OSA

Question 1

What is OSA

Answer 1

Sleep disorder characterized by recurrent airway obstruction caused by the collapse of the upper airway

Question 2

How would you evaluate OSA patient

Answer 2

PMHx, PSH, meds, ALL, social;
HPI –daytime symptoms, hypersomnolence, AM headaches, difficulty concentrating/memory loss, sexual dysfunction, snoring, restless sleep, choking, reflux, nocturia, are they using any sleep appliances or prior tx for osa

I would like to get details of HPI, explore more about the symptoms and previous treatment via STOP-BANG questionnaires.
I will conduct physical examination including inspection of body habitus, intra nasal inspection, neck circumference, airway assessment, dental exam and occlusion.
I would do nasophryngoscopy with mullers maneuvers, obtain lateral ceph or CBCT

Question 3

Are there any questionnaires use in OSA ?

Answer 3

STOP-BANG, ESS

high risk is 5-8 in STOP-BANG

Question 4

What is apnea vs hypopnea?

Answer 4

Apnea = cessation in breathing despite respiratory effort > 10 sec.

hypopnea = decreased in nasal airflow > 50 % a/w desaturation for > 10 seconds

Question 5

What is RERA

Respiratory effort-related arousal (RERA)

Answer 5

An event that causes an arousal or a decrease in oxygen saturation, without qualifying as apnea or hypopnea.

Question 6

What are conditions a/w OSA ?

Answer 6

HTN, stroke, Parkinson dz, seizures, GERD, ED, arrhythmias, DM/insulin resistance, cognitive impairment, depression, HA, pulmonary restriction/HTN

Question 7

Pathophysiology of OSA

Answer 7

OSA increases sympathetic tone and causes autonomic arousals, leading to hypoxia, sleep fragmentation, free radicals, and endothelial damage, resulting in a chronic inflammatory state and higher cardiovascular risk.

Question 8

Describe PE for OSA

Answer 8

facial asymmetries, chin / mandible positioning, neck circumference (>16-17 in), BMI, I/O exam looking at occlusion, tongue, posterior OP including tonsils, long soft palate and uvula , nasal exam

Question 9

Evaluate airway in OSA

Answer 9

Clinical airway examination , DISE, flexible endoscope with muller manuever and lateral ceph

Question 10

What is mueller’s maneuver

Answer 10

Attempt to inhale against closed oral and nasal passages using endoscopy to look at location of airway collapse

Question 11

What are ceph findings a/w OSA -

Answer 11

Decreased PAS (< 11mm; from B point to posterior pharyngeal wall), long soft palate length (> 35mm), hyoid to MP (anterior superior limit of hyoid to MP, ideal < 15mm

Question 12

What monitors are used in a in lab sleep study

Answer 12

PSG- EEG, EOG, Pulse Ox, EMG, bp, sleep position, thoracic mvmt, ETCO2

Question 13

What is the Fujita classification

Answer 13

Type 1: upper pharynx to include the palate, uvula, and tonsils (BOT normal)
Type 2: upper and lower pharynx. Palate and BOT
Type 3: lower pharynx to include the tongue base, lingual tonsils, and supraglottic region.

Question 14

Describe Stanford protocol ?

Answer 14

Phase 1: nasal surgery (sepum/turbs), oropharynx (UPPP, tonsillectomy), hypopharynx (GG advancement, hyoid suspension)

Phase 2: MMA, hypoglossal nerve stimulator

Inspire – pt with moderate-severe OSA; breathing monitor, pulse generator, cuff electrode around CN 12
Moderate to severe OSA, AHI < 65, no mixed picture, can’t tolerate CPAP, BMI < 32, don’t have concentric collapse) around CN12 (for mod-severe

Question 15

What’s NADIR?

Answer 15

Lowest O2 level recorded during sleep in PSG

Question 16

What are the phases of sleep?

Answer 16

There are four sleep stages, including one for rapid eye movement (REM) sleep and three that form non-REM (NREM) sleep.

NREM Stage 1 (Light Sleep)
Transition from wakefulness to sleep.
5-10% of total sleep

NREM Stage 2
Deeper sleep with slowing heart rate and breathing.
45–55% of total sleep

NREM Stage 3 (Deep Sleep)
Also called slow-wave sleep (SWS).
Hard to wake; important for physical restoration.
15–20% of total sleep

Rapid eye movement REM stage 4
Brain activity similar to being awake.
Important for memory and emotional processing.
20–25% of total sleep.

Question 17

What are some treatment options for OSA?

Answer 17

There are non surgical and surgical tx, depend on how sever is the OSA , I would start with educating the pt about weight reduction 10% weight loss = 26% decrease AHI, oral appliances for mild to moderate as first line, as second line in after initiation CPAP.
Surgical tx: including UPPP, hyoid suspension, tongue reduction , tonsillectomy , genioglossus advancement, MMA AND TRACH.

