006 by Mosby, Inc. Slide 1 Chapter 31 Sleep Apnea Figure 31-1. Obstructive sleep...

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