copyright © 2006 by mosby, inc. slide 1 chapter 31 sleep apnea figure 31-1. obstructive sleep...
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Copyright © 2006 by Mosby, Inc.Slide 1
Chapter 31Chapter 31 Sleep Apnea Sleep Apnea
Figure 31-1. Obstructive sleep apnea. When the genioglossus muscle fails to Figure 31-1. Obstructive sleep apnea. When the genioglossus muscle fails to oppose the force that tends to collapse the airway passage during inspiration, the oppose the force that tends to collapse the airway passage during inspiration, the
tongue moves into the oropharyngeal area and obstructs the airway.tongue moves into the oropharyngeal area and obstructs the airway.
Copyright © 2006 by Mosby, Inc.Slide 2
Sleep ApneaSleep Apnea
Despite the fact that the clinical manifestations Despite the fact that the clinical manifestations of sleep apnea have be described for centuries, of sleep apnea have be described for centuries, it was not until the early 1980s that it became it was not until the early 1980s that it became acknowledged by the medical communityacknowledged by the medical community
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Stages of Sleep and Characteristic Stages of Sleep and Characteristic Cardiopulmonary PatternsCardiopulmonary Patterns
Two major sleep stages during normal sleepTwo major sleep stages during normal sleep Non–rapid eye movement (non-REM) sleepNon–rapid eye movement (non-REM) sleep
• Quiet or slow-wave sleepQuiet or slow-wave sleep
Rapid eye movement (REM) sleepRapid eye movement (REM) sleep
• Active or dreaming sleepActive or dreaming sleep
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Non-REM SleepNon-REM Sleep
Usually begins immediately after dozing off Usually begins immediately after dozing off
Four stages of non-REM sleep Four stages of non-REM sleep Each progressing into a deeper sleepEach progressing into a deeper sleep
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Stages 1 and 2Stages 1 and 2
The ventilatory rate and tidal volume The ventilatory rate and tidal volume continually increase and decrease—brief continually increase and decrease—brief periods of apnea may occurperiods of apnea may occur
The ECG shows increased slow-wave activity The ECG shows increased slow-wave activity and loss of alpha rhythmand loss of alpha rhythm
Cheyne-Stokes respiration is common in Cheyne-Stokes respiration is common in older adult males, especially at high altitudesolder adult males, especially at high altitudes
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Stages 3 and 4Stages 3 and 4
Ventilation becomes slow and regularVentilation becomes slow and regular
Minute ventilation is commonly 1 to 2 L/min Minute ventilation is commonly 1 to 2 L/min less than during the quiet wakeful stateless than during the quiet wakeful state
Typically the:Typically the: PaCOPaCO22 levels are higher (4-8 mm Hg) levels are higher (4-8 mm Hg)
PaOPaO22 levels are lower (3-10 mm Hg) levels are lower (3-10 mm Hg)
pH is lower (0.03-0.05 unit)pH is lower (0.03-0.05 unit)
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Stages 3 and 4Stages 3 and 4
Normally, non-REM sleep lasts 60 to 90 minutes Normally, non-REM sleep lasts 60 to 90 minutes
Typically, an individual moves in and out of allTypically, an individual moves in and out of all4 stages during non-REM sleep4 stages during non-REM sleep Most of the time is spent in stage 2Most of the time is spent in stage 2
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Stages 3 and 4Stages 3 and 4
An individual may move into REM sleep, at An individual may move into REM sleep, at any time, directly, from any of the 4 non-REM any time, directly, from any of the 4 non-REM sleep stagessleep stages The lighter 1 and 2 stages, however, are the most The lighter 1 and 2 stages, however, are the most
common levels just before REM sleepcommon levels just before REM sleep
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REM SleepREM Sleep
During this period, sudden burst of fast alpha During this period, sudden burst of fast alpha rhythmsrhythms
Ventilatory rate becomes rapid and shallowVentilatory rate becomes rapid and shallow
Sleep-related hypoventilation and apnea are Sleep-related hypoventilation and apnea are commonly seen during this periodcommonly seen during this period
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REM SleepREM Sleep
In normal adults, apneic periods occur as In normal adults, apneic periods occur as often a five times per houroften a five times per hour
These apneic periods may last 15 to 20 These apneic periods may last 15 to 20 seconds with no discernible effectsseconds with no discernible effects
In normal infants:In normal infants: Apneas are shorter—about 10 seconds longApneas are shorter—about 10 seconds long
