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Advances in the Diagnosis and Treatment of Sleep Apnea and Snoring

PSG (Sleep Apnea) Board Review

Richard J. Schwab, M.D.Richard J. Schwab, M.D.Professor of MedicineProfessor of Medicine

Division of Sleep MedicineDivision of Sleep MedicinePulmonary, Allergy and Critical Care DivisionPulmonary, Allergy and Critical Care Division

University of Pennsylvania Medical CenterUniversity of Pennsylvania Medical CenterPhiladelphia, PennsylvaniaPhiladelphia, Pennsylvania


PSG (Sleep Apnea) Board Review -Disclosures

• NIH grants - RO1/PPG (Obesity and OSA)

• Speakers Bureau (Cephalon)- Nuvigil


Case 1: What is the ECG rhythm?


Case 1What is the ECG rhythm seen in the previousepoch?

A) Third Degree AV blockB) Bradycardia/TachycardiaC) Normal Sinus RhythmD) WenckebachE) Atrial Tachycardia


Case 2: What is the ECG rhythm?


Case 2

What is the ECG rhythm seen in the previousepoch?

A) Normal Sinus RhythmB) Sinus ArrhythmiaC) Third Degree Heart BlockD) Sinus PauseE) Second Degree AV Block


History: - 76 year old gentleman - Complains of snoring and sleep fragmentation - History of congestive heart failure, hypertension,hyperlipidemia, myocardial infarction and atrialseptal defect - Epworth sleepiness scale of 5; not short of breath

Physical exam: - Height 5’10”, weight 180 lbs - BMI of 25.8 kg/m² - Modified Mallampati class 3 airway with mildmacroglossia - Lower extremity edema (1+)- Remainder of examination normal

Case 3


In the next Figure the arrows illustratewhich type of respiratory event?

A. Obstructive apneaB. Central apneaC. Mixed apneaD. Obstructive hypopneaE. Respiratory event-related arousal

(RERA)

Case 3A


60 Second Epoch


In the next Figure the arrow illustrateswhich type of cardiac arrhythmia?

A) Rapid burst of atrial fibrillationB) Rapid burst of atrial flutterC) Event related bradycardia/tachycardiaD) Non sustained ventricular tachycardiaE) Wenckebach

Case 3B


30 Second Epoch


A patient who is without complaints is performing themaneuvers for the biocals at the beginning of the PSG.The PSG technologist keeps having to go into thebedroom because the alarm sounds on the pulseoximeter that displays a pulse rate of 28 beats/minuteeven when the sensor is applied to a different finger andthe other hand. The patient’s blood pressure is 120/80mm Hg. What should the technologist do?A) Contact the physician on callB) Switch the oximeter probe to an ear lobe sensorC) Replace the oximeterD) Deactivate the alarmE) Send the patient to the Emergency Room

Case 4


30 second epoch

Case 4


Case 5What is your diagnosis based on thisrepresentative tracing from an overnighthome polysomnogram?A) Central apneaB) Cheyne-Stokes respirationC) Obstructive apneaD) Obstructive hypopneaE) RERA


5 minute epoch

Case 5


How would you score the first two respiratoryevents?A) Central apneaB) Mixed apneaC) Obstructive apneaD) Obstructive hypopneaE) RERA

Case 6


5 minute epoch

Case 6


What is your diagnosis based on this representativetracing from an overnight polysomnogram in anasymptomatic patient?

A) Central apneaB) Mixed apneaC) Obstructive apneaD) Obstructive hypopneaE) RERA

Case 7


Morganthaler et al. Sleep 29:1203-9, 20063 minute epoch

Case 7


What is your diagnosis based on thisrepresentative tracing from an overnightpolysomnogram?A) Central apnea secondary to narcoticsB) Cheyne-Stokes respirationC) Obstructive apneaD) Obstructive hypopneaE) RERA

Case 8


5 minute epochA B C

5 minute epoch

Case 8


6 minute epoch

Case 8


Recording during a manual CPAP titrationpolysomnogram in a 62 year old man (BMI 33 kg/m2)with OSA (AHI 26.9 events/hr on diagnosticpolysomnogram). The patient has been on 10 cm H2Ofor the past hour during which a similar pattern as shownin this tracing has been present in NREM and REMsleep in the supine and lateral recumbent positions.What should the technologist do?A) Lower the pressureB) Keep the pressure the sameC) Raise the pressureD) Start bilevel positive airway pressure

Case 9


60 second epoch

Case 9


A manual CPAP titration PSG is being performedon a patient with OSA. The patient is in Stage 2NREM sleep and the CPAP setting has recentlybeen increased to 8 cm H2O. The technologistnotes events such as that shown in this tracing.What should the technologist do?A) Lower the pressureB) Keep the pressure the sameC) Raise the pressureD) Start bilevel positive airway pressure

Case 10


60 second epoch

Case 10


A 47-year-old male with a past medical history of OSA presents for a CPAP titration.During the trial he is titrated to a pressure of 9 cm H2O but has persistent snoring.When a pressure of 11 cm H2O is tried, he is noted to have some improvement inthe snoring but has frequent arousals. Artifacts are noted by the arrows in the maskflow channel (Mflo). How should the technologist fix this?

A. Increase theCPAP

B. Decrease theCPAP

C. Change themask

D. Add O2E. Switch to Bi-

Level

Case 11


What are the strengths and weaknesses ofthermistor vs. nasal pressure (“Flow” in thistracing) as surrogate markers of airflow?

Case 12


2 minute epoch - red circle are K complexes

Case 12


Expiration

Inspiration

30 second epoch - arrow is a spindle

Case 12


What is your diagnosis based on this representativetracing from an overnight polysomnogram in anasymptomatic patient?

