Sleep Apnea No More
Obesity is the most common precipitating factor for obstructive sleep apnea and is a requirement for the obesity hypoventilation syndrome, both of which are associated with substantial morbidity and increased mortality.78 Numerous case reports and non-controlled trials document substantial improvement in sleep apnea and the obesity hypoventilation syndrome, particularly with surgically induced weight loss. In a recent Cochrane review of lifestyle modification for obstructive sleep apnea, the reviewers concluded that there were currently no randomized trial data available for analysis.79 Thus, there are currently no data regarding the magnitude of weight loss necessary to produce a clinically significant improvement in obesity related obstructive sleep apnea, nor regarding which group of patients is most likely to benefit from this intervention.
Non-invasive CPAP was first introduced in the 1980s as a therapy for obstructive sleep apnoea (OS A). This is when a tight-fitting face or nasal mask delivers a single pressure throughout the patient's respiratory cycle. It is therefore not ventilation. In OSA, CPAP prevents pharyngeal collapse. CPAP can also be delivered through an endotracheal tube or tracheostomy tube in spontaneously breathing patients and is usually used this way during weaning. The application of a continuous pressure keeps the alveoli open for longer and improves oxygenation. This is therefore the main indication for CPAP. The main indications for acute non-invasive CPAP are CPAP is employed in patients with acute respiratory failure to correct hypoxaemia. In the spontaneously breathing patient, the application of CPAP provides positive end-expiratory pressure (PEEP) that can reverse or prevent atelectasis, improve functional residual capacity, and oxygenation. These improvements may prevent the need for CPAP...
Gastroesophageal reflux is one theory proposed to explain apnea leading to SIDS (35). The introduction of acid into the esophagus was also thought to cause cardiac arrhythmia (35,399). Studies have shown that most apneic episodes are independent of gastroesophageal reflux (399). Reflux is more likely to occur while the infant is awake rather than when the child is sleeping, the usual scenario in SIDS (399). Gastro-esophageal reflux may simply be a manifestation of general developmental delay (35). Reflux is less likely in the prone position, a risk factor for SIDS (ref. 400 see Subheading 3.1.3.).
Exacerbations of COPD usually involve progressive hypoxemia due to bronchospastic worsening of ventilation-perfusion matching. Signs of hypoxemia include tachypnea, cyanosis, agitation and apprehension, tachycardia, and systemic hypertension. The most life-threatening feature of decompensation is hypoxemia where arterial saturation falls below 90 percent. With increased work of breathing, muscle production of carbon dioxide increases and alveolar ventilation is often unable to increase to prevent carbon dioxide retention and respiratory acidosis. Signs of hypercapnia include confusion, tremor, stupor and, finally, hypopnea and apnea.
In the largest retrospective study, 63 adults with epilepsy were referred for PSG for EDS and suspected OSAS (27), suspected OSAS without EDS (22), spells and EDS or suspected OSAS (10), nocturnal spells (2), or EDS alone (2) (Malow et al., 1997). Multiple sleep latency tests (MSLTs) were performed in 33 cases. Sleep disorders were suspected in 79 of patients. Obstructive sleep apnea syndrome was diagnosed in 71 . The disorder was considered mild in 14, moderate in 21, and severe in 10 patients, including 7 females. Other diagnoses included nocturnal seizures (4), mild OSAS and narcolepsy (1), and insufficient sleep syndrome with probable idiopathic hypersomnia (1). In 13 cases, the diagnosis was uncertain. These included six subjects with PLMS with 20 or greater leg movements per hour generally not causing arousal. Of the subjects who had MSLTs, the average mean sleep latency was 6.8 min, suggesting a moderate degree of daytime sleepiness. Treatment of OSAS with continuous positive...
