Transcript The Snoring Patient and Sleep Apnea - ISETT

Obstructive Sleep Apnea and
Other Causes of Excessive
Daytime Sleepiness
Patient Scenario #1
A 45 year old man sought treatment of his
snoring, which had been present for many
years. His wife slept in another room
because the snoring “shook the walls”.
The patient reports excessive sleepiness
(Epworth sleepiness scale score 18/24.
Normal is 10 or less), morning headaches
and problems concentrating at work. He
admits to drinking more than five cups of
coffee daily. There was no history of
recent weight gain or alcohol use.
The Physical Examination
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Height: 5 feet 10 inches
Weight: 190 pounds; Blood Pressure: 150/90
Neck 18 inch circumference
HEENT: long, edematous uvula, dependent palate
(low lying)
• Chest: clear
• Cardiac: normal
• Extremities: no edema
What is The Next Step?
Sleep Apnea is the most common
cause of excessive daytime sleepiness
and snoring, but there are many other
disorders that must be carefully
considered.
Evaluating Causes of Excessive
Daytime Sleepiness (EDS)
Disorders
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Sleep Apnea Syndromes
Upper airway resistance syndromes
Narcolepsy
Periodic leg (limb)movements in
sleep
Restless leg Syndrome
Circadian Sleep Disorders
Insomnia
Withdrawal from Stimulants
Drug dependence/Abuse
Medication side effects
Idiopathic Hypersomnia
Brain tumors
Parasomnias
Evaluation
All Cases
• History
• Self-rating scale of
Sleepiness
• Sleep-wake diary
• Polysomnography
Selected Cases
•MSLT
•Drug Screen
Epworth Sleepiness Scale:
Measures average sleep propensity (chance of dozing) over 8 common situations that almost
everyone encounters.
Situation
•Sitting and reading
•Watching T.V.
•Sitting inactive in a public place (i.e., theater,
meeting)
•As a passenger in a car for 1 hour without a break
•Lying down to rest in the afternoon when
circumstances permit
•Sitting talking to someone
•Sitting quietly after lunch without alcohol
•In a car while stopped for a few minutes in traffic
Total
Chance of Dozing
0-3
0-3
0-3
0-3
0-3
0-3
0-3
0-3
0-24 (0-10 normal)
3= High chance of dozing; 2=moderate; 1=slight; 0=never
Stanford Sleepiness Scale:
Measures subjective feelings of sleepiness
•Feeling active and vital; alert, wide awake
•Functioning at a high level, but not peak, able to
concentrate
•Relaxed, awake, not at full alertness, responsive
•A little foggy, not at peak, let down
•Fogginess, beginning to lose interest in remaining awake,
slowed down
•Sleepiness, prefer to be lying down, fighting sleep, woozy
•Almost in reverie, sleep onset soon, lost struggle to remain
awake
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Obstructive Sleep Apnea
(O.S.A)
• OSA is a common disorder occurring in 4% of
men and 2% of women.
• During sleep, closure of the upper airway results
in cessation or diminished airflow despite
continued respiratory effort. The termination of
the apneic event is associated with a brief
awakening.
• These arousals result in sleep fragmentation which
reduces the amount of slow wave and REM sleep
and causes varying degrees of daytime sleepiness.
Risk Factors for Sleep Disordered
Breathing
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Excess body weight
Large neck circumference
Male gender
Ethnicity
Age
Menopause
Anatomy of airway=soft and hard palate.
Indicators for a
Polysomnography (PSG)
• Suspicion of disorders that disturb sleep like
sleep apnea, periodic limb disorder, REM
behavior disorder
• EDS
• Obesity
• Insomnia with daytime sleepiness
• Nocturnal behavioral disorders
Polysomnography
Multiple physiologic parameters are measured and
compared with the established norms.
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Electrocardiography (EKG)
Electroencephalography (EEG)
Electro-oculography (EOG)
Electromyography (EMG)
Pulse Oximetry
Respiration:
-Effort (chest and abdominal movements)
-Airflow
Snore sensor/microphone
– Heat sensors measure airflow by detecting temperature changes in inspired and
expired air
*Sleep conditions in the laboratory should be as close to the
patients baseline sleep as possible.