A) SeizuresB) SighsC) Snoring related arousalsD) Periodic limb movements with arousalsE) Periodic limb movements without arousals

Case 13


5 minute epoch

Case 13


How would you score the respiratory event?

A) Central apneaB) Cheyne-Stokes respirationC) Obstructive apneaD) Obstructive hypopneaE) RERA

Case 14


60 second epoch

Case 14


Which of the following would be reasons why thetechnologist would increase the pressure on thissplit night polysomnogram when the hypopneaswere eliminated at lower pressures?A) Inspiratory flow limitationB) SnoringC) ArousalsD) Development of respiratory paradoxE) All of the above

Case 15


Case 15


A split night PSG in the 46 year old man withexcessive daytime sleepiness. He was treatedwith bilevel positive airway pressure titration.What phenomenon is present during thetreatment portion of the study?A) Inspiratory flow limitationB) SnoringC) ArousalsD) REM reboundE) All of the above

Case 16


Case 16


What is the particular feature of this patient’s sleepapnea?

A) Positional sleep apneaB) Desaturations consistent with hypoventilationC) CPAP was not effective in treating the SDBD) REM related sleep apnea

Case 17


Case 17


Why does the oxygen saturation drop at about3:45 AM on this split night polysomnogram?

A) Related to COPDB) CPAP setting to lowC) Mask leakD) REM related sleep apneaE) Related to sleep fragmentation

Case 18


Case 18


Following this split night PSG, the patient statesthat he does not want to wear a mask duringsleep. Based on these results, what alternativetreatment would be feasible?A) Oral appliance therapyB) Bilevel positive airway pressureC) Mask desensitization trainingD) Treat the periodic limb movementsE) Positional therapy

Case 19


Case 19


During this split night study, CPAP of 8 cm H2Oeliminated the patient’s OSA. Numerous PLMswere present on the optimal CPAP setting.What would be the best initial course ofmanagement?A) Start treatment with CPAP 8 cm H2OB) Start treatment with CPAP 10 cm H2OC) Start treatment with CPAP 8 cm H2O and

pramipexoleD) Start treatment with pramipexole aloneE) Perform a full night PSG before starting treatment

Case 20


Case 20


You re-evaluate this patient with OSA after beingon CPAP for one year. He is using a nasal mask.You download his compliance data. He tells youthat he is tolerating CPAP well and using it everynight. He is not complaining of EDS. What wouldbe the best next course of management?A) Re-evaluate him in one yearB) Send him to mask clinic to get a full face maskC) Have him come to see the nurse practioner in one

month since his usage is suboptimalD) Increase his CPAP settingE) Decrease his CPAP setting

Case 21


You re-evaluate this patient with OSA after beingon CPAP for 18 days. She is using nasal inserts.You download her compliance data. She tells youthat she is tolerating CPAP well. What would bethe best next course of management?

A) Increase her CPAP from 8 cm H2O to 10 cm H2OB) Repeat her sleep study to determine an optimal CPAP

settingC) Add humidification to her CPAP systemD) Encourage her to use CPAP more consistently and re-

evaluate her in one monthE) Change her CPAP interface

Case 22


Case 22


You re-evaluate this patient with OSA after beingon Bi-level. He is using a full face mask. Youdownload his compliance data. He tells you thatBi-level is helping him and is using it consistently.He is not complaining of EDS. What would be thebest next course of management?

A) Switch to a nasal maskB) Switch him to an auto Bi-level unitC) Re-evaluate him in one yearD) Perform a home sleep studyE) Switch to Bi-Flex

Case 23


Case 23


Central Sleep Apnea/Cheyne-Stokes Respiration isCharacterized by Which of the Following?

A. An arousal occurring at the time the tidal volumebegins to progressively increase

B. An arousal occurring at the time the tidal volumereaches its maximum

C. A central apnea always occurring between eachwaxing-waning respiratory cycle

D. A central apnea that is always longer in durationthan the waxing-waning respiratory cycle

E. A low ventilatory response to hypoxia


Which of the Following Findings has not beenAssociated with Central Sleep Apnea/Cheyne-

Stokes Respiration?

A. Low left ventricular ejection fractionB. Atrial fibrillationC. Ventricular arrhythmiasD. Pulmonary artery hypertensionE. Prolonged circulation time


In Which Stage of Sleep does Cheyne-StokesRespiration Typically Occur?

A. WakeB. Stages 1 and 2C. Stage 3D. REME. It is equally likely to occur in all stages of

sleep


Which of the Following is the Most EfficaciousTreatment for Central Sleep Apnea/Cheyne-

Stokes Respiration?

A. Positive airway pressureB. Supplemental oxygenC. AcetazolamideD. TheophyllineE. Treatment of the patient’s chronic

heart failure


All the Following Findings are Found in Patients withPickwickian Syndrome Except?

A. Daytime hypercapniaB. Cor PulmonaleC. Daytime hypoxemiaD. > 10 torr increase in PCO2 during sleepE. All of the above


Which of the Following Patients are atRisk for a Myocardial Infarction:

A. Patients with loud snoringB. Patients with untreated mild to

moderate OSAC. Patients with untreated severe OSAD. Patients with severe OSA treated with

CPAPE. All of the above


Which of the Following is True of the Relationshipbetween 3 Months of CPAP Usage and Outcomes?

A. 7 hours of CPAP use normalizes theMSLT in 65% of patients

B. 4 hours of CPAP use normalizes theMSLT in 65% of patients

C.7 hours of CPAP use normalizes the ESSin 65% of patients

D.4 hours of CPAP use normalizes theFOSQ in 65% of patients

E. None of the above

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