Sleep Apnea Causes and Treatments

Cure Sleep Apnea Without Cpap

In these real-life case studies youll learn in-depth about the lives and treatments of 9 people who have conquered their apnea. Specifically, youll learn: 1. When they first suspected they had sleep apnea. 2. Symptoms that made them first think they had sleep apnea. 3. Steps they took to get diagnosed. 4. How they felt when they were diagnosed (what was going through their mind) 5. The quality of their sleep before their apnea treatment, and how they felt during the day. 6. What they did to try to get a good nights sleep before their successful treatment. 7. What they did to try to overcome fatigue during the day. 8. A description of exactly what their treatment involved. 9. How they found out about the treatment. 10. Side effects of their treatment. 11. Obstacles they encountered during their treatment, and how they overcame those obstacles. 12. How long it took before the quality of their sleep improved. 13. How long it took before they felt better (more rested) during the day. 14. How long its been since they conquered their sleep apnea. 15. Resources they recommend for others who suffer from sleep apnea, and would like to follow their treatment (the name of specific doctors and medical centers) 16. Final words of advice for people who have just been diagnosed with sleep apnea. Here Is a Tiny Sample of What Youll Get When You Download Your Copy Of Cure Your Sleep Apnea Without Cpap: 78 pages of actionable information on alternative, non-Cpap sleep apnea treatments. 9 case studies of men and women who have completely cured their sleep apnea without Cpap. 7 types of alternative treatments that are proven to cure sleep apnea (detailed descriptions) 12 action steps for each alternative treatment, so you know exactly how to take action on each treatment. 7 quick fix sleep treatments that can help you get a better nights sleep Tonight. 69 hand-picked web links for further information on alternative sleep apnea treatments. 31 diagrams explaining alternative sleep apnea treatments Read more here...

Cure Sleep Apnea Without Cpap Summary


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Obstructive Sleep Apnea

At least 20 muscles and soft-tissue structures control patency of the upper airway. Patients with OSA may have differences in upper airway muscle activity during sleep and may have smaller airways, predisposing them to upper airway collapse and consequent apneic episodes during sleep. The inability of the upper airway to contend with factors that promote collapse, including fat deposition in the neck, negative pressure in the airway during inspiration, and a smaller lower jawbone, also may play a role in the pathogenesis of OSA. Hallmarks of OSA include witnessed apneas, gasping, or both. threefold higher in male patients with severe OSA. OSA is associated with or aggravates biomarkers for cardiovascular disease, including C-reactive protein and lept-in.25,26 Patients with sleep apnea often are obese and may be predisposed to weight gain. Hence, obesity may further contribute to cardiovascular disease in this patient population. Hg with each apneic episode.2 Concentrations of...

Obstructive Sleep Apnea Syndrome

Habitual snoring occurs in 3 to 12 of preschool-age children. The childhood incidence of obstructive sleep apnea syndrome (OSAS) is estimated to be 2 . The American Academy of Pediatrics has published an evidence-based guideline for the diagnosis and management of OSAS (AAP, 2002). In children, OSAS is most often associated with large adenoids and or tonsils, as well as specific facial features such as micrognathia, macroglossia, and Down syndrome. Unlike adults with sleep apnea, children can be affected without large drops in blood oxygen levels, because children can have frequent brief awakenings to quickly reestablish their airway. Thus, the primary clinical issue may be sleep fragmentation. In the context of a child with snoring and restless sleep, OSAS should be considered any time there are symptoms or signs suggesting sleep deprivation, such as difficulty paying attention, emotional lability, partial arousals during the night (night terrors, sleepwalking), or difficulty waking...

Snoring and Obstructive Sleep Apnea

Snoring is extremely prevalent but is also the most common symptom of obstructive sleep apnea. OSA occurs when the upper airway collapses during sleep, leading to obstruction, hypoventilation, and hypoxemia. OSA has been associated with development or exacerbation of hypertension, coronary artery disease, pulmonary hypertension, poor concentration, impotence, obesity, depression, and increased risk of motor vehicle crashes. It is a potentially serious medical condition that can be overlooked if not specifically sought. Strong suspicion of sleep apnea should be confirmed with an overnight sleep study or polysomnogram. The sleep study measures intensity of snoring, presence of apnea or hypopnea (partial apnea), oxygen saturation, sleep efficiency, and cardiac rhythm. The data are compiled and analyzed by a sleep specialist. A numeric value of the total number of apneas and hypopneas is derived, called the apnea-hypopnea index or respiratory distress index (RDI). An RDI of less than 5 is...

Sleep Apnea

The sleep apnea syndrome is a potentially disabling condition characterized by excessive daytime fatigue or sleepiness, disruptive snoring, episodes of upper airway obstruction during sleep, and nocturnal hypoxemia. During sleep, the pharynx repeatedly collapses. The patient The presence of snoring, sleepiness, and tiredness are suggestive of sleep apnea.

Neuroimaging Features

Contrast-enhanced axial computed tomography scan of 10-year-old boy with progressive dysphonia, sleep apnea, and difficulty swallowing. An enhanced tumor is seen arising from the cervicomedullary junction. Contrast-enhanced axial computed tomography scan of 10-year-old boy with progressive dysphonia, sleep apnea, and difficulty swallowing. An enhanced tumor is seen arising from the cervicomedullary junction.

Benign Neonatal Familial and Nonfamilial Convulsions Benign idiopathic neonatal convulsions BINNC

Seizures in BINNC have been referred to as fifth-day fits because of their presentation between the fourth and sixth days of life. Recurrent focal or generalized clonic seizures, apneic events, and status epilepticus are observed. A family history of epilepsy may be present. In BFNNC, seizures begin on the second or third day of life and tend to recur for several months. Although most infants have no other abnormalities on examination, minor neurological findings have been reported. The etiology and pathophysiology of BINNC are unknown BFNNC is an inherited disorder characterized by autosomal dominant transmission with a genetic defect located on chromosome 20q.

Autonomic Dysfunction Secondary to Focal Central Nervous System Disease

Other brain stem disorders associated with autonomic dysfunction include tumors, syringobulbia, Arnold-Chiari malformation type 1, multiple sclerosis, and poliomyelitis. Brain stem tumors may present with intractable vomiting, orthostatic hypotension, or paroxysmal hypertension. Syringobulbia may produce Horner's syndrome, orthostatic hypotension, cardiovagal dysfunction, lability of arterial pressure, and central hypoventilation. y Syncope, sleep apnea, and cardiorespiratory arrest have been reported in association with the Arnold-Chiari malformation type 1. Less common manifestation of brain stem dysfunction include hypertension due to involvement of the medullary reticular formation in poliomyelitis (see Chapter . ) autonomic hyperactivity, most likely due to disinhibition of preganglionic sympathetic and parasympathetic neurons in tetanus (see Chapter s ) and fulminant neurogenic pulmonary edema due to demyelination of the area surrounding the NTS in patients with multiple...

Growth Hormone Hypersecretion Museuloskeletal Increas

Ng hat, glove, or shoe sizes prognathism prominent supraorbital ridges coarsening of facial features (e.g, large bulbous nose, thick lips, separated teeth) Endocrine Hyperhidrosis, fatigue, exercise intolerance, hoarseness, sleep apnea (peripheral and central) MEN-I, Multiple endocrine neoplasia, type I Data from Kissel IT Endocrine myopathies, In Update on Neuromuscular Disease course 423 of the AAN annual meeting, Washington, D.C., May, 1994, pp 34-35 Maugans TA, Coates ML Diagnosis and treatment of acromegaly Am Fam Phys 1995 52 207-213 Molitch ME Clinical manifestations of acromegaly. Endocrinol Metab Clin North Am 1992 21 597-614 and Grunstein RR, Ho KY, Sullivan CE Sleep apnea in acromegaly Ann Intern Med 1991 115 527-532. The prevention of many of the sequelae of disorders associated with acromegaly (e.g., hypertension, cardiovascular disease, stroke, sleep apnea, diabetes, arthropathy) requires early identification and treatment. The management of acromegaly includes the...

