Outcomes Assessment in Sleep Surgery — MCQs
A patient at the orthopedics OPD complains of troubled sleep at night due to numbness and tingling sensation involving his lateral 3 digits. His symptoms are relieved as he lays his arms hanging from the bed. Which of the following options correctly describes his condition and the test used to assess it?
All of the following criteria are required for diagnosis of obesity hypoventilation syndrome except -
All the following are criteria for SIRS, except
Which of the following is not a diagnostic criterion for SIRS?
Visual analogue scale is most widely used to measure
A child presents with night blindness, delayed dark adaptation. Which investigation is to be done further to confirm the diagnosis?
Which of the following is not a risk factor for postoperative pulmonary complication?
A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?
What is the therapy of choice for sleep-apnea syndrome?
What Apnea-hypopnea index (AHI) value is used for the diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) in the absence of symptoms?
Outcomes Assessment in Sleep Surgery Indian Medical PG Practice Questions and MCQs
Question 1: A patient at the orthopedics OPD complains of troubled sleep at night due to numbness and tingling sensation involving his lateral 3 digits. His symptoms are relieved as he lays his arms hanging from the bed. Which of the following options correctly describes his condition and the test used to assess it?
- A. Guyon's canal syndrome, Froment's test
- B. Carpal tunnel syndrome, Froment's test
- C. Guyon's canal syndrome, Durkan's test
- D. Carpal tunnel syndrome, Durkan's test (Correct Answer)
Explanation: ***Carpal tunnel syndrome, Durkan's test*** - The symptoms of **numbness and tingling** in the **lateral 3 digits** (thumb, index, middle, and radial half of the ring finger) are classic for **carpal tunnel syndrome (CTS)**, caused by compression of the **median nerve**. Relief with hanging the arm is due to gravity reducing swelling and pressure. - **Durkan's test** (or **median nerve compression test**) is highly specific for CTS. It involves direct pressure over the carpal tunnel, reproducing symptoms within 30 seconds. *Guyon's canal syndrome, Froment's test* - **Guyon's canal syndrome** involves compression of the **ulnar nerve** at the wrist, primarily affecting the **little finger** and the **ulnar half of the ring finger**, not the lateral 3 digits. - **Froment's test** assesses **ulnar nerve palsy** by observing the strength of adductor pollicis during a pinch grip, which is unrelated to median nerve compression. *Carpal tunnel syndrome, Froment's test* - While **carpal tunnel syndrome** is correctly identified based on the symptoms, **Froment's test** is not used to assess it. - As mentioned, Froment's test evaluates **ulnar nerve function**, particularly the adductor pollicis muscle. *Guyon's canal syndrome, Durkan's test* - The symptoms described (lateral 3 digits) are inconsistent with **Guyon's canal syndrome**, which affects the ulnar nerve distribution. - Although **Durkan's test** is appropriate for carpal tunnel syndrome, the diagnosis for Guyon's canal syndrome is incorrect.
Question 2: All of the following criteria are required for diagnosis of obesity hypoventilation syndrome except -
- A. PaCO2 > 45 mmHg
- B. BMI 30 kg/m2
- C. Hypertension (Correct Answer)
- D. Sleep disorder breathing
Explanation: ***Hypertension*** - While **hypertension** is a common comorbidity in patients with **obesity hypoventilation syndrome (OHS)**, it is _not_ a diagnostic criterion. - OHS is defined by specific respiratory and obesity-related parameters, not the presence of associated cardiovascular conditions. *BMI $\geq$ 30 kg/m$^2$* - A **body mass index (BMI)** of **30 kg/m$^2$** or greater is a fundamental criterion for diagnosing OHS, as the syndrome is directly linked to obesity. - Severe obesity leads to mechanical compression of the lungs and chest wall, contributing to hypoventilation. *PaCO$_{2}$ > 45 mmHg* - A **daytime arterial partial pressure of carbon dioxide (PaCO$_{2}$)** greater than **45 mmHg** is a key diagnostic criterion, indicating chronic alveolar hypoventilation. - This persistent hypercapnia is present even when other causes like obstructive lung disease have been excluded. *Sleep-disordered breathing* - **Sleep-disordered breathing**, most commonly **obstructive sleep apnea (OSA)**, is almost universally present in OHS patients and is a required diagnostic criterion [1]. - The combination of severe obesity and OSA often leads to the development of chronic hypoventilation [1].