Question 18

Post op patient complains of pain in his left eye after MMA

Answer 18

Vertical fracture of maxilla up to orbit
Check IOP
Ophtho consultation
Immediate Post Op CTA
Lateral canthotomy if needed

Question 19

Patient neglected to tell you that he previously had H&N radiation for lymphoma
Its now one week after MMA surgery, what would you do?

Answer 19

Get radiation records
Consider HBO if over 60 gray (2.4 atm, 90 min daily)

Question 20

What is the CPAP?

Answer 20

Non-invasive continuous positive airway pressure (CPAP) delivers pressurized air (4–20 cm H₂O) through a mask worn over the nose, mouth, or both.

Question 21

What is the difference between CPAP and BiPAP

Answer 21

CPAP delivers a single continue positive airway pressure typically between 4–20 cm H₂O

BiPAP provides two pressures:
IPAP (8–25 cm H₂O) for inhalation and EPAP (4–10 cm H₂O) for exhalation, allowing better support for ventilation and CO₂ elimination.

Question 22

CPAP complication

Answer 22

• Nasal symptoms (dryness, congestion, rhinorrhea)
• Claustrophobia
• Pressure on face - skin abrasions
• Air leakage from the mask - conjunctivitis
• Aerophagia

Question 23

What is Polysomnography (PSG)

Answer 23

A diagnostic test used for the evaluation of sleep disorders.
It provides detailed information about an individual’s sleep patterns, sleep stages, and various physiological activities that occur during sleep.

Question 24

What is an RDI?

What is AHI?

Answer 24

What is an RDI?
Respiratory Disturbance Index – the average number of apnea events, hypopnea events, and respiratory event related arousals (RERAs) per hour.
RDI > 5 indicates abnormal.
RDI > 20 indicates clinically significant.
RDI > 30 indicate sever.
RDI= #Apnea + # Hypopnea + #RERA / sleep hours

What is AHI?
Apnea/Hypopnea Index – the average number of apnea and hypopnea events per hour

0–4: Normal (No OSA)
5–15: Mild OSA
15–30: Moderate OSA
>30: Severe OSA

Question 25

How does obesity impact airway and lung function in perioperative management?

Answer 25

Obesity narrows the pharyngeal airway and reduces lung volumes due to increased soft tissue and visceral fat.

Question 26

What are the common symptoms and signs of obstructive sleep apnea (OSA)

Answer 26

poor sleep, daytime fatigue, and cognitive decline. Signs include hypertension, hypoxemia, hypercarbia, polycythemia, and cor pulmonale. Repeated low oxygen and acidosis may cause arrhythmias, pulmonary hypertension, and heart strain.

Question 27

What is ESS?

Answer 27

The  Epworth Sleepiness Scale (ESS) is a self-reporting simple questionnaire used to measure  daytime sleepiness. It asks about the chance of dozing off in  8 daily situations  like reading, watching TV, or sitting in a car. Interpretation 0–5 Lower Normal Daytime Sleepiness 6–10 Higher Normal Daytime Sleepiness 11–24 Excessive Daytime Sleepiness

Question 28

Drug-Induced Sleep Endoscopy (DISE)

Answer 28

DISE is nasopharyngoscopy performed on a patient that is undergoing sedative-induced sleep.Anesthetic agents blunt the negative pressure reflex, thus mimicking the conditions of REM sleep. * The success rate of surgical treatment of OSA based on DISE is 75%, compared to 40% if it was done without DISE.

Question 29

Home Sleep Apnea Testing (HST)

Answer 29

Portable method for diagnosing obstructive sleep apnea (OSA) outside of a sleep lab. Used for mild to moderate cases Can underestimate the severity Usually for non compromised pts This has been tested and validated against standard PSG and has been shown to have high sensitivity and specificity in appropriate patients. Components: Airflow Sensor Pulse Oximeter Respiratory Effort Belts Body Position Sensor

Question 30

What is Pickwickian syndrome?

Answer 30

(obesity hypoventilation syndrome) is marked by red cheeks from polycythemia and pursed-lip breathing to help with ventilation.

Question 31

STOP-BANG questionnaire.

Answer 31

STOP-BANG questionnaire. positive response to three or more of the following questions indicates a high risk for OSA. Less than three positive responses indicates a low risk for OSA. S  Do you Snore loudly (louder than talking or loud enough to be heard through closed doors)? T  Do you often feel Tired, fatigued, or sleepy during daytime hours? O  Has anyone Observed you stop breathing during your sleep? P  Do you have or are you being treated for high blood Pressure? B Is BMI > 35 kg/m? A Is Age > 50 years? N Is the Neck circumference > 40 cm (17 in)? G Is the Gender male? Interpretation High risk of OSA: Yes 5–8. Intermediate risk of OSA: Yes 3–4. Low risk of OSA: Yes 0–2.

Question 32

What are the key features of the ASA checklist for identifying a difficult airway during preoperative evaluation?