Mecanism Of Centripetal Lipid Accumulation Supraclavicular Fat And Face

Hypersecretion of GH is related to a somatotroph adenoma in 98 of cases. Approximately 20 of GH-secreting adenomas also secrete PRL. Other causes include excess GHRH from a hypothalamic hamartoma or choristoma, or from ectopic production (i.e., bronchial carcinoid, pancreatic islet cell tumor, or small-cell lung cancer). Hypersecretion of GH leads to the clinical syndrome of acromegaly in adults and gigantism in children. Acromegaly is characterized by an enlarged protruding jaw (macrognathia) with associated overbite enlarged tongue (macroglossia) enlarged, swollen hands and feet resulting in increased shoe and ring size coarse facial features with enlargement of the nose and frontal bones and spreading of the teeth (Table 6-1). Musculoskeletal symptoms are a leading cause of morbidity and include arthralgias leading to severe debilitating arthritic features. Skin tags hyperhidrosis (in up to 50 of patients), often associated with body odor hirsutism deepening of the voice...

Anesthesia Anesthesiology Consultation

We recommend a consultation before the day of surgery if possible, especially if there are any medical issues that could affect the administration of anesthesia. If you have a history of a significant medical illness or are under treatment for a medical disease, you should schedule a preoperative anesthesiology evaluation at least two working days ahead of your admission to the hospital for the surgery. Such illnesses include heart disease (coronary artery disease, valvular disease excluding mitral valve prolapse, arrhythmias), severe asthma, chronic obstructive pulmonary disease, emphysema, diabetes, thyroid disease, sleep apnea, and morbid obesity. In addition, any woman over the age of 50 should have preoperative clearance from her primary care physician or have a preoperative anesthesia evaluation. Even if you don't fit into any of these categories, if you are more comfortable with an anesthesia evaluation before you go into the hospital, you should ask for a consultation.

Autonomic Neuropathy of Multiple System Atrophy Shy Drager Syndrome

Often in the male, the first symptom is impotence and loss of libido, with disturbance in micturition being common in both sexes. The characteristic orthostatic hypotension may be seen either as so-called drop attacks or as a gradual loss of consciousness over about a minute that is often associated with a neckache that radiates to the occiput and shoulders. Generally, there is at least partial loss of thermoregulatory sweating. Respiratory disturbance occurs as involuntary gasping, cluster breathing, and laryngeal stridor that may lead to obstructive sleep apnea and even death, or to central sleep apnea.

Mapleson E and F systems

The Mapleson E system, or Ayre's T-piece, has virtually no resistance to expiration and was used extensively in paediatric anaesthesia before the advantages of continuous positive airways pressure (CPAP) were recognized. It functions in a manner similar to the Mapleson D system in that the corrugated tube fills with a mixture of exhaled and fresh gas during expiration and with fresh gas during the expiratory pause. Rebreathing is prevented if the FGF rate is 2.5-3 times the patient's minute volume. If the volume of the corrugated tube is less than the patient's tidal volume, some air may be inhaled at the end of inspiration consequently, a FGF rate of at least 4 L min-1 is recommended with a paediatric Mapleson E system. It provides a degree of CPAP during spontaneous ventilation and positive end-expiratory pressure (PEEP) during IPPV.

Hematocrit and ischemic disease

Some men treated with testosterone respond with polycythemia, a phenomenon especially observed in older men (Drinka etal. 1995 Hajjar etal. 1997 Krauss etal. 1991 Sih etal. 1997). Especially the combination of increased red blood cell volume and decreased plasma volume results in a marked elevation of hematocrit, hence blood viscosity. In one study, three of nine patients with hematocrit 48 (53 , 58 and 64 ) experienced central ischemic episodes such as basal ganglia stroke, brain stem stroke and transient ischemic attack (Krauss etal. 1991). Another small study reported polycythemia in two out of eight patients. These were characterized by the highest body mass index within the group anddeveloped sleep apnea (Drinka etal. 1995).

Factors affecting serum testosterone levels in elderly men

In chronic obstructive pulmonary disease (COPD) and in patients with other hypoxic pulmonary diseases serum testosterone levels are often decreasedwith inappropriately low gonadotropin levels (Semple etal. 1981 1984), also in the absence of systemic glucocorticoid treatment (Kamischke etal. 1998). Sleep apnea syndrome is accompanied by a relative hypogonadotropic hypogonadism (Luboshitzky etal. 2002 Veldhuis etal. 1993 Worstman etal. 1987), with massive obesity often being a contributing factor to the hypogonadism in these patients (Grunstein etal. 1989).

Posterior Fossa Anomalies

The clinical spectrum associated with the Chiari I malformation has broadened in recent years with the increasing use of MRI, the imaging modality of choice for the diagnosis of this condition. As opposed to the Chiari II malformation (see the previous discussion of neural tube closure defects), the Chiari I malformation usually becomes symptomatic in teenage to early adult years, although the initial presentation can also be in an infant or older adult. The initial complaint is often neck pain, at times presenting with torticollis or retrocollis. If cervical spinal cord syringomyelia co-exists, symmetrical, asymmetrical, or even totally unilateral arm pain can be the initial complaint. Neurological symptoms and signs also are dependent on the neural structures involved. Predominant impairment of the brain stem and cerebellar tonsils by either compression at the level of the foramen magnum or by extension of the syrinx into the brain stem (syringobulbia) can lead to a variety of brain...

Disorders of sleeping

Sleep disorders following TBI may result from a variety of causes. Some may be preexistent while others may occur as a direct result of the brain injury. Sleepiness is a common cause of road fatalities (36 Leger, 1994) and collisions (42-54 Leger, 1994). Motor vehicle and industrial accidents are more likely to occur in individuals who have sleep apnoea, and it has been estimated that 90 of men and 98 of women with obstructive sleep apnoea (OSA) remain undiagnosed (Young, Evans, Finn, & Palta, 1997). In the unimpaired middle-aged working population, this condition occurs in 2 of women and 4 of men (Guilleminault, Faull, Miles, & van de Hoed, 1983). The sleep disorders represent a complex set of conditions. Nonetheless, a number of the conditions in the context of TBI deserve particular consideration. These are posttraumatic hypersomnia, narcolepsy, central sleep apnoea, obstructive sleep It tends to be the case that immediately following the injury, the subject reports difficulty in...

Sleep Disorders Associated with Degenerative Disorders of the Central Nervous System

Degenerative neurological diseases can lead to sleep disturbance through effects of the disease on neuronal systems involved in sleep-wake regulation, on systems involved with regulation of breathing during sleep, or on systems involved with motor control during sleep. Degenerative processes that affect the suprachiasmatic nucleus or the retina may produce circadian rhythm disturbances. Obstructive sleep apnea may occur if weakness, spasticity, or rigidity affect bulbar muscles, and central or obstructive apneas may occur if respiratory control systems of the lower brain stem are involved. Patients who have degenerative processes that affect motor systems are at increased risk for PLM disorder, RLS, and RBD. Obstructive and central sleep apneas and irregular respiratory patterns during sleep are common in patients with autonomic disturbances, in those with bulbar symptoms, and in those with degeneration of pontomedullary systems involved in the coordination of breathing. y , y The...

