55
By: John J. Beneck MSPA, PA-C 1 Sleep Apnea Sleep Apnea Everything You Never Everything You Never Wanted to Know About… Wanted to Know About…

By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

Embed Size (px)

Citation preview

Page 1: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

By: John J. Beneck MSPA, PA-C 1

Sleep ApneaSleep Apnea

Everything You Never Everything You Never

Wanted to Know About…Wanted to Know About…

Page 2: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

2

Case 1Case 1

• 35 year old male with loud snoring. Spouse 35 year old male with loud snoring. Spouse states she can’t sleep in the same room with states she can’t sleep in the same room with him.him.

Page 3: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

3

Case 2Case 2

• 46 year old obese male in for annual CPE 46 year old obese male in for annual CPE observed by you to appear sleepy during the observed by you to appear sleepy during the medical interview.medical interview.

Page 4: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

4

Case 3Case 3

• In Hospital: Call at 0025 from RN that 42 In Hospital: Call at 0025 from RN that 42 year old female diabetic in with lower year old female diabetic in with lower extremity cellulitis has oxygen saturation in extremity cellulitis has oxygen saturation in the low 80s when checking vital signs. the low 80s when checking vital signs. Awoke when stimulated and SaO2 Awoke when stimulated and SaO2 improved.improved.

Page 5: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

5

ObjectivesObjectives

• Understand OSAH and CSAS in terms of the Understand OSAH and CSAS in terms of the following:following:– DefinitionDefinition

– EpidemiologyEpidemiology

– Pt. PresentationPt. Presentation

– DxDx

– PreventionPrevention

– TxTx

– PrognosisPrognosis

Page 6: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

6

AbbreviationsAbbreviations

• CO2 – Carbon dioxide

• CPAP – Continuous positive airway pressure

• CPE – Comprehensive Physical Exam

• CSAS – Central sleep apnea syndrome

• CV – Cardiovascular

• D/t – due to

• Dx – Diagnosis

• Dz - Disease

• EEG – Electroencephalogram

• HF – Heart failure

• HTN – Hypertension

• LVEF – Left ventricular ejection fraction

• MVC – Motor vehicle crash

• N-CPAP – Nasal CPAP

• O2 - Oxygen

• OSAH – Obstructive sleep apnea hypopnea syndrome

• pCO2 – partial pressure of carbon dioxide

• pO2 – Partial pressure of oxygen

• REM – Rapid eye movement

• RN – Registered Nurse

• SaO2 – Oxygen saturation

• Tx – Treatment

• W/ - With

Page 7: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

7

Neuronal Respiratory ControlNeuronal Respiratory Control

• Neuronal ControlNeuronal Control

– Rhythmic cycle of breath regulated by Rhythmic cycle of breath regulated by

medullary neuron interactionmedullary neuron interaction

– Efferent activityEfferent activity

• Cranial nerves of upper airwayCranial nerves of upper airway

• Chest wall muscle innervationChest wall muscle innervation

Page 8: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

8

Neuronal Control (cont.)Neuronal Control (cont.)

• Medullary groups influenced by pontine & Medullary groups influenced by pontine &

suprapontine descending pathwayssuprapontine descending pathways

• These pathways influenced by sleep-wake These pathways influenced by sleep-wake

cycle, particularly Reticular Activating cycle, particularly Reticular Activating

System activity System activity

Page 9: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

9

Obstructive Sleep Apnea Obstructive Sleep Apnea Hypopnea - DefinitionHypopnea - Definition

• Episodes of airway obstruction during sleep Episodes of airway obstruction during sleep

resulting in recurrent arousals associated resulting in recurrent arousals associated

with:with:

– Otherwise unexplained excessive daytime Otherwise unexplained excessive daytime

sleepiness AND...sleepiness AND...

Page 10: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

10

Definition (cont.)Definition (cont.)

