RESPIRATORY FAILURE AND

OBSTRUCTED SLEEP APNOEA ‫توقف التنفس أثناء‬

‫النوم‬

Prof.Dr.Ahmed Hussein Jasim

F.I.B.M.S (RESP)

‫ﻣﺤﺎﺿﺮة ﻣﮭﻤﺔ ﺟﺪاً ب طﻮارى و اﻣﺘﺤﺎن‬

Respiratory failure
The term ‘respiratory failure’ is used when pulmonary gas exchange fails to maintain normal
arterial oxygen and carbon dioxide levels. hyper = excessive
capnia = carbon dioxide CO2

Its classification into types I and II is defined by the absence or presence of hypercapnia (raised
partial pressure

PaCO2 ).
Pathophysiology
( Alveoli ‫ )ھﻮاء واﺻﻞ‬ventilation ‫اﻛﻮ ﺗﮭﻮﯾﺔ‬
‫ ( او ﻋﻜﺲ‬Alveoli ‫ ) دم ﻣﺎ واﺻﻞ‬perfusion ‫و ﻣﺎﻛﻮ‬
)
‫ ﺗﻨﻔﺲ‬/ ‫ﺗﮭﻮﯾﺔ‬ 2- ventilation/perfusion
1-
When disease impairs ventilation of part of a lung (e.g. in asthma or pneumonia), perfusion V/
‫دخول الدم املحمل بثاني أكسيد الكربون‬
3-
Q mismatch of that region results in hypoxic and CO2-laden blood entering the pulmonary
shunt :- atrial or ventricular septal
shunt ‫ ھﻮ ﻧﻔﺴﮭﺎ‬Pathophysiology ‫ ب‬٣ ‫ﻧﻘﻄﺔ‬
veins. shunt ‫ و ﻧﻄﯿﮫ اوﻛﺴﺠﯿﻦ و ﻣﺎ ﯾﺘﺤﺴﻦ ف ﻋﻨﺪه‬hypoxia ‫اذا ﻣﺮﯾﺾ‬
defect , patent ductus arteriosus ,

Increased ventilation of neighbouring regions of normal lung can increase CO2 excretion,
correcting arterial CO2 to normal,
‫اﺧﺘﻼط‬

Admixture of blood from the under-ventilated and normal regions thus results in hypoxia with
normocapnia, which is called ‘type I respiratory failure’.
Arterial hypoxia with hypercapnia (type II respiratory failure) is seen in conditions that cause
generalised, severe ventilation–perfusion mismatch, leaving insufficient normal lung to correct
PaCO2 , or any disease that reduces total ventilation in neuromuscular disorders.
Or due to shunt as in Pulmonary arteriovenous malformations (PAVMs) ArterioVenous
Malformations
 ‫ﺟﺪول ﻣﮭﻢ‬

‫ارﻗﺎم ﺣﻔﻆ‬

‫ارﻗﺎم ﺣﻔﻆ‬

‫ ف راح‬HCO3 ‫ و ﯾﺰﯾﺪ‬response ‫ﻻن ﻛﻠﻰ ﯾﻄﻮل ﯾﻼ ﯾﺴﻮي‬

Acute ‫ و ﻣﺎ ﯾﺘﻐﯿﺮ ب ﺣﺎﻟﺔ‬Chronic ‫ ب ﺣﺎﻟﺔ‬HCO3 ‫ﯾﺮﺗﻔﻊ‬

‫ﺳﻜﻤﺎ‬

: ‫اﺳﺌﻠﺔ ﻋﻠﻰ ھﺎي ﺟﺪول‬

All flowing cause type I respiratory failure except

anaplasia
l s ‫ﻣﺨﺪر‬ ‫ﺿﻌﻒ ﻋﻀﻼت ﺗﻨﻔﺲ‬

Right-to-left shunts :- e.g. opioids (Morphine)

atrial or ventricular septal defect ,
patent ductus arteriosus , …
‫اﻟﺘﮭﺎب اﻟﻔﻘﺮات اﻟﺘﺼﻠﺒﻲ‬

three or more ribs located next to each

other are fractured in two or more places
 Management of acute respiratory failure
Prompt diagnosis and management of the underlying cause is crucial. In type I respiratory
‫معاير‬
failure, oxygen should be administered and titrated to maintain a normal arterial oxygen
saturation (SaO2 ), which will usually relieve hypoxia by increasing the alveolar PO2 in poorly
ventilated lung units. ‫ﻧﺴﺐ ﻣﺌﻮﯾﺔ ﻣﮭﻤﺔ‬
‫ ب ﺗﺤﻔﯿﺰ‬hypoxia ‫ ف راح ﯾﻌﺘﻤﺪ ﻋﻠﻰ‬CO2 ‫ﺑﺲ اذا دﻣﺎغ ﺗﻌﻮد ﻋﻠﻰ‬ Excess CO2 or excess H+ in blood
act directly on respiratory center