Etiology and epidemiology

Better predictor of prevalence.9 Additionally, adulthood overweight and obesity contribute to an increased risk of death in the presence of hypertension, hyperlipidemia, diabetes mellitus, coronary artery disease (CAD), stroke, sleep apnea, gallbladder disease, osteoarthritis, and certain cancers. Psychosocial functioning also may be hindered because obese patients may be at risk for discrimination if negatively stereotyped.6 Pediatric obesity is also associated with significant health-related problems and thus is a risk factor for much of the adult morbidity and mortality discussed previously.10,11 Cardiovascular (e.g., dyslipidemia and hypertension), endocrine (e.g., hyperinsulinemia, impaired glucose tolerance, type 2 diabetes mellitus, and menstrual

Obesity and Male Infertility

Infertility Obesity Mechanism

Fig. 26.2 Obesity can lead to male infertility via various mechanisms. These mechanisms manifest act directly through or via interplay between reactive oxygen species (ROS) production, the hypothalamus-pituitary-gonadal (HPG) axis, as well as other physical factors (HH hypogonadotro-pic hypogonadism ED erectile dysfunction SA sleep apnea) Fig. 26.2 Obesity can lead to male infertility via various mechanisms. These mechanisms manifest act directly through or via interplay between reactive oxygen species (ROS) production, the hypothalamus-pituitary-gonadal (HPG) axis, as well as other physical factors (HH hypogonadotro-pic hypogonadism ED erectile dysfunction SA sleep apnea)

Diagnostic Tools in Pulmonary Medicine History and Physical Examination

Physical examination begins with vital signs. For example, tachypnea out of proportion to fever may be the first presenting sign of childhood pneumonia. The degree of respiratory difficulty may also be observed in the form of obvious shortness of breath, the work of breathing, the use of accessory respiratory muscles, and the patient's need to take a breath in midsentence (described as three-to-four-word dyspnea). General examination can also reveal either peripheral or central cyanosis. Clubbing of the nails can indicate chronic lung disease. Morbid obesity may be associated with obstructive sleep apnea or right-sided heart failure (cor pulmonale), or both.

Extracorporeal gas exchange ECGE

The newer modes of ventilation such as pressure support ventilation or assisted spontaneous breathing on modern microprocessor-controlled ventilators allow the patient to participate actively in ventilation much earlier in the resolution of lung failure than was possible previously. These modes detect a patient's attempt to breathe spontaneously, synchronize with it and support it to a preset level of positive pressure. At low levels, this compensates for the resistance of the tracheal tube and breathing system at higher levels, it allows the patient to generate an adequate tidal volume with minimal effort. These modes of ventilation are appropriate only for patients with a relatively normal respiratory rate and normal I E ratio. The level of pressure support can be reduced gradually as the patient's ventilatory capabilities improve, and when the level of pressure support has been reduced to the value of PEEP, the patient has been weaned to CPAP. The use of such systems allows lower...

Evaluation Guidelines Table211

Electroencephalography may show epileptiform activity in the temporolimbic areas, which may be associated with syncope or other paroxysmal autonomic phenomena. Sleep polysomnograms in patients with multiple system atrophy may allow the physician to make a diagnosis of sleep apnea.

Pathophysiology of Tricuspid Regurgitation

Hypoventilatory disorders When hypoxia is associated with respiratory acidosis, as may happen with alveolar hypoventilation, pulmonary artery pressures tend to rise significantly. This situation may occur in various hypoventilatory disorders (e.g., Pickwickian syndrome in which marked obesity plays a prominent role, sleep apnea, neuromuscular disorders such as myasthenia, chest wall abnormalities as in kyphoscolio-sis).

Parkinsonism Plus Syndromes

Clinical Features and Associated Disorders. MSA encompasses three neurodegenerative syndromes, which in the past were considered clinically distinct striatonigral degeneration (SND), olivopontocerebellar atrophy (OPCA), and Shy-Drager syndrome (SDS). All these conditions share similarities with one another and with PD. The hallmark features of MSA are parkinsonism that is poorly responsive to levodopa therapy and varying degrees of autonomic, cerebellar, and pyramidal dysfunction. SDS is diagnosed clinically when dysautonomia far outweighs the other signs, SND is designated when anterocollis and pyramidal dysfunction are prominent, and OPCA is used to characterize the patient with prominent cerebellar features of ataxia, limb dyssynergia, and kinetic tremor. For all MSA patients, autonomic insufficiencies include orthostatic hypotension, postprandial hypotension, anhidrosis with thermoregulatory disturbances, poor lacrimation and salivation, constipation, and impotence. Disturbances...

Polycystic Ovary Syndrome

A patient with PCOS is at higher risk for infertility, dysfunctional bleeding, obesity, endometrial hyperplasia, endo-metrial carcinoma, type 2 diabetes mellitus, dyslipidemia, hypertension, obstructive sleep apnea, and possibly cardiovascular disease with familial tendency (increased risk for mother and daughter) (Azziz et al., 2009 Ehrmann, 2005) (Table 35-9).

Sleep Disordered Breathing and Neuromuscular Diseases

Weakness of upper airway muscles may also lead to obstructive apneas and hypopneas, but weakness of inspiratory muscles may prevent generation of sufficient force to produce snoring. Weight reduction may produce marked benefits if obesity has led to decompensation of marginal pulmonary function during sleep. Nocturnal oxygen may be beneficial if hypoventilation is not severe, but it must be administered cautiously in patients with daytime hypercapnia because of the risk of precipitating respiratory failure in patients whose breathing is dependent on hypoxic drive. For patients with upper airway obstruction, nasal CPAP is excellent treatment and if hypoventilation is not reversed with CPAP, BPAP devices that provide a higher pressure during inspiration than during expiration can be used, especially for patients with expiratory muscle weakness. Negative pressure cuirass ventilators and intermittent positive pressure ventilation can be used if additional ventilatory support

Abnormal Findings and Clinical Uses of Polysomnography

It is important in confirming the existence of insomnia and characterizing its nature by determining, for example, whether it is associated with nocturnal myoclonus or periodic leg movements. Some patients complain of insomnia but, in fact, have a normal amount of sleep. Patients with complaints of excessive daytime somnolence may have sleep apnea, which can be diagnosed by polysomnography. Apnea is defined in this context as the cessation of air flow at the mouth and nostrils for at least 10 seconds, whereas hypopnea refers to a reduction in respiratory air flow to one third of its basal value, with an associated reduction of abdominal and thoracic respiratory movements and a decline in oxygen saturation. The number of respiratory irregularities per hour of sleep can be calculated by dividing the number of apneic and hypopneic episodes by the total sleep time in minutes and multiplying the result by 60. A value of 5 or less is regarded as within the normal range. y Polysomnography...