Keywords sleep disorders, sleep apnea, insomnia, jet lag, narcolepsy Millions of Americans suffer from sleep disorders including, but not limited to, sleep apnea, insomnia, narcolepsy, restless legs syndrome, and circadian rhythm disorders. While the quality, extent, and severity of these symptoms depend
Continuous positive airway pressure Continuous positive airway pressure (CPAP) is a continuous positive pressure administered through the ventilator circuit. It is essentially, pressure support (inspiratory positive pressure) plus PEEP (expiratory positive pressure). CPAP provides supplemental pressure to patients who are breathing spontaneously. Patients can be weaned from the ventilator using steadily decreasing levels of CPAP
We have reported on a group of six infants and children who presented for evaluation of apnea and in whom a combined video EEG-PSG study was performed (Kotagal and Dinner, 1991). In three of the six patients, the apnea represented a manifestation of an epileptic seizure. Zucconi and colleagues (1997) reported on two adults who presented with a history of awakening from sleep with a sensation of choking and abnormal motor activity as well as daytime sleepiness, and who had been previously diagnosed with obstructive sleep apnea. These patients underwent video EEG-PSG and were found to have
Very young infants (1 to 3 months) may present with what is often referred to as afebrile pneumonitis, or atypical pneumonia. This syndrome is typified by cough, tachypnea, and sometimes progressive respiratory distress in the absence of fever. Apneic episodes can occur with RSV, chlamydia, and pertussis. There is often radiographic evidence of bilateral diffuse pulmonic infiltrates with air trapping. The viruses listed above are the most common etiologic agents. 14 Chlamydia trachomatis is also often identified in this scenario.1 l4 Ureaplasma urealyticum, Mycoplasma hominis, Pneumocystis carinii, and B. pertussis have also been implicated in this syndrome, but the extent of their role is not as well defined.1 l5
Intubated patients generally require positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP). Occasionally, a patient may require only increased oxygenation and CPAP without mechanical ventilation. Only patients who are alert and unlikely to vomit are candidates for mask or nasal CPAP or other noninvasive ventilation.
A standard tracheostomy is a surgical procedure that creates an opening between cartilaginous rings in the airway by suturing the skin to the anterior tracheal wall (Fig.236 2). Current indications for tracheostomy tube placement include the maintenance of airway patency in patients with functional or mechanical airway obstruction, the provision of airway access for suctioning retained airway secretions, the prevention of aspiration in a patient with glottic dysfunction, significant obstructive sleep apnea, and the management of patients who require long-term access for ventilatory support.
Under some circumstances, respiration is improved if the airway pressure is not allowed to fall to ambient pressure with CPAP (continuous positive airway pressure) therapy. This requires an airtight seal from a cuffed tracheal tube or close fitting facemask and an expiratory valve rated at the desired pressure, typically 2.5-10 cmH2O. The ideal valve functions as a threshold resistor, that is it should remain closed until the desired pressure is reached when it opens offering minimal resistance to flow. Humidified, oxygen enriched air should be supplied at a rate to equal the patients peak inspiratory flow rate to prevent undesirable falls in pressure during inspiration. Either a Venturi (e.g. Downs' flow generator) is employed to deliver a high flow rate into the conductive tubing or a lower flow rate is delivered into a reservoir bag that buffers the pressure changes as the flow rate varies throughout the respiratory cycle.
The widespread use of noninvasive positive-pressure ventilation (NIPPV) for chronic sleep apnea in the 1980s has prompted investigators to look at NIPPV in the acute setting today. NIPPV can be described as an application of a preset volume pressure of inspiratory air through a face or nasal mask. Inspiratory muscle fatigue is the final phase of ventilatory failure in patients with severe reactive airway disease, COPD, and end-state pulmonary edema pneumonia. The airway resistance overcomes the patient's muscular ability to ventilate. Another noninvasive technique used as an effective alternative to the traditional ETT, with its potential complications, is noninvasive, mechanically assisted ventilation with continuous positive pressure (CPAP) or bilevel positive pressure (Bi-PAP). CPAP applied through a face or nasal mask has recently received renewed application in the treatment of patients with acute hypoxemic respiratory failure.8 NIPPV has been used to support patients with acute...
Treatment for hypoxemia is supplemental oxygen. There are three levels of therapy for hypoxemia (1) supplemental oxygen via nasal canula or face mask (2) noninvasive ventilation, such as a continuous positive airway pressure (CPAP) or bilevel positive pressure ventilation (BipAP) mask, in which a patient is given positive-pressure ventilation via a face mask and (3) mechanical ventilation via an endotrachial tube. Due to entrainment of air around a face mask, the maximum amount of supplemental oxygen that can be administered is 60 but varies with the tightness of the seal. If a patient is still hypoxemic, the clinician needs to administer one of the positive-pressure modes of ventilation. For invasive and noninvasive mechanical ventilation, it is helpful to think of oxygenation separately from ventilation. Specifically, Fio2 and PEEP or CPAP should be used to control oxygenation. Both Fio2 and PEEP or CPAP should be titrated upward until hypoxemia is resolved.
