STRIDOR SLEEP APNOEA Dr Robin Smith

STRIDOR Predominantly inspiratory wheeze due to large airways (larynx/trachea/major bronchi) obstruction

Causes of Stridor (children) Infections Croup 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

William Clark LMB obstruction

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

Relaxation of pharyngeal dilator muscles during sleep (esp. REM) 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 Rx Mandibular 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