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OSA is defined by which criteria
Five or more respiratory events (apneas, hypopneas, or respiratory effort-related arousals [RERAs]) in association with excessive daytime somnolence, waking with gastping, choking, or breath-holding, or witnessed apneas or loud snoring. Or 15 respiratory events per hour without symptoms.
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Define hypopnea:
- a reduction in airflow (>50%) at least 10 seconds with >3% desaturation or reduction in airflow of >30% with >4% desaturation.
- associated with arousal on EEG
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Define RERA
Respiratory effort related arousals: sequence of breath over at least 10 seconds with increasing respiratory effort that terminates with an arousal.
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Three major areas of obstruction in OSA
Nose, palate, hypopharynx
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What is the Fujitia classification?
- Type I: collapse in the retropalatal region
- Type II: retropalatal and retrolingual collapse
- Type III: retrolingual collapse
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Craniofacial variations associated with OSA in adults
- increased distance of the hyoid from the mandibular plane
- decreased mandibular and maxillary projection
- downward and posterior rotation of mandibular and maxillary growth
- increased facial length
- increased vertical length of posterior airway
- increased cervical angulation
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The most important muscle in maintaining airway patency.
Genioglossus
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What might you see on a cephalometric radiograph in a patient with OSA?
- inferiorly displaced hyoid
- smaller posterior airway space
- longer soft palates
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Compare oral appliance and CPAP in terms of adherence and efficacy.
oral appliance is cost effective and has higher rates of patient adherence, CPAP has proven to be more effective in reducing AHI.
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What's more common, retropalatal or retrolingual obstruction?
- Retropalatal 88-100%
- Retrolingual 49-77%
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___% of patients experience temporary nasal reflux after UPPP
15%
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Friedman developed a staging system based on these three factors to predict the success rate of UPPP
Mallampati staging, tonsil size, BMI
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In a maxillomandibular advancement procedure, advancement should be at least __ mm.
10 mm
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___% of OSA patients have coexistent other sleep disorders, the most common of which are these two.
- 31% total.
- 15% had inadequate sleep hygeine
- 8% had periodic limb movement disorder
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What percentage of the night is spent in NREM sleep?
80% NREM.
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What are the three stages of NREM sleep and what are the associated EEG findings?
- N1 (previously 1) is a transition stage between sleep and wake. Mixed voltage pattern.
- N2 first true stage of sleep. Characterized by spindles and K complexes. (50% of sleep)
- N3, also called slow-wave sleep, distinguished by high-amplitude delta waves which comprise 20% of a 30 second scoring period.
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2 ways to quantify sleepiness
- Epworth Sleepiness Scale
- Multiple Sleep Latency Test
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What is the multiple sleep latency test?
Consists of four or five 20-minute nap opportunities set two hours apart, often following an overnight sleep study. Measure time to sleep onset and occurrence of sleep onset REM periods.
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During a multiple sleep latency test a patient complaining of daytime fatigue has sleep onset of less than 8 minutes and multiple SOREMPS, or sleep onset REM periods. What
Narcolepsy. Characteristic features include sleep paralysis, the inability to move upon awakening (25% of pts); hypnogogic hallucinations, the sensation of dreaming while awake (30%); cataplexy, the sudden transient loss of muscle tone in response to stronge emotions (70%)
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internal clock is located in the
suprachiasmatic nucleus, associated with external lights and social cues.
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Circadian rhythm promotes wakefulness and has two peaks at these times.
- late morning, 4-8 hours after minimal core temperature
- early evening, at maximal core temperature
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Which neurotransmitter in the suprachiasmatic nucleus is responsible for wakefulness?
glutamate
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Which pineal gland hormones promote wakefulness in response to light in Circadian physiology? Which inhibit it?
- Promote: TSH, cortisol
- Inhibit: melatonin
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In patients with sleep deprivation, what changes will be found in the following hormone levels: TSH, GH, Prolactin?
- increase TSH
- decrease GH
- decrease prolactin
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The cricomental distance that excludes OSA is___.
15 mm.
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6 muscles that maintain airway patency,
- tensor veli palatini
- medial and lateral pterygoids
- genioglossus
- geniohyoid
- sternohyoid
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The most predictive indicator of OSAS
- Neck circumference
- >17" in males
- >15.5" in females
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physiologic endocrine effects of OSAS
- CRP: increase
- serum amyloid: increase
- cortisol: increase
- growth hormone: decrease
- prolactin: decrease
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These two neurotransmitters appear to be responsible for paralysis during REM sleep.
glycine (classic) and GABA (more recent discovery)
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