Note: Specific signs and symptoms vary depending on the severity of the disease in each child and age
Signs & Symptoms:
1. Blockage of intestines (meconium ileus) – meconium becomes so thick it can’t move through
the intestines (tarry, greenish-black stools normally passed by infants in the first day or two
after birth)
2. Failure to thrive (weight loss and malnutrition)
3. Steatorrhea (bulky and greasy stools)
4. Salty taste to the skin – higher amounts of sodium chloride in their sweat
5. Frequent respiratory infections
6. Thick sputum – parents tend to overlook this because young children tend to swallow their
sputum rather than cough it up
7. Coughing or wheezing
8. Frequent chest and sinus infections with recurring pneumonia or bronchitis
9. Polyps in the nasal passages
10. Rectal prolapse – protrusion of part of the rectum through the anus caused by stools that
are difficult to pass or by frequent coughing
11. Blockage in the bowel
12. Displacement of one part of the intestine into another part of the intestine (intussusception)
in children older than 4
13. Clubbing of the fingertips and toes
14. Enlargement of the right side of the heart
15. Pancreatitis
16. Diabetes related to chronic pancreatitis
17. Cirrhosis of the liver due to inflammation or obstruction of the bile ducts
18. Male infertility (obstructive azoospermia)
Sources:
http://www.mayoclinic.com/health/cystic-fibrosis/DS00287/DSECTION=2
http://www.labtestsonline.org/understanding/conditions/cystic_fibrosis-2.html
(Posted by: Vivian)
Thursday, 19 April 2007
Breaking Bad News
Right, it's time for breaking news. Breaking bad news, that is.
(Note from your friendly neighbourhood slacker: You can simply read the bold, coloured, numbered points and skip the rest)
1. Do it in a private place
And by this, we don't mean the janitor's closet. Don't break bad news right in the corridor of the hospital, or in front of a roomful of people. Take the patient aside, bring them to your office (if you are lucky enough to have one), or to an empty room.
2. As soon as possible
Don't wait til you receive a call from the nearest mental hospital stating that your patient has just been admitted due to a nervous breakdown thanks to waiting for ten days for that ominous phone call about whether they tested positive or not. ASAP people. In this world, nobody likes waiting.
3. Both parents together
When breaking bad news regarding children, don't give part A to Dad and part B to Mum. Get them both together, and impart your news to them then.
4. In clear and appropriate language
Don't speak Greek. And don't rattle off medical jargon just because you know your stuff, show off! Explain in clear and concise everyday English Language, as how you would explain it to your grandparents, or parents, who are NOT in the medical field, mind you. And by everyday English Language, we would think it would exclude words like 'dude', 'stuff', 'uh', 'erm' and 'you know'.
5. Appropriate emotions
Don't go in there with a big grin on your face and say, "Sorry matey, seems like you've got CF afterall!" 'Nuff said.
6. Give time for the patient (and parents or other caregivers/loved ones) to ask questions
You are not going to liftoff in 10 seconds to a russian space station. Don't rush through your news and then leave. That self-directed latte can wait!
7. Answer questions in an empathic and non-judgmental manner
I suppose we can all be trusted to behave like the fine medical students we are, right? Right?!
8. Provide supplementary written material (when possible)
Fact: If all else fails i.e. you suddenly have a temporary mindwipe thanks to that all-nighter you pulled before the OSCE, remember this point, and you will be fine. Examples of supplementary written material would be brochures, flyers, booklets, what not. In these days, the supplementary material would also extend to informative websites. NOT wikipedia.org, mind you (no offense to the kind folks who contribute to it).
9. Follow-up consultation for soon after
Fact: very little (only about 10%) of the 1st consultation is absorbed by patients/caregivers. They probably heard: "I'm really sorry, but you have tested positive. Blah blah blah... moo...moo...bahh..bahh..." So set up a follow-up consultation for soon after the first visit. Give the patient time for the information to sink in, for them to read through your supp. written material, and come up with other questions.
(Note from your friendly neighbourhood slacker: You can simply read the bold, coloured, numbered points and skip the rest)
1. Do it in a private place
And by this, we don't mean the janitor's closet. Don't break bad news right in the corridor of the hospital, or in front of a roomful of people. Take the patient aside, bring them to your office (if you are lucky enough to have one), or to an empty room.
2. As soon as possible
Don't wait til you receive a call from the nearest mental hospital stating that your patient has just been admitted due to a nervous breakdown thanks to waiting for ten days for that ominous phone call about whether they tested positive or not. ASAP people. In this world, nobody likes waiting.
3. Both parents together
When breaking bad news regarding children, don't give part A to Dad and part B to Mum. Get them both together, and impart your news to them then.
4. In clear and appropriate language
Don't speak Greek. And don't rattle off medical jargon just because you know your stuff, show off! Explain in clear and concise everyday English Language, as how you would explain it to your grandparents, or parents, who are NOT in the medical field, mind you. And by everyday English Language, we would think it would exclude words like 'dude', 'stuff', 'uh', 'erm' and 'you know'.
5. Appropriate emotions
Don't go in there with a big grin on your face and say, "Sorry matey, seems like you've got CF afterall!" 'Nuff said.
6. Give time for the patient (and parents or other caregivers/loved ones) to ask questions
You are not going to liftoff in 10 seconds to a russian space station. Don't rush through your news and then leave. That self-directed latte can wait!