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REM SleepREM Sleep
A marked reduction occurs in the:A marked reduction occurs in the: Hypoxic ventilatory responseHypoxic ventilatory response
Hypercapnic ventilatory responseHypercapnic ventilatory response
The heart rate becomes irregularThe heart rate becomes irregular
The eyes move rapidly and dreaming occursThe eyes move rapidly and dreaming occurs
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REM SleepREM Sleep
Paralysis of the skeletal muscles occursParalysis of the skeletal muscles occurs ArmsArms
LegsLegs
Intercostal and upper airway musclesIntercostal and upper airway muscles
The diaphragm is NOT affectedThe diaphragm is NOT affected
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Muscle Paralysis during REM Sleep Muscle Paralysis during REM Sleep Affects Ventilation in Two WaysAffects Ventilation in Two Ways
1.1. Paradoxical motion of the rib cageParadoxical motion of the rib cage Causes in tissue to move inward during Causes in tissue to move inward during
inspirationinspiration
This causes the FRC to decreaseThis causes the FRC to decrease
2.2. Loss of muscle tone in the: Loss of muscle tone in the: Posterior muscles of the pharynxPosterior muscles of the pharynx
Genioglossus—protrudes the tongueGenioglossus—protrudes the tongue
Posterior cricoarytenoid—abducts the Posterior cricoarytenoid—abducts the vocal cordsvocal cords
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Loss of Muscle Tone in the Upper Loss of Muscle Tone in the Upper Airway May Result in Airway Airway May Result in Airway
ObstructionObstruction
The negative pharyngeal pressure produced The negative pharyngeal pressure produced when the diaphragm contracts during when the diaphragm contracts during inspiration tends to:inspiration tends to: Bring the vocal cords togetherBring the vocal cords together
Collapse the pharyngeal wallCollapse the pharyngeal wall
Suck the tongue back into the oral pharyngeal Suck the tongue back into the oral pharyngeal cavity cavity
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REM SleepREM Sleep
REM sleep lasts about 5 to 40 secondsREM sleep lasts about 5 to 40 seconds Recurs about every 60 to 90 minutesRecurs about every 60 to 90 minutes
REM sleep lengthens and becomes more REM sleep lengthens and becomes more frequent toward the end of a sleep periodfrequent toward the end of a sleep period
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REM SleepREM Sleep
REM sleep constitutes about 20% to 25% of REM sleep constitutes about 20% to 25% of sleep timesleep time
It is usually more difficult to awaken a subject It is usually more difficult to awaken a subject during REM sleepduring REM sleep
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Types of Sleep Apnea Types of Sleep Apnea
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Types of Sleep ApneaTypes of Sleep Apnea
Apnea—the cessation of breathing for 10 Apnea—the cessation of breathing for 10 seconds or longerseconds or longer
Sleep apnea—more than five episodes of Sleep apnea—more than five episodes of apnea per hour apnea per hour May occur in either or both non-REM and REM May occur in either or both non-REM and REM
sleep, over a 6-hour periodsleep, over a 6-hour period
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Types of Sleep ApneaTypes of Sleep Apnea
Generally, the episodes of apnea are more Generally, the episodes of apnea are more frequent and severe during REM sleep and in frequent and severe during REM sleep and in the supine body positionthe supine body position
Apnea periods last more than 10 seconds Apnea periods last more than 10 seconds and occasionally exceed 100 seconds in and occasionally exceed 100 seconds in lengthlength
In severe cases, as many as 500 apnea In severe cases, as many as 500 apnea periods per night may occurperiods per night may occur
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Types of Sleep ApneaTypes of Sleep Apnea
Sleep apneas may appear in all age groupsSleep apneas may appear in all age groups
In infants, it may play a role in sudden infant In infants, it may play a role in sudden infant death syndrome (SIDS)death syndrome (SIDS)
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Obstructive Sleep ApneaObstructive Sleep Apnea(OSA)(OSA)
Most commonMost common
During periods of OSA, the:During periods of OSA, the: Patient, initially, appears quiet and stillPatient, initially, appears quiet and still
Followed by an increased effort to inhaleFollowed by an increased effort to inhale
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Obstructive Sleep ApneaObstructive Sleep Apnea
OSA often ends only after an intense struggleOSA often ends only after an intense struggle
