Sleep disordered breathing and sleep apnea

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  • Sleep disordered breathing and sleep apnea

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

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