7. Answer questions in an empathic and non-judgmental manner
I suppose we can all be trusted to behave like the fine medical students we are, right? Right?!
8. Provide supplementary written material (when possible)
Fact: If all else fails i.e. you suddenly have a temporary mindwipe thanks to that all-nighter you pulled before the OSCE, remember this point, and you will be fine. Examples of supplementary written material would be brochures, flyers, booklets, what not. In these days, the supplementary material would also extend to informative websites. NOT wikipedia.org, mind you (no offense to the kind folks who contribute to it).
9. Follow-up consultation for soon after
Fact: very little (only about 10%) of the 1st consultation is absorbed by patients/caregivers. They probably heard: "I'm really sorry, but you have tested positive. Blah blah blah... moo...moo...bahh..bahh..." So set up a follow-up consultation for soon after the first visit. Give the patient time for the information to sink in, for them to read through your supp. written material, and come up with other questions.
Management and Prognosis of CF
Prepared by: Ji Keon, LOOI
in consultation with the resources below:
http://www.med.monash.edu.au/paediatrics/resources/cf.html
http://www.cysticfibrosis.org.au/treatment/Physiotherapy/
http://www.cff.org/treatments/
http://www.cysticfibrosis.org.au/treatment/Physiotherapy/
http://www.cff.org/treatments/
Due to the enormous amount of information on the management of cystic fibrosis, the information deemed important is highlighted in red.
Physiotherapy
Airway Clearance Techniques
Chest Percussion
· aids clearance of secretions up and out of the lungs and increasing the amount of air entering the lungs.
· helps to prevent the thick, sticky lung secretions from blocking the air tubes. This helps to reduce infection and prevent lung damage.
· A cupped hand is used to clap the chest firmly (it is more comfortable through clothing or a towel).
Vibrations
· done in a drainage position in alternation with percussion.
· "Vibes" are a gentle shaking or vibrating of the chest whilst breathing out.
· This creates mini bursts of air flow which dislodge the secretions, moving them up and out of the airways. They are usually followed by a huff or cough in combination, to clear secretions from the lungs.
Breathing Techniques (The Active Cycle of Breathing Techniques)
· By controlled deep and shallow breathing to move mucus up through the airways.
· help re-inflate any areas of the lungs which may have been deflated because of mucus blockage of the airways.
Flutter Therapy
This technique uses a handheld oscillating positive pressure device through which you breathe out against an alternating resistance. This causes back pressure which results in expansion of the small airways, keeping them open for longer, whilst mini bursts of air flow move secretions out of the small airways and into larger airways where they can be cleared with a huff of cough in combination.Positive Expiration Pressure (PEP)
Involves breathing out though a mask or mouthpiece where a backpressure is created in the lungs by only allowing air out through a small hole.
This back pressure expands the small airways and opens side channels (collateral ventilation) to get behind secretions, moving them to larger airways where they can be cleared.
Autogenic Drainage
This technique was developed in Belgium and is a controlled method of breathing that requires no equipment. It involves training to breathe at three lung volumes:
low-lung volume to 'unstick' mucus
mid-lung volume to 'collect' mucus
high-volume maneuvers to 'expel' mucus
This technique requires extensive training and frequent practice.
Always ask your doctor before considering any change in your treatment
Medication
Cystic Fibrosis affects the lungs and the digestive tract - these areas are likely to require medication.
Lungs
Medication can be administered in various ways: inhaled into the lungs using nebulisers, taken orally, or taken intravenously.These drugs treat the lungs in the following ways:
Bronchodilator drugs open the airways by relaxing the surrounding muscle. They relieve tightness and shortness of breath.
Antibiotics help to treat or control persistent infection.
Steroids reduce inflammation in the airways.
Digestive System
Cystic Fibrosis affects the pancreas, so enzyme replacement capsules should be taken with meals and snacks to replace pancreatic enzymes and enable people with CF to gain more energy from the food they eat.
Pancreatic Enzyme Insufficiency
Pancreatic enzyme insufficiency is one of the common symptoms of CF. The CF gene defect results in a thickening of the pancreatic secretions. The accumulation of thick secretions causes obstruction and eventually leads to damage of the pancreas. Pancreatic enzyme insufficiency prevents digestion and absorption of nutrients. Large, bulky, smelly stools containing undigested nutrients are a direct result of a lack of pancreatic enzymes.Pancreatic enzyme insufficiency is treated with pancreatic enzyme replacement capsules, which should be taken with every meal or snack. Dosing can be based on the fat content of the food items. Foods containing only carbohydrate, such as fruit, juices and boiled lollies will not require pancreatic enzyme replacement capsules.
Pancreatic Enzyme Replacement Therapy (PERT)
Specially coated enzyme beads (microspheres) have been a treatment breakthrough for people with CF. Effective and acceptable enzyme replacement therapy has been a significant factor in maintaining health for those with CF. For infants and younger children, who cannot swallow capsules whole, the capsules can be opened and the enteric coated microspheres mixed with fruit gel. This is then fed to the infant before and during their feed. Older children can have the microspheres mixed with yoghurt or pureed fruit.
Dosage Of Enzymes
The physician and dietitian will monitor pancreatic enzyme therapy dosing. The dietitian will provide information on the correct dosage of enzymes for different foods.