Snorting is often heard during periods of OSASnorting is often heard during periods of OSA Called “fricative breathing”Called “fricative breathing”
In severe cases, the patient may:In severe cases, the patient may: Suddenly awakenSuddenly awaken
Sit upright in bed, andSit upright in bed, and
Gasp for airGasp for air
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Obstructive Sleep ApneaObstructive Sleep Apnea
OSA patients usually breathe normally during OSA patients usually breathe normally during wakeful periodswakeful periods
OSA seen more often in males than females OSA seen more often in males than females (8:1 ratio)(8:1 ratio)
Between 1% and 4% of male populationBetween 1% and 4% of male population
Commonly seen in obese people with short Commonly seen in obese people with short necksnecks
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Pickwickian SyndromePickwickian Syndrome
Named after a character in Charles Dickens’ Named after a character in Charles Dickens’ The Posthumous Papers of the Pickwick ClubThe Posthumous Papers of the Pickwick Club (1837)(1837) Joe: the fat boy who snored and had excessive Joe: the fat boy who snored and had excessive
daytime sleepinessdaytime sleepiness
Charles Dickens’ description of Joe included Charles Dickens’ description of Joe included many of the classic features now recognized many of the classic features now recognized as OSAas OSA
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Pickwickian SyndromePickwickian Syndrome
However, many patients with OSA are NOT However, many patients with OSA are NOT obese, thus clinical suspicion should not be obese, thus clinical suspicion should not be limited to this grouplimited to this group
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Some Clinical Disorders Some Clinical Disorders Associated with OSAAssociated with OSA
ObesityObesity
Anatomic narrowing of the upper airwayAnatomic narrowing of the upper airway Excessive pharyngeal tissueExcessive pharyngeal tissue
Enlarged tonsils or adenoidsEnlarged tonsils or adenoids
Deviated nasal septumDeviated nasal septum
Laryngeal stenosis Laryngeal stenosis
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Some Clinical Disorders Some Clinical Disorders Associated with OSAAssociated with OSA
Laryngeal webLaryngeal web
Pharyngeal neoplasmsPharyngeal neoplasms
MicrognathiaMicrognathia
MacroglossiaMacroglossia
GoiterGoiter
HypothyroidismHypothyroidism
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Some Clinical Disorders Some Clinical Disorders Associated with OSAAssociated with OSA
Testosterone administrationTestosterone administration
Myotonic dystrophyMyotonic dystrophy
Shy-Drager syndromeShy-Drager syndrome
Down syndromeDown syndrome
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General Clinical Manifestations General Clinical Manifestations Associated with OSAAssociated with OSA
Chronic loud snoringChronic loud snoring
HypertensionHypertension
Morning headachesMorning headaches
Systemic hypertensionSystemic hypertension
NauseaNausea
Dry mouth on awakeningDry mouth on awakening
Intellectual and personality changesIntellectual and personality changes
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General Clinical Manifestations General Clinical Manifestations Associated with OSAAssociated with OSA
DepressionDepression
Sexual impotenceSexual impotence
Nocturnal enuresisNocturnal enuresis
Excessive daytime sleepinessExcessive daytime sleepiness
Car accidents or job malperformance Car accidents or job malperformance related to sleepinessrelated to sleepiness
Pulmonary hypertensionPulmonary hypertension
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Polysomnographic Monitoring Polysomnographic Monitoring FindingsFindings
Apnea-related oxygen desaturationApnea-related oxygen desaturation
More than five obstructive apneas of more More than five obstructive apneas of more than 10 seconds per hour of sleep, and one than 10 seconds per hour of sleep, and one or more of the following:or more of the following: Frequent arousal from the apneasFrequent arousal from the apneas
PVCsPVCs
Profound bradycardia and/or asystoleProfound bradycardia and/or asystole
Shortened sleep latencyShortened sleep latency
Copyright © 2006 by Mosby, Inc.Slide 32
Central Sleep ApneaCentral Sleep Apnea
Occurs when respiratory centers of the Occurs when respiratory centers of the medulla fail to send signals to the respiratory medulla fail to send signals to the respiratory musclesmuscles
Characterized by cessation of airflow at the Characterized by cessation of airflow at the nose and mouth with absence of nose and mouth with absence of diaphragmatic excursionsdiaphragmatic excursions