Clinical Presentation

Signs and symptoms not attributable to the lipoma but secondary to the associated developmental anomalies. Approximately 30 of patients with supratentorial lipomas have a seizure disorder. The seizure disorder is reportedly often severe, is focal or generalized, and has an average onset age of 15 years. Recurrent headaches are a presenting symptom in 25 percent, and . . . 10 to 15 percent have behavioral problems and or mental retardation. 23 Other reported signs and symptoms include fainting spells, vomiting, episodic leg weakness, blurred vision, sleepwalking, diencephalic disturbances such as adiposogenital dystrophy and hypothermia, and even transient ischemic attacks. 6 Presenting signs and symptoms of patients with infratentorial lipomas may include hydrocephalus, cerebellar ataxia, motor weakness, sleep apnea, and cochleovestibular symptoms such as hearing loss, vertigo, otalgia, trigeminal neuralgia, hemifacial spasm, and tinnitus.6,19,23

Chromosomal Anomalies

In addition to the typical phenotypic features of the syndrome, associated congenital cardiac and gastrointestinal abnormalities may be present. A third to a half of patients with Down's syndrome have congenital cardiac defects, of which one third are endocardial cushion defects, and the remainder are ventricular septal defects. Tetralogy of Fallot and atrial septal defects also occur, and there is an increased incidence of moyamoya disease. More than half of patients have bilateral hearing loss, of which many cases are attributable to anomalies of the inner and middle ear. Malformations of the gastrointestinal tract, including intestinal atresia and imperforate anus, occur in about 5 to 7 percent of patients, and there is a reported increased incidence of Hirschsprung's disease. Although abnormalities of T-lymphocyte function have been reported, no specific relationship of these to the infection rate has been established. Other associated abnormalities include gastroesophageal...

Laparoscopic Partial Nephrectomy Models

The following patient parameters were recorded during the retrospective chart review (334 patients) age, sex, surgeon, body mass index, American society in anesthasiology grade, hypertension, prior pancreatitis, prior abdominal surgery, prior deep venous thrombus, peripheral vascular disease, smoking, coronary astery disease, gastic erophageal refull disease, anxiety, hyperlipidemia, depression, renal stone disease, constipation, liver cirrhosis, hepatitis C, hematuria (micro or gross), chronic obstructive pulmonary disease, alcohol use, hypothyroidism, diabetes mellitus, chronic renal insufficiency, cerebrovascular accident, gout, congestive heart failure, osteoarthritis, bleeding disorder, Crohn's disease or inflammatory bowel disease, obstructive sleep apnea, polycystic kidney disease, seizures, anemia, von Hippel-Lindau disease, simple or partial nephrectomy, planned retroperitoneal versus transperitoneal approach, tumor size (by computed tomography), solitary kidney, preoperative...

Laparoscopic Radical Simple Nephrectomy Models

Planned adrenalectomy, planned lymph node dissection, gastro-esophageal reflux disease, hypertension, smoking, diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary disease, coronary artery disease, hematuria (micro or gross), kidney stones, obstructive sleep apnea, congestive heart failure, cerebrovascular accident, polycystic kidney disease depression, fibromyalgia, liver cirrhosis, bleeding disorders, planned transperitoneal versus retroperitoneal approach, side of nephrectomy, tumor size, nodal involvement, renal vein involvement, body mass index, American Society of Anesthesiology grade, planned specimen extraction incision and duration of hospital stay (in days).

Outcome evaluation

Successful management of overweight and obesity is determined by the ability the treatment plan has to (a) prevent weight gain, (b) reduce and maintain a lower body weight, and (c) decrease the risk of obesity-related comorbidities. Since weight is necessary to calculate the BMI, it, as well as waist circumference, should be determined. Obesity management may encompass more than weight loss or maintenance in the presence of other conditions other pertinent parameters should be assessed at baseline. The presence of hypertension, type 2 diabetes, hyperlipidemia, CAD, sleep apnea, hypothyroidism, osteoarthritis, gallbladder disease, gout, or cancer should be determined. Blood pressure and heart rate should be measured prior to implementation of any therapy. Certain laboratory parameters also should be assessed. A basic metabolic panel, liver function tests, complete blood count, fasting lipid profile, full thyroid function tests, and other laboratory studies as deemed necessary should be...

General Approach to Treatment

Determined to guide clinical decisions. Presence of comorbidities (CHD, atherosclerosis, type 2 diabetes mellitus, and sleep apnea) and cardiovascular risk factors (cigarette smoking, hypertension, elevated low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, impaired fasting glucose, family history of premature CHD, and age) requires identification and aggressive management for overall effective treatment of the overweight or obese patient. Therapy implemented to minimize associated risk(s) may not enhance weight loss, but weight loss will positively address risk factors. Weight loss should not be initiated in pregnant or lactating patients, decompensated psychiatric patients, or patients in whom reduced caloric intake

Clinical presentation and diagnosis

Presence of comorbidities (CHD, atherosclerosis, type 2 diabetes mel-litus, and sleep apnea) and cardiovascular risk factors (cigarette smoking, hypertension, elevated low-density lipoprotein cholesterol, low high-density lipoprotein cholesterol, impairedfasting glucose, family history of premature CHD, and age) requires identification and aggressive management for overall effective treatment of the overweight or obese patient. A patient is at very high absolute risk if diagnosed with CHD or other atherosclerotic diseases, type 2 diabetes mellitus, or sleep apnea or if three or more of the risk factors listed in Table 102-3 are present.6 Aggressive disease management should be initiated and not limited to weight loss. If the patient is a child or adolescent and the BMI is greater than the 85th percentile, determine the patient's risk

Reviews And Selected Updates

Wu H, Yan-Go F Self-reported automobile accidents involving patients with obstructive sleep apnea. Neurology 1996 46 1254-1257. 19. Findley L, Unverzagt ME, Suratt PM Automobile accidents involving patients with obstructive sleep apnea. Am RevRespirDis 1988 138 337-340 21. He J, Kryger MH, Zorick FJ, et al Mortality and apnea index in obstructive sleep apnea. Experience in 385 male patients. Chest 1988 94 9-14 22. Partinen M, Guilleminault C Daytime sleepiness and vascular morbidity at seven-year follow-up in obstructive sleep apnea patients. Chest 1990 97 27-32 24. Hung J, Whitford EG, Parsons RW, Hillman DR Association of sleep apnoea with myocardial infarction in men. Lancet 1990 336 261-264 25. Sullivan CE, Issa FG, Berthon-Jones M, Eves L Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1981 1 862-865 46. Chokroverty S, Sachdeo R, Masdeu J Autonomic dysfunction and sleep apnea in olivopontocerebellar degeneration. Arch...

Table 545 Causes Of Daytime Sleepiness

Sleep apnea and other breathing disorders of sleep can determine the presence and severity of sleep apnea, periodic limb movements, and nocturnal sleep disturbance. A Multiple Sleep Latency Test (MSLT), usually performed the following day, provides a measure of the severity of sleepiness and an indication of the presence or absence of early onset of Rem sleep. y Early onset of REM sleep occurs with about 50 percent of sleep episodes, and the presence of two or more sleep- onset REM periods during the four to five nap opportunities provided by the MSLT is the usual diagnostic criterion for narcolepsy. However, this finding is not specific. Other potential causes of early-onset REM sleep include circadian rhythm disturbances, REM sleep deprivation, severe sleep disturbance from sleep apnea or other disorders, and drug or alcohol withdrawal. io , y Some patients with brain pathology in areas concerned with sleep-wake regulation also may have early onset of REM sleep. decades without...