Enzyme Storage
Australia has a unique climate which is not suited to preserving the potency of enteric coated microspheres. Parents and adults with Cystic Fibrosis need to be aware that this is costly medication and needs to be handled carefully. The Pancreatic Enzyme Replacement Capsules need to be stored below 250C, and kept in the dark and dry. They do not like to be left in the car. During summer, the preparations can go off quickly.Enzymes available in Australia are:
CREON® - Solvay Pharmaceuticals (available in several strenghts)
COTAZYM® - Organon
PANCREASE - Janssen-Cilag - Discontinued in Australia December 2005
Your dietitian or doctor can advise you on the appropriate type/dosage of enzyme supplement.
Other Organs
Bones can be effected by a lack of minerals, which can cause osteoporosis (weak/brittle bones). Bisphosphonates, which are used to treat osteoporosis in post-menopausal women, have been shown to be beneficial for the treatment of osteoporosis in CF too. Research is being carried out to investigate the benefits of high doses of vitamin D and calcium.
If someone with CF is having liver problems, they will be treated in the same way as other people with this condition. Promising results have been reported following early treatment with ursodeoxycholic acid.
Nutrition
Nutrition in a person with CF plays a very important role in the treatment and management of their condition. Research has shown there is a link between weight gain and survival. People with CF are required to consume between 120-150% of the daily amount of food recommended for a person of the same age and size that does not have CF. This is needed to ensure they:
Increase their chance of absorbing the nutrients needed for normal and healthy growth (in children) and general sustained health
Increase their body weight in order to fight off infections particularly in times of exacerbation of lung illness
The diet for a person with CF is high in calories, high in fat, high in salt, and high in sugar. Often when children or adults are sick they lose their appetite and will lose weight. Having a good body weight helps them when they are ill as appetite is often reduced and they can lose weight.They need to ensure they maintain a healthy body weight to assist in fighting infection and to help them through when they get sick.Cholesterol is NOT an issue in CF. Increased salt is required to replace that lost through sweat. Good nutrition is important for people with CF and a diet with fruits, vegetables, proteins and fats is required to maintain health. Other Supplements
People with Cystic Fibrosis have difficulty absorbing some vitamins, especially those that are fat-soluble. Often they will need to take supplements of vitamins A, E and K.People with Cystic Fibrosis have sweat that is five times saltier than people without Cystic Fibrosis. This puts them at risk of dehydration and salt depletion in hot weather or with increased activity. The high salt loss means the body's thirst mechanism does not trigger, so the person does not feel thirsty as they lose fluid. To make sure they do not dehydrate, they need to drinks lots of sports drinks (like Isosport) or Glucolyte, take salt tablets and maintain water intake. Salt input needs to be distributed across the day as the very salty sweat means salt loss can be very rapid. Lack of salt and fluid can lead to dehydration which can cause irritability, cramps, headaches, lethargy and fatigue.
Exercise
Research demonstrates a clear link between regular exercise, weight gain, body mass, lung function and survival in CF.
Exercise is an important part of the daily treatment routine for people with CF as it assists with airway clearance and builds up muscle mass and strength.
Coughing is a natural part of having CF. People with CF are encouraged to cough and should not suppress this important airway clearance mechanism. However, it is not convenient to expirate in the pool or gym and therefore airway clearance should be done prior to exercising.
During sporting activities people with CF may experience coughing, wheezing and/or breathlessness.
If any of these symptoms are experienced by a person with CF, it does not necessarily mean that they need to give up their sporting activity. If in doubt individuals should consult their doctor and physiotherapist. Some may need to use a bronchodilator before exercising.
People with CF are encouraged to drink plenty of water during and after exercise to avoid dehydration especially in hot weather.
Salt replacement tablets may be needed during periods of exercise as people with CF lose excessive amounts of salt in their sweat. Speak to your dietitian or doctor.
CF specialist clinics should be consulted to advise gym instructors and physical education teachers if they have any concerns regarding the participation of a person with CF in specific physical activities.
Transplantation
The following general information has been provided as a basic guide to people with CF. For information that relates to their personal health and situation people are encouraged to discuss the issue with their CF specialist.
Type of lung transplantation
In CF the method of lung transplantation is bilateral sequential transplant where both lungs are removed and replaced with the donated lungs. This removes the risk of a new lung being infected by the bacteria in the remaining lung.
Does CF “go away” after transplant?
The transplanted lungs come from people who do not have CF, so the new lungs do not have and will not develop CF. However, after transplant the person still has CF in the pancreas, sweat glands, sinuses and reproductive tract. The person still has to take enzymes with food and to help absorb the anti-rejection medications.
The transplanted lungs come from people who do not have CF, so the new lungs do not have and will not develop CF. However, after transplant the person still has CF in the pancreas, sweat glands, sinuses and reproductive tract. The person still has to take enzymes with food and to help absorb the anti-rejection medications.
Challenges
Transplanted lungs are susceptible to infection, rejection and other complications that require treatment. Following transplantation the immune system is suppressed to help prevent organ rejection and this will decrease the ability to fight infections. Therefore people must become vigilant about their drug treatment in that they need to take their drugs at the same time every day. This ensures that the most constant levels of immunosuppressive drugs is maintained. At first, this, along with the number of drugs, can be quite overwhelming. However, people with CF tend to adjust easily as they are used to taking daily medication. They are swapping one lot of treatment for another. They are also used to attending outpatient clinics and generally taking an active role in the management of their treatment. In addition their carers and families are well rehearsed at providing much needed support.