Human Sleep Architecture
Wake
NREM sleep
•Stages 1 and 2 (light sleep)
•Stages 3 and 4 (deep sleep)
REM sleep
*Recognition of certain characteristic EEG patterns is
essential for staging sleep
Electroencephalographic Lead
Placement
• Central
•Occipital
•Mastoid
*More electrodes can be added if nocturnal seizure is in the differential
Monitoring Eye Movements
Standard : 2 eye channels
• Detecting horizontal/vertical eye movements
• Determining various stages of sleep
Electromyography (EMG)
• Diagnosis of Periodic Limb
Movements(PLMS)
• Chin movement
• Diagnosis of certain sleep stages
Monitoring Respiration During
Sleep
1. Apnea – cessation of airflow at the nose and mouth
for 10 seconds or longer
2. Central Apnea – an absence of inspiratory effort
3. Obstructive Apnea – absence of airflow despite
persistent respiratory effort
4. Mixed Apnea – initially no inspiratory effort…then
terminates as an obstructive event
5. Hypopnea – reduction in airflow by 30% from
baseline for > 10 seconds with > 4 % drop in
oxygen saturation (controversial)
6. Respiratory Effort Related Arousals(RERAs) – an
event not meeting the above criteria, yet produces an
arousal from sleep.
Important Sleep Parameters on
PSG
• Sleep stages (percentage)
• Sleep efficiency
• Apnea Hypopnea index (AHI), Respiratory
Disturbance Index (RDI), paradoxical
respiration; desaturations and cardiac
arrhythmias
Sleep Hypnogram
Diagnosis of OSA
• The Apnea + Hypopnea Index (AHI) a.k.a
Respiratory Disturbance Index (RDI) = The
Number of Apneas + hypopneas Per Hours
of Sleep
Treatment of OSA
• Obesity- Diet and behavior modification
• Positional Therapy
-non-supine sleep (pillow, etc.)
-raise the head of the bed
• Nasal CPAP, BiPAP, Auto CPAP
• Oral appliances
• Soft tissue surgery or UPPP
(Uvulopalatopharyngoplasty)
• Skeletal surgery
• Tracheotomy
Significance of Sleep Disordered
Breathing
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Risk factor for stroke
Risk factor for cardiac arrhythmias
Risk factor for CAD and M.I.
Risk factor for pulmonary hypertension and
right heart dysfunction
• Cause of hypertension
Patient Scenario #2
A 40 year old man was referred because his wife
complained that he kicked in his sleep and constantly
disturbed her. The patient remembered awakening
several times each night, but never noticed any
discomfort at those times. He admitted that at bedtime
he did have an irresistible urge to move his legs and he
described a feeling of “pins and needles.” However
this delayed his sleep only rarely. His Epworth
Sleepiness Scale was 15/24 (sleepy).
PSG shows: Periodic leg movements in sleep (PLMS) – 20% of
these events were associated with arousals.
Periodic Leg Movement in Sleep
(PLMS)
PLMS are repetitive, stereotypic dorsiflexion movements of
the toes, ankles, knees and thighs that recur at regular
intervals. They occur most commonly in stages 1 and 2 but
can occur less commonly in other stages. Patients are rarely
aware of the leg movements themselves and complaints are
usually from bed partners.
Periodic Leg Movement Disorder PLMD
This is a syndrome of leg movements + symptoms (ie.
insomnia or excessive daytime sleepiness.
This is a polysomnographic diagnosis; but, it is often
incorrectly used interchangeably with Restless Leg Syndrome.
International Classification of Sleep Disorders Criteria
for PLMS Severity
Severity
Mild
Moderate
Severe
PLM Index/Hour
5 - 24
25 - 49
> 50
PLM Arousal Index/Hr
Not specified
Not specified
> 25/ hour
Restless Leg Syndrome (RLS)
Characterized by abnormal and uncomfortable
sensations in the limbs that compel the
person to move to relieve the sensation and
these movements are exacerbated by rest.
The symptoms occur primarily in the
evening or at night.
