Sleep disordered breathing and sleep apnea
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Transcript of Sleep disordered breathing and sleep apnea
- 1.Sleep Disordered Breathing
2. Objectives
- Understand CO2, O2 relationships in the lungs
- Describe types of Sleep Disordered Breathing
- Treatment options for OSA
3. Spontaneous Breathing
- Diaphragm flattens
- Thoracic cage increases in volume, intrathoracic pressure decreases
- Negative pressure causes intake of air
4. Lung Unit
- Alveoli and blood capillaries intertwine
5. Gas Exchange
- Occurs at at alveolar-capillary membrane
- Process of diffusion
6. O2 TransportCO2 Transport
- Dissolved in blood
- Bound to Hb
- Dissolved 10%
- Bicarbonate 60%
- Carbamino compounds 30%
7. Diffusion affected by:
- Thickness of membrane
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- Inflammation
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- Fibrosis
- Surface area diminished
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- Emphysema
8. V/Q ratio relationship between blood flow to an individual alveoli and airflow to that alveoli
- Shunt Unit
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- Perfusion with no ventilation
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- Alveoli receives blood supply, airflow blocked by mucous no gas exchange
- Dead Space Unit
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- Ventilation with lack of perfusion
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- Blockage in bloodflow, wasted ventilation no gas exchange occurs
9. Dissociation Curve
- The curve represents the relationship between oxygen and Hb, and the factors that affect the uptake and release of oxygen and the degree of saturation.
10. Dissociation curve 11.
- Basic Principles of the Curve:
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- Increasing O2 tensions result inSat%
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- Flat portion of the curve (60 mmHg - 100 mmHg), large changes in PO2 result in very small changes in Sat%.
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- Steep portion of the curve (10 mmHg - 60 mmHg), small changes in PO2 result in large drops in O2 Sat%.
12.
- Factors Altering HB Affinity for O2:
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- Ph
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- Temperature
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- PaCO2
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- Hemoglobin Variants
13.
- Shifts of the Curve to the Right:
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- Results in a decreased affinity
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- Results in a decreased O2 transport capability (O2 content)
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- Aids in unloading of oxygen to the tissues
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- Extreme shifts are a disadvantage, because O2 content is so depleted the tissue oxygenation is severely impaired
14.
- Shifts of the Curve to the Left:
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- Results in a increased affinity
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- Results in a increased O2 transport capability (O2 content)
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- Hinders unloading of oxygen to the tissues.
15. Capnography
- The measurement and graphical display of the concentration of carbon dioxide in waveform format
16. EtCO2
- Refers to the measurment of carbon dioxide concentration at the end of expiration
17. ETCO2 Assessment
- CO2 measurement with each breath
A-B:A near zero baselineExhalation of CO2-free gas contained in dead space. B-C:Rapid, sharp riseExhalation of mixed dead space and alveolar gas. C-D:Alveolar plateauExhalation of mostly alveolar gas. D:End-tidal value Peak CO2 concentrationnormally at the end of exhalation. D-E:Rapid, sharp downstrokeInhalation 18. Wave form allows us to assess
- alveolar ventilation
- integrity of the airway
- proper functioning of a mechanical ventilator or anesthesia delivery system
- cardiopulmonary system
- rebreathing
19. EtCO2 waveform
- Earliest Detection of Hypoventilation and Apnea
- Shows cessation of breathing before pulse oximetry would alert medical staff to a problem
- Helpful if the patient is on supplemental oxygen
20. Why are dissociation curve and EtCO2 important?
- Windows to ventilation and perfusion
21. Abnormal capnograms
- Sudden loss of EtCO2 to zero or near zero Possible causes: Airway disconnection Dislodged ET tube/esophageal intubation Totally obstructed/kinked ET tube Complete ventilator malfunction
22. Abnormal capnograms
- SustainedlowEtCO2 with good alveolar plateau
- Possible causes: Hyperventilation Hypothermia Sedation, anesthesia Dead space ventilation
23. Abnormal Capnography
- ElevatedEtCO2 with good alveolar plateau
- Possible causes:Hypoventilation Respiratory-depressant drugs Hyperthermia, pain, shivering
24. ABG Values 28 88 50 60 7.38 COPD 22-26 94-99 35-45 80-100 7.40 Normal HCO3 SaO2 PCO2 PO2 pH 25.
- Cyanosis (bluish coloring) occurs with a PaO2 reduction of 5 gm %
26. Hypoventilation
- Causes retention of CO2
- pH drop
27. Hyperventilation
- Causes decrease of CO2
- pH to increase
28. Hypoxic Drive
- Normal drive- CO2 build up
- COPD- low O2
29. Characteristics of Respiratory Events Not required Usually mild cyclic desats Crescendo-Decrescendo pattern Waz-wane May last 15-30 min or more Cheyne-Stoles Respiration Mandatory Not required Slight increase, may crescendo to end of event Slight decrease from baseline Respiratory Event Related Arousal Not required 4% required Yes 30% from baseline 10-120 sec, Longer hypo-ventilation Hypopnea Not required Common; not mandatory NO Absent Minimum 10 sec Central Apnea Not required Not required Yes Absent Minimum 10 sec Obstructive Apnea Arousal Desaturation Effort Airflow Duration 30. Treatment of OSA
- CPAP
- BiLevel
- Auto-titration
- Surgery
- Oral Appliances
31. Goals of Treatment
- Eliminate hypopnea/apnea
- Eliminate snoring
- Eliminate associated arousals
32. Goals cont
- Eliminate associated desaturations
- Maintain SaO2 > 90%
- Increase Sleep Efficiency
33. Titration Techniques
- Initiate at 4-5 cm
- Increase 1-2 cm increments
- Record each pressure for a minimum of 15 minutes
- Record REM sleep while in supine position
34. BiPAP
- Varying pressures; insp 4 cm > expiration
- Initiate if:
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- Pt intolerant to CPAP
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- Optimal CPAP pressure > 15
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- Optimal CPAP pressure is associated with the occurrence of central apneas
35. Lung Volumes 36.
- The use of CPAP / BiPAP increases FRC which in turn improves oxygenation
37. Surgical Options
- Uvulopalatopharyngoplasty (UPPP)
- Laser assisted uvulopalatopharyngoplasty (LAUP)
- Genioglossal advancement
- Maxillomandibular advancement
38. More surgical options
- Nasal surgery
- Tonsillectomy
- Tracheostomy
- Approximately 50% effective
39. Oral Appliances
- Mandibular repostitioners
- Tongue retaining devices
- Palatal lifting devices
40. 41. 42.
- Removable
- Fitted by dentist
- Treatment of patients with:
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- Snoring
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- Mild OSA
43. Identified Risks
- Intraoral gingival, palatal, or dental soreness
- TMJ Syndrome
- Obstruction of oral breathing
- Loosening or flaring of lower anterior teeth
- Excessive salivation
44. Oral appliances, contraindications
- Central sleep apnea
- Severe respiratory disorders
- Loose teeth or advanced periodontal disease
- < 18 yrs of age