The immunosuppressive drugs may cause side effects such as diabetes, kidney problems, cancer-like tumours and osteoporosis. Your transplant centre will be monitoring your progress.
It is important to maintain contact with your CF Clinic post transplant as they are skilled in the total management of CF which still affects you, apart from your lungs.
Waiting
There is a shortage of donor organs in Australia and the wait for lungs is (on average) between 9 – 12 months. The waiting time is very difficult for most people as they struggle to maintain their weight and level of physical activity in an atmosphere of uncertainty. Acceptance on the active waiting list does not guarantee that suitable lungs will be found in time. When suitable donor organs become available the best matched recipient will be contacted. The length of time waiting for new lungs makes little difference to priority on the list. The person with the most compatible blood group and size will be selected. If there is more than one person considered to be suitable then the sickest person gets priority.
Life expectancy after lung transplantation
Currently in Australia over 85% of all people (not just with CF) undergoing bilateral, sequential lung transplants survive at least one year and 60% are still alive five years after the transplant.
Benefits
After recovery from the surgery many people with CF find they have more energy, can gain weight more easily and are more active than they were before.
Monday, 16 April 2007
Anatomy Tasks for Orbit and Ear
- Describe bones of orbit & their relations; describe the relevant anatomy of ' blow-out' fracture (Christine, Chris & Sri)
- Describe structure, function & relations of extarocular muscles (Vivian)
- Describe palsies of oculomotor, trochlear & abducent nerves (Ji Keon)
- Describe the boundaries & contents of superior orbital fissure (Shantini)
- Describe boundaries & contents of orbit (Madhura)
- Describe boundaries & contents of external, middle & inner ear (Lawrence)
- Describe the various types of referred pain to the ear (John)
- Describe structure, function & relations of extarocular muscles (Vivian)
- Describe palsies of oculomotor, trochlear & abducent nerves (Ji Keon)
- Describe the boundaries & contents of superior orbital fissure (Shantini)
- Describe boundaries & contents of orbit (Madhura)
- Describe boundaries & contents of external, middle & inner ear (Lawrence)
- Describe the various types of referred pain to the ear (John)
Tasks For PCL 7
1. Pathophysiology of CF (Shantini)
2. Signs and Symptoms of CF (Vivian)
3. Investigations of CF, including clinical examination, sweat test, heel prick test. (Lawrence)
4. Management and Prognosis of CF (Ji Keon)
5. Respiratory disorders similar to CF - Problems in diagnosing CF (John)
6. Breaking of Bad News (Madhura)
7. Psychosocial issues faced by CF patients , consider support groups available in Australia for CF patients (Christine)
8. Epidemiology of CF, including developments in management of CF since 1969 and on-going research on treatment of CF (Sri)
9. CAM treatment options for CF patients (Chris)
Apologies to Christine, Sri and Chris for allocating tasks to you all without first asking your opinions. Hope you all are alrighht with it. If you have any questions about your tasks, please feel free to approach your friendly chairman for this week.
John
2. Signs and Symptoms of CF (Vivian)
3. Investigations of CF, including clinical examination, sweat test, heel prick test. (Lawrence)
4. Management and Prognosis of CF (Ji Keon)
5. Respiratory disorders similar to CF - Problems in diagnosing CF (John)
6. Breaking of Bad News (Madhura)
7. Psychosocial issues faced by CF patients , consider support groups available in Australia for CF patients (Christine)
8. Epidemiology of CF, including developments in management of CF since 1969 and on-going research on treatment of CF (Sri)
9. CAM treatment options for CF patients (Chris)
Apologies to Christine, Sri and Chris for allocating tasks to you all without first asking your opinions. Hope you all are alrighht with it. If you have any questions about your tasks, please feel free to approach your friendly chairman for this week.
John
Saturday, 14 April 2007
Extra: Doctor-patient confidentiality (Summary)
Patient consent (valid and legal):
1. Patient must have capacity to consent
2. Patient must be adequately informed
3. Patient must consent voluntarily
Patients who can’t give consent:
1. Minors (in Malaysia, below 18)
2. Adults with mental illnesses
3. Adults with intellectual disabilities
4. Adults with senility
5. Unconscious patients
When can we breach confidentiality?
1. Legally Obliged
§ Reportable deaths
§ Infectious diseases
§ Health impaired medical professionals
§ Registration of birth and death
§ Drunk drivers
2. Legally Permissible
§ Patient has consented
§ De-identified information
§ Disclosure to other health professionals (necessary for patient care)
§ Disclosure in the public interest (reasonable grounds to believe there is imminent danger)
3. Ethically
§ Harm to self (patient)
§ Harm to others (must weigh and balance interests of patient and duties to society)
(Sources: MBBS Study Guide MED1011)
(Posted by: Vivian)
1. Patient must have capacity to consent
2. Patient must be adequately informed
3. Patient must consent voluntarily
Patients who can’t give consent:
1. Minors (in Malaysia, below 18)
2. Adults with mental illnesses
3. Adults with intellectual disabilities
4. Adults with senility
5. Unconscious patients
When can we breach confidentiality?
