Managementul Sas In Pw
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Transcript of Managementul Sas In Pw
MANAGEMENTUL SAS IN PRADER - WILLIStefan Mihaicuta
UMF V. Babes
Clinica de Pneumologie
Caz
S. M., n. 20.09.1988, Carei, SM In noiembrie 2008, 150 cm, 105 kg, Circumferinta gat 39 cm, circumferinta
abdominala 121, Circumferinta bazin 141 cm HTA 120/70 mm Hg Trimisa de prof. dr. Puiu Maria
Apnei raportate, fara sforait. Fara somnolenta diurna excesiva, Epworth 3 Rar cefalee matinala, Somn agitat, nicturie 1x/noapte, cu treziri din somn. Fara modificari ORL (deviatie sept, polipoza
nazala, uvula hipertrofica), Malampati III. Tratament cu Levotiroxin (hipotiroidism)
Epworth Sleepiness Score
In poziţia şezând Vizionare TV
Aşezat, inactiv, într-un loc public (cinema, sedinţe, sală de aşteptare, etc.) Pasager într-o maşină, o oră fără oprire
Aşezat pe spate pentru odihnă diurnă
Aşezat şi discutând cu cineva
Aşezat liniştit după un prânz fără alcool
În maşină, la un stop
PSG – traseu normal
PSG cu apnee centrala
PolisomnografiePatient name : SERESAN Acq : 707
First name : MARIA Type : Adult
Sex : F Started : 11/4/2008 at 10:18:13 PM
Birth date : 9/20/1988 Stopped : 11/5/2008 at 7:01:13 AM
Patient age : 20 years Duration : 8:43:00 (523.0 min)
Recording duration : 523.0 min Recording start -> end
TIB : 523.0 min Light off -> Light on
SPT : 488.5 min Sleep Onset -> Last Sleep Page
TST : 469.0 min REM + NREM + MVT (during SPT)
WK before sleep : 32.0 min WK from Light off to Sleep onset
WK during sleep : 19.5 min SPT - TST
WK after sleep : 0.0 min WK from Last sleep page to Light on
TWK duration (tot) : 51.5 min All WK summed
REM duration : 55.0 min REM (during TIB)NREM duration : 416.0 min S1 + S2 + S3 + S4 (during TIB)SWS duration : 78.5 min S3 + S4 (during TIB)Movement : 0.5 min MVT (during TIB)
Durations
Caracteristicile somnului
From Light off (min) From Sleep onset (min)
Sleep onset 34.5 -
S1 32.0 12.5S2 34.5 0.0
S3 144.5 110.0S4
REM 253.5 219.0
Latencies
Sleep efficiency 1 : 89.7% 100 x TST/TIB
Sleep efficiency 2 : 96.0% 100 x TST/SPT
Sleep efficiency 3 : 28.5% 100 x (N3+REM)/TST
Inter-sleep WK : 4.0% WK in sleep / SPT
Evenimente respiratoriiCA OA MA Sum Ap HYP Events
Settings (sec) 10.0 10.0 10.0 - 10.0 -
Number 4 47 1 52 376 428
Max (sec) 15.5 22.5 12.0 22.5 53.0 53.0
Mean (sec) 13.4 12.0 12.0 12.1 16.0 15.5
Tot duration (min) 0.9 9.4 0.2 10.5 100.0 110.5
TST (469.0 min)
% of TST 0.2 2.0 0.0 2.2 21.3 23.6
Index [#/h TST] 0.5 6.0 0.1 6.7 48.1 54.8
PSG – hipopnee cu desaturari
PSG
REM #/h (REM)
NREM #/h(NREM)
TST #/h (sleep)
RDI 31.6 57.8 54.8
Central apnea total duration
: 1.68 minutes (0.3% of sleep)
Total number of central apnea
: 12 (1.5 CA/h (sleep))
Sigh rate : 8%
Periodic breathing total duration
: 1.57 minutes (0.3% of sleep)
PSG – apnei centrale, desaturari, flux respirator scazut
Cardio-vascular
WK REM NREM S1 S2 S3 MVT
