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PULMONARY/CRITICAL CARE BOARD REVIEW WORKSHOP-3

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PULMONARY/CRITICAL CARE BOARD REVIEW WORKSHOP-3 J.Tavares,MD,FCCP,FAASM This shows the setup of equipment on a patient undergoing overnight polysomnography. – PowerPoint PPT presentation

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Title: PULMONARY/CRITICAL CARE BOARD REVIEW WORKSHOP-3


1
  • PULMONARY/CRITICAL CARE BOARD REVIEW WORKSHOP-3
  • J.Tavares,MD,FCCP,FAASM

2
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3
  • A 60 y/o woman is evaluated 3 weeks after
    starting continuous positive airway
    pressure(CPAP) therapy for OSA.The patient was
    initially evaluated for excessive sleepiness,and
    obstructive sleep apnea was diagnosed based on
    the results of the polysomnogram. It was
    determined that CPAP at pressure of 14cm H20
    normalized respiration and 02

4
  • She was prescribed CPAP at this pressure along
    with heated humidification via a nasal mask.She
    has been using CPAP,but she is still often sleepy
    during the day.PE is unremarkable, except for BMI
    of 36.5.
  • She does not smoke or drink alcohol.

5
  • Which of the following is the most appropriate
    next step in the management of this patient?
  • A-Order a multiple sleep latency test
  • B-Prescribe hormone replacement tx
  • C-Prescribe modafinil
  • D-Review CPAP compliance

6
  • A 20 y/o male college student is evaluated for a
    3-year history of persistent daytime
    sleepiness.He snores loudly but has had no
    witnessed apneas or cataplexy.He has occasional
    episodes of sleep paralysis in which he cannot
    move for about a minute after awakening from
    sleep. He typically goes to bed at 1130 PM on
    weekdays and at 1AM on weekends.He falls asleep
    easily,sleeps uneventfully,and awakens at

7
  • about 6AM on weekdays and 11AM on weekends.His
    medical history includes depression diagnosed 1
    year ago for which he takes a selective serotonin
    reuptake inhibitor. He drinks 3 to 4 caffeinated
    drinks a day.

8
  • Which of the following is the most appropriate
    management for this patient?
  • A-Order thyroid function tests
  • B-Perform multiple sleep latency test
  • C-Prescribe modafinil
  • D-Recommend longer nightime sleep
  • E-Refer to polysomnography

9
  • 59 y/o woman with DOE, increase sleepiness and
    pedal edema.Her husband reports that she has
    episodes of funny breathing during sleep,but no
    snoring.
  • She is 62 tall and weighs 150lbsAuscultation of
    the chest reveals bibasilar crackles.EF is 30.
  • Which of the following is the most likely cause
    of this patients hypersomnolence.

10
  • A-Obstructive Sleep Apnea
  • B-Cheyne-Stokes respiration
  • C-Idiopathic central sleep apnea
  • D-Obesity Hypoventilation syndrome
  • E-Insomnia

11
  • A 65 y/o man is evaluated for daytime
    sleepiness.His wife says that he snores nightly
    and in all sleep positions and she has witnessed
    the patient having an apnea episode.The patient
    has repeated episodes of nightime awakenings when
    he feels sort of breath and has headaches and dry
    mouth on awakening in the morning.

12
  • He typically sleeps for about 8 hours each night
    but awakens unrefreshed.He does not smoke or
    drink alcohol,coffee,tea,or cola beverages.
  • On physical examination,vital signs are
    normalBMI is 37. His neck circumference is 45.72
    cm(18 inches).Oxygen saturation is 90 with the
    patient breathing ambient air.

13
  • The patient is edentulous,and examination of his
    oropharynx reveals a low-lying palate,narrow
    pharyngeal wall,and a posterior displaced
    tongue.The rest of the physical examination is
    normal

14
  • Which of the following is the most appropriate
    management at this time?
  • A)Continuous positive airway pressure
  • B)Instructions on avoiding a supine position
  • C)Oxygen therapy
  • D)Referral for a mandibular repositioner
  • E)Polysomnography

15
  • A 60 y/o woman is evaluated for a 2-year history
    of fatigue and daytime sleepiness and an 8 month
    history of dyspnea that occurs only on moderate
    exercise.She does not smoke cigarettes and works
    inside the home.She has hypertension,and her only
    medication is HCTZ.
  • On physical examination,vital signs are normal.

16
  • The patient is obese(BMI 33)the neck is short
    and thick(circumference 50.8cm20 in),and
    posterior airway is crowded.Jugular venous
    distention cannot be adequately assessed.There is
    increased intensity of P2 with fixed splitting of
    S2 and a grade 1-2/6 holosystolic murmur that
    increases with inspiration heard best along left
    lower

17
  • sternal border.Chest radiograph is
    normal.Spirometry,plethysmography,and arterial
    blood gases on room air are normal.Transthoracic
    echocardiogram shows evidence of RVH and mild to
    moderate pulmonary hypertension.A
    ventilation/perfusion scan is normal.

18
  • Which of the following is the most appropriate
    management for this patient?
  • A)Lung Transplantation
  • B)Nocturnal CPAP therapy
  • C)Polysomnography
  • D)Right-heart catheterization

19
Polysomnography
20
Obstructive Sleep Apnea
  • Clinical history snoring,witnessed
    apnea,excessive daytime sleepiness .
  • Laboratory1-Apnea-cessation of airflow for at
    least 10 seconds,with chest and abdominal
    efforts.

21
OSA
  • Laboratory2-Hypopnea
  • 30 reduction of airflow lasting at least 10
    seconds with a 4 oxyhemoglobin desaturation
  • Apnea/Hypopnea Index(AHI)

22
Pathophysiology of Apnea
23
Positive Airway Pressure
24
Oral Appliance Mechanics
25
  • A 63 y/o man with Parkinsons disease,has hx of
    violent behavior during his sleep for one yearHe
    has gotten out of bed,thrashed in bed,and even
    choked his wife these events occur between 3AM
    and 5AMHe is a Vietnam veteran.
  • The sleep study(30 seconds epoch)

26
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27
Rem Sleep Behavior Disorder
  • Dream-enactement disorder associated with LOSS of
    muscle atonia in REM sleep.
  • Majority of patientsa)Parkinsonb)Dementia with
    Lewy Bodies and c)Multiple System Atrophy.

28
RSBD
  • DX 1-Elevated muscle tone during REM
  • 2-Hx of dream enactement
  • 3-Absence of EEG epileptiform activity
  • Tx Avoid SSRIs. Give clonazepam qHS

29
NARCOLEPSY
  • Cataplexy
  • Excessive daytime sleepiness
  • Sleep paralysis
  • Hypnogogic/Hypnopompic hallucinations

30
NARCOLEPSY
  • Loss of Hypocretin neurons of the lateral
    hypothalamus.
  • CSF Hypocretin level lt110pcg/ml
  • Laboratory Dx Multiple Sleep Latency Test

31
NARCOLEPSY
  • Treatment
  • 1)Sleepiness Provigil Ritalindextroamphetamine
    Methamphetamine.
  • 2)CataplexyTCAs SSRIs GHB(xyrem)
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