1. Legally Obliged
§ Reportable deaths
§ Infectious diseases
§ Health impaired medical professionals
§ Registration of birth and death
§ Drunk drivers
2. Legally Permissible
§ Patient has consented
§ De-identified information
§ Disclosure to other health professionals (necessary for patient care)
§ Disclosure in the public interest (reasonable grounds to believe there is imminent danger)
3. Ethically
§ Harm to self (patient)
§ Harm to others (must weigh and balance interests of patient and duties to society)
(Sources: MBBS Study Guide MED1011)
(Posted by: Vivian)
Friday, 13 April 2007
Management of Sleep Apneas and Snoring
In finding a treatment for obstructive sleep apnea, the primary goal is to hold the airway open so it does not collapse during sleep. Treatments include:
Tracheostomy
A tracheostomy is a procedure to bypass the narrowed airway. If the obstruction to airflow is occurring above the larynx, a tracheostomy can be inserted to direct airflow directly into the trachea. The tracheostomy tube is passed through the skin of the lower neck directly into the trachea. Tracheostomy generally is reserved for morbidly obese patients with severe obstructive sleep apnea who are not candidates for other treatments. They usually can keep the tracheostomy tube capped during the day while breathing normally through their nose and mouth, and then open the tracheostomy tube at night. That way, they will have a normal voice and mouth breathing while awake, and breathe through the tracheostomy tube only at night.
A tracheostomy can be a temporary procedure, and is kept in place only as long as it is needed. It is easy to remove the tube, and the body will usually heal the skin and close the opening rather quickly. Tracheostomy has close to a 100% rate of cure for obstructive sleep apnea because it bypasses the problem in the upper airway. In mixed sleep apnea, obstructive apneas resolve immediately, but central apneas, which are due to metabolic changes caused by the obstructive apneas, usually take some time to resolve.
Behavioral changes,
Medications,
Dental appliances,
Surgeries,
CPAP (continuous positive airway pressure).
Medications,
Dental appliances,
Surgeries,
CPAP (continuous positive airway pressure).
Behavioral changes
Behavioral changes are the simplest treatments for mild obstructive sleep apnea, but often the hardest to make. Occasionally, apneas occur only in some positions (most commonly lying flat on the back). A person can change his or her sleeping position, reduce apneas, and improve their sleep.
Obesity is a contributing factor to obstructive sleep apnea. A healthy lifestyle and diet that encourages weight loss will improve obstructive sleep apnea. Unfortunately, most people with obstructive sleep apnea are tired and do not have much energy for exercise. This is a difficult behavioral spiral since the more tired a person is -- the less they exercise -- the more weight they gain -- the worse the obstructive sleep apnea becomes -- and the more tired they become. Frequently, after obstructive sleep apnea is treated by other methods, people are able to lose weight, and the obstructive sleep apnea improves.
Behavioral changes are the simplest treatments for mild obstructive sleep apnea, but often the hardest to make. Occasionally, apneas occur only in some positions (most commonly lying flat on the back). A person can change his or her sleeping position, reduce apneas, and improve their sleep.
Obesity is a contributing factor to obstructive sleep apnea. A healthy lifestyle and diet that encourages weight loss will improve obstructive sleep apnea. Unfortunately, most people with obstructive sleep apnea are tired and do not have much energy for exercise. This is a difficult behavioral spiral since the more tired a person is -- the less they exercise -- the more weight they gain -- the worse the obstructive sleep apnea becomes -- and the more tired they become. Frequently, after obstructive sleep apnea is treated by other methods, people are able to lose weight, and the obstructive sleep apnea improves.
Medications
Many medications have been studied for obstructive sleep apnea; however, because obstructive sleep apnea is due to an anatomic airway narrowing, it has been difficult to find a medication that will help. In people with nasal airway obstruction causing obstructive sleep apnea, nasal steroid sprays have been shown to be effective. Topical nasal decongestants, like oxymetalizone and neosynephrine, also can temporarily improve nasal swelling. The problem is that they cannot be used for more than 3-5 days without decreased effectiveness and withdrawal symptoms.
People who have obstructive sleep apnea secondary to hypothyroidism (low thyroid hormone production) improve with thyroid replacement therapy. However, people with normal thyroid function, will not improve with this therapy.
People who have obstructive sleep apnea due to obesity may improve with diet medications, if they are effective in helping them lose weight.
There are also new medications to help increase alertness. They may be temporarily successful in increasing attention; however, they do not treat the sleep deprivation or the cause of obstructive sleep apnea.
People who have obstructive sleep apnea secondary to hypothyroidism (low thyroid hormone production) improve with thyroid replacement therapy. However, people with normal thyroid function, will not improve with this therapy.
People who have obstructive sleep apnea due to obesity may improve with diet medications, if they are effective in helping them lose weight.
There are also new medications to help increase alertness. They may be temporarily successful in increasing attention; however, they do not treat the sleep deprivation or the cause of obstructive sleep apnea.
Dental appliances
A dental appliance holds the jaw and tongue forward and holds the palate up thus preventing closure of the airway. This small increase in airway size often is enough to control the apneas. Dental appliances are an excellent treatment for mild to moderate obstructive sleep apnea. It is reported to be about 75% effective for these groups. A dental appliance does not require surgery; it is small, portable, and does not require a machine. A dentist is needed to fit and adjust the appliance. A dental appliance requires natural teeth to fit properly and must be worn every night.
