Episode 29: OSA with Clau.
Obstructive sleep apnea (OSA) can be confused with ADHD in pediatric patients. Dr Carranza explains how to work up and treat OSA in kids. Listen to several adventitious breath sounds as explained by Xeng, and learn what Dormir means. Cruel joke about thalidomide. Contest: Define mittleschmerz.
The sun rises over the San Joaquin Valley, California, today is September 25, 2020.
As allopathic doctors, medications are our most potent tools to fight and prevent diseases. Today, we want to remind everyone about substance abuse and give you an update on a procoagulant agent.
Substance abuse is a growing problem. Due to increased stress, anxiety, depression, and unemployment, drug abuse is on the rise during the current pandemic[1]. Some medications may not be considered a “drug of abuse” when prescribed alone, but they can be combined with other medications to cause a potentially addictive effect.
Such is the case of promethazine[2,3], which is usually combined with codeine, dextromethorphan and expectorants for cough. Promethazine is also used as an antiemetic, for procedural sedation, and for allergic reactions. Promethazine-containing products are abused for their sedative effects. Specifically, when promethazine is combined with opioids, it potentiates euphoria, alleviates withdrawal symptoms and relieves opioid-induced nausea. So, be aware of drugs that can potentially be misused or abused, even when they are not scheduled. Other examples include quetiapine, baclofen, gabapentin, fluoxetine, and more. Examples of OTC medications that can also be misused are diphenhydramine and loperamide.
Now, let’s talk briefly about tranexamic acid. You may remember this medication as a treatment for menorrhagia, and to control bleeding in general. UptoDate stated in December 2019 that this medication is now recommended in patients with moderate Traumatic Brain Injury (TBI) presenting within 3 hours of the event[4]. Interestingly, tranexamic acid is a potent neurotoxin with a mortality rate of 50%, but ONLY when given accidentally via intraspinal route. Remember, it’s safe IV and oral, but NOT intraspinal. Survivors of intraspinal injection often experience seizures, permanent neurological injury, ventricular fibrillation, and paraplegia. Container mix-ups were involved in 3 recent cases[5]. So, this is why checking medication labels is critical.
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This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program, from Bakersfield, California. Sponsored by Clinica Sierra Vista, Providing compassionate and affordable care since 1971.
“A life without a cause is a life without effect.” ― Paulo Coelho
Think about your purpose in life, what motivates you? Where do you want to be? Start now to direct your life to get you where you want to be. Claudia Carranza is here with us today, a Wednesday after didactics to discuss another topic
Who are you?
My name is Claudia Carranza; you might recognize my voice from the “Espanish word of the week”, I am a PGY3 resident in our Rio Bravo Family Medicine residency program. I am married to an internal medicine resident, we have 2 dogs and they keep us really busy going to the dog park, long walks and jogging.
What did you learn this week?
This week I learned about obstructive sleep apnea (OSA). I actually had a patient recently with obstructive sleep apnea which persisted despite prior tonsillectomy. I also learned that obstructive sleep apnea in children can present with symptoms similar to ADHD. I thought, I definitely need to read more about management and I would like to focus mostly on pediatrics.
A lot of patients ask me: what is obstructive sleep apnea? And I would tell them in my own words that “it’s a condition in which something blocks your upper airway and it makes you sometimes snore and wake up multiple times at night because you are unable to breath”. A fancier definition is “a complete or partial upper airway obstruction which can result in gas exchange abnormalities”.
This doesn’t sound very pleasant and patients won’t necessarily come to you complaining that they are waking up at night. Instead, it can be presented to you as different complaints such as snoring, daytime sleepiness with car rides or at school, nocturnal enuresis, and in particular in children it can manifest as inattention, learning problems, hyperactivity, impulsivity, rebelliousness and even aggression. But wait; these last few symptoms sound a lot like attention deficit hyperactivity disorder or ADHD.
So here where SCREENING becomes very important, and usually you will ask your patient or their parent: does your child snore? More often than not the parents will know; sometimes I have even had a patient’s brother or sister in the room who says: “yes he/she snores!” Another part of your yearly check-ups will be looking at the oropharynx and you will see whether the patient has enlarged tonsils. Remember: not everyone who snores will have enlarged tonsils and not everyone who has enlarged tonsils will snore.
But any child who snores 3 or more nights per week, has loud snoring and has pauses in breathing should undergo a full diagnostic evaluation for Obstructive Sleep Apnea.
Once you OSA has been diagnosed and treated it is still important to monitor children as they can have residual symptoms or recurrence. Look out for weight gain.
Question number 3: Why is that knowledge important for you and your patients?
Not only can undiagnosed OSA lead to sometimes unnecessary ADHD treatment but it can also lead to failure to thrive if OSA is severe; cardiopulmonary problems including ventricular dysfunction, systemic HTN, endothelial dysfunction. It has also been associated to a lesser degree with pulmonary HTN.
