DIP Episode 510 - Obstructive Sleep Apnea and It’s Many Integrations (Step 1-3)

Welcome. My name is Divine. Welcome to episode 510 of the Divine Intervention Podcasts. Into this podcast we're going to be addressing a mystery topic. Let me introduce this with a Vini at first. So what if they give you a question about the 35 year old male and detail you that this guy snores a lot at work and he has been having a lot of nasal congestion for the last you know one year that has gotten increasingly worse and we're told that he's beginning to have marital issues you know the complaints of you know being able to get it up with his wife and then we're told that his BMI is 32 what should you be thinking about here when I would hope you're saying this is obstructive sleep apnea pretty straightforward so that introduces us to what our topic is going to be today and we're going to be talking about obstructive sleep apnea and its main integrations obstructive sleep apnea and its main integrations it's going to be a short topic but it's going to be a super high-yield topic. The thing is OSA is a concept but there are many peripheral concepts around OSA that our friends at the MBM is love to wafter. In fact you may have noticed this in recent times I've started making a lot of podcasts where yeah there's a central concept we're discussing but there's a lot of peripheral stuff around here that I'm going after.

Again I'm telling you this and I may make a podcast on this in the future but the MBM is these days they're very good on the periphery so I just want to make sure that you're good with those things like if you listen to the sickle cell disease podcast yes it was titled a sickle cell diseases podcast but I mean gee we talked about like a ton of ton of stuff there that was not even related sickle cell disease but that ton of stuff was definitely high yield for the exam. So again obstructive sleep apnea right it's pretty pretty straightforward the symptoms are pretty classic so you're going to see a person in the exam that usually is going to be a guy because obstructive sleep apnea is way more common in men than women is like three x more common in men than women. You're going to see it in people that they smell a lot the rubies that's going to be a big one you're going to see people that have a big neck you're going to see people they can give you these recurring nasal congestion. I'm telling you this the MBM is these days sometimes they're very good on some of these kind of weird presentations or things you may not think of nasal congestion as an OSE presentation on the exams but yeah it is a presentation on the exams.

So you see a person like nasal congestion or a person with big tonsils especially in the pediatric population or you see a person with morning headaches they will try to trick you that it's pseudo-tomo cerebride but no it's not right don't get me wrong pseudo-tomo cerebride can cause morning headaches you know remember these days we call that idiopathic intra-creature hypertension but OSE can also cause morning headaches you see a little of D time fatigue a little of D time sleepiness the continue the the person is getting more depressed more anxious right because if you're not sleeping well I mean I think anyone that has a medical background in the US can probably attest to this pretty firmly but if you're not sleeping well you're going to have a little mood swings you're going to feel pretty good right neurocognitive decline like your memory actually gets worse with less sleep right so these are always they can test obstructive sleep happening and again I want to provide a small foundation then we're going to start making all these integrations right but again remember obstructive sleep happening is super common right many people in the US have OSA and again remember the big thing with OSA is you have these episodic right recurring episodes it just keeps coming back and back right off you know partial or complete error obstruction while you're sleeping so while you sleep your early closes partially or closes completely that's literally obstructive sleep happening right and believe it or not they can give you a question on your exams and say a patient with obstructive sleep apnea they will basically give you a vignette where they're clearly talking about OSA and then they'll ask this patient is at increased risk of which of the following events and then they will put an answer that says murovi equal accidents they will put an answer that says drug abuse they will put

an answer that says a bunch of other stuff you want to pick the answer choice that says murovi equal accident I kid you not I know you may be like divine no there's no way they can ever test this okay I wish all the best right but these people have a high risk of murovi equal accidents because they have a lot of problems with attention during the day they have a lot of problems with memory right they can really stay awake during the day for whatever reason right because they're getting poor sleep at night so the risk of murovi equal accidents is markedly increased and then our friends at the NBM is going to ask you which of the following ABG findings may be seen at night let's say they are doing like a sleep study whatever which of the following could be obtained by ABG during these episodes well I hope you're picking the answer choice of the series of hours that deal with a low p little a2 and a high p c o2 and a p ish that is less than 7.35 right these people are going to be high boxemic so the p little a2 is going to be low the oxygen tension in their their cells their blood vessels going to be low in your order is going to be low they're going to have hypercapnia right at night so the p c o2 is going to be high it's going to be over 45 at night and then you're also going to notice they're going to have a respiratory acidosis or respiratory acidosis so again keep this in mind deep time somalins right or they can even ask you like oh they can give you a question about a person that has had a wasey for a long time and in detail in the question that oh this person over the last three months has been having trouble sleeping and they tell you that the person has like a little bit of jovial venous pressure you can hear a loud p2 heart sound and they tell you that you don't hear any pulmonary crackles you see something like this that person has developed pulmonary hypert