Duration (min) 51.5 55.0 416.0 86.0 251.5 78.5 0.5
Mean HR (BPM) 90.5 88.8 88.6 94.2 87.3 86.4 113.0
Stand. dev. 8.356 6.891 8.777 8.908 8.232 7.718 2.000
Coef. var. 0.092 0.078 0.099 0.095 0.094 0.089 0.018
Median (BPM) 89.000 87.000 87.000 94.500 86.000 85.000 112.000
IQ 8.000 4.000 10.000 12.000 8.000 5.000 2.000
# of LHR 0 0 16 0 11 5 0
LHR min (BPM) 57 57 58
# of HHR 0 7 34 9 18 7 0
HHR max (BPM) 124 186 135 186 130
Mean RR (BPM) 92.4 89.7 89.7 95.4 88.4 87.3 112.9
Stand. dev. 20.215 12.928 12.548 13.067 12.521 9.677 2.641
Coef. var. 0.219 0.144 0.140 0.137 0.142 0.111 0.023
Mean RR (msec) 663.0 676.0 677.6 636.9 687.4 694.6 531.7
Stand. dev. 130.181 56.643 72.330 65.540 70.506 67.921 12.488
Coef. var. 0.196 0.084 0.107 0.103 0.103 0.098 0.023
ECG fail (min) 0.0 0.0 0.0 0.0 0.0 0.0 0.0
Statistics
Saturatia in O2WK REM NREM TOTAL
Fail duration (min)
0.2 0.0 0.0 0.2
Average (%) 98 97 96 96
Desat Index (#/hour) 8.7 29.7 27.2
Duration desat/hour 1.8 6.3 5.8
Desat max (%) 0 5 19 19
Desat max dur (sec) 0.0 20.0 45.0 45.0
Desaturari
Longest continuous duration spent below 0%: 0.0 minute(s)
Lowest SpO2 (>= 2 seconds) [%]: 79
# Episodes (>= 5.0 minutes) SpO2 < 88 %: 0
Longest duration SpO2 < 88 % 0.0 minute(s)
Mean of the resp. event SpO2 min levels [%] : 93
Mean of the resp. event SpO2 min levels with desat [%] : 92
Minimum of the resp. event SpO2 min levels [%] 79
Total number of WK or MVT episodes : 3
Arousal index : 5.8/h(sleep)
% of pages with arousal during sleep : 4.8
Number of arousals associated with leg movements : 0
Number of arousals NOT associated with leg movements
: 45
Hipnograma completa
DiagnosticSindrom de apnee in somn forma obstructiva (predominant hipopnei) cu indice de apnee- hipopnee 54,8/h, indice de desaturare 27/h, saturatia medie 96%. Tahicardie sinusala nocturna (88/min). Hipnograma cu alterarea structurii somnului, reducerea somnului REM.Scaderea duratei si eficientei somnului profund la 28%. Se recomanda titrare CPAP in timpul somnului.
HipnogramaHR,BPM
30507090110130150170190
SpO2,%
50
60
70
80
90
100
Stage
S4
S3
S2
S1
REM
MVT
WK
CA,sec
0
10
20
OA,sec
0
10
20
MA,sec
0
10
20
HYPO,sec
0
10
20
Night Hypnogram
10:18:13 PM 12 AM 1 AM 2 AM 3 AM 4 AM 5 AM 6 AM 7 AM
ManagementFORMA CLINICĂ TRATAMENT
RECOMANDAT IAH > 30/H, CU SIMPTOME SEVERE NCPAP, DIETĂ, IGIENA
SOMNULUI
IAH < 30, CU SIMPTOME UŞOARE DIETĂ ŞI IGIENA SOMNULUI
IAH < 30, CU SIMPTOME SEVERE DIETĂ, IGIENA SOMNULUI, CPAP PROVIZORIU
IAH > 30/H, RISC CV IGIENA SOMNULUI, DIETĂ, CPAP
HIPERTROFIE ŢESUT MOALE
FARINGIAN SAU ANOMALII SCHELETALE INTERVENŢII CHIRURGICALE ORL
Managementul opţiunilor în SASOformă severă
1. CPAP- opţiune de elecţie.
2. Altele – nonresponderi la CPAP, când nu este tolerat: scădere ponderală, poziţie non-supin.
3. Măsurile de a avansa mandibula:(i) dispozitive orale(ii) Osteotomia maxilomandibulară – f rar...
Doar la pacienţii tineri, slabi şi foarte motivaţi.