Associated with cardiovascular, metabolic, or Associated with cardiovascular, metabolic, or central nervous system disorderscentral nervous system disorders
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Central Sleep ApneaCentral Sleep Apnea
Diagnosed when the frequency of apnea Diagnosed when the frequency of apnea episodes is more than 30 in a 6-hour periodepisodes is more than 30 in a 6-hour period
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Clinical Disorders Associated with Clinical Disorders Associated with Central Sleep ApneaCentral Sleep Apnea
Congestive heart failureCongestive heart failure
Metabolic alkalosisMetabolic alkalosis
Idiopathic hypoventilation syndromeIdiopathic hypoventilation syndrome
EncephalitisEncephalitis
Brainstem neoplasmBrainstem neoplasm
Brainstem infarctionBrainstem infarction
Bulbar poliomyelitisBulbar poliomyelitis
Cervical cordotomyCervical cordotomy
Spinal surgerySpinal surgery
HypothyroidismHypothyroidism
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General Noncardiopulmonary Clinical General Noncardiopulmonary Clinical Manifestations Manifestations
Tendency to be of normal weightTendency to be of normal weight
Mild snoringMild snoring
InsomniaInsomnia
Some of the following may also occurSome of the following may also occur Daytime fatigueDaytime fatigue
DepressionDepression
Sexual dysfunctionSexual dysfunction
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Mixed Sleep ApneaMixed Sleep Apnea
Combination of obstructive and central Combination of obstructive and central sleep apneasleep apnea
Usually begins as central sleep apnea, Usually begins as central sleep apnea, followed by:followed by: Ventilatory efforts without airflow—OSAVentilatory efforts without airflow—OSA
Clinically, mixed sleep apnea is usually Clinically, mixed sleep apnea is usually classified and treated as OSAclassified and treated as OSA
Copyright © 2006 by Mosby, Inc.Slide 37
Figure 31-2. Patterns of airflow, respiratory efforts (reflected through the esophageal pressure), Figure 31-2. Patterns of airflow, respiratory efforts (reflected through the esophageal pressure), and arterial oxygen saturation produced by central, obstructive, and mixed apneas.and arterial oxygen saturation produced by central, obstructive, and mixed apneas.
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DiagnosisDiagnosis Begins with a careful historyBegins with a careful history
Noting presence of snoring, sleep disturbance, and Noting presence of snoring, sleep disturbance, and daytime sleepinessdaytime sleepiness
Followed by examination of upper airway and Followed by examination of upper airway and PFT to determine presence of upper airway PFT to determine presence of upper airway obstructionobstruction
Blood evaluationBlood evaluation PolycythemiaPolycythemia
Thyroid functionThyroid function
ABGsABGs
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DiagnosisDiagnosis
Chest radiographChest radiograph
Electrocardiogram to determine:Electrocardiogram to determine: Presence of pulmonary hypertensionPresence of pulmonary hypertension
State of right and left ventricular compensationState of right and left ventricular compensation
Presence of any other cardiopulmonary diseasePresence of any other cardiopulmonary disease
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Diagnosis and Type of ApneaDiagnosis and Type of Apnea
Confirmed with the following:Confirmed with the following: Polysomnographic sleep studies, which Polysomnographic sleep studies, which
include:include: EEG and EOG—to identify sleep stagesEEG and EOG—to identify sleep stages
Airflow monitorAirflow monitor
ECGECG
Monitor of patient’s ventilatory rate and effort Monitor of patient’s ventilatory rate and effort
Oximetry Oximetry
CT scanCT scan
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Overview of the Cardiopulmonary Overview of the Cardiopulmonary Clinical Manifestations Clinical Manifestations
Associated Associated with SLEEP APNEAwith SLEEP APNEA
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Clinical Data Obtained at theClinical Data Obtained at the Patient’s Bedside Patient’s Bedside
CyanosisCyanosis
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Pulmonary Function Study: Pulmonary Function Study: Lung Volume and Capacity Findings Lung Volume and Capacity Findings
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Arterial Blood GasesArterial Blood Gases
Severe Sleep ApneaSevere Sleep Apnea
Chronic ventilatory failure with hypoxemiaChronic ventilatory failure with hypoxemia
pH PapH PaCOCO22 HCO HCO33-- Pa PaOO2 2
Normal Normal (Significantly)(Significantly)
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Figure 4-7. PaO2 and PaCO2 trends during acute ventilatory failure.