Now that we know how serious OSA can be and that you need to order a full work up when it is suspected I want to quickly go over the next steps in clinic:
Focused sleep history and physical exam including detailed oropharynx exam, close attention to blood pressure, BMI, craniofacial abnormalities, shape of mouth/palate/jaw and size of tongue
Polysomnography (PSG) or referral to a specialist such as ENT or sleep medicine for further evaluation and treatment
For those of us in Family medicine, treating adult patients, keep in mind that children and adults have different risk factors to look out for:
Risk factors of pediatrics sleep apnea in children: Adenotonsillar hypertrophy and obesity (in otherwise healthy children). If OSA appears in infancy the child likely has anatomic or genetic abnormality.
Risk factors of OSA in adults: older age, male sex, obesity, craniofacial and upper airway abnormalities (short mandibular size, wide craniofacial base and tonsillar and adenoid hypertrophy.
How did you get that knowledge?
I think the more patients I see the more knowledge I accumulate and it comes from a combination of sources like my attendings, UptoDate and my fellow residents.
Where did that knowledge come from?
I read Uptodate, and article from Thorax titled “Ambulatory blood pressure in children with obstructive sleep apnoea: a community based study” Tal et al, which showed that children with OSA had significant elevation in BP both while sleeping and awake. Also, “Diagnosis and management of childhood obstructive sleep apnea syndrome” published on Pediatrics.
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Speaking Medical: Adventitious Breath Sounds
by Xeng Xai Xiong, MS3
Hey, what’s cooking? Did you hear that? It was the sound of bacon sizzling in the fresh cozy morning. Now, this is the sound of the sound of fine crackles coming from the lungs. I’m not sure whether hearing sizzling bacon reminds me of fine crackles of the lungs [delete repeated sentence] or fine crackles of the lungs remind me of bacon. Either way, you would agree that bacon tastes good.
I am getting too carried away with this now so I’m going to jump straight to the point. As a medical student, it was intimidating to differentiate the different lung sounds. Maybe I need an ear check, or maybe I haven’t listened to enough lungs. The latter sounds more probable since the first two years of medical school was spent listening to standardized patients' lungs. Today, I’m going to share with you four of the most common abnormal lung sounds. But before we talk about the abnormal, let’s review the vesicular breath sound, which is the normal breath sound, just in case you forgot about it: https://www.youtube.com/watch?v=VtnMRG0ORLs
Wheezing is a high-pitched whistling noise that can happen on inspiration or expiration. It’s usually a sign that something is making your airways narrow or keeping air from flowing through them. Although there can be many things that cause wheezing, two of the most common causes are chronic obstructive pulmonary disease and asthma. Here is a sound bite of expiratory wheezing: 1:50-1:57 https://www.youtube.com/watch?v=KRtAqeEGq2Q
Stridor is a harsh, noisy, squeaking sound that happens with every breath. It can be high or low, and it’s usually a sign that something is blocking your airways. It can be heard in laryngomalacia, croup, and more. Here is an example of stridor: 3:03-3:11 https://www.youtube.com/watch?v=KRtAqeEGq2Q.
Crackles (rales) is a series of short, explosive sounds. They can also sound like bubbling, rattling, or clicking. You can have fine crackles, which are shorter and higher in pitch, or coarse crackles, which are lower. Either can be a sign that there’s fluid in the air sacs. Here is the sound of a course crackling (0:55-1:01 https://www.youtube.com/watch?v=KRtAqeEGq2Q). Here are fine crackles (1:08-1:15)
Rhonchi is a low-pitched wheezing sounds sound like snoring and usually happen when you breathe out. They can be a sign that your bronchial tubes are thickening because of mucus. Rhonchi sounds can be a sign of bronchitis or COPD. Here is the sound of rhonchi (2:35-2:43).
For your undivided attention, here is a bonus lung sound (silent for 3 seconds). Yep, that was an absent lung sound; it can mean air or fluid in or around the lungs such as pleural effusion or pneumothorax. Lung sounds can be intimidating at first, but they can be easily differentiated if you spend some time to study them.
That’s it for now hasta la vista baby.
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Espanish Por Favor: Dormir
by Claudia Carranza
This is Dr Carranza again bringing you the “Espanish word of the week”. This week’s word is “Dormir”. Dormir is one of our favorite activities, especially when we are tired; for any residents out there “Dormir” must sound very appealing, especially after a long shift. “Dormir” comes from the latin word “dormire” which means Sleep or rest.
Since we just talked about sleep apnea, one important question you can ask your patient is “ senor, puede DORMIR bien en la noche” which means “ sir, do you sleep well at night?”.
A different question you can ask is “Señor, ¿tiene problemas para DORMIR?” which means, “sir, do you have difficulty sleeping?”. Also remember that if you want to ask about their child you can replace the “señor” with “su niño”. Now you know the Spanish work of the week “DORMIR.” Have a great weekend!