• ……AND AND >> 2 of the following 2 of the following• Loud disruptive snoringLoud disruptive snoring

• Nocturnal choking/gasping/snortNocturnal choking/gasping/snort

• Recurrent nocturnal awakeningRecurrent nocturnal awakening

• Unrefreshed sleepUnrefreshed sleep

• Daytime fatiqueDaytime fatique

• Impaired concentrationImpaired concentration

• ...AND......AND...• Documented overnight sleep monitoringDocumented overnight sleep monitoring

• >5 episodes hypopnea and apnea per hour>5 episodes hypopnea and apnea per hour

Page 11: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

11

More DefinitionsMore Definitions

• ApneaApnea– <20% baseline airflow for <20% baseline airflow for 10 seconds in adults 10 seconds in adults

• HypopneaHypopnea 30% baseline airflow30% baseline airflow 10 seconds10 seconds 90% of duration of 90% of duration of airflow airflow 30% baseline flow 30% baseline flow airflow accompanied by airflow accompanied by 4% 4% oxygen saturation oxygen saturation

Page 12: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

12

EpidemiologyEpidemiology

• Overall Overall 2-20%2-20% depending on sex and symptoms depending on sex and symptoms

• Estimated 3 million men and 1.5 million womenEstimated 3 million men and 1.5 million women

• M:F 2-4:1M:F 2-4:1

• Daytime sleepiness 2-4%Daytime sleepiness 2-4%

– (narcolepsy 0.02-0.06%)(narcolepsy 0.02-0.06%)

• Up to 85% in obese personsUp to 85% in obese persons

Page 13: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

1 - UpToDate, 2006 13

HistoryHistory

• Charles Dickens - “The Postumous Papers Charles Dickens - “The Postumous Papers of the Pickwick Club”of the Pickwick Club”– Pickwickian SyndromePickwickian Syndrome– (Obesity Hypoventilation Syndrome)(Obesity Hypoventilation Syndrome)

• ObesityObesity• HypersomnolenceHypersomnolence• Signs of Chronic Alveolar HypoventilationSigns of Chronic Alveolar Hypoventilation• PolycythemiaPolycythemia• Sleep apneaSleep apnea

Page 14: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

14

Practical PredictorsPractical Predictors

• HTNHTN

• History of habitual snoringHistory of habitual snoring

• Observed reports of nocturnal choking or Observed reports of nocturnal choking or

gaspinggasping

• Neck size > 17 inchesNeck size > 17 inches

Page 15: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

15

Airway PatencyAirway Patency

• Airway size - flow resistanceAirway size - flow resistance– Anatomic traitsAnatomic traits

• Neck sizeNeck size

• ObesityObesity

• Crowded upper airwayCrowded upper airway– Large tongueLarge tongue

– Small chinSmall chin

• Nasopharyngeal tumorsNasopharyngeal tumors

Page 16: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

16

Page 17: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

17

OSAH EtiologyOSAH Etiology

• Sleep affects respiratory control systemSleep affects respiratory control system

– Reduced tonic input to upper airway musclesReduced tonic input to upper airway muscles

– Diminished reflexes that protect against airway Diminished reflexes that protect against airway

collapsecollapse

Page 18: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

18

Etiology (cont)Etiology (cont)

• Exaggerated inspiratory effortExaggerated inspiratory effort• Decreased gas exchangeDecreased gas exchange• Resolves with arousal or change in sleep Resolves with arousal or change in sleep

state state

Page 19: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

19

Recurrent ApneaRecurrent Apnea

• Instability of feedback controlInstability of feedback control

• Ventilation Ventilation cyclescycles instead of being instead of being maintainedmaintained at a constant level at a constant level

Page 20: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

20

MechanismMechanism

• Sleep…Sleep…

Upper airway tone...Upper airway tone...

• Obstruction...Obstruction...

• Apnea…Apnea…

pO2, pO2, pCO2…pCO2…

Page 21: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

21

Mechanism (cont.)Mechanism (cont.)

• ……Arousal…Arousal… Upper airway tone…Upper airway tone…• Resumption of breathing…Resumption of breathing…• Hyperventilation…Hyperventilation…• Return to sleep…Return to sleep… Upper airway tone…Upper airway tone…• This occurs HUNDREDS of times each nightThis occurs HUNDREDS of times each night

Page 22: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

22

Etiology (cont)Etiology (cont)

• Upper airway is Upper airway is destablilizeddestablilized

• Partial or Partial or complete complete obstruction of obstruction of nasopharynx, nasopharynx, oropharynx, or oropharynx, or bothboth

Page 23: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

23

PresentationPresentation

• Primarily relate to effects on pt’s sleepPrimarily relate to effects on pt’s sleep

– Typically overweight menTypically overweight men

– Awaken unrestedAwaken unrested

– Daytime somnolenceDaytime somnolence

– Disruptive snoring Disruptive snoring

• 45% men & 30% women >65 yrs old snore45% men & 30% women >65 yrs old snore

Page 24: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

24

SleepinessSleepiness(Of course we need to define sleepiness)(Of course we need to define sleepiness)

• MildMild– Sleep during times of restSleep during times of rest– Incidental functional impairmentIncidental functional impairment

• ModerateModerate– Sleep during activities requiring some attentionSleep during activities requiring some attention

• ConcertsConcerts

• MeetingsMeetings

• PresentationsPresentations

Page 25: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

25

Sleepiness (cont.)Sleepiness (cont.)