ension right because that chronic hypoxia especially at night can cause pulmonary visual constriction that's going to make it that can cause pulmonary hypertension that's going to make it hard for the right heart to empty of blood so you're going to have a right heart failure basically remember many times on the usml if they're giving you like a distinct right heart failure question in the absence of left heart left heart failure you're going to see the person having heart failure symptoms you're going to see a loud p2 or remember a loud p2 means that oh man the boney valve when it closes is really loud that tells you there's pulmonary hypertension they may say loud p2 allowed s2 right and you're going to notice that these people they're going to have jvd they're going to have the classic heart failure symptoms but you will not hear crackles in the lungs that's very high-yout you will not hear crackles in the lungs when you see that combination honestly you really want to think about a person having a right heart failure because remember right heart failure you can get it from like a osc and what not but remember the most one cause of right heart failure is left heart failure right but again a nice way you can differentiate left heart failure as the cause of a person's right heart failure from many of the causes of right heart failure like osc corpomonali and things like that is that many times when people have left heart failure they're going to have crackles in the lungs on a scutition of the chest but people because the problem is distal to the pulmonary veins but when a person has pulmonary hypertension or corpomonalio osc the problem is primarily like in the pulmonary vessels like pulmonary arteries pulmonary capillaries right so ultimately that person may not have crackles although one thing you should actually keep in mind is believe it or not people that have

osc they have a high risk of heart failure they have a high risk of live ventricular dysfunction so what makes that out of the right heart failure they may actually over time progress to having like just full blown left and right heart failure well why me that happened well think about it if a person is police like if a person is a it's just almost give up my answer if a person has osc that chronic hypoxia what do you think it does to ipo production well it's going to make you raise your ipo and if you raise your ipo what's it going to do to your ribloxel count well that's going to jack it up right so it's not going to have a high ipo and they're going to have a high you know red cell count high hematocrate high hemoglobin they're going to have poli-cythemia they're going to have poli-cythemia they're going to have poli-cythemia that poli-cythemia makes their blood more viscous if your blood is more viscous is it going to flow fast or is it going to flow slow i hope you're saying oh divine it's going to flow slow if your blood is flowing slow then your heart has to work harder to push that slow blood through your vessels so guess what slow flowing blood very viscous blood is like literally putting a person putting putting normally when we give patients fluids we put like the most saline inside their vessels right but if we're giving is almost like putting like grease like oil in the person's vessel that's not going to be a good good thing right so that's going to jack up the afterload because the blood is slow flowing so i'm going to jack up the afterload that's going to over time cause a pressure overload a chronic pressure overload on the person's left ventricle and that's going to lead to the stolic dysfunction over over time so just going to keep that at the back of your the back of your mind okay so that's the mechanism behind actually that's the mechanism behind

many things that's the mechanism behind the left heart failure that stolic dysfunction they can get uh and that's also that's the mechanism behind uh these people having poli-cythemia we've kind of talked about that already right there's so many things they can test and that's also the mechanism behind them having secondary hypertension right because again if your blood is flowing slow if your blood is flowing slow again that blood is very viscous right very very viscous it's almost like to move it along blood has to just keep generating all this force force force on the walls of your blood vessels that's going to cause hyper tension again i'm sure you never thought that wow oh i say there are so many ways they can go with this uh absolutely right there are so many ways they can go with this and again you're gonna see me i'm gonna keep drilling drilling drilling on pathophets why because the usm al is again especially over the last few months um have going very big on pathophets especially in this onkey generation we live in right they're trying to see if you can make integrations if you can make connections if you understand the pathophets behind what's going on right so again kind of keep all these things at the back of your mind right they can literally give you so many arrow questions with us a right again we've talked about the major hours your period will be down right your psu 2 is going to be up your pH is going to be down because they have a respiratory acidosis um and you know they can give you after load as an arrow your after load is going to go up they can give you epo as an arrow epo is going to go up i'm just using this as a summary of what we've talked about already they can give you hematocrit as an arrow hematocrit is going to go up uh we've talked about all these things right um and i know when you can actually ask about like by your cardiovascular

