Obstructive sleep apnea (OSA) is characterized
by recurrent episodes of upper airway collapse and obstruction during sleep.
These episodes of obstruction are associated with recurrent oxyhemoglobin
desaturations and arousals from sleep. When associated with excessive daytime
sleepiness, the term obstructive sleep apnea syndrome (OSAS) is frequently
used. Despite being a common disease, OSA is underrecognized by most primary
care physicians in the
Medical Care: The treatment of OSA in part depends upon the severity of the sleep-disordered breathing. Mild apneics have a wider variety of options, while moderate to severe apneics should be treated with nasal CPAP.
Conservative measures include weight loss, avoidance of alcohol for 4-6 hours prior to bedtime, and sleeping on the side. These measures should be included in the treatment of all patients with OSA but should be used exclusively only in patients with very mild apnea whose main complaint is snoring.
Nasal Continuous Positive Airway Pressure (CPAP): CPAP is the most effective treatment for OSA and has become the standard of care for OSA. CPAP works by splinting the upper airway, preventing the soft tissues from collapsing. By this mechanism it effectively eliminates the apneas/hypopneas, decreases the arousals and normalizes the oxygen saturation (Figure 6).
Most sleep centers still titrate the CPAP level during a sleep study. This can be done as a second night of study or during the second half of the diagnostic study (this type of study is called split-night polysomnography). There are now CPAP devices that automatically change pressures based upon the presence/absence of OSA. The exact indications for these devices are still being determined.
CPAP has been shown to improve daytime sleepiness, mood and cognitive function in both mild and moderate apneics. Has also been shown to increase quality of life and decrease health care costs.
The most common side effects of CPAP are dry mouth, rhinitis and sinus congestion. These can be effectively treated with humidification and antihistamines and/or nasal steroids.
Unfortunately, compliance is a major problem, with only about 50% of patients using their CPAP on a regular basis, in short term studies. Predictors of compliance include severe daytime sleepiness, baseline AHI and a higher degree of education.
In a study of long-term compliance, 68% of patients were using their CPAP machine at 5 years. Predictors of long-term compliance were baseline AHI and degree of sleepiness. the best predictor, However, was regular use at 3 months of therapy, indicating that physicians must work to increase patient compliance early in the treatment period.
Recent studies indicate that heated humidification, increased patient education and weekly phone calls early in the treatment period can increase compliance.
Some patients require the use of bilevel positive airway pressure (BPAP). In BPAP, there is a higher inspiratory pressure (IPAP) and a lower expiratory pressure (EPAP). In patients with sleep apnea, the levels are set such that the EPAP eliminates apneas and the IPAP eliminates hypopneas. BPAP is generally used in patients who cannot tolerate high CPAP pressures (find it difficult to exhale) or have barotrauma complications (ear infections, bloating). Many laboratories will automatically place a patient on BPAP if the CPAP level needs to be increased above 15 cmH2O. Compliance on BPAP has not been shown to be better than on CPAP.
Dental devices act by moving the tongue or mandible forward. They can be effective for patients with an AHI less than 40/hr. Early evidence suggests there is a patient preference to these devices compared to CPAP. Evidence now suggests appropriate first-line therapy in mild apneics; use as an alternative if patient fails CPAP. Needs more definitive studies of efficacy before can be routinely recommended.
Surgical Care: Surgical correction of the upper airway is no longer considered primary therapy. It is generally recommended only for patients who have failed CPAP or refuse to consider it, or have very mild (AHI less than 10) OSA. Surgeries include:
Uvulopalatopharyngoplasty (UPPP): Resection of the uvula and soft palate. Effective in about 40% of patients, but it is impossible to predict which patients will benefit from the procedure
The new laser-assisted approach should only be used for patients with simple snoring.
Craniofacial Reconstruction: Involves advancement of tongue or maxillomandibular bones. Should be performed only at centers with expertise. Moderate success rates.
Tracheostomy: Provides definitive correction as it bypasses the obstruction. Recommended in very severe OSA, especially if the patient does not tolerate CPAP or has cor pulmonale.
Consultations: All patients with signs and/or symptoms of OSA should be referred to a sleep disorders center for an evaluation by a sleep physician and polysomnography. A comprehensive sleep evaluation is recommended because up to 25% of sleep patients have more than one sleep disorder, many of which are only identified because of the sleep consultation.
Any patient with loud habitual snoring and any other feature of OSA being considered for surgery should be referred for a sleep study prior to surgery. This is important to rule out OSA, as the surgery will likely correct the snoring but may not correct the apnea/hypopneas, which are associated with other morbidities.
Diet: All obese patients should be counseled about the importance of diet and exercise and be referred to a dietitian and/or weight loss program.
ccsasthmatic child coming to er
Asthmatic child coming to the ER:
Albuterol inhaled 2puffs
Beclomethasone inhaled 2 puffs 5 minutes after albuterol
If the patient status improve->move to ward room and keep him there for 3 days.Consider chronic maintanance therapy with
Cromolyn Na 2puffs qid
and Albuterol inhaled.RAST test before discharge.Recomand removal of allergens.