OXYGENATION AND VENTILATION Oxygen (100 ) should be given by mask and arterial blood gases obtained. The patient should be seated upright to pool systemic blood and reduce venous return. If hypoxia persists with supplemental oxygen, then positive pressure ventilation is required. Positive end-expiratory pressure (PEEP) applied via face mask as continuous positive airway pressure (CpAP) or bilevel continuous positive airway pressure (BiPAP) or via endotracheal tube can be used to prevent alveolar collapse.8 Although impedance of venous return with PEEP via the endotracheal tube can be beneficial in reducing preload, care
That receptors in the airway are sensitive to changes in transmural pressure across the airway, and that deformation of the airway by a negative transmural pressure leads to a sensation of breathing discomfort. The technique of pursed lip breathing, commonly employed by patients with COPD, and the application of continuous positive airway pressure (CPAP) in patients with emphysema and respiratory distress are examples of how dyspnea may be reduced by diminishing airway compression and stimulation of mechano-receptors.
Example, many years of stable overall function and good quality of life maybe possible with the addition of non-invasive mechanical ventilatory support. In these young men the use of a fitted nasal mask may begin with the application of continuous positive airway pressure (CPAP) for specific periods of time (often overnight). As respiratory failure progresses the mode of mechanical ventilation may be increased from CPAP to biphasic positive airway pressure (BiPAP) support. As such mechanisms of ventilatory support become easier to apply and more pervasive they will undoubtedly play an increasingly important role in the management of dyspnoea in children with advanced disease. As with other methods of management of dyspnoea in children, mechanical ventilation is but one option and is almost always coupled with the other modes of dyspnoea treatment mentioned in this chapter.
Fulfillment of diagnostic criteria and genetic testing confirm in individuals suspected with PWS. In 1993, age-stratified diagnostic criteria were published by Holm et al. PWS is very likely in children 3 years of age with 8 points (4 from major criteria). Major diagnostic criteria for PWS (1 point for each) include infantile central hypotonia, feeding difficulties in infancy, accelerated weight gain in early childhood, hypgonadism, developmental delay and typical facial features (narrow bifrontal diameter, almond palpebral fissures, narrow nasal bridge, down-turned mouth). Current minor diagnostic criteria for PWS (1 2 point each) include decreased fetal movement, sleep apnea, short stature, hypopigmenta-tion, small hands feet, narrow hands with straight ulnar border, esotropia myopia, thick saliva, skin picking and speech problems. Other commonly reported features of individuals with PWS include high pain threshold, decreased vomiting, temperature instability, premature adrenarche...
Psychiatric disorders are estimated to afflict up to 50 percent of the developmentally disabled population. Although mood disorders, particularly depression, are most frequent, they are relatively unlikely to precipitate ED evaluations. Instead, emergency visits are usually precipitated by aggression or extreme agitation. In such cases, benzodiazepines or low-dose, low-potency antipsychotics, such as chlorpromazine, may be acutely helpful in controlling the patient's behavior sufficiently to proceed with an evaluation. However, it is essential to try to identify the underlying etiology of these behaviors and changes in their frequency or intensity. Undiagnosed, painful medical problems, including severe constipation, often lead to exacerbation. 16 Sleep apnea can also be manifest as increased irritability. In addition, anxiety may be manifest primarily as agitation. Often environmental factors can be identified that are increasing the patient's anxiety. Such factors may include...
The knowledge of the pathophysiology of acute respiratory failure and the changes in lung physiology during positive-pressure ventilation will aid in the selection of an appropriate ventilatory modality and in the selection of the initial settings. 20 Ventilators are pressure- or volume-cycled. Volume-cycled ventilators are used routinely in EDs. Other decisions regarding mechanical ventilatory support in the ED include the rate, mode, F p2, minute ventilation, and use of positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP). The initial Fio2 should be guided by the oximetry. Set the tidal volume at 10 to 15 mL kg ideal body weight and adjust the rate accordingly. Allow sufficient time for expiration. Maintain the peak airway pressure (PAP) below 35 to 45 cmH20 to prevent barotrauma. The PAP appears to be related to barotrauma more than the level of CPAP. The tidal volume can be increased up to 15 mL kg to adjust the PaCo2 unless it elevates the PAP...
Obstructive apnea can occur when reflexes do not respond to the normal negative pressure in the upper airways during inspiratory flow and induce the normal contractions of upper airway muscles to support the airways in an open position. Increased inspiratory effort, for example, in response to chemoreceptor stimulation, makes the tendency for airway collapse worse if the upper airways do not respond also. Therefore, the fundamental problem in obstructive apnea is a lack of coordination between the inspiratory and upper airway muscles and this is worst in REM sleep. The most effective treatment for obstructive apneas is nasal continuous positive airway pressure (nasal CPAP). This treatment applies a positive pressure to the upper airways by a mask fitted over the nose of the sleeping patient, to counteract the decrease in airway pressure during inspiration and support the airways in an open position. Sleep apnea also occurs in other conditions also. High-altitude sleep apnea may occur...