Oxygen should be administered to maintain the SaO2 within the target range of 94%–98% for
‫ ف ﻣﺮاﻛﺰ ﺗﻨﻔﺲ ﺑﺪﻣﺎغ راح ﺗﮭﺪء و ﯾﺒﺪي‬hypoxia ‫اذا ﻧﺤﺴﻦ‬
‫ ﯾﺘﺮاﻛﻢ ﺑﺎﻟﺪم و ﯾﺼﯿﺮ دم ﺣﺎﻣﻀﻲ و ﺑﺘﺎﻟﻲ ﯾﻤﻮت ﻣﺮﯾﺾ‬CO2

those with type l respiratory failure , or 88%–92% for those patients at risk of type II respiratory
failure, pending a rapid examination of the respiratory system and measurement of arterial
blood gases.
A small proportion of patients with severe chronic lung disease and type II respiratory failure
‫ﺗﺤﻤﻞ‬
develop abnormal tolerance to raised PaCO2 and may become dependent on hypoxic drive to
breathe. In these patients only, lower concentrations of oxygen (24%–28% by Venturi mask)
should be used to avoid precipitating worsening respiratory depression
1- 2- ‫اﻧﺨﻔﺎض‬
Failure to respond to initial treatment, declining conscious level and worsening respiratory
3- 4- CPAP
acidosis (pH <7.35), PaCO2 >6.6 kPa) on blood gases are all indications that supported
ventilation is required. kPa 6.6 ‫بابثاني أوكسيد كاربون اكثر‬-4 ‫حامضي‬ ‫ الدم‬-3 ‫ وعيه يقل‬-2 ‫ ما يستجيب للعالج‬-1 ‫اذا مريض‬
‫ سي‬CPAP ‫ و نشدله جهاز‬ICU ‫ف راح نطبب مريض لالنعاش‬
 The obstructive sleep apnoea/hypopnoea syndrome pnoea = breathing

Recurrent upper airway obstruction during sleep, sufficient to cause

‫تجزئة النوم والنعاس أثناء النهار‬

sleep fragmentation and daytime sleepiness, is thought to affect 2%

of women and 4% of men aged 30–60 years in populations of
predominantly European descent. ‫ممل‬
.‫السكان من أصل أوروبي في الغالب‬

Daytime sleepiness, especially in monotonous situations, results in a

‫ﯾﻨﺎم وھﻮ ﯾﻘﻮد ﺳﯿﺎرة‬

threefold increased risk of road traffic accidents and a ninefold

increased risk of single-vehicle accidents. Pathophysiology
.‫حوادث مركبة واحدة‬

Sleep apnoea results from recurrent occlusion of the pharynx during

sleep, usually at the level of the soft palate. Inspiration results in -: ( ‫فسلجة ) طبيعي‬
‫ راح ينشل كل عضالت الجسم ب استثناء عضالت القلب و حجاب الحاجز و حركة حجاب حاجز يعتمد على‬REM sleep ‫ملن تدخل ب‬
negative pressure within the pharynx. ‫ و انت نايم على ظهرك راح يرجع فك سفلي ل ورا و ممكن اشوي يقل قطر مجرة هواء بس هاي شئ بسيط ما يأثر على شخص‬PH
‫ يزداد‬CO2 ‫ او هو سمني ف تماماً ينسد مجرة هواء و يبدي‬recessed mandible ً‫بس ب حال شخص عنده مشكلة تشريحية مثال‬
(: ‫و يحفز دماغ و دماغ ينطي حافز قوي للحجاب حاجز و يگعد مريض ) اگعد ولك راح تموت‬

