A 70-year-old lady presented to the emergency room with complaints of chest pain and difficulty breathing for 10 days. She reported generalized swelling for 1 month with fever but no decrease in urine output. On examination, she was found to have wheezing and crackles on lung auscultation. Her blood sugar was high. The impression was pulmonary edema and chronic obstructive pulmonary disease (COPD), with a history of chronic kidney disease and diabetes.

1. 70 YR OLD LADY , ER – 1/12/2016
C/O CHEST PAIN – 10 AM , DYSPNOEA
GENERALISED SWELLING – 1MONTH, FEVER, NO H/O DECREASE UO
VITALS-
O/E
BP – 170/90MMHG, T- 36⁰ , P- 120/MIN, RR- 32/MIN, SPO2- 92 WITH O2, GRBS – 167MG/DL
RS – WHEEZES +, CREPS +
CVS – S1S2 N JVP⁰
CNS – CONFUSED ,ORIENTED
HX -
∆SIS – AS CKD, DIABETIC NEPHROPATHY – 5MONTH BACK
1 EPISODE OF DIALYSIS DONE OUTSIDE
IMPRESSION – PULMONARY EDEMA 2⁰ CCF , COPD?
Obesity hypoventilation syndrome (also known as Pickwickian syndrome) is a condition in which
severely overweight people fail to breathe rapidly enough or deeply enough, resulting in low blood
oxygen levels and high blood carbon dioxide (CO2) levels
pH 7.36 7.43
paO2 89 67
paCO
2
67 50
Na⁺ 133 132
K⁺ 4.0 4.1
Lac 1.2
HCO3
⁻
50.3 44.4
Pickwickian syndrome

3. OSA
 OSA syndrome is sleep disruption secondary to increased ventilator effort that results in
increased daytime sleepiness (or hypersomnolence)
 Sleep apnea is defined as repeated episodes of complete cessation of airflow for 10 seconds or
longer.
OSA
Obstructive – upper airway
obstruction
Central ( caused by lack of ventilator
effort) , primary CNS lesion, stroke, CHF
High altitude hypoxemia

4. Recognization
STOP-BANG Questionnaire to Screen for Obstructive Sleep Apnea
 Snore: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
 Tired: Do you often feel tired, fatigued, or sleepy during the daytime?
 Observed: Has anyone observed you stop breathing during sleep?
 Pressure: Do you have or are you being treated for high blood pressure?
 BMI: Greater than 35 kg/m2?
 Age: Age older 50 years?
 Neck: Neck circumference greater than 40 cm?
 Gender: Gender male?
 One point assigned for each positive question.
 Total score less than three = low probability for OSA.
 Total score three or greater = high probability for OSA.
 Total score five or greater = high probability of moderate to severe OSA.
From Chung F, Subramanyam R, Liao P, et al: High STOP-BANG score indicates a high probability of
obstructive sleep apnoea. Br J Anaesth 108:768–775, 2012.

5. Common Clinical Features of Obstructive Sleep Apnea
Male
Age greater than 40 years
Upper body obesity (neck >16.5 inches)
Habitual snoring
Fatigue or daytime sleepiness
Diurnal hypertension
patients with sleep apnea report habitual snoring that has become progressivelyworse
Sensations of nocturnal choking, gasping, or resuscitative snorting are frequently
reported
chronic nasal congestion, morning headaches, and symptoms of depression

6. Evaluation
an overnight polysomnogram (PSG) should be obtained to confirm the clinical
diagnosis
 Obstructive sleep apnea. defined as cessation of
airflow for 10 seconds or longer. Paradoxical
movement of the rib cage and abdomen in response
to the closed airway occurs. Ventilatory effort, usually
increases until a threshold is reached that triggers a
brief arousal seen on the electroencephalogram
(EEG), and airway opening occurs. Oxyhemoglobin
 B, Obstructive hypopnea.defined as a reduction of airflow
by 30% to 50% for 10 seconds or longer. Paradoxical
movement of the rib cage and abdomen in response to the
narrowed airway occurs. Ventilatory effort usually increases
until a threshold is reached that triggers a brief arousal
seen on the EEG, and complete airway opening occurs.
Oxyhemoglobin desaturation usually accompanies the
event and usually is of a lesser degree than occurs with

7. Cont’
 After the sleep study is completed, the sleep technologist scores it.
 The number of apneas and hypopneas per hour of sleep are reported as an apnea-hypopnea index (AHI) or
respiratory disturbance index (RDI). The AASM has operationally defined the severity of OSA as follows:
 mild, AHI 5 to 15;
 moderate, AHI 15 to 30; and
 severe, AHI greater than 30.
 AHI less than 5 is considered within the normal range for adults.

8. Treatment
 Management of OSA should be individualized but
generally canbe classified into three options:
 behavioral,
 medical, and
 Surgical interventions.

9.  Behavioural
 must be informed of the risks of uncontrolled sleep apnea.
 Several behavioral interventions can be beneficial, including weight loss in obese patients; avoiding alcohol, sedatives, and hypnotics;
and avoiding sleep deprivation. Although weight loss clearly influences the severity of sleep apnea,
 Positional Therapy
 Medical Interventions
 (CPAP) therapy was introducedfor management of OSA in 1981.
 Firstline therapy for OSA
 CPAP pressures between 7.5 cm H2O and 12.5 cm H2O.6
 shown to decrease daytime sleepiness and improve neurocognitive testing, vigilance scores,insulin sensitivity, and lipid
profiles
 decreases the incidence of pulmonary hypertension and right heart failure and decreases the number of
ventilation-related arousals and nocturnal cardiac events
 BiPAP was developed to take advantage of the fact that some patients may have different
pressure requirements between inspiration and expiration.

10. Adverse Consequences of Obstructive Sleep Apnea
 CARDIOPULMONARY
• Nocturnal arrhythmia
• Diurnal hypertension
• Pulmonary hypertension
• Right or left ventricular failure
• Myocardial infarction
• Stroke
 NEUROBEHAVIORAL
• Excessive daytime sleepiness
• Diminished quality of life
• Adverse personality change
• Motor vehicle accidents
 METABOLIC
• Insulin resistance
• Altered lipid metabolism

11. Epworth Sleepiness Scale
Most
appropriate
number for each
situation
0 = would never
doze
1 = slight chance of
dozing
2 = moderate
chance of dozing
3 = high chance of
dozing
Situation Chance of Dozing (0-3)
Sitting and reading _____
Watching TV _____
Sitting, inactive in a public place (e.g. a theatre or a meeting) __
As a passenger in a car for an hour without a break
_____
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
_____
Sitting quietly after a lunch without alcohol
_____
In a car, while stopped for a few minutes in the traffic

12. Thankyou

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