This CAP is then superimposed on a relatively homogeneous background of EEG activity, lasting for more than 60 s in duration, referred to as non-CAP. The CAP consisted of two phases, CPAP-A, which is characterized by a paroxysm of phasic activity, representing a state of greater arousal, and alternates with a second phase, CAP-B, which consists of a return to the background EEG activity and represents a state of lesser arousal. These two phases alternate during CAP, which then alternates with the NCAP state. The amount of sleep time in CAP was expressed as a percentage of the total sleep time, defined as the CAP rate. This represented the amount of relative arousal defined by the microarchitecture. Studies in relation to both primary generalized epilepsy and focal epilepsy report an increase in the CAP rate compared with normal controls. In addition, epileptiform discharges appear to be activated in the CAP-A phase (Gigli et al., 1992). Focal motor seizures occurring in NREM sleep...
Respiratory disturbances may cause stroke if the oxygen delivery to the brain is sufficiently impaired. For example, sleep apnea is associated with a tendency to stroke and silent stroke as well as vascular dementia. Occlusion of the airway leads to cessation of air movement (apnea), causing oxygen levels to fall (desaturation) and carbon dioxide levels to increase (hypercarbia). Oxygen desaturation may be so severe that cardiac rhythm disturbances occur. Hypercarbia stimulates respiratory drive and increases CBF, and these responses to the apnea may maintain oxygen delivery within acceptable limits. The recognition that this common sleep disorder increases the risk of stroke and silent stroke has led to improved surveillance and treatment.
Monge's disease, also called chronic mountain sickness or CMP, has now been recognized in all high altitude locations of the world. Both long-term high altitude residents and lowlanders who relocate to high altitude may develop this condition after variable length of residence. The incidence is much higher in males and increases with age. The disease is characterized by excessive polycythemia for a given altitude, which causes symptoms such as headache, muddled thinking, difficulty sleeping, impaired peripheral circulation, drowsiness, and chest congestion. The diagnosis is made by the characteristic symptoms and a hemoglobin value greater than expected for the altitude, generally over 20 to 22 g dL. Any problem causing hypoxemia at sea level causes greater hypoxemia at altitude, and the etiology of CMP can be traced to problems such as chronic obstructive pulmonary disease (COPD) and sleep apnea in 50 percent of patients. The etiology of pure CMP is attributed to idiopathic...
Most infants resolve apnea of prematurity before discharge and do not require apnea monitoring at home. 15 However, home monitoring is sometimes utilized for premature infants with severe apnea or if apnea persists beyond 38 weeks' postconceptional age.11Z Infants may be brought to an emergency department because of an actual apneic episode or because the parents are not sure of the significance of an alarm. Studies have demonstrated that the majority of alarms at home are not associated with a change in cardiorespiratory status and probably represent monitor dysfunction, such as loose leads. 16 However, caution must be exercised before attributing an alarm to a mechanical problem with the monitor.
Behavioral strategies and lifestyle modifications are paramount to managing sleep disorders and their sequelae. In addition to sleep hygiene, utilizing a cognitive-behavioral approach and conceptualization may produce additive benefit. Similar to helping patients with medical conditions, such as chronic pain or cardiovascular disease, examining the beliefs, attitudes, thoughts, and emotional responses of patients with sleep disorders is likely to provide an even greater understanding and treatment development compared to solely taking a medical-model approach. Charles Morin and colleagues address these factors in patients with insomnia and have achieved considerable success. Extending and combining these principles for patients with other sleep disorders may similarly provide a more comprehensive management compared to medical recommendations alone. While some strategies, such as systematic desensitization or exposure therapy, for CPAP users await further empirical validation,...
Excessive daytime sleepiness as measured by the ESS was found in 28 of 158 subjects with epilepsy and 18 of 68 control subjects with other neurologic disorders (Malow et al., 1997). Symptoms of sleep apnea and RLS reliably predicted daytime sleepiness. Having epilepsy conferred only a nonsignificant trend for EDS. Patients with epilepsy between the ages of 30 and 45 years were most likely to report daytime sleepiness. In patients with epilepsy, the number and type of AEDs, seizure frequency, epilepsy syndrome, and presence of sleep-related seizures were not significant predictors of daytime sleepiness.