4. Intervenţia chirurgicală asupra căilor aeriene superioare (UPPP) şi ablaţia prin radiofrecvenţă - nu în cazurile severe.
PSG
Dispozitive
CPAP
80% din pacienţi acceptă CPAP ca terapie de lungă durată la domiciliu
W. T. McNicholas, M. R. Bonsignore, Eur Respir J, January 2007; 29:156-178
CPAP: impactul asupra activităţii din timpul zilei
Engleman HM et al, Lancet 1994;343:572–575
Engleman HM et al, Thorax 1998;53:341–345
Redline S et al, AJRCCM 1998;57:858–865
Jenkinson C et al, Lancet 1999;353:2100–2105
, B a lle s t e r E e t a l AJRCCM 1 9 9 9 ;1 5 9 :4 9 5 – 5 0 1 , , 2 0 0 1 , 1 6 4 :6 0 8 -1 3M o n t s e r r a t e t a l A J R C C M
nCPAP aduce îmbunătăţiri semnificative
pe somnolenţă şi calitatea vieţii la pacienţii
cu simptome de SAS moderată sau severă
, , 2 0 0 0 , 1 6 1 :1 7 7 5 -8R D a v ie s a n d J S t r a d lin g A J R C C M
Morbiditate cardiovasculară
Cauze de HTA secundară Sindromul de apnee în somn HTA indusă de medicamente sau droguri Nefropatiile cronice Hiperaldosteronismul primar Boala renovasculară Corticoterapia cronică şi sindromul Cushing Feocromocitomul Coarctaţia de aortă Afecţiunile tiroidiene sau paratiroidiene
(The Seventh Report of the Joint National Comittee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. The JNC Report). JAMA 2003; 289: 2560-2572.
Somers et al, NEJM 2005
Moarte subită
Mortalitatea crescută la pacienţii care nu primesc CPAP
Doherty LS Chest. 2005;127:2076-2084Long-term Effects of Nasal Continuous Positive Airway Pressure Therapy on Cardiovascular Outcomes in Sleep Apnea Syndrome*
Chest. 2005;128:624-633.Mortality in Obstructive Sleep Apnea-Hypopnea Patients Treated With Positive Airway Pressure* Francisco Campos-Rodriguez,
Marti, S, Sampol, G, Muñoz, X, et al Mortality in severe sleep apnoea/hypopnoea syndrome patients: impact of treatment. Eur Respir J 2002;20,1511-1518
Medical care
Initial management of hypotonia or poor feeding
Evaluation for hypogonadism or hypopituitarism
Management of obesity Monitoring for scoliosis
Therapy for behavioral issues
Surgical Care
Complications of obesity: gastric bypass Cryptorchidism Scoliosis intervention. Urgent surgical attention for abdominal issues:
cholecystitis, appendicitis, or acute gastric dilation with risk for progression to necrosis.
Tonsillectomy, adenoidectomy, or tracheostomy placement may be required in patients with obstructive sleep apnea.
Consultations Geneticist for initial diagnosis and counseling Developmental pediatrician for stimulation programs
Endocrinologist for management of hypogonadism
Nutritionist for dietary counseling
Ophthalmologist for management of strabismus
Pulmonologist for management of sleep apnea
Psychiatrist, psychologist, or both for management of behavioral issues
Circumferinţa abdominală medie 120,06 cm
Obezitatea abdominală (plus ≥2 elemente) - element obligatoriu în noua definiţie a sindromului metabolic: peste 80 cm la femei şi peste 94 la bărbaţi la europeni
Lancet 2007; 369:2059-2061
Diet +Activity
Limitation of access to foods Supplemental occupational and physical therapy to
promote acquisition of gross and fine motor skills and to strengthen spinal musculature in order to minimize scoliosis.
Encouragement of physical activity at home, at school (eg, increased physical education periods), and in the community (eg, Special Olympics)
Follow-up
Inpatient evaluation and treatment for hypotonia and poor feeding during infancy.
Individuals with scoliosis and complications of obesity or pickwickian syndrome, may require inpatient therapy.
Patients with severe behavioral problems may merit admission to a facility staffed with individuals with long-term experience with PWS.
Follow-up
Routinely monitor for symptoms of sleep apnea.
Obtaining a sleep study within the few months after initiation of growth hormone therapy at the first sign of symptoms.