Complications of Sleep Apnea — MCQs

10 questions

A 42-year-old obese male presented with disturbed sleep and daytime somnolence. All of the following are correct except?

The sleep apnea syndrome is defined as -

Patient with obstructive sleep apnea-hypopnea syndrome is unlikely to have which of the following?

A 28-year-old man presents to the emergency department with a severe headache, palpitations, excessive sweating, chest pain, visual disturbances, dyspnea, paresthesias, constipation, and a sense of impending doom, which occur primarily at night, over a period of two weeks. His blood pressure is 130/80 mmHg while supine and 90/60 mmHg while standing, and his blood sugar is 240 mg/dL. Which of the following is the most likely diagnosis?

A 47-year-old man comes to the physician for a follow-up examination. He feels well. He was diagnosed with hypertension 3 months ago. He has smoked one pack of cigarettes daily for 20 years but quit 4 years ago. He occasionally drinks alcohol on the weekends. He walks for 45 minutes daily and eats three meals per day. His current diet consists mostly of canned tuna and cured meats. He started eating whole-wheat bread after he was diagnosed with hypertension. He drinks 1 to 2 cups of coffee daily. His mother has a history of hyperthyroidism. Current medications include hydrochlorothiazide and a multivitamin pill every night before sleeping. His wife told him that he sometimes snores at night, but he reports that he usually sleeps well and feels refreshed in the mornings. His pulse is 80/min, respirations are 18/min, and blood pressure is 148/86 mm Hg. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

All are absolute indications of tonsillectomy except which of the following?

A 3-week-old infant presents with a cough and sore throat. The mother reports that the infant develops a paroxysm of cough followed by apnea. The total leucocyte count is >50,000 cells/μL. Based on these symptoms, which of the following drugs is the most appropriate treatment for this patient?

In pseudocholinesterase deficiency, which drug should be used cautiously?

What is the standard duration used to define apnea of prematurity?

Q10

All of the following are correct about the image shown except:

Complications of Sleep Apnea Indian Medical PG Practice Questions and MCQs

Question 1: A 42-year-old obese male presented with disturbed sleep and daytime somnolence. All of the following are correct except?

A. Apnea with hypoxia
B. Pharyngeal muscle contraction increases OSA (Correct Answer)
C. Apnea with awakening
D. Apnea with fall in saturation

Explanation: ***Pharyngeal muscle contraction increases OSA*** - Obstructive sleep apnea (OSA) is caused by the collapse of the upper airway due to the **relaxation** and consequent loss of tone in the **pharyngeal muscles** during sleep, not by their contraction [1]. - While muscle contraction normally helps maintain airway patency, **reduced muscle activity** allows the airway to narrow or collapse. *Apnea with hypoxia* - **Apnea**, defined as a cessation of breathing for at least 10 seconds, often leads to periods of **hypoxia** (decreased blood oxygen levels) due to insufficient gas exchange [1]. - This **recurrent hypoxia** is a hallmark of OSA and contributes to its cardiovascular and neurological consequences. *Apnea with awakening* - Following an apneic episode, the body's protective reflex often causes a brief **arousal or awakening** from sleep to restore airway patency and ventilation [2]. - These frequent **micro-awakenings** are a primary reason for the disturbed sleep and subsequent daytime somnolence experienced by patients with OSA [2]. *Apnea with fall in saturation* - During an apneic event, the lack of airflow into the lungs results in a **decrease in oxygen saturation (SpO2)**, which is a key diagnostic criterion for OSA severity [2]. - This **desaturation** is directly linked to the duration and frequency of apneic episodes.

Question 2: The sleep apnea syndrome is defined as -

A. Apnea-Hypopnea Index (AHI) ≥ 5/hour (Correct Answer)
B. Apnea-Hypopnea Index (AHI) ≥ 10/hour
C. Apnea-Hypopnea Index (AHI) ≥ 30/hour
D. Apnea-Hypopnea Index (AHI) ≥ 15/hour

Explanation: ***Apnea-Hypopnea Index (AHI) ≥ 5/hour*** - The definition of **sleep apnea syndrome** generally requires an **AHI of 5 or more events per hour**, often accompanied by symptoms like excessive daytime sleepiness or cardiovascular complications [1]. - This threshold identifies individuals with clinically significant sleep-disordered breathing that warrants further evaluation and potential treatment [1]. *Apnea-Hypopnea Index (AHI) ≥ 10/hour* - While an AHI of 10/hour indicates sleep apnea, it is a higher severity criterion and does not represent the **minimum threshold** for defining the syndrome [1]. - Patients with an AHI between 5 and 10 also have sleep apnea and can experience significant symptoms. *Apnea-Hypopnea Index (AHI) ≥ 30/hour* - An AHI of 30/hour or more signifies **severe sleep apnea**, which requires aggressive management. - This is far above the **general diagnostic threshold** for sleep apnea syndrome. *Apnea-Hypopnea Index (AHI) ≥ 15/hour* - An AHI of 15/hour is typically classified as **moderate sleep apnea**. - This value is higher than the **lowest AHI threshold** used to define the presence of sleep apnea syndrome.