Respiration may have been postictal apnea following a seizure. With a seizure, an infant is frequently awake before becoming apneic. Gastroesophageal reflux may lead to apnea and also may occur in awake infants following a feeding. A history of an upper respiratory infection followed by paroxysmal cough with an apneic episode would be suggestive of pertussis. Hypoglycemia may also be associated with apnea, with or without a seizure. The differential diagnosis also includes infection (sepsis or meningitis) and cardiomyopathy. Infantile botulism may be the cause in 5 to 10 percent of SIDS victims.
CPAP CPAP CPAP * If NIV or CPAP is used as a trial of treatment in pneumonia or postoperative respiratory failure, this should be done on an ICU with close monitoring and rapid access to intubation. ARDS, acute respiratory distress syndrome BiPAP, bilevel positive airway pressure COPD, chronic obstructive pulmonary disease CPAP, continuous positive airway pressure NIV, non-invasive ventilation. * If NIV or CPAP is used as a trial of treatment in pneumonia or postoperative respiratory failure, this should be done on an ICU with close monitoring and rapid access to intubation. ARDS, acute respiratory distress syndrome BiPAP, bilevel positive airway pressure COPD, chronic obstructive pulmonary disease CPAP, continuous positive airway pressure NIV, non-invasive ventilation.
The goal is to prevent devastating end organ injury while the patient is being transported for definitive treatment. Maintenance of adequate mean arterial pressure to prevent adverse neurologic and renal sequelae is vital. Dopamine or noradrenaline (norepinephrine), depending on the degree of hypotension, should be initiated promptly to raise mean arterial pressure and be maintained at the minimum dose required. Dobutamine may be combined with dopamine at moderate doses or used alone for a low output state without frank hypotension. Intra-aortic balloon counterpulsation should be initiated before transportation when facilities are available. Arterial blood gas and oxygen saturation should be monitored with early institution of continuous positive airway pressure or mechanical ventilation as needed. The ECG should be monitored continuously, and defibrillating equipment, intravenous amiodarone, and lidocaine should be readily available. (Thirty three per cent of patients in the early...
The Hering-Breuer reflex is only weakly present in man, who can continue to breathe spontaneously with continuous positive airway pressures (CPAP) in excess of 40 cmH2O. This reflex in man is not activated until VT 1.5 litres, and is probably is a protective mechanism for preventing excess ventilation, rather than an important component of the normal ventilatory control.
Integrated ventilatory responses to changes in activity and the environment illustrate many important interactions between elements of the respiratory control system. Such interactions are typical in patients, and the physician needs to understand them to make an intelligent diagnosis and provide appropriate treatments. The most common stimulus to increase ventilation in healthy subjects is exercise. Relatively common problems in control of ventilation during sleep are described in the Clinical Note on sleep apnea. The next sections compare and contrast the integrative response to chronic hypoxemia in normal subjects during acclimatization to high altitude and patients with lung disease.
The main side effects associated with parenteral opioid administration are nausea and vomiting, and cardio-respiratory depression. The incidence of severe respiratory depression during PCA is approximately 0.5 which compares favourably with the intramuscular route. The risk of this is increased in patients receiving background opioid infusions or other sedative drugs. The elderly and patients with preexisting sleep apnoea also have an increased risk of respiratory depression.
Initial measures are directed at preventing the tongue from falling backwards and obstructing the airway. The unconscious patient should be recovered in the lateral position with the jaw supported. Blood and secretions should be cleared by suction and supplemental oxygen given via a face mask. If upper airway obstruction develops the head should be tilted backwards and the jaw pushed forward by applying pressure behind the angle of the jaw. If this measure does not rapidly clear the airway then an oropharyngeal or nasopharyngeal airway should be inserted. Care should be taken on insertion of an oral airway as this may cause laryngospasm, coughing or vomiting in the waking patient and, if in doubt, a nasal airway should be passed. If this does not immediately rectify the situation then senior help should be sought and 100 oxygen administered via a tight fitting mask. Continuous positive airway pressure (CPAP) at this stage may help to open the airway or break' the laryngospasm....
Pseudotumor cerebri This syndrome is characterized by increased intracranial pressure, headaches, blurred vision or loss of vision, and papilledema. It is most common in massively obese individuals and may be seen in association with sleep apnea or with the obesity-hypoventilation syndrome. It may be associated with retinal hemorrhage or loss of vision from severe papilledema. Some investigators believe that increased intraabdominal pressure with massive obesity is an etiologic factor for pseudotumor cerebri. Major weight loss, particularly after obesity surgery, results in dramatic improvement.