Continuous positive airway pressure (CPAP)
Continuous positive airway pressure (CPAP) is probably the best, non-surgical treatment for any level of obstructive sleep apnea. CPAP uses air pressure to hold the tissues open during sleep. As a person breathes, the gentle pressure holds the nose, palate, and throat tissues open. The CPAP machine blows heated, humidified air through a short tube to a mask. The mask must be worn snugly to prevent the leakage of air. The CPAP machine is a little larger than a toaster. It is portable and can be taken on trips. .
Determining CPAP pressure.
With CPAP it is important to use the lowest possible pressure that will keep the airway open during sleep. This pressure is determined by “titration.” Titration frequently is performed with the help of polysomnography. In the sleep laboratory, an adjustable CPAP machine is used. A mask is fit to the subject, and he or she is allowed to fall back asleep. During baseline sleep, the apneas and hypopneas occur. The technician then slowly increases the CPAP pressure until the apneas and hypopneas stop or decrease to a normal level. A different pressure may be needed for different positions or levels of sleep. Typically, laying on the back and REM sleep promote the worst obstructive sleep apnea. The lowest pressure that controls obstructive sleep apnea in all positions and sleep levels is prescribed
With CPAP it is important to use the lowest possible pressure that will keep the airway open during sleep. This pressure is determined by “titration.” Titration frequently is performed with the help of polysomnography. In the sleep laboratory, an adjustable CPAP machine is used. A mask is fit to the subject, and he or she is allowed to fall back asleep. During baseline sleep, the apneas and hypopneas occur. The technician then slowly increases the CPAP pressure until the apneas and hypopneas stop or decrease to a normal level. A different pressure may be needed for different positions or levels of sleep. Typically, laying on the back and REM sleep promote the worst obstructive sleep apnea. The lowest pressure that controls obstructive sleep apnea in all positions and sleep levels is prescribed
Effectiveness of CPAP.
CPAP has been shown to be effective in improving subjective and objective measures of obstructive sleep apnea.
It decreases apneas and hypopneas.
It decreases sleepiness as measured by surveys and objective tests.
It improves cognitive functioning on tests.
When adjusted properly and tolerated, it is nearly 100% effective in eliminating or reducing obstructive sleep apnea.
It decreases apneas and hypopneas.
It decreases sleepiness as measured by surveys and objective tests.
It improves cognitive functioning on tests.
When adjusted properly and tolerated, it is nearly 100% effective in eliminating or reducing obstructive sleep apnea.
Bi-level positive airway pressure (BiPAP)
Bi-level positive airway pressure (BiPAP) was designed for people who do not tolerate the higher pressures of CPAP. It is similar to CPAP in that a machine delivers a positive pressure to a mask during sleep. However, the BiPAP machine delivers a higher pressure during inspiration, and a lower pressure during expiration. That allows a person not to feel like they are breathing out against such a high pressure, which can be bothersome. It is most helpful for people who require a higher pressure to keep their airway open.
Auto-titrating continuous positive airway pressure
A new development in sleep apnea treatment is the auto-titrating CPAP machine. These “smart” CPAP machines make pressure adjustments throughout the night. At a given pressure, if a person starts to have an apnea or hypopnea, the machine adjusts the pressure higher until the episodes are controlled. If a person is in a sleep level or position that doesn’t need a higher pressure, the pressure is reduced.
A new development in sleep apnea treatment is the auto-titrating CPAP machine. These “smart” CPAP machines make pressure adjustments throughout the night. At a given pressure, if a person starts to have an apnea or hypopnea, the machine adjusts the pressure higher until the episodes are controlled. If a person is in a sleep level or position that doesn’t need a higher pressure, the pressure is reduced.
Surgical treatments for obstructive sleep apnea
There are many surgical options to treat obstructive sleep apnea. The type of surgery that is chosen is dependent on an individual’s specific anatomy and severity of sleep apnea. People often want surgery because it promises a cure with a single treatment. Surgery sounds easier than losing ten pounds and more convenient than wearing a dental appliance or mask every night.
However, surgery should be considered only after all the risks, benefits, and alternatives to surgery are understood. For example, CPAP, if tolerated, controls most sleep apnea, and this is better than all surgical options. It is difficult to have a serious, permanent complication using CPAP as compared to the possible of such a complication with surgery.
Any surgical treatment for sleep apnea must address the anatomic problem areas. There may be one or several areas that compromise airflow and cause apnea. Surgical treatments can address the nose, palate, tongue, jaw, neck, obesity, or several of these areas at the same time. Each surgery’s success rate is determined by whether or not a specific airway collapse is prevented. Therefore, the ideal surgery is different for each patient and depends on each patient's specific problem. Some surgical options include:
However, surgery should be considered only after all the risks, benefits, and alternatives to surgery are understood. For example, CPAP, if tolerated, controls most sleep apnea, and this is better than all surgical options. It is difficult to have a serious, permanent complication using CPAP as compared to the possible of such a complication with surgery.
Any surgical treatment for sleep apnea must address the anatomic problem areas. There may be one or several areas that compromise airflow and cause apnea. Surgical treatments can address the nose, palate, tongue, jaw, neck, obesity, or several of these areas at the same time. Each surgery’s success rate is determined by whether or not a specific airway collapse is prevented. Therefore, the ideal surgery is different for each patient and depends on each patient's specific problem. Some surgical options include:
nasal airway surgery,
palate implants,
uvulopalatopharyngoplasty,
tongue reduction,
genioglossus advancement,
hyoid suspension,
maxillomandibular procedures,
tracheostomy,
bariatric surgery, and
combinations of the above.
palate implants,
uvulopalatopharyngoplasty,
tongue reduction,
genioglossus advancement,
hyoid suspension,
maxillomandibular procedures,
tracheostomy,
bariatric surgery, and
combinations of the above.