Question 3: Patient with obstructive sleep apnea-hypopnea syndrome is unlikely to have which of the following?

A. Absence of snoring
B. Bradycardia during sleep episodes (Correct Answer)
C. Normal oxygen saturation throughout sleep
D. Decreased neck circumference

Explanation: ***Bradycardia during sleep episodes*** - While patients with **obstructive sleep apnea (OSA)** commonly experience various cardiovascular complications, **bradycardia** during apneic episodes is *less typical* than **tachycardia**. - The body's initial response to apnea and **hypoxia** usually involves a sympathetic surge leading to tachycardia upon arousal, followed by bradycardia if the apnea is prolonged. However, the dominant pattern is often elevated heart rate variability. *Normal oxygen saturation throughout sleep* - Patients with OSA frequently experience intermittent **hypoxemia** due to repeated apneas and hypopneas, leading to significant drops in **oxygen saturation** [1]. - A *normal oxygen saturation throughout sleep* would effectively rule out significant OSA, as desaturation is a hallmark of the condition [1]. *Absence of snoring* - **Snoring** is a classic and highly prevalent symptom of OSA, caused by the vibration of upper airway tissues as air struggles to pass through an obstructed pharynx. - While not all snorers have OSA, the *absence of snoring* makes OSA less likely, although it can occur in some subsets of patients, particularly those with central sleep apnea or certain anatomical variations. *Decreased neck circumference* - A **large neck circumference** is a well-established anatomical risk factor for OSA, indicating increased soft tissue in the neck that can contribute to upper airway collapse. - A *decreased neck circumference* would generally be protective against OSA, making it less likely for an individual to have the condition.

Question 4: A 28-year-old man presents to the emergency department with a severe headache, palpitations, excessive sweating, chest pain, visual disturbances, dyspnea, paresthesias, constipation, and a sense of impending doom, which occur primarily at night, over a period of two weeks. His blood pressure is 130/80 mmHg while supine and 90/60 mmHg while standing, and his blood sugar is 240 mg/dL. Which of the following is the most likely diagnosis?

A. Familial dysautonomia syndrome
B. Opiate withdrawal syndrome
C. Pheochromocytoma (Correct Answer)
D. Alcohol withdrawal syndrome

Explanation: **Pheochromocytoma** - This patient presents with a classic triad of symptoms: **headaches**, **sweating**, and **palpitations**, often referred to as the "PHE" symptoms, which are highly suggestive of **pheochromocytoma**. - Additional findings such as **orthostatic hypotension**, **hyperglycemia**, and nocturnal episodes further support the diagnosis of a **catecholamine-secreting tumor**. *Familial dysautonomia syndrome* - This is a rare genetic disorder affecting the **autonomic nervous system**, primarily seen in individuals of Ashkenazi Jewish descent, and typically presents in infancy or early childhood. - While it involves autonomic dysfunction, it is not characterized by paroxysmal episodes of severe hypertension and acute symptoms like those described, nor by a new onset of these symptoms in a 28-year-old. *Opiate withdrawal syndrome* - Symptoms of opiate withdrawal include **muscle aches**, **nausea**, **vomiting**, **diarrhea**, **dilated pupils**, and **piloerection**, often accompanied by psychological distress. - The presented symptoms, particularly the severe headache, chest pain, visual disturbances, and significant hyperglycemia, are not typical features of opiate withdrawal. *Alcohol withdrawal syndrome* - This syndrome can cause **tremors**, **autonomic hyperactivity** (e.g., sweating, elevated heart rate, hypertension), **anxiety**, and in severe cases, **seizures** or **delirium tremens**. - While some autonomic symptoms overlap, the highly specific triad of severe headache, palpitations, and profuse sweating, along with significant hyperglycemia and orthostatic hypotension, points away from alcohol withdrawal as the primary diagnosis.

Question 5: A 47-year-old man comes to the physician for a follow-up examination. He feels well. He was diagnosed with hypertension 3 months ago. He has smoked one pack of cigarettes daily for 20 years but quit 4 years ago. He occasionally drinks alcohol on the weekends. He walks for 45 minutes daily and eats three meals per day. His current diet consists mostly of canned tuna and cured meats. He started eating whole-wheat bread after he was diagnosed with hypertension. He drinks 1 to 2 cups of coffee daily. His mother has a history of hyperthyroidism. Current medications include hydrochlorothiazide and a multivitamin pill every night before sleeping. His wife told him that he sometimes snores at night, but he reports that he usually sleeps well and feels refreshed in the mornings. His pulse is 80/min, respirations are 18/min, and blood pressure is 148/86 mm Hg. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?

