osa

 watch pad measures tone

in lab study

nasal cannula

strap on chest

struggling to breathe

nose tells if snoring or breathing from the nose

not as involved as a regular sleep study

trac

sleep apnea

not breathing well here, struggling well here

breathing. 

pulse ox is dropping measures pulse and rhythm, pulsing dropping

56 AHI severe

> 30 considered severe

5 5-15 15-30

mild OSA

moderate OSA, severe OSA

cessation of flow for > 10 seconds

hypopnea reduction in flow with desaturation

apnea / hypopnea

apnea not breathing at all

hypopnea decrease in flow w/ desaturation associated w/ it

eeg limb movement

EKG can pick up arrhythmias

if going into vtach or bradycardiac events could disrupt sleep

should be ablet o manager sleep apnea patients

complex w/ multiple sleep disorders, send to sleep specialist

see patients to be able to treat them

no point in testing if not treating them

getting proper test.

narcolepsy sending for sleep study will not make diagnosis

if this is a clear case, sleep apnea patient that is fine, young 25 year old since high school

no features of sleep apnea

not functioning may have narcolepsy/ hypersomnolence

discuss what patient goes through

all leads hook up to

sleep labs look like

technicians in separate room, no technicians staring at them

if diagnosed w/ sleep apnea prepare for treatments

mild between 5-15 events, want to counsel for weight loss, treat nasal congestion, talk to them about sedatives like alcohol, sleeeping pills can worsen symptoms

if symptomatic can treat

if snoring / sleep great all night wide awake during the day, dosing off, no problems from work, may not be needed to treat

symptomatic need to treat

near miss accidents

diet, exercise, if morbdily obese can offer bariatric surgery

positional

sleep on sides, have minimal events

treatments commercially available

tennis balls to t-shirt, put a wedge on the side

$20-30 wear positional devices that make it uncomfortable

management

CPAP - gold standard

most patients able to tolerate if counseled properly

the correct mask option

gold standard treatment

sleep apnea, dental appliances, counsel on wt loss

blows air in to stent the airway open

mechanical problem, pill won't rid of issues

push all the tissue out of the way, so air stays open

pump air to stay open

pressure to help them stay in deep sleep

pressure setting, mask, size of mask

heated humidifier

usually heated tubings

get regular tubings

get condensation in them and get air and condensation

tradiationally in lab overnight titration / polysomnography test

exact pressures CPAP titration

not comfortable can order autopap machine

machine that titrates itself while they sleep

bipap indicated for central apnea / high pressures beceause more comfortable than cpap

medicare - note showing you ordered a sleep study

patient worrieda bout sleep apnea, ordering sleep stduy, medicare won't approve DME won't pay

positive sleep study, prescribe the machine for them, have them follow up and use the machine

use > 4 hours per nights and 70% of nights

get a compliance report from their machine

if not compliant in first 3 months

>4 hours a night 70% medicare will not pay for the machine

3 months to train how to use

patient comes back after 30 dayts, start troubleshooting

could be mask and pressure

could be humdification

relationship between hours used sleepiness, quality of life, and blood pressure

reduction of arrhythmias

compliance report, old 

patient using it more than 4 hours a night, black is less than 4 hours a night

empty didn't use that night

percentage of nights using more than 4 hours.

not very compliance below, lots of empty spots and black, less than 4 hours a night

early follow up come back in 4 weeks, 

hard to get back in office

get machine from office

partners are supportive

exhalation ports and bothers partners

partners are happy, no longer snoring at nighttime

explain the goal, machine at least 4 hours a night, use every night

nasal congestion / nasal steroids, nasal humidification

sick - nasal infection, afren

Oxymetazoline

sedatives make sleep apnea worse, if they use just sedatives and not machine can make it worse