demand in my cardiovascular demand is going to jack up if you have chronic USA right because again if your heart is working so hard to move to generate force to move that more viscous blood because you develop a list of themia then uh it's going to be using up more oxygen so your my cardiovascular demand is going to go up okay your cardiovascular demand is going to go up now uh friends at the mdm is one question they can ask you about USA's uh which of the following uh physical exam uh uh screening tools can be used you know to visit a screener person for USA don't forget the stop banged questionnaire the stop banged questionnaire right it's a screening tool it's not a diagnostic tool right remember screening test why do we choose screening tests we choose screening tests because one of them is very sensitive right one of them to have a very high negative predictive value hmm that's by your stats right there right so the stop banged questionnaire is a screening tool for USA that's the key one you want to remember for you exactly right so the stop banged questionnaire is very sensitive right obviously if it's sensitive it has a very high negative predictive value right yeah i can already imagine them asking oh uh stop banged questionnaire use for blah blah blah blah to screen a person for USA because before they have surgery or whatever and then they'll see which of the following is the most likely reasoning behind uh picking this uh as the screening test for whatever right and they can put an answer that says high sensitivity they can put an answer that says high negative predictive value right just gonna keep that at the back of your mind again the USME Ls are all about integration integration integration okay now what is the biggest risk factor for USA remember our friends at the MBM is they love your risk factors what is the biggest risk factor for USA the biggest

risk factor for USA is excess body weight okay i'm gonna say that again the biggest risk factor for obstructive sleep apnea is excess body weight is excess body weight is excess body weight okay is excess body weight and remember there are many other risk factors right so they don't put obesity as an answer excess body weight as an answer don't forget that they're certain ethnicities that tend to have a lot of uh USA right like African Americans in fact they love to give USA to African American kids on the USMEL exams right Mexican Americans high risk of USA right and also if you think of people that have like a big like like short thick necks large neck circumference that can certainly increase the person's risk of USA right if you have a crowded firings they love to throw these in the pediatric population on the exam right so like you have like a low line uvula you have a low line soft palate right you have a big tongue macroglossia remember macroglossia can be found in many disorders right like you can find it in people that have um uh Beckwith Whitman syndrome uh you can find it in people that have congenital hypothyroidism that can raise their risk of obstructive sleep apnea right or if people have to have like enlarged tonsils in large adnoids that can raise their risk of USA of USA right so again i've talked about how you screen for USA you're gonna screen with a stop bank questionnaire right you're usually gonna ask the patient questions you're gonna see the classic findings snoring yada yada yada right but then what did they ask you um what do you use to diagnose USA we're gonna do a polysomnography right you're gonna do a sleep study you're gonna do perform polysomnography many times while people are getting a polysomnography we get an EEG at the same time uh because one is he kind of helps us he it almost makes the test a little better but we're not gonna g

o into much detail on that and basically whenever you do a polysomnogram what are the measuring or they're measuring something called the apnea hipopnea index okay the apnea hypopnea index and basically it just measures how many apnea or hypopnea events you have per hour if you have more than five per hour you have USA you literally have more than five per hour you have obstructive sleep apnea so again please don't forget you're gonna screen for USA you're gonna screen for USA with the stop bank questionnaire you're gonna diagnose USA with a polysomnogram many times it's gonna be done in combination with an EEG right well let's say hmm you're testing a person for USA and you notice that man this is during the day right you're you're in your office during the day are you measure are you getting a DJ you notice that man this person's PECL2 is more than 45 and this is during the day this is during what the day that person has what obesity hyperventilation syndrome okay because usually people that have obstructive sleep apnea on the USMLE's they're gonna have the high PSU2 only at night they're gonna have it not churnally at night hmm but if you see a person that is obese they have the classic sleep apnea symptoms and you notice that they have hypercapnea defined as a PSU2 over 45 during the day your job is done that patient has obesity hyperventilation syndrome okay obesity hyperventilation syndrome and again just to bring in just another quick thing here again I said that the stop bank questionnaire high sensitivity high negative predictive value how we biostatistically categorize polysomnography in the diagnosis of USA I hope you're saying hmm divine polysomnography must have a very high specificity was have a very high positive predictive value for USA okay again that's the thing about my podcast don't be don't feel like you should only listen to them because you know