A. Counsel on dietary modification (Correct Answer)
B. Conduct a sleep study
C. Add metoprolol
D. Start a structured exercise program
E. Measure thyroid-stimulating hormone levels

Explanation: ### Counsel on dietary modification - This patient's diet of **canned tuna** and **cured meats** is likely very high in sodium, contributing to his uncontrolled hypertension despite being on hydrochlorothiazide. [2] - Counseling him on a **low-sodium diet** patterned after the **DASH diet** (Dietary Approaches to Stop Hypertension) is the most appropriate next step to improve blood pressure control. [1] ### Conduct a sleep study - While snoring can be a sign of **sleep apnea**, the patient reports sleeping well and feeling refreshed, making sleep apnea less likely to be the primary concern for his hypertension at this point. - Addressing his likely high-sodium diet has a more direct and immediate impact on his uncontrolled blood pressure. [2] ### Add metoprolol - Adding a second antihypertensive medication (like metoprolol) is an option if **lifestyle modifications** and the current diuretic are insufficient. However, addressing preventable dietary factors first is key. - It's important to optimize non-pharmacological interventions before escalating drug therapy, especially when a clear modifiable risk factor like diet is present. [2] ### Start a structured exercise program - The patient already walks for **45 minutes daily**, which meets recommended exercise guidelines (moderate intensity for at least 30 minutes most days of the week). - While an exercise program is generally beneficial, his current exercise regimen is adequate, and dietary sodium is a more prominent and unaddressed factor for his uncontrolled hypertension. [2] ### Measure thyroid-stimulating hormone levels - Although his mother has a history of **hyperthyroidism**, this patient presents with no symptoms suggestive of thyroid dysfunction, such as weight changes, tremors, or significant fatigue. - His controlled pulse and feeling well do not indicate an immediate need for thyroid function testing as a primary cause for his hypertension.

Question 6: All are absolute indications of tonsillectomy except which of the following?

A. Peritonsillar abscess
B. Tonsils causing obstructive sleep apnea
C. Chronic tonsillitis (Correct Answer)
D. Suspicious malignancy

Explanation: ***Chronic tonsillitis*** - **Chronic tonsillitis** is a **relative indication** for tonsillectomy, not an **absolute indication**. - It becomes an indication based on frequency criteria (e.g., Paradise criteria: ≥7 episodes in 1 year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years). - Absolute indications involve conditions requiring urgent surgical intervention. *Suspicious malignancy* - Suspected **malignancy** is an **absolute indication** for tonsillectomy to obtain tissue for histopathological diagnosis. - Early diagnosis and treatment of tonsillar malignancy is critical for patient outcomes. *Peritonsillar abscess* - **Peritonsillar abscess** (quinsy) is typically managed with needle aspiration or incision & drainage plus antibiotics, NOT immediate tonsillectomy. - Acute tonsillectomy during active infection ("hot tonsillectomy") is generally **contraindicated** due to increased bleeding risk and surgical complications. - **Recurrent peritonsillar abscess** may warrant **interval tonsillectomy** (4-6 weeks after resolution) as a **relative indication**, not an absolute one. *Tonsils causing obstructive sleep apnea* - **Obstructive sleep apnea (OSA)** caused by tonsillar hypertrophy is an **absolute indication** for tonsillectomy, particularly in children. - Untreated OSA can lead to serious complications including failure to thrive, cor pulmonale, developmental delays, and neurocognitive problems.

Question 7: A 3-week-old infant presents with a cough and sore throat. The mother reports that the infant develops a paroxysm of cough followed by apnea. The total leucocyte count is >50,000 cells/μL. Based on these symptoms, which of the following drugs is the most appropriate treatment for this patient?

A. Azithromycin (Correct Answer)
B. Amoxicillin
C. Cotrimoxazole
D. Erythromycin

Explanation: ***Azithromycin*** - This infant's symptoms are highly suggestive of **pertussis** (whooping cough), characterized by **paroxysmal coughs** followed by **apnea** in young infants, along with **marked leukocytosis**. - **Macrolides** are the treatment of choice due to their effectiveness against *Bordetella pertussis*; **azithromycin** is preferred in infants due to better tolerability and a shorter course compared to erythromycin. *Amoxicillin* - **Amoxicillin** is a penicillin-class antibiotic primarily effective against various bacterial respiratory infections, but it has **no activity against *Bordetella pertussis***. - Using amoxicillin for pertussis would lead to **treatment failure** and a worsening of the infant's condition. *Cotrimoxazole* - While **cotrimoxazole** (trimethoprim-sulfamethoxazole) can be used as an alternative for pertussis in patients **allergic to macrolides**, it is **not the first-line treatment** in infants. - It carries a risk of **kernicterus** in newborns and young infants due to displacement of bilirubin from albumin, so it is generally avoided. *Erythromycin* - **Erythromycin** is a macrolide and is effective against *Bordetella pertussis*, but it is **associated with a higher incidence of infantile hypertrophic pyloric stenosis** when given to young infants. - Due to this adverse effect, **azithromycin** is generally preferred over erythromycin in infants for pertussis treatment.