trying on shoes

nasal pillow mask, doesn't mean that is mask they are stuck with

oronasal full face masks

CPAP masks be chosen

can't keep mouth closed, blows out of mouth

don't tolerate nasal masks

nasal go over nose claustrophobic

nasal pillow mask

nasal cannula but bigger

better for beards

therapeutic pressure

low pressure and titrate them up as they are falling asleep

pressures up as they sleep

MAD - dental devices, oral appliance device

to pull the lower jaw forward, stiffening up tissue at the top

could exacerbate TMJ, change patients bite

should not go to regular dentists

device bill 2000-3000

not trained to treat sleep patients

dentists make device, not send to another study

can give device that makes osa works

devices mild to moderate sleep apnea

not for severe sleep apnea

follow up sleep study pulls lower jaw forward, and brings back of pharynx

surgery 50% effective

not a fun surgery, all tissue trimmed away, worse sore throat of their life for a week

tonsillectomy / nasal septoplasty, done in kids and teenagers with large tonsils w/ sleep apnea

maxillomandibular advancement, break jaw and advance it

long recovery period 90% effective

tracheostomy life threatening sleep apnea had cardiac arrest

tracheostomy to treat

bypasses the whole upper airway

uvulopalatopharyngoplasty trim away

beig opening in th eback of the throat. 

posterior pharynx blocks airway, gets rid of uvula and soft palate, but obstruction can be in the back

inspire, used for those who can't tolerate cpap

inspire two incisions

chin and chest

battery in chest

dissected down to thoracic lead

incision under chin and dissect under the wire

under the chin connect around hypoglossal nerve

device

turns on

delay for it to go on 

starts stimulating after 30 minutes

get a stimulation to hypoglossal nerve each time they take a breath

opens posterior pharynx

removes apnea

moderate to severe sleep apnea

BMI <40

AHI 15 and 100 new guidelines

insurance companies 

15 to 65

works very well as good as CPAP

doesn't get rid of cpap get rid of machine and doing great

drug induced sleep endoscopy to see if airway opens properly

right BMI and AHI

one day surgery morning and afternoon

one month to heal before turning device on

6 month titrating

CPAP gets improvement right away

50,000-100,000

generator, batter, respiratotion sensor

risk factors, surgery, risks of procedure

risks, infection, foreign body in, pneumothorax for poking too far in

sunning of hypoglossal nerve

slurred speech

not a risk free procedure, less than 1%, if you are 1% not going to be happy if not explained

ensure cpap and all sleep follow ups

compliance reports, well rested, side effects, sneezing, running nose

irritation from masks, try different masks

question each time they come

monitor if they lose weight

bariatric surgery lost significant weight > 20 pounds may not need cpap machine, restudy them for sleep apnea

possibly remove cpap machine

if they are drosy and driving, may have gotten rid of sleep apnea

could have secondary causes

sleep apnea and narcolepsy

make sure not to miss anything

relapses still tired want to make sure therapy is adequate

titration, compliance report, how many events patient is having, could have significant events while on cpap

make adjustments to cpap, naso pillow to full face mask

other nonobstructive sleep apnea issue

go to hospital

bring cpap machine clear for surgery, continuous pulse ox and etco2

use machine if being given sedatives after surgery

make anesthesia aware

not tolerating sleep apnea

persistent symptoms

may need multiple sleep disorders

complex sleep disordered breathing

bus driver, compliant on machine, do multiple wake test

not too tired to be driving.

sedatives make sleep apnea worse

if treated

cpap machine, for those patients use it and decide not to

counsel to be cautious about using it

oxygen treat sleep apnea oxygen stent open airway, can make things worse

oxygen is not awlay the answer

treating sleep apnea could help the blood pressure

prevent from arrhythmias

supplemental oxygen while on cpap

cpap / MAD reduce blood pressure, arrhythmias, heart failure, increase EF, anything that helps helps

encourage to use device

if having problems with driving, monitor those patients closer

autotitrate may have a lot of events

increase minimum pressure

sometimes it is the mask

nasal and pillow mask

having large leaks

leads physiologically events in rem, more events in rem sleep, muscles are paralyzed during rem sleep

everything starts collapsing, more events in rem sleep

doesn't change management if most events in rem

certain amount of events in rem per hour

copd co2, bipap, co2 doesn't work for co2, need bipap

either goes bipap or ASV adaptive support ventilation

bipap or avaps

avaps get paid more for dmes

avaps bipap is good enough