stridor sleep apnoea dr robin smith. stridor predominantly inspiratory wheeze due to large airways...
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STRIDOR
SLEEP APNOEA
Dr Robin SmithDr Robin Smith
STRIDOR
• Predominantly inspiratory wheeze due to large airways (larynx/trachea/major bronchi) obstruction
Causes of Stridor (children)
• InfectionsCroup
Epiglottitis
Pseudomembranous croup
Retropharyngeal abscess
Diphtheria
Infectious mononucleosis
• Foreign Body
• Anaphylaxis / angioneurotic oedema
• Other (eg burns)
Causes Of Stridor (adult)
• Neoplasms– Larynx– Trachea– Major bronchi
• Anaphylaxis• Goitre (retrosternal)• Trauma (eg
strangulation, burns, irritant gases)
• Other (eg bilateral vocal cord palsy; Wegener’s granulomatosis; cricoarytenoid arthritis (RA); tracheopathia
Coal Miner who had been trapped in roof-fall 12 years previously
Pea in Left Upper Lobe Bronchus
Investigation of stridor
• Laryngoscopy (beware in acute epiglottitis)
• Bronchoscopy
• Flow volume loop
• Chest X ray
• Other imaging (CT; thyroid scan)
Treatment of laryngeal obstruction
• Treat underlying cause eg foreign body removal, anaphylaxis
• Mask bag ventilation with high flow O2
• Cricothyroidotomy
• Tracheostomy
Heimlich Manoeuvre
Foreign body inhalation
(café coronary syndrome)
Rapid upward thrust in epigastrium forces upward movement of diaphragm and forced expiration
Treatment of malignant airway obstruction
Tumour removal:laser; photodynamic therapy; cryotherapy; diathermy;
surgical resection
Tumour compression: intraluminal stent
Radiotherapy (external beam; brachytherapy)
(Chemotherapy; Corticosteroids)
Anaphylaxis
Acute Anaphylaxis
• Type 1 (immediate) hypersensitivity (IgE)
• Flushing, pruritus, urticaria,
• Angioneurotic oedema (lips, tongue face, larynx, bronchi)
• (abdominal pain, vomiting)
• Hypotension (vasodilatation and plasma exudation) circulatory collapse (shock)
• Stridor, wheeze and respiratory failure
Causes of anaphylaxis
• Foods eg nuts; shellfish
• Insect venom (bee, wasp)
• Drugs (eg penicillin, aspirin, anaesthetics)
• Other eg latex
Treatment of anaphylaxis (1)
• IM Epinephrine (adrenaline)
• IV antihistamine
• IV corticosteroid
• High flow O2
• Nebulised bronchodilators
• Endotracheal intubation if necessary
Treatment of anaphylaxis (2)
• Allergen avoidance (where possible)
• Desensitisation (immunotherapy) eg venom
• Self-administered epinephrine
STILL AWAKE ??
Epworth Sleepiness Scale
• SITUATIONS– sitting and reading– watching TV– sitting inactive in public eg
theatre– car passenger for 1h– lying down to rest in the
afternoon– sitting talking– sitting after lunch without
alcohol– In car, stopped for few
minutes in traffic
• CHANCES OF DOZING
– 0 = would never doze
– 1 = slight chance of dozing
– 2 = moderate chance
– 3 = high chance
NORMAL = <10/24
Obstructive sleep apnoea
Sleep apnoea/hypopnoea syndrome
Snoring
Relaxation of pharyngeal dilator muscles during sleep (esp. REM)
Upper airway narrowing, turbulent airflow and vibration of soft palate and tongue base
Obstructive Apnea
Obstructive Sleep Apnoea
• Intermittent upper airway collapse in sleep
• apnoeas or hypopnoeas ± hypoxaemia
• recurrent arousals / sleep fragmentation
• 1-4% adult population (3,000 – 12,000 in Tayside – only 1500 currently treated)
Risk Factors for Sleep Apnoea• Enlarged tonsils, adenoids• Obesity• Retrognathia• Acromegaly, hypothyroidism• Oropharyngeal deformity• Neurological: stroke, MS, myesthenia gravis,
myotonic dystrophy• Drugs: benzodiazepines, opiates, alcohol,• Post-operative period after anaesthesia
Consequences of Sleep Apnoea
• excessive daytime sleepiness
• personality change
• cognitive / functional impairment
• Major impact on daytime function
Consequences of Sleep Apnoea
• 7-fold increase in RTA
• Driving simultion – equivalent to being twice legal limit for alcohol
Consequences of Sleep Apnoea
• Independent risk factor for hypertension• Activated sympathetic system• Raised CRP• Impaired endothelial function• Impaired glucose tolerance• (probable increased risk of stroke and
cardiovascular events)
All improved by CPAP
Obstructive Sleep Apnoea
Diagnosis
• Snoring & EDS (raised Epworth score)
• Overnight sleep study
- oximetry
- domicillary recording (airflow, oximetry, thoracic/abdominal movement)
- full polysomnography
Obstructive Sleep Apnoea
Treatment
• Remove underlying cause
• CPAP (continuous positive airway pressure)
- most effective therapy
Effect of Positive Airway Pressure on Upper Airway Patency
Continuous Positive Airway Pressure (CPAP) therapy
Obstructive Sleep Apnoea
Other RxMandibular Advancement Device- improves snoring- moderate reduction in AHI- use in mild OSA (AHI 5-15/hr)Surgery (UPPP, laser Rx)- avoid if sleep apnoea (future CPAP less effective)- may be used in simple snoring
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