Transcript Claman-OccMed.2011

OVERVIEW OF SLEEP
AND SLEEP APNEA
David Claman, MD
Professor of Medicine
Director, UCSF Sleep Disorders Center
SLEEP HYPNOGRAM
SLEEPY FIREFIGHTER?
• 45 year old firefighter complains of daytime
sleepiness; “Doctor: I snore – could I have sleep
apnea? I sleep alone so no one can tell me.”
• Reports “sleep hours 11 pm – 7 am”
• Real schedule is 24 hr at work, then 48 hrs off
– At work sleep 2-4 hrs (no reports of apnea)
– 1st night after work: 10 pm – 8 am
– 2nd nightafter work: 1 am – 5:15 am (up early to drive
to work!)
CIRCADIAN RHYTHM DISORDERS
• Sunlight is main “Zeitgeber”; meals, exercise, &
social activities can also shift sleep rhythms
• Internal Clock located in Suprachiasmatic nucleus
(SCN) of hypothalamus
• Jet lag: light and social stimuli help shift internal
biological clock 1-2 hrs / day
• Shift work: light and social stimuli are in conflict
with work schedule; may lead to poor sleep
quality, insomnia and chronic fatigue
JET LAG
• Start trip sleep deprived
• Dehydration on plane worsened by
caffeine and alcohol
• Circadian rhythm “out of phase”
• Flying West is easier
– delay sleep schedule by 1-2 hr/d
• Flying East is harder
– advance sleep schedule by 0.5-1 hr/d
JET LAG INTERVENTIONS
• Avoid sleep deprivation before trip
– Consider daytime flight
– Avoid important meetings the morning of arrival
• Adjust schedule before trip
– 1-2 hours per day, for 1-2 days before trip
• Avoid alcohol and caffeine
• Bright light
– In morning when flying east (to advance schedule)
– In afternoon/evening when flying west (to delay)
• Hypnotic prn (zolpidem or melatonin)
SHIFT WORK DISORDER
• Shift Work Disorder (SWD) is
characterized by complaints of insomnia,
excessive sleepiness and impaired
performance that occur when work hours
are scheduled during the usual sleep period
• 20% of workforce in industrialized
countries are shift workers, & 40-80% of
night workers report sleep difficulties
SHIFT WORK DISORDER
• Most common schedule is to work Mon
through Fri nights 11 pm – 7 am, but to
sleep during those same hours on Sat / Sun
• Since sunlight is strongest stimulus of
circadian rhythms, the body’s preferred
sleep schedule stays oriented for the hours
11 pm – 7 am
SHIFT WORK DISORDER
• Interventions:
– Optimal approach is to stay awake at night on nonworking days and always sleep on the same schedule
– If patient continues to alternate their sleep schedule, try to
maximize overlap between weekday and weekday
schedules (if 7a-2p weekdays, then 3a-10a weekends)
– Avoiding sunlight on drive home at 7 am (using “glacier”
sunglasses) may also be helpful
DDx of Insomnia
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Psychiatric / psychological
Medical
Drugs (especially caffeine and alcohol)
Psychophysiological insomnia
– Somatized tension and anxiety causing insomnia
• Poor sleep hygiene
– Maladaptive coping mechanisms are common
• Circadian rhythm issues
SLEEP HYGIENE
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Keep regular bedtime and wake-up time
Keep bedroom quiet, comfortable, & dark
Relaxation technique for 10-30 min before bed
Get regular exercise
Don’t nap
Don’t lie in bed feeling worried, anxious, or frustrated
Don’t lie awake in bed for long periods of time
Don’t use alcohol, caffeine, or nicotine
DEFINITIONS:
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Apnea: complete cessation of airflow lasting 10
second or more
Hypopnea: reduced airflow for 10 seconds or
more, associated with 4% oxygen desaturation
(4% is classical definition)
Apnea-hypopnea index (AHI): average number
of apneas & hypopneas per hour of sleep
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AHI < 5 is normal
AHI 5-15 is mildly elevated
AHI 15-30 is Moderate
AHI > 30 Severe
CLINICAL PREDICTORS OF OSA
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Sleep Heart Health: Clinical predictors of AHI > 15:
Male gender, older age, higher BMI, larger neck girth,
snoring & episodes of witnessed apnea
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Young T et al. Arch Intern Med 2002 Apr 22;162(8):893-900
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Young T et al. Excess weight and sleep-disordered breathing. J Appl
Physiol 2005;99(4):1592-9.
Wisconsin OSA prevalence by gender and BMI
Young T. J Appl Physiol 2005;99(4):1592-9
HYPERCAPNIA IN OSA
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French Multicenter Study; n=1141 from database
Excluded those with FEV1<80%
Overall prevalence of 11% with PaCO2 >45
BMI < 30 – prevalence 7.2%
BMI 30-40 – prevalence 9.8%
BMI > 40 – prevalence 23.6%
• Laaban J-P et al. Chest 2005;127:710-715
OSA TREATMENT
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Weight loss (10% weight loss reduces AHI 25%)
Avoid alcohol and sedatives
Postural training (side sleeping since apnea worse on back)
Nasal patency (treat allergies?)
CPAP (also autoCPAP & Bi-level)
Oral (dental) appliances
ENT surgery:
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Tonsillectomy in kids
UPPP in adults 50% success; mandibular surgery 80-90% success
Nasal expiratory resistor (Provent)
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Nasal bandaid with microvalve – delivers approx 5 cm pressure
CPAP – Site Non-specific
LONGTERM USE OF CPAP
Best compliance if AHI >30 & ESS >10
McArdle N et al. AJRCCM 1999;159:1108-1114
PROFESSIONAL DRIVERS
• Hours of Service Rules
– 10-11 hr driving limit; 14-15 hr on-duty limit
– http://www.fmcsa.dot.gov/rules-regulations/topics/hos/index.htm
• Sleep Deprivation
– Common in truck drivers; 35% up before 6 am
• Sleep Apnea – age and obesity major risks
– Effect similar to being over legal alcohol limit in simulator
– Pack & Dinges: OSA prevalence
• Mild 17%, Moderate 5.8%, Severe 4.7%
• www.fmcsa.dot.gov/facts-research/research-technology/tech/Sleep-Apnea-Technical-Briefing.htm
National Transportation Safety Board
• Sleep Apnea Alert October 2009
• Recommend “screening” but no regulations in
place
• Federal Motor Carrier Safety Administration
– Trucks, buses, trains
• US Coast Guard – ship pilots
• FAA – airline pilots
DRIVER SAFETY
• In California, if patient has caused an accident by
falling asleep at the wheel in the last 3 years, then
Dept of Public Health must be notified
• If patient reports concerns about sleepiness while
driving, chart should document: “Patient was
advised not to drive if he / she is drowsy.”
SLEEP
HISTORY!!!
REFERENCES
• Behavioral and pharmacological therapies for late-life insomnia. CM
Morin et al. JAMA 1999;281:991-9
• Cognitive Behavioral Therapy and Pharmacotherapy for Insomnia
Jacobs GD; Arch Intern Med 2004;164:1888-1896
• Principles and Practice of Sleep Medicine. 4th Edition. Kryger, Roth,
& Dement. 2005
• Jet lag and shift work sleep disorders: How to help reset the internal
clock. Kolla BP & Auger RR. Cleveland Clinic J of Med
2011;78(10):675-684
• Circadian Rhythm Sleep Disorders. Lu BS & Zee PC. CHEST
2006;130:1915-1923
• Marin JM et al. Long-term cardiovascular outcomes in men with
obstructive sleep apnoea-hypopnoea: an observational study. Lancet.
2005;365(9464):1046-53