Population And What Tests Best Distinguish One Disorder From Another

Sleep disorders have been increasingly recognized in recent years. Obstructive sleep apnea is common in the elderly, affecting perhaps 5 10 or more of elderly persons, and may have significant consequences.36 Excessive daytime somnolence is the most common consequence and may greatly affect functioning in addition, nocturnal cardiac arrhythmias may increase the risk of cardiac or cerebral ischemia and of sudden death. Sleepiness can sometimes manifest itself as microsleeps, which are brief periods of unresponsiveness because of sleep these can be confused with partial seizures. Rarely, intermittent confusion or even apparent dementia can be a result of excessive sleepiness. Other causes of poor nocturnal sleep, such as periodic limb movement syndrome, can have similar daytime manifestations.36 Occasionally, the limb movements themselves may be mistaken for seizure activity, although they are usually easy to distinguish, occurring as sustained 0.5 5-s movements at 20-60-s intervals...

Physical Manifestations

Obese males also encounter physical mechanisms that may enhance and, thus, further attribute to decreased fecundity and fertility. These problems include hypogo-nadotropic hypogonadism (HH), erectile dysfunction (ED) and sleeping disorders, such as sleep apnea. Sleep Apnea Sleep apnea is a common disorder in which an individual has one or more pauses in breathing or shallow breaths while sleeping. The chronic condition affects 4 of middle-aged men, but usually goes undiagnosed. Interestingly, it has been reported that about two-thirds of middle-aged men with obstructive sleep apnea suffer from obesity, particularly central obesity 92 . Patients suffering from sleep apnea often have a fragmented sleep course due to repetitive episodes of upper airway obstructions and hypoxia followed by arousal 93 . Furthermore, these patients demonstrate a blunted nocturnal rise of testosterone needed for normal spermatogenesis 94 . This obstructive condition has been linked to lowered mean...

Do I need to be monitored while on testosterone therapy

Digital rectal examination should undergo further evaluation to rule out prostate cancer prior to starting testosterone replacement therapy. Once testosterone therapy has been started, patients return for an assessment of the efficacy of treatment and measurement of testosterone levels. Once an appropriate dose of testosterone has been identified, patients are followed at 3 to 6 month intervals during the first year and yearly thereafter. At each visit, an assessment of response, voiding symptoms, and sleep apnea symptoms should be determined. In addition, a digital rectal examination is performed and blood tests, including serum testosterone, PSA and hemoglobin hematocrit levels. In patients receiving intramuscular testosterone, there is more variability in the serum testosterone levels. Typically, the testosterone levels peak 2 to 5 days after the injection and often return to baseline at 10 to 14 days after injection. This variability must be kept in mind when interpreting...

Cushings Syndrome Cushings Disease

The hypersecretion of GH produces various forms of disfigurement and other physical changes ( Ia(, e 3.8.-i 1., ). Central sleep apnea has been reported in one third of acromegalic patients with sleep apnea. W Importantly, the presence of sleep apnea increases the risk for hypertension, myocardial infarction, and stroke, as well as accident susceptibility due to daytime sleepiness. Wi Mononeuropathies, especially compression neuropathies such as carpal tunnel syndrome (CTS), may be noted. CTS occurs in 50 percent of patients and is noted in 75 percent when EMG testing is performed. y Objective weakness, in a myopathic pattern, is observed in about 40 percent of acromegalic patients. 77 The weakness typically has an insidious onset and is a late manifestation, correlating best with the duration of acromegaly. 76 Polyneuropathies, nerve root and spinal cord compression, headaches, and visual changes have also been described. y

Frequency of Complications

Some potential medical problems must be sought proactively. When specifically monitored during physical therapy, up to one-half of patients experience cardiac arrhythmias and wide variations in blood pressure, especially during stair climbing, walking, stationary bicycling, and tall kneeling.24,25 Although many patients with stroke have some heart disease, the symptoms of fatigue and exercise intolerance from congestive heart failure, chronic obstructive lung disease, anemia, deconditioning, ex-ertional angina, sleep apnea, and orthostatic hypotension limit therapy the most. The combination of congestive heart failure and a systolic blood pressure below 130 also predicts cognitive impairment that may interfere with learning during rehabilitation.26

Erythropoiesis and marrow stimulation

Iron supplementation in iron deficiency anemia (Victor et al. 1967). Although the hemoglobin response to androgen therapy is usually modest in magnitude (typically 10g l), a small proportion ( 1 ) of normal (Palacios etal. 1983 Wu etal. 1996) or hypogonadal (Drinka et al. 1995 Krauss et al. 1991) men exhibit idiosyncratic polycythemic responses to androgen therapy. Such androgen-inducedpolycythemia may be asymptomatic or produce significant clinical effects due to hyperviscosity and or ischemia. Androgen-induced polycythemia is usually reversible following cessation of treatment but occasionally clinical circumstances (e.g. unstable angina or transient ischemic attack) may warrant venesection. The biochemical basis of the idiosyncratic polycythemic response to testosterone is not fully understood, but it appears to be more frequent with testosterone ester injections, presumably reflecting the transient supraphysiological peak blood testosterone concentrations following each injection...

Risk Factor Modification

Control of dyslipidemia and diabetes is also very important in the management of patients with CHF. Screening for sleep apnea and thyroid disease and aggressively treating these conditions need to be done. The avoidance of alcohol, illicit drug use, and smoking is strongly advised. Losing weight and establishing a routine exercise program are also important preventive measures in the CHF patient. Patients with a history of heart palpitations need to be evaluated for tachycardia because this is a well-established risk factor for cardiomyopa-thy and CHF. If patients have daily palpitations, a 24-hour Holter monitor is sufficient to help establish the type of arrhythmia. On the other hand, if palpitations occur infrequently (a few times per month), an event care monitor is more useful because patients can keep this type of monitor with them at home for a month and record the arrhythmia as it occurs. If palpitations are very infrequent, it is unlikely that they will be contributing to...

Le Fort III osteotomy

The subcranial Le Fort III osteotomy and its variants are used primarily for correction of total midface hypoplasia, usually of craniosynostotic origin, typically in the Apert and Crouzon's syndromes. In this situation there is usually significant proptosis of the eyes, severe malar and maxillary hypoplasia and a class III malocclusion with a short midface height. This can be accompanied by other problems such as sleep apnoea, postnasal choanal atresia and sometimes a cleft deformity. There is often a skull deformity that may require correction either at the same time or at a later date. It may be necessary to carry out bimaxillary surgery in this situation, with the advancement of the midface as well as its vertical repositioning. A Le Fort I osteotomy may be needed at the same time for vertical repositioning and to achieve a good occlusion.

Infancy through Adolescence

Although malnutrition is still a problem in the United States, inappropriate nutrition, especially calorie-nutrient imbalance leading to overweight and obesity, has become commonplace. Recent NHANES studies demonstrate that the prevalence of overweight (BMI 95 ) in girls 2 to 19 years old increased from 13.8 in 1999-2000 to 16 in 2003-2004, and the prevalence of overweight in boys 2 to 19 years old increased from 14 to 18.2 (Ogden et al., 2006). Increased pediatric BMI is associated with high blood pressure, sleep apnea, asthma, polycystic ovarian syndrome, type 2 diabetes, gastroesophageal reflux, and orthopedic problems (Benson et al., 2009). A nationwide survey of more than 6000 children and adolescents found that at least 30 consumed fast food on a typical day. These children consumed more total fat, total carbohydrate, more added sugars and sugar-sweetened beverages, less milk, and fewer fruits and nonstarchy vegetables than children who did not eat fast food (Bowman, 2004). The...

Acromegaly Patient Care and Monitoring

Routinely assess acromegaly complications include blood pressure, glucose tolerance, fasting lipid profile, cardiac evaluations (if clinically indicated), colono-scopy, dual energy x-ray absorptiometry (DEXA) scan (hypogonadal only), evaluation of residual pituitary function, and evaluation of sleep apnea.