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For your Sanity: Define mittleschmerz
by Dr Steven Saito and Dr Sally Wonderly
Three pregnant women were waiting in the doctor’s waiting room for an antenatal check-up and were all knitting garments for their respective babies.
Suddenly the first expectant mother stops knitting, checks her watch, pulls a bottle of pills from her handbag and takes one.
"What was that?", the other two ask, curiously.
"Calcium tablet. Good for mommy, good for baby", she replies, patting her stomach affectionately.
Satisfied, all three continue with their knitting. Five minutes later, the second one stops knitting, checks her watch, takes a bottle of pills from her handbag and takes one.
"What was that?", the other two enquire.
"Vitamin tablet", she replies, “Good for mommy, good for baby" and she pats her stomach affectionately.
All three smile and continue busily with their knitting. Five minutes later, the last woman stops knitting, checks her watch, takes a bottle of pills from her handbag and takes one.
"What was that?" ask the other two.
"Thalidomide. I can’t knit sleeves."
Dr Arreaza: Thalidomide was a teratogenic medication linked to phocomelia, or congenital malformation of the limbs)
Dr Wonderly: Listen up! Today we have a gift for those who believe that learning is not only fun, but can also bring rewards. Yes, this time we want to reward the listener who sends the most creative definition of mittleschmerz. Yes, mittleschmerz is used in English too. Your definition of mittleschmerz will be used in our next episode of Rio Bravo qWeek. Type your definition of mittleschmerz, keep it brief and interesting, maybe 1 or 2 paragraphs, and send it to rbresidency@clinicasierravista.org ASAP. Looking for your five minutes of fame? Well, you can also record your definition of mittleschmerz for our next episode. Don’t send an audio, let us know if you want to record it and we will give you a call.
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Now we conclude our episode number 29 “OSA with Clau.” Dr Carranza reminded us to think about Obstructive Sleep Apnea in kids as part of the work up of ADHD. Xeng eloquently explained the four most common adventitious breath sounds, and reminded us that crackles may sound like sizzling bacon. Claudia then explained what you want to do after your night shift, dormir, which means sleep. Don’t forget our contest. Send your definition of mittleschmerz to rbresidency@clinicasierravista.org, and if you want to record it, we’ll give you a call.
Conclusion: Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Golriz Asefi, Claudia Carranza, Mariel Chan, Xeng Xiong, Sally Wonderly and Steven Saito. Audio by Suraj Amrutia. See you next week!
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References:
Sparkman, David, Drug Abuse on the Rise Because of COVID-19, EHS Today, August 29, 2020, https://www.ehstoday.com/covid19/article/21139889/drug-abuse-on-the-rise-because-of-the-coronavirus
Promethazine Abuse: A Growing Problem? Tox Tid Bits, Maryland Poison Center, University of Maryland School of Pharmacy, March 2017, https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2017/March%202017%20ToxTidbits.pdf
Klein-Schwartz, Wendy, PharmD, MPH, et al, Abuse of Nonscheduled Medications and Nonprescription Drugs, American College of Medical Toxicology, Online Library, https://www.acmt.net/_Library/2019_Israeli_Conference/Non-prescription_-_Klein.pdf
Eichler, April F, MD, MPH, and Sadhna R Vora, MD, Practice Changing UpDates, Up to Date, https://www.uptodate.com/contents/practice-changing-updates, Last updated: Sep 09, 2020.
Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial, The Lancet, Vol 394, Issue 10210, P1713-1723, November 09, 2019, Open Access Published: October 14, 2019, DOI: https://doi.org/10.1016/S0140-6736(19)32233-0
National Alert Network, Dangerous wrong-route errors with tranexamic acid, https://www.ismp.org/sites/default/files/attachments/2020-09/NAN%20Alert%2020200909.pdf, accessed on Sep 24, 2020.
Paruthi, Shalini, MD, et al, Evaluation of suspected obstructive sleep apnea in children,
UptoDate, Last updated: Mar 19, 2020, https://www.uptodate.com/contents/evaluation-of-suspected-obstructive-sleep-apnea-in-children?search=osa%20children&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Li AM, Au CT, Sung RYT, et al, Ambulatory blood pressure in children with obstructive sleep apnoea: a community based study, Thorax 2008;63:803-809. https://thorax.bmj.com/content/63/9/803
Clinical Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome, Pediatrics April 2002, 109 (4) 704-712; https://pediatrics.aappublications.org/content/109/4/704
Robinson, Jennifer, MD, “Lung Sounds: What Do They Mean?” WebMD Medical Reference, reviewed on June 12, 2020, https://www.webmd.com/lung/lung-sounds, accessed on Sep 16, 2020.
Audio of sizzling bacon, courtesy of http://www.texashighdef.net, courtesy of yogaduke YouTube Channel, https://www.youtube.com/watch?v=e-5GirZe_jY
Audio of lung sounds, courtesy of EMTPrep YouTube Channel: https://www.youtube.com/watch?v=KRtAqeEGq2Q