Many people have several levels of obstruction; therefore these surgical techniques frequently are performed together, for example, uvulopalatopharyngoplasty with genioglossus advancement and hyoid suspension.
Nasal airway surgery
The nasal cavity can be obstructed by swelling of the turbinates, septal deviation, and nasal polyps. Surgeries to address each of these potential causes of obstruction can improve the flow of air through the nasal passages. Nasal surgery is most successfully used for sleep apnea to improve the effectiveness of CPAP.
The nasal cavity can be obstructed by swelling of the turbinates, septal deviation, and nasal polyps. Surgeries to address each of these potential causes of obstruction can improve the flow of air through the nasal passages. Nasal surgery is most successfully used for sleep apnea to improve the effectiveness of CPAP.
Palate implants
Palate implants stiffen the palate. They prevent the palate from collapsing into the pharynx where it can obstruct the airway. They also decrease the vibrations of the palate that cause snoring.
Palate implants stiffen the palate. They prevent the palate from collapsing into the pharynx where it can obstruct the airway. They also decrease the vibrations of the palate that cause snoring.
Uvulopalatopharyngoplasty (UPPP)
Uvulopalatopharyngoplasty (UPPP) is a long and fancy term to describe a surgery aimed at preventing collapse of the palate, tonsils, and pharynx which is common in sleep apnea. UPPP is most successful in patients who have large tonsils, a long uvula (the most posterior part of the palate that hangs down in the back of the throat), or a long, wide palate. It also is more successful in patients who are not obese. In simple terms, the tonsils are removed, the uvula is removed, and the palate is trimmed higher. A UPPP is successful 50-60% of the time in preventing or decreasing obstructive sleep apnea.
Uvulopalatopharyngoplasty (UPPP) is a long and fancy term to describe a surgery aimed at preventing collapse of the palate, tonsils, and pharynx which is common in sleep apnea. UPPP is most successful in patients who have large tonsils, a long uvula (the most posterior part of the palate that hangs down in the back of the throat), or a long, wide palate. It also is more successful in patients who are not obese. In simple terms, the tonsils are removed, the uvula is removed, and the palate is trimmed higher. A UPPP is successful 50-60% of the time in preventing or decreasing obstructive sleep apnea.
Tongue reduction surgery
In some people with obstructive sleep apnea, the area of collapse is between the base of the tongue and the back wall of the throat (pharynx). Several surgeries have been used to decrease the size of the base of tongue and to open the airway. Most of these procedures are performed as an addition to other surgical procedures.
In some people with obstructive sleep apnea, the area of collapse is between the base of the tongue and the back wall of the throat (pharynx). Several surgeries have been used to decrease the size of the base of tongue and to open the airway. Most of these procedures are performed as an addition to other surgical procedures.
Genioglossus advancement
The genioglossus muscle is the muscle that attaches the base of the tongue to the inside front of the jaw bone. The genioglossus pulls the tongue forward. In people with obstructive sleep apnea, it has been shown that the genioglossus is more active in holding the airway open at rest. When this muscle relaxes during sleep, the airway narrows and collapses. A genioglossus advancement typically detaches the part of the jaw bone where the muscle attaches and moves it forward about 4 mm. This pulls the base of the tongue forward. This usually is performed in combination with hyoid suspension or UPPP.
The genioglossus muscle is the muscle that attaches the base of the tongue to the inside front of the jaw bone. The genioglossus pulls the tongue forward. In people with obstructive sleep apnea, it has been shown that the genioglossus is more active in holding the airway open at rest. When this muscle relaxes during sleep, the airway narrows and collapses. A genioglossus advancement typically detaches the part of the jaw bone where the muscle attaches and moves it forward about 4 mm. This pulls the base of the tongue forward. This usually is performed in combination with hyoid suspension or UPPP.
Hyoid Suspension
The hyoid bone helps support the larynx and tongue in the neck. It is located below the mandible and tongue, but above the laryngeal cartilages. It is not directly attached to any other bones, but rather is attached to strap (tongue) muscles above and below. The strap muscles elevate or depress the larynx during swallowing. As part of a surgery to bring the tongue and soft tissues up and forward, the hyoid bone may be suspended. This is usually performed with other surgical procedures like UPPP or genioglossus advancement. In general, the hyoid bone is sutured up closer to the mandible. This pulls the tongue forward and up.
The hyoid bone helps support the larynx and tongue in the neck. It is located below the mandible and tongue, but above the laryngeal cartilages. It is not directly attached to any other bones, but rather is attached to strap (tongue) muscles above and below. The strap muscles elevate or depress the larynx during swallowing. As part of a surgery to bring the tongue and soft tissues up and forward, the hyoid bone may be suspended. This is usually performed with other surgical procedures like UPPP or genioglossus advancement. In general, the hyoid bone is sutured up closer to the mandible. This pulls the tongue forward and up.
Maxillomandibular advancement
Maxillomandibular advancement is a surgical procedure that moves the jaw and upper teeth forward. This pulls the palate and base of the tongue forward and opens the airway. This procedure is best suited for a thin patient with a small jaw. Both the jaw and maxillary bones are cut, moved forward, realigned, and plated into place.
