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Sleep apnea-diagnosis and treatment
,The Journal of Gneqency
Medicne.
Prinkd in the USA
Vol. 5. pi. 341-348,1987
0 SLEEP APNEA-DIAGNOSIS AND TREATMENT. Ballard RD, Martin RJ. Western J Med 1986; 145:248-250. As more people use emergency departments as their private physicians, it is useful to review various diseases usually seen by the primary care physician. This is a review of the group of sleep-associated respiratory disorders known as sleep apnea. Four types of sleep apnea are described. In obstructive apnea, the most common form, negative inspiratory pressuresresult in collapse of the oropharyngeal airway. Central apnea is a cessation of airflow for at least 10 seconds, with no respiratory effort. Mixed apnea has characteristics of both obstructive and central apnea. Primary alveolar hypoventilation manifests with both hypoxia and hypercarbia without associated apnea. Diagnostic techniques are discussed with descriptions of common symptoms and clinical features. Daytime laboratory studies are not found to be helpful. In obstructive apnea, low-volume curves may show a characteristic saw-tooth pattern on expiration or a flattening of the inspiratory curve. The diagnostic study of choice is nocturnal sleep polysomnography, monitoring cardiac rhythm, oxygen saturation, and respiratory movement during sleep. Therapy is presented in algorithmic form with life-threatening conditions indicating tracheostomy. Some conditions may be corrected surgically. A variety of medical treatments are described. [Paul C Howes, MD] Editor’s Note: These problems are very difficult to recognize in the emergency department. This history is frequently not perceived as real disease, and the patients are either dis-
v
l
Cqyii
0 1987 Pergamcn Journals Ltd
missed as “hysterics,” or written off as chronic obstructive pulmonary disease.
0 ACUTE CARDIAC EVENTS TEMPORALLY RELATED TO COCAINE ABUSE. Isner JM, Estes NAM, Thompson PD, et al. NEngl JMed 1986; 315:1438-1443. Cocaine has been used by one in ten Americans at least once. One quarter of these persons use this drug on a regular basis. This review of seven cases explores acute cardiac events related to cocaine abuse. Of the sevencases(ages 20 to 37 years), four had myocardial infarctions (one with ventricular tachycardia), two were found dead (one with thrombus in the left anterior descending artery), and one had myocarditis with complete heart block. Cocaine has a direct small-vesselconstriction effect and by blocking norepinephrine uptake, an indirect sympathomimetic stimulation property. Thrombotic coronary artery occlusion associated with cocaine use has been reported by other authors. Yet several of these young patients had clean coronaries unresponsive to ergonovine on angiography. This suggests that cocaine can precipitate cardiac events in individuals with no underlying heart disease. Only one person in this study had levels of cocaine metabolites in the fatal range. Hence, cocaine in any dose can be fatal. Though contaminants were not examined in this study, the authors note that potentially fatal cardiac events are associated with cocaine use. [John Neufeld, MD]
Abstracts-designed to keep readers up to date by providing original abstracts of current literature from all fields relating to emergency medicine- are prepared by the Emergency Medicine Residentsof the University of Chicago Medical Center, Chicago, Illinois; and the Residency in Emergency Medicine in Denver General, St. Anthony’s, St. Joseph’s Porter Hospital and University of Colorado Health Sciences Center, Denver, Colorado, with editorial notes by Suchintu Hakim, MD, University of Chicago Medical Center, and Peter Rosen, MD, Editor-in-chief, JEM. 0736~4679/87 $3.00 + .OO 341
Medicne.
Prinkd in the USA
Vol. 5. pi. 341-348,1987
0 SLEEP APNEA-DIAGNOSIS AND TREATMENT. Ballard RD, Martin RJ. Western J Med 1986; 145:248-250. As more people use emergency departments as their private physicians, it is useful to review various diseases usually seen by the primary care physician. This is a review of the group of sleep-associated respiratory disorders known as sleep apnea. Four types of sleep apnea are described. In obstructive apnea, the most common form, negative inspiratory pressuresresult in collapse of the oropharyngeal airway. Central apnea is a cessation of airflow for at least 10 seconds, with no respiratory effort. Mixed apnea has characteristics of both obstructive and central apnea. Primary alveolar hypoventilation manifests with both hypoxia and hypercarbia without associated apnea. Diagnostic techniques are discussed with descriptions of common symptoms and clinical features. Daytime laboratory studies are not found to be helpful. In obstructive apnea, low-volume curves may show a characteristic saw-tooth pattern on expiration or a flattening of the inspiratory curve. The diagnostic study of choice is nocturnal sleep polysomnography, monitoring cardiac rhythm, oxygen saturation, and respiratory movement during sleep. Therapy is presented in algorithmic form with life-threatening conditions indicating tracheostomy. Some conditions may be corrected surgically. A variety of medical treatments are described. [Paul C Howes, MD] Editor’s Note: These problems are very difficult to recognize in the emergency department. This history is frequently not perceived as real disease, and the patients are either dis-
v
l
Cqyii
0 1987 Pergamcn Journals Ltd
missed as “hysterics,” or written off as chronic obstructive pulmonary disease.
0 ACUTE CARDIAC EVENTS TEMPORALLY RELATED TO COCAINE ABUSE. Isner JM, Estes NAM, Thompson PD, et al. NEngl JMed 1986; 315:1438-1443. Cocaine has been used by one in ten Americans at least once. One quarter of these persons use this drug on a regular basis. This review of seven cases explores acute cardiac events related to cocaine abuse. Of the sevencases(ages 20 to 37 years), four had myocardial infarctions (one with ventricular tachycardia), two were found dead (one with thrombus in the left anterior descending artery), and one had myocarditis with complete heart block. Cocaine has a direct small-vesselconstriction effect and by blocking norepinephrine uptake, an indirect sympathomimetic stimulation property. Thrombotic coronary artery occlusion associated with cocaine use has been reported by other authors. Yet several of these young patients had clean coronaries unresponsive to ergonovine on angiography. This suggests that cocaine can precipitate cardiac events in individuals with no underlying heart disease. Only one person in this study had levels of cocaine metabolites in the fatal range. Hence, cocaine in any dose can be fatal. Though contaminants were not examined in this study, the authors note that potentially fatal cardiac events are associated with cocaine use. [John Neufeld, MD]
Abstracts-designed to keep readers up to date by providing original abstracts of current literature from all fields relating to emergency medicine- are prepared by the Emergency Medicine Residentsof the University of Chicago Medical Center, Chicago, Illinois; and the Residency in Emergency Medicine in Denver General, St. Anthony’s, St. Joseph’s Porter Hospital and University of Colorado Health Sciences Center, Denver, Colorado, with editorial notes by Suchintu Hakim, MD, University of Chicago Medical Center, and Peter Rosen, MD, Editor-in-chief, JEM. 0736~4679/87 $3.00 + .OO 341