Patient Encounter Part 3 Modifying Treatment Plan

CH returns to the clinic 3 months later. The physician previously diagnosed him with OSA and RLS. He received a prescription for CPAPs for OSA and ropinirole 0.5 mg at bedtime for RLS at his last visit. Via phone calls, his ropinirole dose has been increased to 3 mg at bedtime. He has received moderate relief of his RLS symptoms, but on occasion, he still awakens and cannot fall back asleep. His sleepiness and RLS symptoms are improved ESS 13 24. How would you assess the patient's CPAP therapy and adherence

Restless Legs Syndrome

Larly in patients with painful symptoms. BZDRAs such as temazepam, clonazepam, zolpidem, and zaleplon effectively reduce arousals associated with PLMS in patients with RLS.49 Their main benefit is derived from improving sleep continuity in patients with RLS, particularly as adjunct treatment with other pharmacologic therapies. Opioids are effective for some patients' RLS symptoms, with oxycodone, pro-poxyphene, hydrocodone, and codeine being used most frequently. For both BZDRAs and opioids, caution should be used in the elderly, in patients who snore and are at risk for sleep apnea, and in patients with a history of substance abuse. Low iron levels frequently exacerbate RLS symptoms. Iron supplementation should be prescribed in patients who are iron-deficient. Iron supplementation in patients with serum ferritin concentrations of less than 50 mcg L improves RLS symptoms. Medications frequently used for RLS are shown in Table 41-3.

Disorders of Breathing

Sleep apnea may be obstructive or central in origin, or a combination of both. The effects of recurrent apnea extend well beyond simple fatigue or sleep deprivation, causing significant cardiovascular and neurologic disease. Patients with obstructive sleep apnea are often but not always obese. They experience episodes of intermittent apnea, often associated with snoring, especially during deeper stages of sleep. In addition to obesity, adenoidal or tonsillar enlargement, mac-roglossia, and laxity of the soft palate and pharyngeal tissue can contribute to sleep apnea. Stroke, brain tumors, trauma, cerebral edema, and other CNS disorders can affect breathing at the central level as well. Brainstem infarctions can lead to respiratory arrest and death. Cheynes-Stokes respirations describe an undulating pattern of breathing of increased depth and frequency alternating with waves of shallow, slower breathing and even apnea. Many patients with obstructive sleep apnea have elements of central...

Monitoring Of Respiratory Function

When combined technique of light general anesthesia, regional anesthesia, and sedation is used, a pulse oximeter is mandatory, especially in patients with a history of sleep apnea or snoring, significant obesity, and orofacial or neck disturbances. The pulse oximeter can determine the moment when the O2 saturation falls. To prevent this undesirable situation, respiratory rate interval monitoring can be used to detect the effect of opioids on the respiratory center. Apnea alarms are also useful if breathing is not detected over a predetermined period of time. A breath interval varies between 0.9 minute and 1.4 minutes and is a useful and reproducible method of monitoring the duration of opioid effect in anesthetized patients who can breathe spontaneously when surgical stimulation is not affecting the CNS. These data can provide information on the duration of action of fentanyl and can help to determine the correct dosage.123

Burden of Disease

Obesity is a substantial health problem in the United States, and the percentage of the population who is overweight or obese continues to rise. Defined as a BMI of 30 or higher, the prevalence of obesity in adults in the United States has increased from 13 to 27 over the past 40 years (McTigue et al., 2003). The prevalence of overweight rose from 31 to 34 . Obesity and overweight are associated with an increased risk of CHD, hypertension, stroke, type 2 diabetes, sleep apnea, musculoskeletal disorders, gallbladder disease, and several types of cancer. Obesity is associated with a decreased quality of life and social stigmatization.

Behavioral Interventions

Bladder-irritants and may worsen incontinence symptoms. Alcohol has diuretic properties, causing increased urinary frequency. Weight loss may be beneficial for some patients, in particular women with stress incontinence. Nocturia is a common complaint for many elderly patients with multifac-torial causes (Sugaya et al., 2008). Minimizing late-afternoon and evening fluid intake may decrease nocturnal episodes for some patients. Reduced production of antidiuretic hormone has been seen in patients with obstructive sleep apnea. Treatment of the sleep apnea may help reduce nocturia symptoms (Kujuba and Aboseif, 2008).

Excessive Daytime Somnolence

EDS indicates the occurrence of abnormal sleepiness during the normal waking hours. y EDS may be associated with inadequate nocturnal sleep and can arise secondary to insomnia. EDS can also occur independently of insomnia. y Primary sleep disorders, such as sleep apnea and PLMD, may disrupt nocturnal sleep, leading to sleep deprivation and EDS. Often, patients with these disorders have frequent arousals punctuating the night but are unaware of these events. During the day, they report a susceptibility to falling asleep. When the condition is mild, inadvertent napping may occur only during sedentary activities during the normal nadirs in daytime alertness in the afternoon or evening. As EDS becomes more severe, patients may report nodding off during active periods, such as driving a car or when conversing. Narcolepsy is characterized by a propensity to sleep during the day. Sometimes, these periods may present as microsleeps in which there is a sudden but momentary lapse of...

Associated Medical Findings

The physical examination in a patient with a suspected sleep disorder focuses on several features. To assess for physical abnormalities associated with obstructive sleep apnea, particular attention is directed toward examination of height, weight, and blood pressure. Abnormalities of the upper airway, including enlarged tonsils, tongue, or low palate, can indicate possible airway obstruction. A reddened uvula and palate may be associated with loud snoring. Retrognathia and a small pharyngeal opening may also be seen in patients with sleep apnea.

Neurological Examination

Central sleep apnea is the loss of respiratory airflow associated with a loss of respiratory muscle effort. It is thought to arise from alterations in the functioning of chemoreceptors monitoring hypoxic and hypercapnic influences on respiration. Patients should be examined for waking respiratory difficulties and cardiac functioning, in particular for congestive heart failure. Neuromuscular diseases likewise may predispose to episodes of sleep apnea, as can autonomic nervous system instability. Patients should be assessed for evidence of orthostatic hypotension and examined for those disorders with autonomic nervous system involvement, including multiple system atrophy, Guillain-Barre(c) syndrome, and diabetes. Neurovascular System. A general cardiac and vascular examination reveals signs of cardiac failure and blood pressure, specifically signs of pulmonary hypertension that is frequently associated with obstructive sleep apnea.

Demyelinating Disorders

Obstructive sleep apnea Even though the patient has been adequately preoxygenated, some method of supplemental oxygen delivery is still necessary. This may be accomplished either by placing a suction catheter near the carina with a 10 L min oxygen flow, or by using a continuous positive airway pressure (CPAP) circuit with 10 cm H 2 O pressure. A CPAP circuit does not provide ventilation, so it does not interfere with observation for spontaneous respirations. Even with one of these methods employed, some patients with cardiorespiratory dysfunction may not tolerate the approximately 10 minutes of apnea necessary to raise the PaCO 2 to 60 mm Hg without becoming hypoxemic and hypotensive. In this circumstance, a confirmatory test may be necessary.

Idiopathic Hypersomnia

Other diagnostic considerations in patients who complain of long periods of unrefreshing sleep include atypical depression and chronic fatigue syndrome. In both of these disorders, patients often spend many hours in bed, but actual sleep time is increased only mildly or not at all. Idiopathic hypersomnia is usually considered in a patient who complains of sleepiness and has no apparent cause for sleepiness based on the clinical history and a nocturnal polysomnogram. For such patients, the differential diagnosis includes narcolepsy, upper airway resistance syndrome, insufficient sleep syndrome, and obstructive sleep apnea that occurs during some nights but not others. The diagnosis of idiopathic hypersomnia is not easy because it requires ruling out all other causes to the extent possible.


