Unit 3 Sleep Apnea
Case Studies
Case study # 1
Mr. Franklin is a thin 73 year old WM whose wife is concerned about his activities at night. She describes him as breathing faster, faster then stopping for several seconds before he starts the cycle again.
What other history do you need to hear?
The patient has no prior history of lung disease, or cardiac disease. He denies morning headaches. His wife states that he’s not confused, nor does he fall asleep often in the daytime. He c/o frequent urination at night; urination is not difficult nor painful.
He is retired but for his age he stays pretty active. He walks the dog and works in the garden regularly. He drinks one beer on Saturday night as he’s done for 50 years. His feet are frequently swollen at the end of the day.
What would you like to assess by inspection?
His blood pressure is the same at 7AM as it is at 7PM. His resting Sp02 is 92% with HR 50bpm but impulses fade out every once in a while--- as if there is poor contact or poor perfusion
There is no jugular vein distension. His abdomen is mildly distended. His uvula is grossly normal in size, location and color His HEENT exam is basically WNL
What would you like to assess by palpation/percussion?
The tracheal is midline, there is good chest excursion & there is no vocal fremitus. There is no palpable lymphatic or thyroidal material
His pulse is slow, irregular and present in all four extremities.
What would you like to assess by auscultation?
He has a few inspiratory crackles in the bases. No wheeze, rhonchi or stridor. When listening over the heart you hear S3.
What lab work would you like to see ordered?
The doctor orders the following studies:
ABG on room air:
|
PH |
PaC02 |
HC03 |
P02 |
|
7.38 |
43 |
25 |
80 |
12 lead EKG: first degree heart block with evidence of an old MI in the RV
CBC: H/H a bit low
Electrolytes: WNL for age
EEG: WNL for age
X-ray: while in the bilateral bases we find Kerley B lines, increased hilar markings and the C/T ratio is higher than .5. On a lateral decubutus there is tiny plural effusion on the Right side.
Thyroid studies are WNL
At this point, is a polysomnographic study indicated?
No, but we need to assess him for MSLT to rule out periods of excessive daytime sleepiness for completeness. Is loss of sleep effecting him negatively?—no, he is WNL
We might also consider placing him on a halter monitor for 24 hour EKG to r/o nocturnal arrhythmia. ---We discover that his first degree heart block slips into 2nd degree periodically throughout the day and frequently at night.
If we took him to the sleep lab, what could we use to assess his sleep level?
If we placed him in a sleep lab we could monitor:
1. sleep levels by EEG
2. Oxygenation by pulse oximetry
3. upper chest wall movement by motion detectors
4. lower chest wall movement by motion detectors
5. eye movement by EOG [placed in the corner of the eye]
6. air flow by thermistor at the lip/nose
7. cardiac status by EKG
8. chin movement by EMG
9. leg movement by EMG
Does this patient fit the profile for OSA?
Not at all
Does this patient fit the profile for CSA?
Not at all
What do you think is going on with this man?
He has s/s of Congestive heart failure which has as s/s Cheyne-Stoke breathing due to lowered CO causing lag in central and peripheral chemoreceptors
Case study # 1
Mr. Kent is a chubby 55 year old BM whose wife is concerned about his activities at night. She describes him as snoring so loudly that she has to kick him. She’s sent him to the doctor because he has started to ‘stop breathing’ with these episodes
What other history do you need to hear?
The patient has a long history of COPD. He is not 02 dependent and he treats himself with inhaled steroids, and Beta II agonists and cholinergic blockers. He c/o morning headaches and, of frequent naps all day long. His wife states that he falls asleep in the recliner watching TV every night—she has to call him to bed.
He is retired for medical reasons. He drinks one glass of wine with dinner.
What would you like to assess by inspection?
He has increased AP diameter.
His blood pressure is higher at 7AM than it is at 7PM. His resting Sp02 is 91% with HR 99bpm There is no jugular vein distension.