The question thus posed to the primary physician was whether these events represented obstructive sleep apnea, possibly secondary to the patient's tracheostomy, a primary central apnea phenomenon, or a new form of seizure. It was decided that the patient should undergo combined video EEG-PSG to further elucidate the etiology of these apneic spells.
When evaluating children and adults with Down syndrome for behavioral concerns, it is important to determine whether there are acute or chronic health problems impacting on development and or behavior. Vision and hearing problems can have a significant effect on a person's ability to function both at home and in the school workplace setting and should be monitored closely as recommended in the Healthcare Guidelines for Persons with Down Syndrome (Cohen, 1999). Other medical problems that can be associated with behavioral changes include hypo- and hyperthyroidism, celiac disease (sensitivity to oats, wheat, barley, and rye), sleep apnea, anemia, gas-troesophageal reflux, and constipation. Evaluation by the primary care physician to assess for medical neurological problems is an important component of the workup for behavioral concerns in persons with Down syndrome of any age.
Nasal-mask or facial-mask ventilation employs a tight-fitting mask that allows for a CPAP or BiPAP support system. The patient with impending respiratory failure receives either continuous pressure or inspiratory expiratory (bilevel) support, thus allowing a decrease in inspiratory effort, rest for respiratory and accessory muscles, improvement of gas exchange, avoidance of intubation, and improved comfort.914 A nasal-mask protocol with BiPAP appears to be the most advanced
Acetazolamide has also been used in the treatment of certain pulmonary disorders. In patients with central sleep apnea, induction of systemic acidosis with acetazolamide may prove effective in stimulating the respiratory center and reducing the number of apneic episodes. High altitude pulmonary edema can be prevented in susceptible individuals by prophylactic administration of acetazolamide. While the mechanism of this protective effect is multifactorial, the development of metabolic acidosis stimulates the respiratory center and has favorable effects on the oxygen disassociation curve.
Sleep Apnea Sleep apnea is a disordered breathing condition that is characterized by the constriction of the airway during sleep. Due to disrupted sleep throughout the night, individuals report tiredness, fatigue, sleepiness, memory and judgment problems, irritability, difficulty concentrating, and personality changes. Medical treatments involve nasal continuous positive airway pressure (CPAP), oral dental devices, and surgical procedures to eliminate sleep fragmentation, apneas, and oxygen desaturation. CPAP, one of the most effective and widely used therapies, requires the patient to wear a mask. This mask fits over the apneic's face during sleep to assist with breathing. Despite the effectiveness of CPAP, the discomfort associated with wearing the mask, its cumbersome nature, and, for some, the sensation or fear of suffocation, often deters patients from its use. Therefore, compliance with utilization of the CPAP device is low and is an obstacle to effective management of sleep...
The adipose fat cell is not only a passive storage site but an endocrinologically active secretor of many substances like leptin, adiponectin, and cyto-kines, which participate in an inflammatory response and may mediate a host of adverse consequences, including insulin resistance and diabetes. Obesity is related to an increased risk of developing type 2 insulin-resistance diabetes mellitus, hyper-lipidemia, heart disease, obstructive sleep apnea, asthma and other respiratory problems, back pain and orthopedic problems, fatty liver (nonalcoholic steato-hepatitis or NASH), gallstones, and depression. The increasing incidence of type 2 diabetes in obese adolescents is already being noticed, with estimates of 200 000 diabetics under age 20 years in the US predicted to rise to a lifetime risk of developing diabetes of 33-39 for those born in the year 2000.
Recurrent upper respiratory infections, chronic sinusitis, and chronic middle ear effusions are seen in many young children with Down syndrome. These can be treated using standard protocols but should be referred to an otorhinolaryngologist or pulmonologist when they occur repeatedly. Sleep apnea and obstructive apnea are described but are not generally problems in the emergency setting.
Future studies should aim for more powerful design, better focus on appropriate subgroups of men and end-points likely to benefit, and or alternative hormonal regimens. Pharmacological androgen therapy, using supraphysiological doses or novel synthetic androgens, might improve muscle, bone or other androgen-dependent functions in older men regardless of androgen deficiency status, nature or dose of androgen. Viewed like any other anti-ageing treatment, this would require evidence of efficacy, safety and cost-effectiveness from controlled trials rather then relying on supposed replacement status to lighten the burden of proof for efficacy and safety. This approach would diversify androgen therapies to allow enhanced targeting of androgen therapy via exploiting variations in tissue selectivity and metabolic activation (5a reduction, aromatization) profiles (Sundaram et al 1994) that could be developed in novel potent designer androgens (Dalton et al 1998, Edwards et al 1998). Regardless...
