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Sleep Disordered Breathing

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Richard Stephenson

on 26 February 2014

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Transcript of Sleep Disordered Breathing


Stages of Sleep
Official definition of OSA is:
Period of apnea lasting at least 10 seconds
Documentation of abdominal and/or chest wall movement
4% drop in SpO2
Hypopneas: 30-50% drop in airflow with a 4% drop in SpO2

READ Chapter 30 in Clinical Manifestations and Assessment of Respiratory Disease

Write out the answers to the first 6 chapter objectives on page 396
Due Monday February 24th

Sleep disordered breathing
- Breathing abnormalities that prevent normal sleep and can cause sleep deprivation in individuals
Sleep disordered breathing
The National Sleep Foundation estimates that 18 million adults in the USA have sleep apnea

The website World Sleep Day reports that at least 2% of women and 4% of men have sleep apnea
The World Health Organization reports:

1 in 4 men have sleep apnea
1 in 9 women have sleep apnea
Teenagers and infants have been diagnosed with OSA
In all, about 23 million people in the U.S. are affected with OSA
Most are undiagnosed

Sign and Symptoms of Sleep Disordered Breathing
Daytime somnolence
Morning headaches
Memory loss
Low energy
Loss of libido

Whose at risk?
Obese patients
Neck size > 17 inches
Males are 2x more likely to have sleep apnea
Increasing age
ETOH/sedative abuse
Patients with narrow upper airway
Individual with certain craniofacial abnormalities

Morbidities linked to sleep disordered breathing:
Cardiac arrhythmias
Atrial fibrillation
Pulmonary and systemic hypertension
Automobile accidents
Mortality ak.a. DEATH

Obstructive Sleep Apnea (OSA)

Sleep disordered breathing

Central Sleep Apnea
Mixed Sleep Apnea
We will discuss each of these.
Obstructive sleep apnea

However the patient is still trying to breath but can’t
The patient awakens enough to open their airway and resume breathing

This is repeated throughout the entire sleeping period

What is hypopnea?
Lower than normal tidal volume, caused by a partially occluded airway
Stage W Wakefulness
Stage N1 NREM 1
Stage N2 NREM 2
Stage N3 NREM 3
Stage R REM
We will discuss each of these

Stages of Sleep
Wakefulness: eye are closed
EEG will show alpha waves which are associated with relaxation
Trying to fall asleep in this stage

Let's discuss the stages of sleep
Stage N1:
Stages of sleep

Slow rolling eye movement
A person is arousable but slowly falling asleep
Alpha waves disappear
Theta waves (low frequency and amplitude) are present
Respirations are regular
Stage N2:
Stages of sleep

Eye movement is absent
Starting to fall asleep

Theta waves continue
K waves (wave with a large + and – deflection) and spindles (12-14Hz) may appear
Respirations and heart rate decrease slightly

Stage N3
Delta waves are present
Deeper sleep
Respirations decrease
No eye movement
Stages of sleep

Stage REM: Rapid eye movement
Dreaming occurs
Alpha waves may reappear
Saw-toothed brain waves
Respirations increase, are irregular, shallow
Blood pressure is labile
REM occurs every hour to an 1 ½ hours during sleep
25% of the time sleeping is spent in Stage REM
The skeletal muscles are paralyzed
Breathing become paradoxical

Stages of sleep

The throat muscles loose their tone during the REM phase causing a upper airway collaspe during inspiration
The tongue and soft palate fall back also collapsing the airway
The person is APNEIC due to obstruction thus OSA
The patient is now apneic; brain activity spikes to wake-up the patient enough where they will generate enough effort to forcefully open their upper airway

This can go on all night long; you never get to a restful restorative sleep
AHI: Apnea/Hypopnea Index
AHI is how many apneas/hypopneas documented per hour
A normal AHI is < 5
AHI between 5-15 = mild OSA
AHI between 15-30 = moderate OSA
AHI > 30 = severe OSA
An AHI > 5 qualifies one for CPAP
Apnea-Hypopnea Index
CPAP: we will discuss
BIPAP: we will discuss
Weight lose
Sleep posture
Surgery: uvulopalatopharyngeal plasty
Mandibular advancement: oral devices
O2 therapy
CPAP: How does it work?
A CPAP pressure is ordered by a sleep certified physician based on a titration during the polysomnogram (sleep study
The pressure ordered acts as a "stent" to keep the throat from collapsing
The Polysomnogram or Sleep Study
Test to ascertain if someone has sleep disordered breathing

What is monitored during a sleep study?
EEG: electroencephalogram
Pulse Oximetry
Limb Movements
EOC: Electroocculargram
Abdominal Movement
Chest Movement
Nasal Flow
EMG: electromyogram
Sleep Study Monitoring
Indications for a Sleep Study*
Excessive daytime drowsiness
c/o insomnia
Morning headaches
Obesity/ large neck size > 17 inches
Admits to not having any dreams
c/o waking up during the night gasping for air
Apnea observed by bed partner
How CPAP works
CPAP machines
CPAP: compliance is the key!

Patient should wear their CPAP/BIPAP at least 4 to 6 hours per night to achieve therapeutic success
Adjustment to interfaces is the number one problem
Humidify the air
Follow-up is necessary to assure compliance
Don’t take sleep aids if not wearing CPAP
Insurance will not pay for non-compliance

CPAP Interfaces
Nasal Pillows
Nasal Mask
Full Face Mask
Oral Interface
Hybrid Interface
The Key to Success!!!
Once OSA has been determined:
The polysomnography technician will initiate PAP
A PAP of 4 cmH2O will be initiated
The technician will titrate the PAP to determine the right pressure that stents the throat to prevent obstruction of the airway which causes the brain arousals and awakens the patient
Fisher/Paykel Icon
Respironics BIPAP

Nasal mask

Full face mask: covers the nose and mouth

Nasal pillows


Oral interfaces

Total face mask

Total Face Mask
Central Sleep Apnea

Breathing centers of the brain fail to send signals to the respiratory muscles to breath
Seen in pre-mature infants
May be the cause of SIDS
Compare: OSA, CSA, Mixed sleep apnea

Possible causes of CSA
Cheyne-stokes breathing which is associated with CHF
Metabolic alkalosis
Idiopathic hypoventilation syndrome
Brain stem infarct or tumor
Bulbar poliomylitis
Spinal surgery (cordotomy)

Treatment of CSA
BIPAP or Bi-level
There 3 modes of BIPAP:
1. S or spontaneous mode
2. ST or Spontaneous-Timed mode
Treatment of CSA
VPAP Adapt SV (Adaptive Servo Ventilation)
How does it work?
monitors the patient's breathing to get a baseline minute volume
adjust the pressure support (what?) to maintain the minute volume throughout the sleep period
if the patient becomes apneic, the VPAP Adapt will start breathing for the patient at a frequency of 15 breaths/minute
Vpap adapt sv: how it works

On the polysomnogram, there will be an absence of airflow and absence of abdominal and chest wall movement

CPAP: Common Complaints
Skin irritation
Nasal congestion
Dryness: mouth and nose
Too much pressure
3. T or Timed-mode
How does BIPAP work?
BIPAP or bi-level helps to improve ventilation
An inspiratory or "I" pressure is ordered
An expiratory or "E" pressure is ordered
The difference is between the I and E pressure is called PRESSURE SUPPORT
The greater the pressure support, the higher the Vt (remember IPPB?)
Bilevel can be used to make it easier for a patient to exhale when pressure feel excessive
To improve ventilation increase the difference between the I pressure and the E pressure; why?
To improve oxygenation, increase the E pressure; why?
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