• SevereSevere– Sleep during activities requiring at least Sleep during activities requiring at least

moderate attentionmoderate attention• EatingEating

• ConversationConversation

• WalkingWalking

• DrivingDriving

– Marked functional impairment Marked functional impairment

Page 26: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

26

Differential Diagnosis of Differential Diagnosis of SleepinessSleepiness

• Sleep restrictionSleep restriction

• NarcolepsyNarcolepsy

• Restless leg syndromeRestless leg syndrome

• Cardiovascular, respiratory, metabolic Cardiovascular, respiratory, metabolic disturbancesdisturbances

• Drug addictionDrug addiction

• DepressionDepression

Page 27: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

27

OSAH Diagnosis-suspicionOSAH Diagnosis-suspicion

• Presentation as abovePresentation as above

• Witnessed apneic periods, nocturnal Witnessed apneic periods, nocturnal

gasping or chokinggasping or choking

– >10 events per hr typical for symptomatic pts>10 events per hr typical for symptomatic pts

• Body habitusBody habitus

• HTNHTN

Page 28: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

28

Diagnosis-definitiveDiagnosis-definitive• Nocturnal PolysomnographNocturnal Polysomnograph

– EEGEEG– ElectromyelographElectromyelograph

• ChinChin activity during REMactivity during REM

• Limbs Limbs – checks non-respiratory causes of arousalchecks non-respiratory causes of arousal

– Electro-oculogramElectro-oculogram• Detects REMDetects REM

Page 29: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

29

DDx (cont.)DDx (cont.)

– Nasal/oral airflowNasal/oral airflow

– Thoracic/abdominal movementThoracic/abdominal movement

– Oxygen saturationOxygen saturation– Cardiac rate & rhythmCardiac rate & rhythm– Body positionBody position

Page 30: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

30

Split studiesSplit studies

• Part 1 – Definitive diagnosisPart 1 – Definitive diagnosis

• Part 2 – Optimal CPAP levelPart 2 – Optimal CPAP level

Page 31: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

31

Terms of OSA QuantificationTerms of OSA Quantification

– Apnea-hypopnea index (AHI)Apnea-hypopnea index (AHI)

– Apnea Index (AI)Apnea Index (AI)

– Respiratory Disturbance Index (RDI)Respiratory Disturbance Index (RDI)

– Respiratory Arousal Index (RAI)Respiratory Arousal Index (RAI)

Page 32: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

32

Apnea-Hypopnea Index (AHI)Apnea-Hypopnea Index (AHI)

• # episodes apnea & hypopnea / # hrs sleep# episodes apnea & hypopnea / # hrs sleep

OSAH = AHI > 15 / hrOSAH = AHI > 15 / hr

Page 33: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

33

Apnea IndexApnea Index

• # apneic episodes / # hrs sleep# apneic episodes / # hrs sleep

Page 34: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

34

Respiratory Disturbance Index Respiratory Disturbance Index (RDI)(RDI)

• # times per hour SaO2 drops > 3%# times per hour SaO2 drops > 3%

– <5 - No OSA<5 - No OSA

– 5-15 - Mild OSA5-15 - Mild OSA

– 16-30 - Moderate OSA16-30 - Moderate OSA

– >30 - Severe OSA>30 - Severe OSA

Page 35: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

35

Respiratory Arousal Index (RAI)Respiratory Arousal Index (RAI)

• Computed with EEG measurementComputed with EEG measurement

• # inspiratory associated arousals per hour of # inspiratory associated arousals per hour of

sleepsleep

Page 36: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

36

OSAH ComplicationsOSAH Complications

• SleepinessSleepiness

– Somnolence during activitiesSomnolence during activities

– Impaired concentrationImpaired concentration

• Systemic hypertensionSystemic hypertension

• Vascular diseaseVascular disease

Page 37: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

37

OSAH and CV DiseaseOSAH and CV Disease

• Arousals – bursts of sympathetic activityArousals – bursts of sympathetic activity– Not goodNot good