Question 8: In pseudocholinesterase deficiency, which drug should be used cautiously?

A. Succinylcholine (Correct Answer)
B. Barbiturates
C. Gallamine
D. Halothane

Explanation: ***Succinylcholine*** - **Succinylcholine** is primarily metabolized by **pseudocholinesterase** (also known as butyrylcholinesterase). - In individuals with **pseudocholinesterase deficiency**, the metabolism of succinylcholine is significantly delayed, leading to **prolonged neuromuscular blockade** and extended paralysis. *Barbiturates* - **Barbiturates** are mainly metabolized by the **hepatic cytochrome P450 system** and do not depend on pseudocholinesterase for their breakdown. - Their metabolism would not be significantly affected by pseudocholinesterase deficiency. *Halothane (an inhalational anesthetic)* - **Halothane** is primarily metabolized by the **hepatic cytochrome P450 system** and excreted via the lungs. - Its metabolism is unrelated to **pseudocholinesterase activity**. *Gallamine (a neuromuscular blocker)* - **Gallamine** is a **nondepolarizing neuromuscular blocker** that is primarily eliminated by **renal excretion** as an unchanged drug. - Its metabolism and elimination are independent of **pseudocholinesterase**.

Question 9: What is the standard duration used to define apnea of prematurity?

A. Between 10 and 15 sec
B. 20 sec (Correct Answer)
C. More than 30 sec
D. Less than 10 sec

Explanation: ***20 sec*** - Apnea of prematurity is defined as a cessation of breathing lasting **20 seconds or longer**, or a shorter pause in breathing accompanied by **bradycardia** (heart rate <100 bpm), **cyanosis**, or **pallor**. - This duration is crucial for determining the need for intervention and diagnosis in preterm infants. - The definition is standardized by the **American Academy of Pediatrics (AAP)** and is widely accepted in neonatal care. *Between 10 and 15 sec* - While pauses in breathing of this duration can be observed in preterm infants, they are usually considered **central periodic breathing** and not true apnea of prematurity unless accompanied by desaturation or bradycardia. - These shorter pauses are often considered benign, as significant physiological changes like bradycardia or cyanosis are less likely to occur. *More than 30 sec* - While a breathing cessation of more than 30 seconds certainly qualifies as apnea of prematurity, **20 seconds is the established minimum duration** for diagnosis. - Any apnea lasting longer than 20 seconds signifies a more severe event, indicating a greater risk to the infant. *Less than 10 sec* - Pauses in breathing lasting less than 10 seconds are generally considered **normal physiological variations** in both preterm and full-term infants. - These short pauses do not typically lead to significant oxygen desaturation or bradycardia and are not indicative of apnea of prematurity.

Question 10: All of the following are correct about the image shown except:

A. Omega shaped epiglottis
B. High pitched expiratory stridor (Correct Answer)
C. Cry is normal
D. 10% cases need surgery due to development of OSA or Cor Pulmonale

Explanation: ***High pitched expiratory stridor*** - The image depicts an **omega-shaped epiglottis** and collapsed aryepiglottic folds, consistent with **laryngomalacia**. - Laryngomalacia typically presents with **inspiratory stridor**, not expiratory, resulting from airway collapse during inspiration. - **This is the EXCEPT answer** - high-pitched expiratory stridor is NOT a feature of laryngomalacia. *Omega shaped epiglottis* - The image clearly shows an **omega-shaped epiglottis**, a characteristic feature of **laryngomalacia**. - This anatomical variation contributes to the collapse of supraglottic structures during inspiration. *Cry is normal* - In laryngomalacia, the **vocal cords** themselves are not affected, so the **cry typically remains normal**. - The abnormal sounds (stridor) arise from the supraglottic structures, not the vocal cord function during crying. *10% cases need surgery due to development of OSA or Cor Pulmonale* - While most cases of laryngomalacia are self-limiting, approximately **10% of infants may require surgical intervention** (supraglottoplasty). - This is usually due to severe symptoms like **obstructive sleep apnea (OSA)**, failure to thrive, or the rare development of **cor pulmonale**.

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