During wakefulness, upper airway dilating muscles, including

palatoglossus and genioglossus, contract actively during inspiration to
preserve airway patency. During sleep, muscle tone declines,
impairing the ability of these muscles to maintain pharyngeal patency.
‫اقلية‬
In a minority of people, a combination of an anatomically narrow
palatopharynx and under-activity of the dilating muscles during sleep
results in inspiratory airway obstruction.
Incomplete obstruction causes turbulent flow, resulting in snoring
(44% of men and 28% of women aged 30–60 snore).
After a series of loud deep breaths that may wake their bed partner,
the patient rapidly returns to sleep, snores and becomes apnoeic once
more. This cycle of apnoea and awakening may repeat itself many
hundreds of times per night and results in severe sleep fragmentation
and secondary variations in blood pressure, which may predispose
over time to cardiovascular disease.
Aetiology
Predisposing factors

Factors that predispose to the obstructive sleep apnoea/hypopnoea

syndrome (OSAHS) include
• male gender ‫راحة‬
‫امراض‬•
‫مشاكل‬
Nasal obstruction or a recessed mandible
• Acromegaly and hypothyroidism also predispose by causing submucosal
‫ب مولود‬

‫وراثة‬

infiltration and narrowing of the upper airway

• Familial
• Alcohol and sedatives predispose to snoring and apnoea by relaxing the upper
CNS ‫خمر و ادوية‬

airway dilating muscles

 ‫مضاعفات‬ ‫ و يتحفز دماغ ف راح يصعد‬CO2 ‫ملن يزداد‬
corticosteroids ‫ادرينالني عنده و‬
‫مطلوب صور‬

As a result of marked sympathetic

activation during apnoea,
‫يقظة‬

sleep-disordered breathing is
1-
associated over time with sustained
hypertension and an increased risk of
2- 3-
co ro n a r y events a n d stro ke.
Associations
4-
have also been 5-described
with insulin resistance, the metabolic
6-
syndrome and type 2 diabetes.
In addition to improving symptoms
and reducing vehicular risk,
treatment of sleep apnoea reduces
sympathetic drive and blood pressure
and may also improve these
associated metabolic disorders.
 Clinical features
Excessive daytime sleepiness is the principal symptom and snoring
ً‫تقريبا‬ ‫عالي‬

is virtually universal.
The patient usually feels that he or she has been asleep all night
‫غير مدرك‬ ‫يتذكر‬ ‫اختناق‬

but wakes unrefreshed, though may recall waking with choking/

‫ﯾﻠﮭﺖ‬

gasping episodes.
‫ﯾﻌﻨﻲ ﯾﻔﺘﺢ ﺷﺒﺎك و ﺑﺲ ﯾﺮﯾﺪ ھﻮء‬
‫تركيز‬ ‫ادراك‬

Difficulty with concentration, impaired cognitive function and work

noct = night uria = urination

performance, depression, irritability and nocturia are other features.

Early morning headaches may be a sign of more severe OSAHS.
Investigations
Overnight studies of breathing, oxygenation and sleep quality are diagnostic
The severity of OSAHS is determined by the number of apnoeas/hypopnoeas per hour of sleep
(apnoea/hypopnoea index, AHI). stop
An apnoea is defined as a 10-second or longer breathing pause and a hypopnoea is a 10-second
or longer 50% reduction in ventilation that results in a 4% drop in arterial oxygen saturation.
An AHI of 5–14 indicates mild OSAHS, 15–30 is moderate and more than 30 is severe.
Management ‫ اسطر مهمة‬3 ‫اول‬

• Overweight
‫عالج السمنة‬
or obese patients should be encouraged to lose weight, and be considered for
bariatric surgery if appropriate. weight loss decreases the AHI and blood pressure, and
improves overall health and quality of life.
• In a minority, relief of nasal obstruction
• the avoidance of alcohol or sedating medication may prevent obstruction.
• Mandibular advancement devices that fit over the teeth and hold the mandible forward,
thus opening the pharynx, are an alternative that is effective in some patients. There is no
evidence that palatal surgery is of benefit.
• The gold standard therapy for the majority of patients is continuous positive airway pressure ‫يثبت‬

(CPAP) delivered by a mask every night to splint the upper airway open. When CPAP is
tolerated, the effect is often dramatic , with relief of somnolence and improved daytime
performance, quality of life and survival. Unfortunately, 30%–50% of patients do not tolerate
CPAP or have poor adherence.

ۚ‫مَن قَتَلَ نَفۡسَۢا بِغَيۡرِ نَفۡسٍ أَوۡ فَسَادٖ فِي ٱألَۡرۡضِ فَكَأَنَّمَا قَتَلَ ٱلنَّاسَ جَمِيعٗا وَمَنۡ أَحۡيَاهَا فَكَأَنَّمَآ أَحۡيَا ٱلنَّاسَ جَمِيعٗا‬