Question 3: All the following are criteria for SIRS, except
- A. Heart rate >90/min
- B. Systolic blood pressure <90 mmHg (Correct Answer)
- C. Respiratory rate >20 bpm
- D. Temperature >38 degree Celsius or <36 degree Celsius
Explanation: ***Systolic blood pressure <90 mmHg*** - This criterion is associated with **septic shock** or **hypotension**, indicating organ dysfunction, which is a more severe stage beyond **SIRS**. - While low blood pressure can be seen in severe infections, it is not a direct diagnostic criterion for **SIRS** itself. *Heart rate >90/min* - An elevated **heart rate** (tachycardia) is a common physiological response to systemic stress and inflammation. - This criterion fulfills one of the four clinical parameters to diagnose **SIRS**. *Respiratory rate >20 bpm* - An increased **respiratory rate** (tachypnea) reflects the body's attempt to compensate for metabolic acidosis or increased oxygen demand during a systemic inflammatory response. - This criterion is one of the four clinical parameters used to diagnose **SIRS**. *Temperature >38 degree Celsius or <36 degree Celsius* - Both **fever** (>38°C) and **hypothermia** (<36°C) are indicators of a systemic inflammatory response, as the body's thermoregulation is affected [1]. - This criterion is one of the four principal parameters used to diagnose **SIRS** [1].
Question 4: Which of the following is not a diagnostic criterion for SIRS?
- A. Hypotension (Correct Answer)
- B. Tachypnoea
- C. Leucocytosis
- D. Tachycardia
Explanation: ### Hypotension - **Hypotension** is a criterion for **sepsis** and **septic shock**, but not for **SIRS** itself. - **SIRS** criteria are based on inflammatory responses, while hypotension indicates a more severe systemic compromise. *Tachycardia* - **Tachycardia**, defined as a **heart rate >90 beats per minute**, is a diagnostic criterion for **SIRS** [1]. - It reflects the body's physiological stress response to a systemic inflammatory state [1]. *Tachypnoea* - **Tachypnoea**, indicated by a **respiratory rate >20 breaths per minute** or a **PaCO2 <32 mmHg**, is a diagnostic criterion for **SIRS** [1]. - This symptom shows the body's effort to compensate for metabolic acidosis or increased oxygen demand. *Leucocytosis* - **Leucocytosis**, defined as a **white blood cell count >12,000/mm³** or **<4,000/mm³**, or the presence of **>10% immature neutrophils (bands)**, is a diagnostic criterion for **SIRS** [1]. - This indicates a significant systemic inflammatory response in the blood [1].
Question 5: Visual analogue scale is most widely used to measure
- A. Sleep
- B. Sedation
- C. Depth of anaesthesia
- D. Pain intensity (Correct Answer)
Explanation: ***Pain intensity*** - The **Visual Analogue Scale (VAS)** is a psychometric response scale primarily used to measure the subjective intensity of **pain**. - It allows patients to indicate their pain level on a continuous scale, typically a 10 cm line, providing a more nuanced measure than categorical scales. *Sleep* - While sleep quality and subjective experience can be assessed, the **VAS** is not the primary or most widely used tool for measuring sleep itself. - **Polysomnography** and various sleep questionnaires are more commonly employed for sleep assessment. *Sedation* - Though subjective sedation levels can be rated, more specific scales like the **Ramsay Sedation Scale** or **Richmond Agitation-Sedation Scale (RASS)** are more commonly used for objective and consistent evaluation of sedation. *Depth of anaesthesia* - **Depth of anaesthesia** is primarily measured using objective physiological parameters and processed **electroencephalogram (EEG)** analysis (e.g., Bispectral Index or BIS), not subjective scales like the VAS. - These objective measures provide real-time data to guide anesthetic administration.