If the patient status is worsening intubate+mechanical ventilation
move to ICU
keep in ICU until improvement+1day
weaning before move
take off iv medication
replace with inhaled medication
keep in ward room for other 3 days.
Tx at discharge:Cromolyn Na
Obtain a CBC and differential to evaluate infectious causes (eg, pneumonia, viral infections such as croup), allergic bronchopulmonary aspergillosis and Chrug-Strauss vasculitis.
Obtain arterial blood gases (ABGs) to assess the severity of the asthma attack and to substantiate the need for more intensive care. ABGs are indicated when the peak expiratory flow rate or FEV1 are less than or equal to 30% of predicted, or the patient shows evidence of fatigue or progressive airways obstruction despite treatment. ABGs are important to identify the severity of the asthma attack. The 4 stages of blood gas progression in status asthmaticus are as follows:
The first stage is characterized by hyperventilation with a normal partial pressure of oxygen (PO2).
The second stage is characterized by hyperventilation accompanied by hypoxemia.
Stage 3 is characterized by the presence of a false normal partial pressure of carbon dioxide (PCO2), which is a very serious sign of fatigue that signals that the patient needs expanded care, such as admission to the intensive care unit, and, probably, intubation with mechanical ventilation.
The last stage is characterized by a low PO2 and a high PCO2, which is an even more dangerous sign that mandates intubation and ventilatory support.
Obtain a chest radiograph looking for pneumonia, pneumothorax, congestive heart failure, and signs of chronic obstructive pulmonary disease (COPD) that would complicate the patient's response to treatment or reduce the patientís baselinespirometry values.
The most important and readily available test to evaluate the severity of an asthma flare is the measurement of peak flow. In most patients with asthma, the decrease in peak flow in terms of percent of predicted corrrelates with changes in spirometry.
Severe asthma exacerbation usually associated with peak expiratory flow (PEF) or FEV1 <50% of predicted. Hospitalization is generally indicated when PEF or FEV1 after treatment is > 50% but <70% of predicted. Hospitalization in the intensive care unit is indicated when PEF or FEV1 is < 50% of predicted
Use pulse oximetry and spirometry to follow the progression of asthma. As the results improve, treatment may be adjusted accordingly.
A drop in the forced expiratory volume in the first second (FEV1) below 25% of the predicted value indicates a severe airway obstruction.
If a portable spirometry unit is not available, a peak expiratory flow rate of 20% or less of the predicted value (ie, usually <100 L/min) suggests severe airflow obstruction and impending respiratory failure.
An FEV1 of greater than 60% of the predicted value may be managed on an outpatient basis, depending on the clinical situation. However, if patient's FEV1 or PEF drops to less than 50% of predicted, admission to the hospital is recommended.
Medical Care: After confirming the diagnosis and
assessing the severity of the asthma flare, direct treatment towards
controlling bronchoconstriction and inflammation.
Bronchodilator treatment with beta-2 agonists
The first line of therapy is bronchodilator treatment with a beta-2 agonist, typically albuterol.
Handheld nebulizer treatments may be given, either continuously (10-15 mg/hour)or by frequent timing (eg, q5-20 min), depending on the severity of the bronchospasm.
The dose of albuterol for intermittent dosing is 0.3-0.5 cc of a 0.5%-formulation mixed with 2.5 cc of normal saline. Many of these preparations are available in a premixed form with a concentration of 0.083%.
Studies have also shown an excellent response to well-supervised use of albuteral via metered-dose inhaler with a chamber. The dose is 4 puffs, repeated at 15-30 minute intervals as needed.
Most patients respond within 1 hour of treatment.
Recently, the US Food and Drug Administration (FDA) approved the use of the R isomer of albuterol known as levalbuterol for treating patients with acute asthma. This isomer has fewer effects on the heart rhythm (ie, tachyarrhythmia) and is associated with fewer incidences of tremors, while having the same or greater clinical bronchodilator effects as racemic albuterol.
The decreased incidence of adverse effects with this new medication may allow physicians to use nebulizer therapy in patients with acute asthma more frequently with less concern over the adverse effects of other bronchodilators (eg, albuterol, metaproterenol).
The dose of levalbuterol is either 0.63-mg vials for children or 1.26-mg vials for adults. These drugs, especially albuterol, are safe to use during pregnancy.
Nonselective beta-2 agonists
Patients whose bronchoconstriction is resistant to continuous handheld nebulizer treatments with traditional beta-2 agonists may be candidates for nonselective beta-2 agonists, such as epinephrine (0.3-0.5 mg) or terbutaline (0.25 mg)given subcutaneously. However, there is no proven advantage of systemic therapy over aerosol therapy with selective beta-2 agents.
Exercise caution in patients with other complicating factors such as congestive heart failure or a history of cardiac arrhythmia.
Intravenous isoproterenol is not recommended in the treatment of asthma because of the risk of myocardial toxicity.
Ipratropium, which comes in premixed vials at 0.2%, can be synergistic with albuterol or other beta-2 agonists.
Use ipratropium every 4-6 hours.
Adults may be less responsive to parasympathetic stimulation than children, because children appear to have more cholinergic receptors.