In 1998 the American Heart Association reclassified obesity as a major modifiable risk factor for coronary heart disease.4 This is a step forward from the earlier notion that obesity contributes to heart disease primarily through covari-ates related to obesity, including hypertension, dyslipidemia, and impaired glucose tolerance or type 2 (non-insulin dependent) diabetes mellitus. Overweight and obesity are now also recognized as important risk factors for stroke, renal dysfunction, gallbladder disease, certain types of cancer, osteoarthri-tis, sleep apnea and a host of other disorders.5 Importantly, increased body weight is also an important determinant of impaired quality of life.6
Primary sleep enuresis is caused by a combination of genetic, maturational, psychosocial, and endocrinological factors the relative importance of each of these varies across individuals. Anatomic abnormalities of the genitourinary system and other sleep disorders such as obstructive sleep apnea are uncommon in enuretic children although they may contribute to enuresis in some (Friman, 1995). Psychosocial factors that may contribute to or exacerbate enuresis include marital discord, parental separation, sexual abuse, and birth of a sibling.
CLINICAL FEATURES Spontaneous pneumothorax can occur in term and postterm infants following intrapartum asphyxia and meconium aspiration. Currently, however, pneumothorax has increased in incidence with the use of continuous positive airway pressure, positive end-expiratory pressure, mechanical ventilation, and cardiopulmonary resuscitation. Uneven ventilation caused by aspirated blood, mucus, meconium, and amniotic fluid debris can also result in an air leak. Atelectasis, poor ventilation, and air trapping are common predisposing factors. Premature, low-birth-weight infants with surfactant deficiency have a high incidence of air leaks (30 percent), as do newborns with meconium aspiration syndrome (10 percent).
Studies of infants with ALTE may reveal (1) hypoventilation (P co2 45 mmHg) and chronic hypoxemia, (2) a depressed ventilatory response to CO2 breathing, (3) prolonged sleep apnea ( 15 s, associated with cyanosis or pallor), (4) bouts of frequent short apnea, (5) increased periodic breathing (characterized by repeated 3-s pauses in breathing followed by normal breathing for less than 20 s with bradycardia), (6) obstructive apnea, and (7) mixed obstructive and central apnea. 21
Nebulized oxygen is helpful in the treatment of pulmonary aspiration. Inhaled b 2 agonists may also be useful, especially in the setting of bronchospasm, but their role in the treatment of hydrocarbon pneumonitis has not been studied. Positive end-expiratory pressure (PEEP) or continuous positive-airway pressure (CPAP) may sometimes be required, but because of the potential for further injury from barotrauma, one should observe for the development of pneumatoceles or pneumothoraces. In cases of severe pulmonary aspiration resulting in refractory hypoxemia, treatment with extracorporeal membrane oxygenation (EMCO) and high frequency jet ventilation (HFJV) has proved successful.2425 Consensus remains that corticosteroids are contraindicated because they impair the cellular immune response and increase the chance of bacterial superinfection.26 Antibiotics have no proven role in prophylaxis and are usually not required except in cases of continued pulmonary deterioration because of the...
Infants with PWS exhibit decreased fetal movement, weak cry, neonatal hypotonia, genital hypoplasia (cryptorchidism and clitoral hypoplasia), and failure to thrive (due to hypotonia and poor feeding). Toddlers with PWS acquire major motor milestones later than controls (walk at 24 months). Hyperphagia becomes evident between 18 months and 7 years of age. The majority of patients with PWS have growth hormone deficiency with short stature manifest during childhood and lack of a pubertal growth spurt. Individuals with PWS have an elevated pain threshold and vomiting threshold, with reports of delayed diagnoses of fractures, appendicitis, and gastroenteritis with significant morbidity. Obesity-related comorbid-ities, including sleep apnea, diabetes, and cor pulmo-nale, will shorten life expectancy without aggressive interventions. Behavioral problems, including obsessive-compulsive behavior (skin picking and rectal digging), stubbornness, and food foraging (including garbage and frozen...
