obstructive sleep apnea and pulmonary embolism

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Khushbu on Jul 19, 2012 Says :

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Obstructive sleep apnea and pulmonary thromboembolism- a case MICU Dr. SUNIL PAWAR KEM HOSPITAL,PAREL MUMBAI

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HISTORY 45 yr/ M r/o dahisar Symptomatic since 10 days acute onset breathlessness dry cough symptoms were progressive No h/o chest pain, expectoration,palpitations No h/o fever,trauma,immobilization,PND, oliguria h/o pain in calf 10 days back

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Past h/o IHD in 2003 no h/o kochs h/o sleep disturbance in night,day time sleepiness,snoring Personal history veg., non addict, sales agency owner HTN on regular treatment Treatment history inj STK 5 lack unit over 1 hr f/b 1 lack u/hr for 24 hrs in private hospital 1 day back

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EXAMINATION Pulse : 100/min reg Blood pressure : 100/68 mm Hg on dopa 10 micro/kg/hr RR : 36/min , unable to lie flat in bed JVP not raised HT: 170 cm WT: 101 kg BMI:35 kg/sq m Pallor/cya/club/edema absent RS : breath sounds b/l equal no crepts CVS: S1 S2 normal PA/CNS: WNL

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CLINICAL IMPRESSION Acute onset breathlessness in morbidly obese person Acute pulmonary embolism Acute left ventricular failure Myocardial infarction Acute severe asthma Extrinsic allergic alveolitis

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INVESTIGATIONS

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ECG : sinus tachycardia,S1Q3T3,T inv in V1-V6 CXR : Cardiomegaly (ratio-65%) ABG : day1 Ph 7.36 PaO2 70 mmhg PaCO2 27 mmhg HCO 3 29 day6 Ph 7.36 PaO2 70 mmhg PaCO2 49 mmhg HCO 3 29 CTPA : Pulmonary thromboembolism b/l descending pulm arteries with lung infarct to rule out acute on chronic PTE LL DOPPLER : WNL 2 D ECHO : dilated RA & RV

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CTPA

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ACLA/lupus anticoagulant : normal Thrombophilia profile cannot be sent due to starting of heparin early Homocysteine :27 (upto 13 micromol/ltr) HIV /ANTI HCV/HBsAg : NEG

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DIAGNOSIS PULMONARY THROMBOEMBOLISM IN SUSPECTED CASE OF OBSTRUCTIVE SLEEP APNEA WITH HYPERHOMOCYSTEINEMIA

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Patient was started on Inj heparin T.Warfarin 5 mg/day folate and B 12 supplement Inj Dopamine was tapered over 4 days

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OBSTRUCTIVE SLEEP APNEA

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DEFINITION Sleep apneas are divided into: Central sleep apnea: neural drive to all respiratory muscles is abolished Obstructive sleep apnea: unexplained excessive day time sleepiness with at least 5 apnea/hypopnea events per hour. Airflow ceases despite continuing respiratory drive because of occlusion.

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Apnea is cessation or near cessation of flow (inspiratory flow decreases to < 20%) = 10 seconds Hypopnea is continued breathing, but ventilation decreases by 50% for = 10 seconds Apnea-Hypopnea Index (AHI) – total number of apneas and hypopneas per hour of sleep

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PATHOLOGY

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PREDISPOSING FACTORS Male sex Middle age 40-65 yrs BMI >30 Shortened mandible and/or maxilla Hypothyroidism Acromegaly Smoking Myotonic dystrophy Ehler danlos syndrome Childhood causes – adenoids, tonsils

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CLINICAL FEATURES Incidence : 1-4 % of middle age, males > females Clinical presentation : Daytime sleepiness, impaired vigilance, Cognitive performance, snoring, disturbed Sleep, hypertension Increase Risk of MI 20 %, stroke 40 % Associated with Diabetes mellitus and hepatic steatosis

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OSA:RISK FACTOR FOR PULMONARY EMBOLISM Increase weight gain and obesity : resistance to leptin Increase reactive oxygen species Superoxide release from neutrophils Increase levels of catecholamines Increase platelet aggregability Pulmonary hypertension Increase homocysteine level Insulin resistance Increase c reactive protein Arnulf I,merino- andreu M et al.Obstructive sleep apnea and venous thromboembolism.JAMA 2002;287:2655-6 Weiss,Sleep Medicine 2000 Philipps. Curr Opin Pulm Med 2002

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DIFFERENTIAL DIAGNOSIS Insufficient sleep Shift work Psychologic : depression Drugs: sedative as well stimulant Narcolepsy: less common, teens, cataplexy Idiopathic hypersomnolence

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DIAGNOSIS Sleep history Physical Examination : obesity, jaw structure, upper airway anatomy, BP Sleep Questionnaires Polysomnography

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BERLIN QUESTIONNAIRE Consists of ten questions divided into 3 categories, Snoring, Daytime somnolence, and Hypertension and Obesity (BMI > 30 kg/m2). high risk of OSA : positive response in two or more of Persistent symptoms (>3 to 4 times per week) in two or more questions about snoring; Persistent symptoms (>3 to 4 times per week) of daytime sleepiness or falling asleep while driving; History of hypertension or obesity.

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POLYSOMNOGRAPHY Detailed overnight sleep study with recordings of: ECG (arrythmias), EEG (brain waves – level of sleep ), EOG (eye movements – REM sleep) and submental EMG (muscle twitches - REM sleep)to evaluate sleep Ventilatory variables: movement of chest wall and airflow at the mouth and nose Arterial O2 saturation (finger/ear oximetry) Heart rate

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TREATMENT Conservative Therapy - Weight loss, avoid alcohol and other sedative drugs (BZD) Drugs : modafinil Continuous Positive Airway Pressure (CPAP) Most effective & treatment of choice Oral Appliances Pillar technique Surgery

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Continuous Positive Airway Pressure Indications AHI >15 events/h or AHI 5-14 events/h with clinical sequelae (excess daytime sleepiness, cognitive impairment, mood, insomnia, cardiovascular dis.) Consider CPAP in patients with lower AHI (~5) who have symptoms, perform mission critical work (pilots, bus drivers) Mechanism: Splints open the upper airway to prevent airway collapse

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Benefits Improvements in: sleepiness, QoL, mood, cognitive function, healthcare costs, BP control ??

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CPAP Compliance Usually Poor Better with: Weekly phone calls Written info : OSA and CPAP Intense hospital and home care support Adverse Effects Dry mouth, rhinitis, congestion : treat symptomatically

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ORAL APPLIANCES Mandibular Repositioning Splint Protrude the mandible forward and hold tongue more anteriorly, away from the posterior pharyngeal wall More effective in patients with mild – moderate OSA, AHI 5-15 events/h High drop outs

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PILLAR TECHNIQUE Three less than 1 inch small rods inserted in soft palate to make it stiffen. One day procedure Done under local anaesthesia

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SURGERY Indication: CPAP or oral appliance ineffective Procedures Uvulopalatopharyngoplasty – resection of uvula and soft palate Craniofacial Reconstruction – tongue advancement or maxillo-mandibular osteotomy Tracheostomy – bypasses obstruction, for severe OSA patients Bariatric surgery

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Have A Nice Sleep Thank you

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obstructive sleep apnea as a risk for venous and arterial thrombosis
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