Time and Progression of DiseaseTime and Progression of Disease
100100
5050
3030
80
0
PaO2
1010
2020
4040
Alveolar HyperventilationAlveolar Hyperventilation
6060
7070
9090Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
Point at which PaO2 declines enough to stimulate peripheral oxygen receptors
PaCO 2
Chronic Ventilatory Failure Chronic Ventilatory FailureDisease OnsetDisease Onset
Point at which disease becomes severe and patient begins to become fatigued
Point at which disease becomes severe and patient begins to become fatigued
Pa0
2 o
r P
aC0 2
Pa0
2 o
r P
aC0 2
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Acute Ventilatory Changes on Acute Ventilatory Changes on Chronic Ventilatory FailureChronic Ventilatory Failure
Acute alveolar hyperventilation on chronic Acute alveolar hyperventilation on chronic ventilatory failureventilatory failure
Acute ventilatory failure on chronic ventilatory Acute ventilatory failure on chronic ventilatory failure failure
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Oxygenation IndicesOxygenation Indices
QS/QT DO2 VO2 C(a-v)O2
Normal Normal
O2ER SvO2
QS/QT DO2 VO2 C(a-v)O2
Normal Normal
O2ER SvO2
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Hemodynamic Indices Hemodynamic Indices (Severe)(Severe)
CVP CVP RAPRAP PAPA PCWPPCWP
COCO SVSV SVISVI CICI
RVSWIRVSWI LVSWILVSWI PVRPVR SVRSVR
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Radiologic FindingsRadiologic Findings
Chest radiographChest radiograph
Right- or left-sided heart failureRight- or left-sided heart failure
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Cardiac ArrhythmiasCardiac Arrhythmias
Sinus arrhythmiaSinus arrhythmia
Sinus bradycardiaSinus bradycardia
Sinus pausesSinus pauses
Atrioventricular blockAtrioventricular block
Premature ventricular contractionsPremature ventricular contractions
Ventricular tachycardiaVentricular tachycardia
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General Management of General Management of Sleep ApneaSleep Apnea
Weight reductionWeight reduction
Sleep positionSleep position
Oxygen therapyOxygen therapy
Drug therapyDrug therapy REM inhibitorsREM inhibitors
• Protriptyline (Vivactil)Protriptyline (Vivactil)
Acetazolamide (Diamox)Acetazolamide (Diamox)
Protriptyline hydrochlorideProtriptyline hydrochloride
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General Management of General Management of Sleep ApneaSleep Apnea
SurgerySurgery UvulopalatopharyngoplastyUvulopalatopharyngoplasty
Laser-assisted uvulopalatoplastyLaser-assisted uvulopalatoplasty
Nasal surgeryNasal surgery
TracheostomyTracheostomy
Mandibular advancementMandibular advancement
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General Management of General Management of Sleep ApneaSleep Apnea
Mechanical ventilationMechanical ventilation Continuous positive airway pressureContinuous positive airway pressure
Continuous mechanical ventilationContinuous mechanical ventilation
Negative-pressure ventilationNegative-pressure ventilation
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Figure 31-3. Figure 31-3. A, Normal airway. B, Obstructed airway during sleep. C, Nasal CPAP A, Normal airway. B, Obstructed airway during sleep. C, Nasal CPAP generates a positive pressure and holds the airway open during sleep.generates a positive pressure and holds the airway open during sleep.
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General Management of General Management of Sleep ApneaSleep Apnea
Phrenic nerve pacemakerPhrenic nerve pacemaker
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General Management of General Management of Sleep ApneaSleep Apnea
Medical devicesMedical devices Neck collarNeck collar
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Classroom DiscussionClassroom DiscussionCase Study: Case Study:
Obstructive Sleep ApneaObstructive Sleep Apnea