Voiding (bladder) diaries can provide valuable information for the clinician and patient. The diary includes documentation of each urination episode and any associated symptoms of incontinence for three 24-hour periods. If possible, the patient can also record the amount of fluid intake and output (Abrams and Klevmark, 1996). Several patterns of abnormality can emerge from the voiding diary. For example, frequent small volumes can occur in patients with overactive bladder syndrome, detrusor overactivity, and some painful bladder conditions (e.g., cancer). Frequent large-volume voids are associated with polyuria, as seen in patients with excessive fluid intake and conditions causing polyuria (e.g., diabetes, hypercalcemia). Obstructive sleep apnea, physiologic aging, congestive heart failure, and medications can all cause nocturnal polyuria (Bryan et al., 2004). A simple office tool that can help detect stress incontinence is the cough test. The patient is asked to produce a forceful...


Chloral hydrate is a commonly used sedative-hypnotic and can be prescribed to both children and adults with good effect and minimal toxicity (Loewy et al. 2006). However, children with obstructive sleep apnea, wheezing, and brain stem disorders may be at increased risk for respiratory compromise. Respiratory suppression may also occur in overdose situations, with deep stupor and coma. Chronic use of chloral hydrate for insomnia is usually discouraged due to concerns about the side effects and tolerance (Pelayo et al. 2004).

Clinical History

Obtaining a detailed clinical history is especially important when diagnosing a sleep disturbance because routine physical examination is often not revealing during the waking hours. From the history, age of onset, duration and progression of the sleep complaint, and the general classification of the type of sleep disturbance is usually obtained. The International Classification of Sleep Disorders categorizes sleep disturbances as (1) dyssomnias or disorders that result in insomnia or excessive sleepiness (2) parasomnias or disorders of arousal, partial arousal, or sleep stage transition and (3) sleep disorders associated with medical or psychiatric disorders. The dyssomnias include the intrinsic sleep disorders arising from bodily malfunctions such as psychophysiological insomnia, obstructive and central sleep apnea, restless legs syndrome (RLS), and periodic limb movement disorder (PLMD). Examples of parasomnias include sleep walking, sleep terrors, sleep talking, nightmares, REM...

Arousal Disorders

Children are affected more than adults with a peak incidence between ages 4 and 10 years however, onset in adulthood can occur. About 1 to 6 percent of children have recurrent sleep terrors. An increased prevalence in first-degree relatives suggests that genetic factors may play a role. In susceptible persons, sleepwalking and sleep terrors may be precipitated or aggravated by stress, sleep deprivation, fever, sleep apnea, and noise. Snoring without sleep apnea Infant sleep apnea Sleep apnea in infants Evaluation. For otherwise normal children with typical behaviors of sleepwalking or sleep terrors that occur during the first third of the night, the diagnosis can usually be made based on clinical criteria. When the diagnosis is uncertain, polygraphic monitoring with simultaneous video monitoring is indicated for 1 or 2 nights, particularly if the events are occurring several times per week. If nocturnal seizures are a consideration, several additional...

Eating Disorders

Obese children and youth are at greater risk for bone and joint problems, sleep apnea, and social and psychological problems such as stigmatiza-tion and poor self-esteem. Obese youth are likely to become overweight or obese adults and be at risk for associated adult health problems, including heart disease, type two diabetes, stroke, several types of cancer, and osteoarthritis.

Pulmonary Lobectomy

One-lung anaesthesia allows dissection in a field disturbed only by the movement of the mediastinum. Inflation of the lung temporarily may help to identify the lung fissures. Passive insufflation of the collapsed lung either through a suction catheter or with 5 cm continuous positive airway pressure may augment oxygenation achieved by one-lung anaesthesia. Surgical traction on mediastinal structures and disturbance to the mediastinum by surgeons' hands, instruments or retractors may cause bradycardia, interruption of the venous return to the heart or compression of the chambers of the heart.


Narcolepsy is a genetically based neurological disorder associated with abnormalities of REM sleep and of sleep- wake control. Although the disorder has been recognized for more than 100 years, the discoveries of sleep apnea, other syndromes of excessive sleepiness, and the association of narcolepsy with REM sleep abnormalities and specific human leukocyte antigen (HLA) markers helped delineate narcolepsy as a distinct syndrome. Clinically, the usual hallmarks are excessive sleepiness and cataplexy.

Airway management

The lackson Rees modification of the Ayres T-piece is the breathing system traditionally used for children under 20 kg in weight. It has been designed to be lightweight with a minimal apparatus dead space. The apparatus may be used for both spontaneous and controlled ventilation. The open-ended reservoir bag is used for manual controlled ventilation. This mode of ventilation is especially useful in the neonate and infant, as one is able to detect changes in compliance produced by tube displacement. The reservoir bag also allows the application of continuous positive airway pressure for both the spontaneously breathing child and one undergoing ventilation. This may be helpful in improving oxygenation. The bag may be removed and an appropriate ventilator such as the Penlon 200 attached to the expiratory limb. A minimum gas flow rate of 3 L mii r1 is required to operate this apparatus satisfactorily. Fresh gas flows of 300 ml kg-1 for spontaneous respiration and flows of 1000 ml plus 100...


Blood loss during tonsillectomy is not usually measured but may be deceptively large. Increasing numbers of children under 3 years of age (15 kg) are presenting for tonsillectomy for sleep apnoea syndrome. Particular care is required in this group as blood transfusion is necessary after 100 ml blood loss. Many of these children should have an intravenous infusion until they are ready to take oral fluids.

Potential risks

Androgens may exacerbate obstructive sleep apnea (Matsumoto et al. 1985 Sandblom et al. 1983). Therefore, patients should be specifically questionned for symptoms of sleep apnea, and chronic obstructive pulmonary disease, especially in overweight subjects or heavy smokers, who may be regarded as having a relative contra-indication for androgen therapy.


This has been discussed in detail above. Moderate hypoventilation, with some elevation of PaC02, leads to a modest reduction in Pac 2 (Fig. 41.3). Obstructive sleep apnoea may produce profound transient but repeated decreases in arterial oxygenation. Sac 2 may decrease to less than 75 , corresponding to a Pa02 of less than 5 kPa (40 mmHg). These repeated episodes of hypoxaemia cause temporary, and possibly permanent, defects in cognitive function in elderly patients and may contribute to perioperative myocardial infarction. Obstructive sleep apnoea is exacerbated by opioid analgesics, and patients who are known to suffer from this condition should be monitored carefully in the postoperative period, preferably in a high-dependency unit. Patients who normally use a continuous positive airways pressure (CPAP) mask to reduce obstructive sleep apnoeic episodes should use the mask at night throughout the postoperative period.

Subjective Objective

Myopathy can be a feature of hypothyroidism and manifests with proximal muscle weakness. Regardless of the cause of the hypothyroidism, weakness is observed in about one third of these patients.y Increased muscle size and firmness, which is most obvious in the limb musculature, as well as slowed muscle contraction are important features to identify. Exertional pain, stiffness, and cramps may be noted, and myoedema may be observed. Myoedema, a mounding of the muscle in response to direct percussion, is painless and electrically silent, and occurs in one third of hypothyroid patients. y Difficulty relaxing the hand grip and exacerbation by cold weather may suggest myotonia. However, unlike myotonia, hypothyroid myopathy involves a slowness of muscle relaxation and contraction, and resolves with correction of the hypothyroid state. y Although sleep apnea is usually of the obstructive type, other possibilities include a central abnormality, chest muscle weakness, and blunted responses to...