Answer 32

The ASA evaluation checklist for difficult airway management includes: Incisors: Long, prominent overjet, or maximal incisal opening <30 mm. Uvula: Not visible when tongue is protruded (Mallampati > II). Palate: Highly arched or narrow. Mandibular space: Stiff, indurated, mass-occupied, or nonresilient. Thyromental distance: Less than 3 finger breadths. Neck: Short or thick. Head and neck motion: Limited flexion or extension (e.g., can't touch chin to chest)

Question 33

Obesity anesthesia consideration

Answer 33

If sedation or anesthesia is planned, patients should bring their home continuous positive airway pressure or biphasic positive airway pressure machines with them to provide airway support during recovery. Short procedures and minimal sedation are recommended. The hospital setting should be strongly considered for surgery that requires moderate or deeper levels of anesthesia. The width of the blood pressure cuff should be greater than one-third the circumference of the arm. An alternative in an obese patient is to place the cuff on the patient’s forearm. Treat the patient in the upright or ramping position to increase the airway space behind the epiglottis and improve visualization of the airway for intubation. Such positioning also can decrease the likelihood of aspiration of gastric contents The duration of action may be slightly decreased by an increase in plasma volume An induction dose calculated on a milligram per kilogram basis may lead to plasma concentrations beyond therapeutic recommendations because fat has low blood flow. Initial doses of anesthetic agents should be based on ideal body weight Small doses of drugs should be administered slowly until the desired effect is achieved

Question 34

Independent risk factors for the difficult mask ventilation.

Answer 34

BBASL Age older than 55 years BMI greater than 26 snoring beard lack of teeth

Question 35

Define snoring

Answer 35

Interruption of free flowing air through nasal passage causing turbulence with the soft palate List 3 treatments for snoring i. UPPP?/ LAUPPP ii. Sleep on side/ stomach iii. dental device

Question 36

CSA

Answer 36

Lack of respiratory drive from the brain (no effort to breathe). Treat underlying cause (e.g., heart failure), BiPAP or adaptive servo-ventilation (ASV).

Question 37

What are 5 daytime and 5 nighttime symptoms of OSA

Answer 37

a. Daytime = somnolence, irritability, poor memory, headaches, fatigue, impotence, depression b. Nighttime = repeated awakenings, gasping for air, frequent urination, sweating

Question 38

When should you get a post-op polysomnogram?

Answer 38

3 months – 6 months – 1 year

Question 39

How do you define success after surgery for OSA?

Answer 39

* Improve QOL * Subjective S&S * Objective S&S Better answer: postoperative AHI < 20 and a ≥ 50% reduction in AHI, the success rate of this operation has been estimated to be 86.0%

Question 40

What is a UPPP?

Answer 40

A procedure to shorten the SP and enlarge the retro-palatal area - What are the potential complications? i. VPI ii. Bleeding iii. PAIN iv. Hyper-nasal speech v. Pharyngeal stenosis

Question 41

OSA symptoms

Answer 41

* Nocturnal – Loud snoring – Witnessed breathing interruptions – Awakenings due to gasping or choking – Nocturia * Diurnal – Waking up unrefreshed – Morning headaches – Daytime sleepiness: Should be quantified using the Epworth Sleepiness Scale; scores range from 0 to 24; normal ranges from 0 to 8 – Impaired concentration and memory * Criteria for OSAS diagnosis – Five or more obstructive events per hour of sleep AND presence of symptoms – Fifteen or more obstructive events per hour of sleep, irrespective of symptoms

Question 42

Neurostimulation: Inspire

Answer 42

Hypoglossal nerve stimulator is an implant that uses mild stimulation to restore muscle tone in a patient's airway during sleep to prevent obstruction

Question 43

What are the component of inspire?

Answer 43

1- Implanted Pulse Generator (IPG) 2- Simulation Lead with electrodes placed on the medial branches of the hypoglossal nerve 3- Respiratory sensing lead

Question 44

How dose inspire work

Answer 44

* The system will sense the respiration and provide a synchronized stimulation to the HGN during inspiration * Palatoglossus Coupling: Stimulation of the genioglossus muscle will open the the soft palate * Glossopharyngeal Coupling: Indirect opening of the lateral pharyngeal wall with tongue stimulation * This will open the airway at the retropalatal and retrolingual levels

Question 45

Indication of inspire

Answer 45

1- Adults > 18 2- BMI <40kg/m2 3- AHI between 14-100/h for moderate and sever. 4- CPAP intolerance 5- AP collapse at the level of the velum or nasophyrnex during DISE 6- FDA now approved therapy for pediatric Down syndrome patient who has obstruction at the level of the tongue

Question 46

What is VOTE score

Answer 46

VOTE Scoring system Velum ( if obstruction inspire can be indicated ) Oropharnyx Base of tongue Epiglottis (0 = no obstruction, 1 = partial obs, 2= complete) Inspire is not indicated for concentric collapse