Obstruction of the airway is one of the most urgent complications that can develop in the postoperative patient, and is all the more likely due to the manipulation of the airway that occurs as part of general endotracheal anesthesia. Although the majority of the risk occurs in a highly monitored environment of the PACU, a significant number of cases of airway obstruction occur in delayed settings on surgical wards. This is also becoming a more recognized phenomenon as obstructive sleep apnea and obesity have become more common in the general and surgical populations.
This is usually due to a decrease in airway muscle tone, which may persist up to 5 days postoperatively. In the first 48 h these muscle tone changes are thought to be related to opioids. From about 48 h onwards changes in sleep pattern, not unlike obstructive sleep apnoea, are implicated.
The measurement of airflow and respiratory movement has become standard practice for the recording of all PSG. It is, of course, essential in the diagnosis of apnea as well as hypopnea or respiratory pauses. There is also a known association between these as well as other breathing disturbances and a variety of other sleep-related conditions, such as parasomnias and seizures. Air exchange is commonly monitored using a thermistor or thermocouple, simultaneously recording both nasal and oral airflow. Nasal pressure transducers are an alternative method. Respiratory movement or effort can be recorded in a variety of ways. The use of intercostal electrodes, abdominal and thoracic strain gauges, and abdominal and thoracic belts all have proven to be dependable. The use of pulse oximetry to monitor blood oxygen levels collects vital information concerning the severity of any recorded desaturations.
There is normally no pressure gradient at the end of expiration between the airway and atmosphere. Rarely in anaesthesia but often in the intensive care unit, end-expiratory pressure is applied. It is termed positive end-expiratory pressure (PEEP) when ventilation is controlled (Intermittent positive pressure ventilation, IPPV) or continuous positive airway pressure (CPAP) if ventilation is spontaneous.
The primary uses of caffeine as a drug are based on its effects on the respiratory, cardiovascular, and central nervous systems. Premature infants, for example, are subject to apnea, a transient but potentially dangerous cessation of breathing. Caffeine has been used to control this syndrome. It decreases apneic episodes and regularizes breathing patterns (28). It is also used for the treatment of bronchiospastic disease in asthmatic patients. Caffeine is used widely in drug mixtures designed for relief from migraine-type headaches because of its vasoconstrictor effects on the cerebral circulation. Many OTC preparations of this type are available. They contain 30 to 200 mg of caffeine per tablet. A common application of caffeine's
The list of possible causes of hypoxemia in the postsurgical patient is long and complex. For this reason, diagnosis and treatment must proceed systematically. Hypoxemia is defined as PaO2 less than 60 mmHg, and is usually diagnosed by pulse oximetry or less often, arterial blood gas measurement. Clinically, hypoxic patients appear restless, tachycardic, and cyanotic, although cyanosis may not be apparent in severely anemic patients. At more advanced stages, however, patients become somnolent, and will eventually suffer respiratory arrest. Patients at highest risk for postoperative hypoxia are those at the extremes of age, those with a history of obesity, obstructive sleep apnea, or a high ASA Classification status, or those who have undergone a lengthy surgical procedure. Also, at risk are those with particularly high-oxygen consumption rates, for example, those shivering or those with sepsis or other hypermetabolic state.
The obesity-hypoventilation syndrome may be associated with, or exacerbated by, obstructive sleep apnea, a syndrome characterized by repeated collapse of the upper airway and cessation of breathing with sleep. Obstructive sleep apnea occurs when the tongue obstructs the glottis and prevents entry of air into the trachea. Up to 50 of massively obese people have sleep apnea. The risk of arrhythmias and sudden death increases during apneic episodes. Weight reduction usually reduces the severity of sleep apnea, and massive weight reduction, such as that after gastric bypass surgery, eliminates the disease in most patients.
Pickwickian syndrome Very severe obesity may be associated with hypoventilation and or upper respiratory obstruction with sleep apnoea. (The sleepy fat boy in Charles Dicken's Pickwick Papers is the origin of the syndrome's name.) Underventilation leads to increased circulating carbon dioxide levels, which may precipitate pulmonary hypertension and right-sided heart failure. Rising circulating carbon dioxide levels may result in the respiratory centre of the brain ceasing to respond to carbon dioxide buildup and instead responding to falling oxygen levels as stimulus to breathe. Thus, if affected individuals are given oxygen because of increasing cyanosis, the stimulus to breathe may be removed with potentially disastrous consequences.
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Have You Been Told Over And Over Again That You Snore A Lot, But You Choose To Ignore It? Have you been experiencing lack of sleep at night and find yourself waking up in the wee hours of the morning to find yourself gasping for air?