Etiology of MCI

There appear to be several causes of MCI in the elderly population other than preclinical dementia. The association between several systemic disease states common in the elderly and MCI is well known. For example, several studies have demonstrated that hypoxemic chronic obstructive pulmonary disease (COPD) results in cognitive dysfunction that is measurable with neuropsychological instruments and that the severity of the cognitive dysfunction is related to the severity of hypoxemia as well as quality of life (Grant et al., 1987 McSweeny and Labuhn, 1996). However, the nature of the cognitive dysfunction associated with hypoxemic COPD is different than that associated with AD and most other forms of progressive dementia. Rather than prominent memory deficits, individuals with chronic hypoxemia demonstrate impaired complex perceptual-motor learning and cognitive flexibility (Grant et al., 1987). Other studies have demonstrated associations between MCI and obstructive sleep apnea,...

Sleep Disorders

Sleep apnea is reported in 4 of middle-aged men. Obesity and alcohol and cigarette use are risk factors. During rehabilitation, one-third of patients with TBI of less than 3 months duration who scored higher than level 3 on the Rancho Los Amigos Scale (see Table 11-7) had central and obstructive sleep apnea.264 After SCI, sleep apnea is more prevalent in people with quadriplegia than paraplegia and in patients with motor-incomplete injuries, affecting from 15 to 45 of patients with chronic SCI.265 Impaired sensory feedback from respiratory muscles, sleeping in a supine position, and antispasticity agents may contribute. Central and obstructive sleep apnea or a mix of both can develop from brain stem and cortical lesions, especially with bulbar dysfunction, or in relation to a superimposed toxic-metabolic encephalopathy. These disorders may have preceded the stroke, given that they have been associated with a higher risk for stroke.266 Pha-ryngeal muscle weakness and impaired neural...


The application of CPAP via a close-fitting face mask in the spontaneously breathing patient increases FRC and reduces the incidence of atelectasis in postoperative patients with pulmonary disease. It may reduce the need for mechanical ventilation, although it is not tolerated by all patients. Intermittent positive pressure breathing using face mask or mouth piece also expands the lungs and aids clearance of secretions.


Testosterone has been claimed to potentiate sleep apnea (see Chapter 15) however, only case reports about the incidence of sleep apnea during testosterone treatment have been published (Matsumoto et al. 1985) and paradoxically hypogonadism has also been cited as a cause of this condition (Luboshitzky et al. 2002). The two men who demonstrated worsening of obstructive apnea on testosterone replacement therapy had pathologically elevated erythrocyte counts and hema-tocrit ( 59 ), sufficient to require therapeutic phlebotomy. Increased hematocrit, increased mass of pharyngeal muscle bulk, as well as neuroendocrine effects of testosterone during therapy were discussed as possible reasons. The development of signs and symptoms of obstructive sleep apnea during testosterone therapy warrants a formal sleep study and treatment with continuous positive airway pressure (CPAP) if necessary. If the patient is unresponsive or cannot tolerate CPAP, the testosterone must be reduced or discontinued.

Cardiac Failure

Treatment involves delivery of a high inspired oxygen concentration (with continuous positive airways pressure CPAP or mechanical ventilation in severe cases), intravenous opioid, nitrate (by infusion if failure is severe) and loop diuretic. The aim of treatment is to optimize both the left ventricular filling pressure and cardiac output. If left ventricular failure is precipitated by arrhythmias, these should be treated, avoiding negatively inotropic drugs.

Patient management

In mild cases, simple postural measures are often adequate and careful supervision with the judicious use of devices such as pulse oximeters and sleep apnoea monitors to detect episodes of airway obstruction are sufficient. The immense emotional and physical stress imposed on the parents or carers of the child must not be underestimated. It is essential to ensure that the child is kept in a suitable high-dependency or intensive care facility until it has been established that the risk of apnoea or cyanotic spells is minimal and the parents feel comfortable about the prospect of managing the problem at home.


An important problem often associated with heavy snoring is obstructive sleep apnea. Many affected patients are overweight and have a history of excessive daytime sleepiness. A bed partner may describe the patient as at first sleeping quietly then a transition occurs to louder snoring, followed by a period of cessation of snoring, during which time the patient becomes restless, has gasping motions, and appears to be struggling for breath. This period is terminated by a loud snort, and the sequence may begin again. It is common for patients with sleep apnea to have many of these episodes each night.

Surgical Treatment

Hemorrhage, (3) the presence of any bolster or other aspiratable dressing material, (4) pre-existing pulmonary disease or obstructive sleep apnea, or the simultaneous operation or compromise of the nasal airway, and (5) the need for frequent endotracheal suctioning or ventilation support.

Reflux Laryngitis

The correct diagnosis is often initially overlooked. Constant throat clearing may be the only presenting symptom. Other manifestations include a feeling of a lump in the throat with a choking sensation (globus pharyngeus), odynophagia, dysphagia, chronic cough, and hoarseness. The patient may also complain of postnasal drainage. Spicy foods, fats, caffeine, chocolate, beer, milk, and orange juice are known to exacerbate the condition by lowering LES pressure. Several medications increase reflux of acid into the esophagus, such as beta blockers, calcium channel blockers, diazepam, and progesterone. Obesity and sleep apnea also predispose the patient to GERD and reflux laryngitis.


The increased EPO production to consider include heart or chronic pulmonary disease, in which there is desaturation of Hb as it leaves the lungs, or less common causes such as renal cysts, hepatic or cerebellar tumors, uterine leiomyoma, or impaired Hb function caused by heavy smoking, which results in elevated levels of carboxyhemoglobin, which is essentially inert as an oxygen transporter. Severe obstructive sleep apnea may cause enough desaturation to raise EPO levels, resulting in secondary polycythemia. Athletes using EPO, androgens, or blood doping may also present with secondary polycythemia.


Treatment centers on the underlying cause, and a voiding diary may aid clinical decisions. Prostate hyperplasia or bladder dysfunction often receives first attention. Treating BPH may help, although BPH often does not result in true physical obstruction, and epidemiologic data have indicated that noc-turia is common in men without prostatic obstruction. Thus, family physicians should consider the contribution of nocturnal polyuria. For example, patients with chronic heart failure and leg edema may benefit from fluid restriction and napping with leg elevation during the day. Treating obstructive sleep apnea helps alleviate the increased urine production resulting from increased atrial natriuretic peptide production. Behavioral Obstructive sleep apnea


The patient might exhibit an allergic salute, an upward thrust of the palm against the nares to relieve itching and open the nasal airways and a gaping expression from mouth breathing. Allergic shiners or Dennie's lines are wrinkles beneath the lower eyelid. Speech can have a nasal quality. In children, nasal irritation can result in nose picking and recurrent epistaxis. Sleep disruption is often associated with nasal obstruction and mouth breathing. Patients might have sleep apnea-like symptoms, including restless sleep, snoring, or nighttime coughing, associated with postnasal mucus drainage and mild hoarseness. The nasal mucosa is typically moist, with enlarged, pale turbinates and serous discharge. Because the sense of smell is impaired, appetite may be decreased. Maxillomandibular alignment problems (overbite or underbite) result from chronic symptoms.

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