the topic now listen to them because you're not just learn the topic but you learn a bunch of other stuff that's one thing I try to achieve with many of these podcasts okay so keep that at the back of your mind you see a person USA symptoms during the day they have D time hypercapnea PSU2 over 45 that person has obesity hyperventilation syndrome okay so how in the world do we manage obstructously about me how well here's the way we're gonna break this down we're gonna break this down as first line second line and third line okay I'm gonna break it down from an MBME fashion okay so please what I'm about to say now may not match up perfectly with what you see you'll be love it cue banks or you'll be love it on key decks that's fine just follow what I'm teaching you for your exams gonna give you a few scenarios I'm gonna tell you some things if you follow these rules you're gonna be in good shape so how do you manage obstructously partner your exams the first line treatment for USA is a lifestyle changes and nocturnal CPAP gonna say it again lifestyle changes and nocturnal CPAP that's the first line treatment what are these lifestyle chains before we talk about CPAP well the lifestyle changes is losing weight that's the big one like literally your risk some people can literally cure their USA by just dropping about 10% of their weight so let's say you're a 200 pound person if you lose like 20 pounds your risk of OSE is gonna drop significantly because by losing all that fat you're gonna be losing some of the fat along your early that's gonna make your early little bigger it's gonna make your early little bigger and sometimes on the US one kind of weird thing they do because they know that everyone can intuit that yeah weight loss is probably something we should do every now and then you won't see weight losses and answer so you want to kind of keep some other things in

mind right some other lifestyle changes tell these people don't drink alcohol don't take anything that has sedated in properties three to four hours before bedtime right because those alcohol these sedatives they pretty much make your early dilators lose their muscle tone if they lose their muscle tone they're not gonna be able to keep your early open right and another thing that certainly helps is also sleeping in the lateral position this is actually a very high yield one to know for your exams sleeping in what the lateral position when you're sleeping in the lateral position it makes it a lot harder for your earliest two collapse means it a lot harder for your earliest two collapse now I say that in addition to the lifestyle changes you want to do CPAP right no channel CPAP so what does no channel mean means you're doing it at night doing it at night because basically it just blows air down your early and almost like a balloon is like blowing air and inflating your early like a balloon right so it's basically splitting open your your early right so what is it gonna do to your intra-loving early pressures gonna raise your intra-loving early pressure what is it gonna do to your functional residual capacity hmm I wonder it's going to increase your functional residual capacity because you're literally pumping more into the lungs what is it gonna do to your peep it's going to raise your peep right because it's little bit more air inside your lungs right and again they can make this again an improving morbidity and mortality question in a person that has OSA right people that you see PAP in the management of OSA right is going to reduce the risk of hypertension is going to reduce the risk of many bad things right many many bad things so it's kind of helpful so again it's one of these things that actually does improve symptoms in people that have OSA okay keep that in min

d please keep that in mind right so if they ask you what's the intervention that has been shown to significantly improve symptoms in OSA it's going to be no channel CPAP okay or you can see lower the risk they very likely will not test it as a survival thing but it will test it more as like or reduce the risk of hypertension in OSA where it's going to be the use of CPAP right just gonna keep that at the back of your at the back of your mind right now here's the thing if lifestyle plus CPAP does not work unless the person just really does in one CPAP what's going to be a second line treatment second line treatment is going to be by PAP right by level positive airway pressure pretty much works the same the same way for some people is just a little more comfortable okay now let's say a person CPAP has not worked by PAP has not worked all these lifestyle changes nothing has worked what are you going to do well your third line treatment is going to be surgery okay your third line treatment is going to be surgery and what is this surgery called on the USML is it's called a Yuvalo Palato Faringo Plasty Yuvalo Palato Faringo Plasty Yuvalo Palato Faringo Plasty I'm gonna spell that it's going to be UVULOPALATOPHARIYNGO PLASTY Yuvalo Palato Faringo Plasty right basically it's like surgery to essentially open up your airway now one thing I'm gonna say on your exams they love to test this especially with the pediatric population you see a kid that has OSA and you know the child is not obese nothing but the child has pretty severe OSA don't forget that you may actually be able to do a tons electomy one add an I Dectomy for those kids that's one situation where you may actually skip all these steps and just say you know what I'm just gonna resec these tonsils resec these uh admoids resec these tonsils resec these admoids now one thing that's super high yield to know they can say um