His uvula is grossly reddened and swollen. His neck seems thicker than usual—like a football player. Other wise, his HEENT exam is basically WNL
What would you like to assess by palpation/percussion?
The tracheal is midline, there is good chest excursion & there is no vocal fremitus. There is no palpable lymphatic or thyroidal material
His pulse is regular.
What would you like to assess by auscultation?
He has diffuse wheezes to all lobes which has poor response to Beta II. No stridor. BBS are distant
What lab work would you like to see ordered?
The doctor orders the following studies:
ABG on room air:
|
PH |
PaC02 |
HC03 |
P02 |
|
7.37 |
48 |
27 |
57 |
12 lead EKG: NSR with Right ventricular hypertrophy
CBC: WNL
Electrolytes: WNL
EEG: WNL
X-ray: baseline COPD changes not to different from his earlier ones
Thyroid studies: WNL
Halter monitor: rare PVC at night with periods of SVT and Sinus tachycardia
At this point, is a polysomnographic study indicated?
Yes, [1] he has s/s of cor pulmonale but his daytime Pa02 is above 55 [2] his PE shows s/s of being at risk for OSA [3] he has documented nocturnal cardiac arrhythmias
If we took him to the sleep lab, what could we use to assess his sleep level?
If we placed him in a sleep lab we could monitor:
10. sleep levels by EEG
11. Oxygenation by pulse oximetry
12. upper chest wall movement by motion detectors
13. lower chest wall movement by motion detectors
14. eye movement by EOG [placed in the corner of the eye]
15. air flow by thermistor at the lip/nose
16. cardiac status by EKG
17. chin movement by EMG
18. leg movement by EMG
When we take him to the sleep Lab for the night we discover the following;
Mr. Kent first goes into a period of alpha waves—the chest movement and the air flow are synched, both are slowed but regular and his extremities stop moving. His Sp02 drops from awaken 92% to 89%
After a few minutes, you see theta waves with sleep spindles and K complexes & after a few more minutes the theta waves increase. His RR and HR continue to drop. His Sp02 stabilizes at 87-88%
At this point, is there anything pathological about his sleep patterns?
He is undergoing the normal staging from awake to stage 1 and stage 2 with normal decreases in VE and HR. His Sp02 is expected to drop, but the level of hypoxemia is troublesome.
Mr. Kent goes from stage 2 into stage 3 with slow delta waves. His HR drops as does his FF. His Sp02 drops to 86%. After a few minutes of this, his respiratory rate becomes more rapid and variable. On EKG you see sinus tachycardia & 2 PVC/ minute. His Sp02 increases back to 88%. Now his EOG is showing movement of the eyes. His chin falls down
At this point, is there anything pathological about his sleep patterns?
He is moving into REM sleep, so his VE and HR have increased, not surprisingly his Sp02 is rising.
His eyes are moving rapidly and his chin has dropped because his skeletal muscles are paralysed—this is normal for REM sleep—but his EKG shows distressing changes.
Mr. Kent is deeply into REM sleep. He is snoring now. You see that the upper and lower chest motion detectors are showing a RR of 18 bpm, but the thermistor at the lip and mouth both show a RR of zero. The Sp02 drops from 88% to 50%. The EKG goes into SVT with 5 PVC/minute. After 23 seconds of this, he arouses back up into N-REM sleep
At this point, is there anything pathological about his sleep patterns?
Yes, he is have an apnea period caused by airway obstruction. The resulting hypoxemia is triggering the EKG changes. He has woken himself up but if this goes on more than 5 x an hour, we have a diagnosis of OSA
How would we treat Mr. Kent?
1. get him to lose weight
2. get him nocturnal supplementary 02 for cor pulmonale
3. repeat the halter test to assess the supplementary 02
4. consider changing positions if sleep studies showed differences as patient turned into different positions
5. consider CPAP or BiPap ST/D with sleep studies to titrate the parameters
6. consider surgery or tracheostomy if above doesn’t work
7. repeat the sleep study [can use simpler home versions] to assess the effectiveness of the clinical decision