Maxillomandibular advancement is a surgical procedure that moves the jaw and upper teeth forward. This pulls the palate and base of the tongue forward and opens the airway. This procedure is best suited for a thin patient with a small jaw. Both the jaw and maxillary bones are cut, moved forward, realigned, and plated into place.
TracheostomyA tracheostomy is a procedure to bypass the narrowed airway. If the obstruction to airflow is occurring above the larynx, a tracheostomy can be inserted to direct airflow directly into the trachea. The tracheostomy tube is passed through the skin of the lower neck directly into the trachea. Tracheostomy generally is reserved for morbidly obese patients with severe obstructive sleep apnea who are not candidates for other treatments. They usually can keep the tracheostomy tube capped during the day while breathing normally through their nose and mouth, and then open the tracheostomy tube at night. That way, they will have a normal voice and mouth breathing while awake, and breathe through the tracheostomy tube only at night.
A tracheostomy can be a temporary procedure, and is kept in place only as long as it is needed. It is easy to remove the tube, and the body will usually heal the skin and close the opening rather quickly. Tracheostomy has close to a 100% rate of cure for obstructive sleep apnea because it bypasses the problem in the upper airway. In mixed sleep apnea, obstructive apneas resolve immediately, but central apneas, which are due to metabolic changes caused by the obstructive apneas, usually take some time to resolve.
Bariatric surgery
This is a surgery on the stomach and/or intestines to help a person with extreme obesity lose weight. There are two main types of bariatric surgery, adjustable gastric banding and gastric bypass. In adjustable gastric banding, insertion of a band restricts the size of the opening from the esophagus to the stomach. The size of the opening to the stomach determines the amount of food that can be eaten and can be controlled by the surgeon by inflating or deflating the band through a port that is implanted beneath the skin on the abdomen. The band can be removed at any time.
Gastric bypass is a permanent reduction in the size of the stomach. The proximal portion of the stomach is used to create an egg-sized pouch that is connected to the intestine in a location that bypasses about 2 feet of normal intestine. The amount of food that can be eaten is limited by the size of the pouch and the size of the opening between the pouch and the intestine.
It is effective for sleep apnea caused by or worsened by obesity. Bariatric surgery is associated with a marked reduction in weight post-operatively. Bariatric surgery is only an option for morbidly obese patients with severe obstructive sleep apnea. It must be noted that patients can regain the weight they lost after surgery.
Note: Difference in Goals of treatment for snoring vs. sleep apnea
The treatments for obstructive sleep apnea are similar to the treatments for snoring.
It must be noted that snoring, without the presence of obstructive sleep apnea generally does not pose much of a problem to the patient. However, snoring may and usually is a problem for the bed partner or roommate. Therefore, successful treatment should include the goal of achieving a successful night’s sleep for the other person. This makes treatment of snoring a difficult challenge. For example, someone may have a successful treatment if their snoring decreases from a jackhammer level to that of a passing truck. If their bed partner is happy, then the snoring problem is “cured.” However, another person whose snoring decreases from a mild sound to the level of heavy breathing may still have an unhappy bed partner. Hence, the successes of treatments for snoring are subjective to each particular case.
This is a surgery on the stomach and/or intestines to help a person with extreme obesity lose weight. There are two main types of bariatric surgery, adjustable gastric banding and gastric bypass. In adjustable gastric banding, insertion of a band restricts the size of the opening from the esophagus to the stomach. The size of the opening to the stomach determines the amount of food that can be eaten and can be controlled by the surgeon by inflating or deflating the band through a port that is implanted beneath the skin on the abdomen. The band can be removed at any time.
Gastric bypass is a permanent reduction in the size of the stomach. The proximal portion of the stomach is used to create an egg-sized pouch that is connected to the intestine in a location that bypasses about 2 feet of normal intestine. The amount of food that can be eaten is limited by the size of the pouch and the size of the opening between the pouch and the intestine.
It is effective for sleep apnea caused by or worsened by obesity. Bariatric surgery is associated with a marked reduction in weight post-operatively. Bariatric surgery is only an option for morbidly obese patients with severe obstructive sleep apnea. It must be noted that patients can regain the weight they lost after surgery.
Note: Difference in Goals of treatment for snoring vs. sleep apnea
The treatments for obstructive sleep apnea are similar to the treatments for snoring.
It must be noted that snoring, without the presence of obstructive sleep apnea generally does not pose much of a problem to the patient. However, snoring may and usually is a problem for the bed partner or roommate. Therefore, successful treatment should include the goal of achieving a successful night’s sleep for the other person. This makes treatment of snoring a difficult challenge. For example, someone may have a successful treatment if their snoring decreases from a jackhammer level to that of a passing truck. If their bed partner is happy, then the snoring problem is “cured.” However, another person whose snoring decreases from a mild sound to the level of heavy breathing may still have an unhappy bed partner. Hence, the successes of treatments for snoring are subjective to each particular case.
Note: Central Sleep Apnea
In adults with central sleep apnea, the apneas are treated by treating the underlying heart disease, medication interaction, high altitude, or other primary problem.
In adults with central sleep apnea, the apneas are treated by treating the underlying heart disease, medication interaction, high altitude, or other primary problem.
Source: Medicinenet.com
Contributed by John Lee
Subscribe to:
Posts (Atom)
