Doctor123.org

Sleep Apnea, Emergency Medicine

Basics

Description

- Associated illness: - Various dysrhythmias, particularly atrial fibrillation and bradyarrhythmia - Right and left heart failure - MI - Stroke - Motor vehicle accidents - Hypertension poorly controlled by medical therapies

- Continuous positive airway pressure (CPAP) is the standard of treatment: - Acts as a pneumatic splint by maintaining upper airway patency - BiPAP is an alternative for patients requiring high pressures or with comorbid breathing disorders. - Long-term CPAP therapy decreases BP, insulin resistance, metabolic syndrome, and risk of cardiovascular disease.

  • Disorder characterized by cessation of breathing during sleep:Defined as apneic episodes >10 sec with brief EEG arousals or >3% oxygenation desaturation
  • Risk factors:ObesityMale>40 yr of ageUpper airway anomaliesMyxedema (hypothyroidism)Alcohol/sedative abuseSmoking
  • Associated illness:Various dysrhythmias, particularly atrial fibrillation and bradyarrhythmiaRight and left heart failureMIStrokeMotor vehicle accidentsHypertension poorly controlled by medical therapies

Epidemiology

  • Affects about 9% of middle-aged men and 4% of middle-aged women
  • 80% of moderate or severe cases undiagnosed in middle-aged adults

Etiology

3 classifications of sleep apnea: ‚

  • Obstructive (84%) is due to upper airway closure despite intact respiratory drive:Also known as Pickwickian syndromePharyngeal airway is narrowed
  • Central (0.4%) is due to lack of respiratory effort despite patent upper airway.
  • Complex (15%) is due to a combination of obstructive and central sleep apnea.

Diagnosis

Signs and Symptoms

  • Excessive daytime sleepiness
  • Snoring
  • Irritability

History

  • Significant other apnea report
  • Difficulty sleeping
  • Decreased attention/concentration
  • Depression
  • Decreased libido/impotence

Physical Exam

  • Hypertension, hypoxemia
  • Obesity
  • Craniofacial anomalies
  • Macroglossia
  • Enlarged tonsils
  • Elevated jugular veins (secondary to pulmonary hypertension)
  • Large neck circumference

Essential Workup

  • Pulse oximetry
  • ECG
  • Chest radiograph

Diagnosis Tests & Interpretation

Lab

ABG is the best test to demonstrate hypercarbia and hypoxemia. ‚

Imaging

  • Consider lateral neck soft tissue radiograph to rule out other etiologies of upper airway obstruction.
  • Chest radiograph to assess other etiologies of hypoxemia
  • Chest CT rarely indicated

Diagnostic Procedures/Surgery

Polysomnogram (PSG) is required for diagnosis: ‚

  • >5 apneic episodes per hour
  • Not a consideration for ED management

Differential Diagnosis

  • Asthma
  • Cheyne " “Stokes breathing
  • COPD
  • Diaphragmatic paralysis
  • High altitude " “induced periodic breathing
  • Hypothyroidism
  • Left heart failure
  • Narcolepsy
  • Obesity hyperventilation syndrome
  • Primary pulmonary hypertension

Treatment

Pre-Hospital

Caution not to overventilate patient with chronic CO retention ‚

Initial Stabilization/Therapy

Chin lift/jaw thrust maneuver, oxygen as needed, oral or nasal airway devices ‚

Ed Treatment/Procedures

  • Proper technique is required for airway management:Supplemental oxygen as neededBag-valve-mask ventilation may be difficult:Consider the use of nasal and oral airways2-person technique to ensure a good seal
  • Continuous positive airway pressure (CPAP) is the standard of treatment:Acts as a pneumatic splint by maintaining upper airway patencyBiPAP is an alternative for patients requiring high pressures or with comorbid breathing disorders.Long-term CPAP therapy decreases BP, insulin resistance, metabolic syndrome, and risk of cardiovascular disease.

Endotracheal intubation

  • Higher prevalence of difficult intubation:Patients frequently have higher Mallampati scores.Excess pharyngeal tissue in lateral walls often obstructs airway visualization.Patients have overall lower arterial oxygen saturation.
  • Plan and consider several methods of definitive airway control:Have alternative devices (laryngeal mask airway, bougie) available.Be prepared to perform cricothyroidotomy if necessary.
  • Use neuromuscular blockade only if successful oral intubation is reasonably likely and bag-mask ventilation is easy.
  • Positive end-expiratory pressure for ventilated patients

Medication

  • Insufficient evidence to recommend any medication for treatment
  • See Airway Management for details on induction agents and neuromuscular blockade.
  • Wakefulness-promoting agents (modafinil and armodafinil) are approved as an adjunct to CPAP patients with excessive sleepiness.