Question 6: A child presents with night blindness, delayed dark adaptation. Which investigation is to be done further to confirm the diagnosis?
- A. ERG (Correct Answer)
- B. Retinoscopy
- C. Dark adaptometry
- D. EOG
Explanation: ***ERG*** - **Electroretinography (ERG)** measures the electrical responses of various retinal cells, including **rods** and **cones**, to light stimuli. - In conditions like **retinitis pigmentosa** which cause night blindness and delayed dark adaptation, ERG will show characteristic abnormal or extinguished responses, confirming retinal dysfunction. *Retinoscopy* - **Retinoscopy** is an objective method to assess the refractive error of the eye by observing the light reflex from the retina. - It does not directly evaluate the functional integrity of photoreceptors or diagnose conditions causing **night blindness**. *Dark adaptometry* - **Dark adaptometry** measures the time it takes for the eye to adapt to dim light after exposure to bright light, quantifying the function of **rod photoreceptors**. - While it can *detect* delayed dark adaptation, it is a functional test that assesses the symptom, not the underlying cause provided by ERG. *EOG* - **Electrooculography (EOG)** measures the potential difference between the cornea and the retina, primarily assessing the function of the **retinal pigment epithelium (RPE)**. - While useful for conditions like **Best's disease**, it is less direct for evaluating generalized rod dysfunction causing night blindness compared to ERG.
Question 7: Which of the following is not a risk factor for postoperative pulmonary complication?
- A. Normal BMI (18.5-24.9) (Correct Answer)
- B. Age 25-40 years
- C. Upper abdominal surgery
- D. Patient with 20 pack years of smoking
Explanation: ***Patient with 20 pack years of smoking*** - This is a significant risk factor for postoperative pulmonary complications, as **chronic smoking** impairs lung function and mucociliary clearance. - Patients with a history of **20 pack-years or more** are at a substantially increased risk of developing atelectasis, pneumonia, and respiratory failure after surgery. *Normal BMI (18.5-24.9)* - A **normal BMI** is not considered a risk factor for postoperative pulmonary complications; instead, it is associated with a lower risk compared to obesity or underweight states. - Patients with a normal BMI generally have **better respiratory mechanics** and lung volumes, reducing their susceptibility to pulmonary issues. *Age 25-40 years* - This age range is generally associated with a **lower risk** of postoperative pulmonary complications compared to very young or elderly patients. - Younger adults typically have **better physiological reserves** and healthier lungs, contributing to a reduced incidence of respiratory problems post-surgery. *Upper abdominal surgery* - **Upper abdominal surgery** is a significant risk factor for postoperative pulmonary complications due to its proximity to the diaphragm. - It often leads to **diaphragmatic dysfunction**, reduced lung volumes, and increased pain, all of which predispose patients to atelectasis and pneumonia.
Question 8: A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?
- A. History + c/e + routine labs + V/Q scan
- B. History + c/e + routine labs
- C. History + c/e + routine labs + stress test (Correct Answer)
- D. History + c/e + routine labs + angiography to assess graft patency
Explanation: ***History + c/e + routine labs + stress test*** - A **stress test** is crucial in patients with a history of MI and CABG to assess **myocardial ischemia** and functional capacity, guiding perioperative management. - This evaluation helps determine the patient's **cardiac risk** for non-cardiac surgery and the need for further cardiac optimization. *History + c/e + routine labs + angiography to assess graft patency* - **Coronary angiography** is an invasive procedure and is generally not indicated as a routine preoperative assessment unless there are new, significant cardiac symptoms or signs of **graft dysfunction**. - Assessing graft patency through angiography carries risks and would only be justified if there were strong clinical indications suggesting acute or severe **cardiac ischemia**. *History + c/e + routine labs* - While critical for any preoperative assessment, **routine history, physical examination, and basic laboratory tests** are insufficient for a patient with a significant cardiac history like MI and CABG. - This approach would **underestimate the cardiac risk** and might miss undetected ischemia, leading to adverse perioperative cardiac events. *History + c/e + routine labs + V/Q scan* - A **ventilation-perfusion (V/Q) scan** is primarily used to diagnose **pulmonary embolism** or assess regional lung function. - It does not provide information about myocardial ischemia or cardiac functional capacity, making it **irrelevant** for assessing cardiac risk in this clinical scenario.