it can give you a question about a person that has been diagnosed with OSA has just had the Yuvalo Palato Faringo Plasty and then they see which of the following follow-up measures uh which of the following follow-up uh testing should be performed you want to do a police amnogram okay I want to do a police amnogram right so after a person has had surgery for OSA please make sure your USML is do a police amnogram you just want to see the effect did this thing this procedure that I did actually work the USML is they love this weird thing where there's a condition where you treat and then you do like a almost like a test of cure uh in a sense they don't have to do this with OB-GYN questions especially like pregnant women that have uh the diagnosis of the UTI you're gonna treat that pregnant woman right because UTI is in pregnancy or really bad uh you're gonna treat that woman but after they're gonna do another urine contrast of the test of cure I just figured out throwing that tidbit for for you guys so um just real quick if you're interested in any of my review courses um I have a bunch of courses that in next week for step one to step three on Thursday next week I have a testing and strategies class for step one to three is two and a half hours long on Friday I have a bio stats class that's a four-hour class um and Saturday I have a five-hour social sciences ethics quality improvement professionalism healthcare systems class many people have taken these classes they found them to be profoundly helpful and then the week after that from Monday to Friday I have the 20-hour step two step three course and then the first week in March I have the um 25-hour step one class again these courses they're not lectures they're expecting lectures wrong course for you but they're all clinical scenarios they're all exam style questions and again if you like the way I explain pathophysi

ology and make a lot of integrations those courses are perfectly for you the evening they're gonna be over zoom tons of people have taken them found them to be profoundly helpful and then I have this podcast on apple google and Spotify have a youtube channel you can check out and then I have also have a 50-hour step two step three class but that's gonna be held only once this year I want to really invest in everyone that attends it it's like 500 multiple choice questions you're pretty much going through like a mini-cube bank that is MDME style over the course of 10 days super high-yield class um I'm telling you to put that attended the last quarter it's defunded to be super super helpful and I think you will as well so just should be an email through the website yeah very limited spots for that one so if you're interested should be an email I can give you some more information and then I have another website called a divine intervention life lessons.com basically every week I post two podcasts where from a political perspective I address a life lesson I'm pretty sure I have like 250 episodes on there there's actually an Apple podcast associated with that called the divine intervention life lessons podcast and then finally I also offer one or one tutoring for all the USMLE exams or the complex exams preclinical medical exams 30th of exams and I offer help with ERAS applications and mock interviews and things of that nature so if you're interested in any of these things just should be an email I can give you some more information so thank you for listening to this podcast again super high-yield stuff god bless you bye for now see you in a piece of 5-1-1

Males are three times more common than females.

JVD and a loud P2 sound, but no lung crackles.

The STOP-BANG questionnaire.

Obesity Hypoventilation Syndrome (OHS).

Lifestyle changes (weight loss, avoiding sedatives/alcohol) combined with nocturnal CPAP.

BiPAP (Bilevel Positive Airway Pressure).

Polysomnography (Sleep Study).

Apnea-Hypopnea Index (AHI); >5 events/hour indicates OSA.

Weight loss, avoiding alcohol, and sleeping in the lateral position.

Uvulopalatopharyngoplasty (UPPP).

Respiratory acidosis (Low pH, High PaCO₂, Low PaO₂).

Hypoxia $\rightarrow$ Polycythemia $\rightarrow$ Increased blood viscosity $\rightarrow$ Increased afterload on the heart $\rightarrow$ Left ventricular strain/failure.

Polysomnography (Sleep Study).

Apnea-Hypopnea Index (AHI); >5 events/hour indicates OSA.

Weight loss, avoiding alcohol, and sleeping in the lateral position.

Uvulopalatopharyngoplasty (UPPP).

Respiratory acidosis (Low pH, High PaCO₂, Low PaO₂).

Hypoxia $\rightarrow$ Polycythemia $\rightarrow$ Increased blood viscosity $\rightarrow$ Increased afterload on the heart $\rightarrow$ Left ventricular strain/failure.