Monitoring the patient's oxygen saturation is, of course, essential during the initial treatment.
ABGs usually are used to assess hypercapnia during the patientís initial assessment.
Oxygen saturation is then monitored via pulse oximetry throughout the treatment protocol.
Oxygen therapy is essential. It can be given via a nasal canula or mask, although patients with dyspnea often do not like masks.
With the advent of pulse oximetry, oxygen therapy can be easily titrated to maintain the patients's oxygen saturation above 92%, or above 95% in pregnant patients or those with cardiac disease.
Steroids are the most important treatment of status asthmaticus.
The usual dose is daily oral prednisone at 1-2 mg/kg/d.
In the author's experience, methylprednisolone provides excellent efficacy when given intravenously at 1 mg/kg per dose every 6 hours.
Some authorities report that pulse therapy with steroids at a high dose (eg, 10-30 mg/kg/d as a single dose) is associated with a more rapid response and less hospitalization time, with similar adverse effects. This, however, is not standard therapy. The adverse effects of pulse therapy, in the author's experience, are very minimal and comparable to the traditional doses of intravenous steroids. Adverse effects may include hyperglycemia, which usually is reversible once steroid therapy is stopped; increased blood pressure; weight gain; increased striae formation; and hypokalemia. Long-term adverse effects depend on the duration of steroid therapy after the patient leaves the hospital.
Steroid treatment for acute asthma is necessary but has potential adverse effects. Serum glucose needs to be monitored and insulin can be given on a sliding scale if needed. Monitoring of the patient's electrolytes, especially potassium, is essential. Hypokalemia can cause muscle weakness, which may worsen respiratory distress and cause cardiac arrhythmias.
The use of nebulized steroids for treating status asthmaticus is controversial. Recent data in children comparing nebulized budesonide with prednisone suggests that the latter therapy is more effective for treating status asthmaticus.
No good scientific evidence exists to support using nebulized dexamethasone or triamcinolone via a handheld nebulizer.
To the contrary, in the author's experience, more adverse effects, with a cushingoid appearance and irritative bronchospasm, have occurred with these nebulizers.
Intravenous fluids should be given to restore euvolemia.
Discourage routine antibiotic use. Patients should only use antibiotics when they show evidence of infection, such as pneumonia or sinusitis.
Conflicting reports on its efficacy have made aminophylline therapy controversial.
Starting intravenous aminophylline may be reasonable in patients who do not respond to medical treatment with bronchodilators, oxygen, corticosteroids, and IV fluids within 24 hours.
Recent data suggests that aminophylline may have an anti-inflammatory effect in addition to its bronchodilator properties.
The loading dose usually is 5-6 mg/kg, followed by continuous infusion of 0.5-0.9 mg/kg/h.
Physicians must monitor the patientís theophylline level. Traditionally, the level was targeted to the higher end of the local therapeutic range; however, many authorities suggest that the lower portion of the range (ie, >5 but <10) may be preferable if the patient can obtain the benefits of the drug in the lower range.
Adverse effects can include tachyarrhythmia, nausea, seizures, and anxiety.
A 33-year-old woman comes to the local health
clinic because for the last 6 months she has had recurrent urticarial lesions,
which occasionally leave a residual discoloration. She also has had
arthralgias. Sedimentation rate obtained now is 85 mm/h. The procedure most
likely to yield the correct diagnosis in the case would be
A: a battery of wheal-and-flare allergy skin tests
B: measurement of total serum immunoglobulin E (IgE) concentration
C: measurement of C1 esterase inhibitor activity
D: skin biopsy
E: patch testing
The answer is D
Urticaria and angioedema are common disorders, affecting approximately 20 percent of the population. In acute urticarial angioedema, attacks of swelling are of less than 6 weeks' duration; chronic urticarial angioedema is by definition more long-standing. Urticaria usually is pruritic and affects the trunk and proximal extremities. Angioedema is generally less pruritic and affects the hands, feet, genitalia, and face. The woman described in the question has chronic urticaria, which probably is due to a cutaneous necrotizing vasculitis. The clues to the diagnosis are the arthralgias, presence of residual skin discoloration, and elevated sedimentation rate-these would be uncharacteristic of other urticarial diseases. Diagnosis can be confirmed by skin biopsy. Chronic urticaria is rarely of allergic cause; hence, allergy skin tests and measurement of total immunoglobulin E levels are not helpful. Measurement of C1 esterase inhibitor activity is useful in diagnosing hereditary angioedema, a disease not associated with urticaria. Patch tests are used to diagnose contact dermatitis.
What's the effect of oral OCP [ combo pills ] on
What's the effect of ocp patch [ skin patch ] on LDL/HDL/TG/Total chl/glucose
Is there any difference guys ?
According to MKSAp: ACp recommendation.you
can give metronidazole in 1st Trimester also. .Infact there is a quetion in
MKSAp and they advice giving metronidazole
metro is used for treatment of symptomatic bacterial vaginosis because of the strong association with PID as well as with adverse pregnancy outcomes such as preterm delivery. In randomized trials treatment of bacterial vaginosis in pregnancy has shown to reduce the rate of preterm delivery.
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