SaO2 / SaO2 / SaO2 causes ischemia then reperfusion SaO2 causes ischemia then reperfusion– Oxydative stressOxydative stress

• SubsequentSubsequent– HTNHTN– Insulin resistanceInsulin resistance– InflammationInflammation

• Ultimately leading to…Ultimately leading to…– CV endothelial dysfunctionCV endothelial dysfunction

Page 38: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

38

Other Potential ComplicationsOther Potential Complications

• StrokeStroke

• Cardiac arrhythmiaCardiac arrhythmia

• Pulmonary HTNPulmonary HTN

• Morning head acheMorning head ache

• Peri-operative complicationsPeri-operative complications

– Impaired intubationImpaired intubation

– Impaired arousal from sedativesImpaired arousal from sedatives

Page 39: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

39

PreventionPrevention

• Modifiable Modifiable risk factorsrisk factors::– ObesityObesity– Exacerbative medicationsExacerbative medications– Inadequate sleepInadequate sleep

• Modifiable Modifiable complicationscomplications::– Machinery/motor vehicle operationMachinery/motor vehicle operation– Inform Anesthesiologist before elective Inform Anesthesiologist before elective

proceduresprocedures

Page 40: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

40

Treatment - GeneralTreatment - General

• Depends on severity of diseaseDepends on severity of disease

– No Tx for < 15 events per hourNo Tx for < 15 events per hour

• Behavioral ModificationsBehavioral Modifications

Page 41: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

41

Treatment - General (Cont.)Treatment - General (Cont.)

• Weight lossWeight loss

– 5-10% 5-10% body weight may be effective body weight may be effective

• Nasal CPAPNasal CPAP

• Oral appliancesOral appliances

Page 42: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

42

Treatment - MedicalTreatment - Medical

• Vasoconstrictive spraysVasoconstrictive sprays

• Weight loss medsWeight loss meds

• Oxygen (select patients)Oxygen (select patients)

• Chemical avoidanceChemical avoidance– Sedative hypnoticsSedative hypnotics– AlchoholAlchohol– AntihistaminesAntihistamines

Page 43: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

43

Treatment - SurgicalTreatment - Surgical

• HyoplastyHyoplasty

• LinguloplastyLinguloplasty

• Mandibular advancementMandibular advancement

• UvulopalatopharyngoplastyUvulopalatopharyngoplasty

• TracheostomyTracheostomy

Page 44: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

44

Treatment - SurgicalTreatment - Surgical

• For loud snoring:For loud snoring:

– Laser-assisted uvuloplastyLaser-assisted uvuloplasty

– Radiofrequency tissue ablationRadiofrequency tissue ablation

– May May apnea and/or delay definitive treatment apnea and/or delay definitive treatment

Page 45: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

45

PrognosisPrognosis

• Natural history largely unknownNatural history largely unknown• IF dz progresses, it does so slowlyIF dz progresses, it does so slowly• Implications with death:Implications with death:

– ? ? in-hospital mortality d/t: in-hospital mortality d/t:• Cardiorespiratory failureCardiorespiratory failure• Pulmonary embolusPulmonary embolus• Case reports complications of anesthesiaCase reports complications of anesthesia

– Accidents Accidents • 2-7 times greater chance of MVC2-7 times greater chance of MVC• Equipment operationEquipment operation

Page 46: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

46

CentralCentral Sleep Apnea Syndrome Sleep Apnea Syndrome

• > 10 second cessation of breathing in the > 10 second cessation of breathing in the absence of respiratory effort.absence of respiratory effort.

Page 47: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

47

CentralCentral Sleep Apnea Syndrome Sleep Apnea Syndrome

• Airflow stops without obstructionAirflow stops without obstruction

• Interruption of central respiratory driveInterruption of central respiratory drive

• Airflow AND respiratory effort are absentAirflow AND respiratory effort are absent

• Disorder of Apneic Threshold Disorder of Apneic Threshold

• Relation to OSA (Mixed Apnea)Relation to OSA (Mixed Apnea)

Page 48: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

48

CSAS - EtiologyCSAS - Etiology

• Neural disordersNeural disorders

– PoliomyelitisPoliomyelitis

– Posterior fossa tumorsPosterior fossa tumors

– Idiopathic failure of Idiopathic failure of

central breathing central breathing

controlcontrol

• Complication of Complication of OSAHOSAH

• Narcotic induced Narcotic induced CSASCSAS

• High altitude induced High altitude induced periodic breathingperiodic breathing

Page 49: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

49

CSAS – Etiology (Cont.)CSAS – Etiology (Cont.)