Avoid sedative use: ‚

  • Relaxes the upper airway and worsens airway obstruction and snoring

Long-term Management

  • Gold StandardCPAP compliance and weight loss strongly recommended by the American College of Physicians
  • Surgical considerations:Most intend to reduce or bypass the excessive pharyngeal/airway resistance that occurs during sleep.Efficacy is unpredictable; no good randomized trialsNot a consideration for ED management
  • Dental devices:Currently recommended by the American Academy of Sleep Medicine (AASM)Available appliances include tongue repositioning and mandibular devices or soft-palate lifters.

Follow-Up

Disposition

Admission Criteria

  • Ventilatory failure, especially if intubation is necessary
  • Hemodynamic instability

Discharge Criteria

  • Maintenance of O2 saturation >85% for several hours using oxygenation or ventilation equipment available to the patient at home
  • Very low likelihood of decompensation overnight
  • Patients with sleep apnea who present after motor vehicle crashes:Manage initially like other blunt trauma patients.Later, consider the increased risk with sleep apnea and intervene to prevent future accidents.

Follow-Up Recommendations

  • PCP referral for sleep apnea and associated comorbidities
  • Encourage compliance, use of CPAP
  • Referral of patients with suspected sleep apnea to a pulmonologist
  • Encourage weight loss and diet control
  • Cardiology referral is appropriate when sleep apnea is complicated by heart failure or dysrhythmias.

Pearls and Pitfalls

  • Sleep apnea increases risk of cardiovascular disease, stroke, and diabetes mellitus.
  • CPAP is the standard of treatment.
  • Avoid the use of sedatives.
  • Preparation is essential, as sleep apnea increases intubation complications.
  • Primary care referral and CPAP compliance education improve therapy.

Additional Reading

  • Buchner ‚ NJ, Sanner ‚ BM, Borgel ‚ J, et al. Continuous positive airway pressure treatment of mild to moderate obstructive sleep apnea reduces cardiovascular risk. Am J Respir Crit Care Med. 2007;176(12):1274 " “1280.
  • Caples ‚ SM, Gami ‚ AS, Somers ‚ VK. Obstructive sleep apnea. Ann Intern Med. 2005;142(3):187 " “197.
  • Epstein ‚ LJ, Kristo ‚ D, Strollo ‚ PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263 " “276.
  • Mulgrew ‚ AT, Fox ‚ N, Ayas ‚ NT, et al. Diagnosis and initial management of obstructive sleep apnea without polysomnography: A randomized validation study. Ann Intern Med. 2007;146(3):157 " “166.
  • Qaseem ‚ A, Holty ‚ JE, Owens ‚ DK, Dallas ‚ P, Starkey ‚ M, Shekelle ‚ P, for the Clinical Guidelines Committee of the American College of Physicians. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159:471 " “483.
  • Rosenberg ‚ R, Doghramji ‚ P. Optimal treatment of obstructive sleep apnea and excessive sleepiness. Adv Ther. 2009;26:295 " “312.
  • Sharma ‚ SK, Agrawal ‚ S, Damodaran ‚ D, et al. CPAP for the metabolic syndrome in patients with obstructive sleep apnea. N Engl J Med. 2011;365:2277 " “2286.

See Also (Topic, Algorithm, Electronic Media Element)

The author gratefully acknowledges Mark Sagarin for his previous edition of this chapter. ‚

Codes

ICD9

  • 327.21 Primary central sleep apnea
  • 327.23 Obstructive sleep apnea (adult)(pediatric)
  • 780.57 Unspecified sleep apnea
  • 327.29 Other organic sleep apnea
  • 327.27 Central sleep apnea in conditions classified elsewhere
  • 780.53 Hypersomnia with sleep apnea, unspecified

ICD10

  • G47.30 Sleep apnea, unspecified
  • G47.31 Primary central sleep apnea
  • G47.33 Obstructive sleep apnea (adult) (pediatric)
  • G47.39 Other sleep apnea
  • G47.37 Central sleep apnea in conditions classified elsewhere

SNOMED

  • 73430006 Sleep apnea (disorder)
  • 78275009 Obstructive sleep apnea syndrome (disorder)
  • 27405005 Central sleep apnea syndrome (disorder)
  • 230493001 Mixed sleep apnea