Question 9: What is the therapy of choice for sleep-apnea syndrome?
- A. Invasive ventilation
- B. Non-invasive ventilation (Correct Answer)
- C. Oxygen inhalation
- D. Use of respiratory stimulants
Explanation: **Explanation:** **1. Why Non-invasive Ventilation (NIV) is the Correct Choice:** The gold standard treatment for Obstructive Sleep Apnea (OSA) is **Continuous Positive Airway Pressure (CPAP)**, which is a form of non-invasive ventilation. The underlying pathophysiology of OSA is the collapse of the upper airway during sleep. CPAP acts as a **"pneumatic splint,"** providing constant positive pressure that keeps the pharyngeal airway open, preventing collapse and ensuring uninterrupted ventilation. **2. Why Other Options are Incorrect:** * **Invasive Ventilation:** This involves endotracheal intubation or tracheostomy. While a permanent tracheostomy is the most effective surgical cure for OSA (as it bypasses the obstruction), it is reserved for life-threatening cases due to its morbidity. It is not the first-line "therapy of choice." * **Oxygen Inhalation:** Oxygen may improve saturation but does not address the mechanical obstruction. In some patients, it can actually worsen hypercapnia (CO2 retention) by reducing the hypoxic respiratory drive. * **Respiratory Stimulants:** Drugs like acetazolamide or medroxyprogesterone have limited efficacy and significant side effects. They do not prevent the physical collapse of the airway, which is the primary issue in OSA. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Overnight Polysomnography (Sleep Study). * **Apnea-Hypopnea Index (AHI):** Diagnostic if AHI >5 with symptoms, or AHI >15 regardless of symptoms. * **First-line Surgery:** Uvulopalatopharyngoplasty (UPPP) is the most common surgery, but CPAP remains the primary medical therapy. * **Friedman Staging:** Used to predict the success of UPPP based on palate position, tonsil size, and BMI.
Question 10: What Apnea-hypopnea index (AHI) value is used for the diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) in the absence of symptoms?
- A. 5 episodes/hr
- B. 10 episodes/hr
- C. 15 episodes/hr (Correct Answer)
- D. 20 episodes/hr
Explanation: ### Explanation The diagnosis of **Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS)** is based on the **Apnea-Hypopnea Index (AHI)**, which measures the number of apnea and hypopnea events per hour of sleep recorded during polysomnography. According to the American Academy of Sleep Medicine (AASM) criteria, the diagnostic thresholds are: 1. **AHI ≥ 5 episodes/hr:** Diagnostic **ONLY IF** the patient has associated symptoms (e.g., daytime sleepiness, loud snoring, witnessed gasping) or co-morbidities (e.g., hypertension, ischemic heart disease). 2. **AHI ≥ 15 episodes/hr:** Diagnostic **regardless of the presence of symptoms**. In an asymptomatic patient, this higher threshold is required to confirm the syndrome. **Analysis of Options:** * **Option A (5 episodes/hr):** This is the minimum threshold for diagnosis, but it requires the presence of clinical symptoms. * **Option B (10 episodes/hr):** This value does not represent a standard diagnostic cutoff in current international guidelines. * **Option C (15 episodes/hr):** **Correct.** This is the definitive cutoff for diagnosing OSAHS in an asymptomatic individual. * **Option D (20 episodes/hr):** While this indicates moderate-to-severe OSAHS, it is not the minimum threshold for diagnosis. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Overnight Polysomnography (Sleep Study). * **Severity Grading:** * Mild: AHI 5–15 * Moderate: AHI 15–30 * Severe: AHI > 30 * **Epworth Sleepiness Scale:** A subjective tool used to measure daytime sleepiness. * **Treatment of Choice:** Continuous Positive Airway Pressure (CPAP) is the gold standard for moderate-to-severe OSAHS. * **Surgical Procedure:** Uvulopalatopharyngoplasty (UPPP) is the most common surgical intervention.
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