• Heart FailureHeart Failure– 37% of Pts with HF & LVEF < 45% have 37% of Pts with HF & LVEF < 45% have

CSASCSAS– 12% have OSAH12% have OSAH

Page 50: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

50

CSAS - PresentationCSAS - Presentation

• InsomniaInsomnia

• Nocturnal awakeningsNocturnal awakenings

• Nocturnal polysomnographNocturnal polysomnograph

– No evidence of obstructionNo evidence of obstruction

– No respiratory movementNo respiratory movement

Page 51: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

51

CSAS – Definitive DxCSAS – Definitive Dx

• Pleural pressure Pleural pressure

monitoring monitoring

• Airflow Airflow

monitoringmonitoring

Both recorded and at Both recorded and at least one shown to be least one shown to be abnormal during abnormal during eventsevents

Page 52: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

52

CSAS - TreatmentCSAS - Treatment

• Tx underlying causeTx underlying cause

• AcetazolamideAcetazolamide

• O2 for non-HF ptsO2 for non-HF pts

• Phrenic nerve Phrenic nerve

stimulationstimulation

• Inspired CO2Inspired CO2

• N-CPAP (? w/ CO2)N-CPAP (? w/ CO2)

• CV med optimizationCV med optimization

Page 53: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

53

In Review…In Review…

• 3 types of sleep apnea3 types of sleep apnea– Obstructive (common)Obstructive (common)– Central (less common)Central (less common)– Mixed (very common)Mixed (very common)

• Possibly serious implicationsPossibly serious implications

• Multiple effective tx optionsMultiple effective tx options

• Awareness is keyAwareness is key

Page 54: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

54

Remember the Cases?Remember the Cases?

• 35 year old male with loud snoring. Spouse states she can’t 35 year old male with loud snoring. Spouse states she can’t sleep in the same room with him.sleep in the same room with him.

• 46 year old obese male in for annual CPE observed by you 46 year old obese male in for annual CPE observed by you to appear sleepy during the medical interview.to appear sleepy during the medical interview.

• In Hospital: Call at 0025 from RN that 42 year old female In Hospital: Call at 0025 from RN that 42 year old female diabetic in with lower extremity cellulitis has oxygen diabetic in with lower extremity cellulitis has oxygen saturation in the low 80s when checking vital signs. saturation in the low 80s when checking vital signs. Awoke when stimulated and SaO2 improved.Awoke when stimulated and SaO2 improved.

Page 55: By: John J. Beneck MSPA, PA-C1 Sleep Apnea Everything You Never Wanted to Know About…

55

ReferencesReferences

• Westbrook, PR. An overview of Obstructive Sleep Apnea: Epidemiology, Pathophysiology, Clinical Westbrook, PR. An overview of Obstructive Sleep Apnea: Epidemiology, Pathophysiology, Clinical Presentation, and Treatment in Adults. In UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, Presentation, and Treatment in Adults. In UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2006.2006.

• Kingman, PS. Sleep Disordered Breathing in Adults – Definitions. In UpToDate, Rose, BD (Ed), Kingman, PS. Sleep Disordered Breathing in Adults – Definitions. In UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2008.UpToDate, Waltham, MA, 2008.

• Eckert DJ, Jordan AS, Mercha P, Malhotra A. Central Sleep Apnea: Pathophysiology and Treatment. Eckert DJ, Jordan AS, Mercha P, Malhotra A. Central Sleep Apnea: Pathophysiology and Treatment. Chest 2007 Feb: 131(2): 595-607Chest 2007 Feb: 131(2): 595-607

• Douglas NJ. Harrison’s online. Douglas NJ. Harrison’s online. http://www.merckmedicus.com/pp/us/hcp/frame_textbooks.jsp?pg=http://www.accessmedicine.com/content.aspx?aid=2869600. Accessed 8/12/08. Accessed 8/12/08