1. STRIDOR SLEEP APNOEA
Dr Robin Smith

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

5. Causes of Stridor (children)
Infections
Croup
Epiglottitis
Pseudomembranous croup
Retropharyngeal abscess
Diphtheria
Infectious mononucleosis
Foreign Body
Anaphylaxis / angioneurotic oedema
Other (eg burns)

8. 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

10. Coal Miner who had been trapped in roof-fall 12 years previously

11. Pea in Left Upper Lobe Bronchus

19. William Clark LMB obstruction

20. Investigation of stridor
Laryngoscopy (beware in acute epiglottitis)
Bronchoscopy
Flow volume loop
Chest X ray
Other imaging (CT; thyroid scan)

23. Treatment of laryngeal obstruction
Treat underlying cause eg foreign body removal, anaphylaxis
Mask bag ventilation with high flow O2
Cricothyroidotomy
Tracheostomy

24. Heimlich Manoeuvre Foreign body inhalation (café coronary syndrome)
Rapid upward thrust in epigastrium forces upward movement of diaphragm and forced expiration

27. Treatment of malignant airway obstruction
Tumour removal:
laser; photodynamic therapy; cryotherapy; diathermy; surgical resection
Tumour compression: intraluminal stent
Radiotherapy (external beam; brachytherapy)
(Chemotherapy; Corticosteroids)

31. Anaphylaxis

32. 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

34. Causes of anaphylaxis Foods eg nuts; shellfish
Insect venom (bee, wasp)
Drugs (eg penicillin, aspirin, anaesthetics)
Other eg latex

35. Treatment of anaphylaxis (1)
IM Epinephrine (adrenaline)
IV antihistamine
IV corticosteroid
High flow O2
Nebulised bronchodilators
Endotracheal intubation if necessary

37. Treatment of anaphylaxis (2)
Allergen avoidance (where possible)
Desensitisation (immunotherapy) eg venom
Self-administered epinephrine

39. STILL AWAKE ??

40. 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

41. Obstructive sleep apnoea Sleep apnoea/hypopnoea syndrome

42. 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

44. Obstructive Apnea

45. 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)

47. 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

48. Consequences of Sleep Apnoea
excessive daytime sleepiness
personality change
cognitive / functional impairment
Major impact on daytime function

50. Consequences of Sleep Apnoea
7-fold increase in RTA
Driving simultion – equivalent to being twice legal limit for alcohol

51. 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

52. Obstructive Sleep Apnoea
Diagnosis
Snoring & EDS (raised Epworth score)
Overnight sleep study
- oximetry
- domicillary recording (airflow, oximetry, thoracic/abdominal movement)
- full polysomnography

54. Obstructive Sleep Apnoea
Treatment
Remove underlying cause
CPAP (continuous positive airway pressure)
- most effective therapy

55. Effect of Positive Airway Pressure on
Upper Airway Patency

56. Continuous Positive Airway Pressure (CPAP) therapy

57. 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