International RLS Study Group Criteria
for Diagnosis of RLS
Primary Features
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Unpleasant limb sensations: desire
to move the limbs usually
associated with
paresthesias/dysesthesias
(abnormal/unpleasant sensations)
Motor restlessness: patient is
compelled to move
Symptoms precipitated by rest and
relieved by activity: symptoms are
worse or exclusively present at rest
(i.e., sitting or lying with at least
partial and temporary relief by
activity
Symptoms worse in the evening or
at night
Associated Features
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Sleep disturbance and consequences:
difficulty initiating or maintaining
sleep; less commonly, excessive
daytime sleepiness
Involuntary movements during wake or
sleep (PLMS)
Normal neurologic exam in primary
RLS; in secondary forms, possible
evidence of neuropathy
Clinical course: onset any age, usually
chronic and progressive, remissions
may occur, can be exacerbated by or
exclusively during pregnancy
Family history: sometimes present;
suggestive of autosomal dominant
pattern
PSG : Quasi-periodic movements of
the legs during wakefulness with a
prolonged sleep latency. After sleep,
PLMs are noted in 70 –90% of
Patients
RLS
PLMs
Differential Diagnosis of RLS
• Neuropathy
• Claudication
• Painful toes and moving leg syndrome
(lumbrosacral radiculopathy)
• Neuroleptic akathesia
Causes and associations of
PLMs
Causes of RLS/PLMD
•Any cause of RLS
•Withdrawal of anti-convulsant,
barbiturates, hypnotics
•Associated with narcolepsy, OSA, CPAP
titration
Primary RLS
•Cause unknown
•? If there’s an abnormality in Fe (iron)
transport into the CNS or a defect in the
use of Fe as it relates to dopaminergic
neurons.
Secondary RLS
•Fe deficiency
anemia
•ESRD
•Pregnancy
•Medications
-caffeine
-SSRI’s
-TCA’s
-Dopamine blockers
Treatment options for RLS/
PLMs
• Nonpharmacologic-avoid etoh, caffeine, do
light stretching, exercise, warm baths
• Dopaminergic agents (ie, Sinemet)
-Treats PLMs and improves sleep quality
• Dopamine agonists
• Benzodiazepines
• Narcotics (usually reserved for severe
cases)
Patient Scenario #3
A 30 year old woman was evaluated for excessive
daytime sleepiness of 5 year duration. There was
no history of snoring or observed apnea. The
patient recalled having difficulty holding her head
up when she laughed or was embarrassed. The
patient’s husband reported that sometimes she
kicked the covers at night. Rarely, the patient felt
she could not move for a while as she was falling
asleep at night.
• Narcolepsy is related to
abnormal regulation of REM
sleep and inappropriate
intrusion of REM sleep
physiology into wakefulness.
• 1998 Hypocretin/orexin (2
peptides) secreted by the
hypothalamus and other brain
areas.
• 2 major pathways:
-hypothalamus
cortex
-hypothalamus Brain stem
-locus ceruleus- NE secreting
neurons important in
maintaining wakefulness
• 7 of 9 patients with
narcolepsy had low orexin
levels in their CSF.
• Other studies have shown
an absence of orexinsecreting neurons in the
hypothalamus
• Antigen DQB1* 0602 is
the most sensitive marker
for narcolepsy across all
ethnic groups
Narcolepsy is a Neurological
Disorder Characterized by:
Pathognomonic
Prevalence Symptoms
100%
70%
66%
Can be followed
years later by
the other SX’s
60%
Excessive daytime sleepiness (EDS); sleep
attacks
Cataplexy-loss of muscle tone during periods
of high emotion
Hallucinations: Hypnagogic (dreaming at sleep
onset)/hypnopompic (dreaming just after
awakening)
Sleep paralysis-loss of muscle tone at sleep
onset or on awakening
Disrupted nocturnal sleep
Automatisms
Narcolepsy
• Prevalence of disorder is .03 - .05% in the
general population
• Adolescence is the common age of onset
• Second peak at about 40 years of age
– (5% of cases start after age 50)
Secondary Narcolepsy
• Head Trauma
• Stroke
• MS
• Neurodegenerative
Disorders
• Brain tumors
• CNS infections
PSG Findings:
Short REM Latency (low sleep efficiency) Sleep
fragmentation; reduced slow wave sleep; +/- PLMs
Indications for a Multiple Sleep
Latency Test (MSLT)
• Unexplained hypersomnolence (sleepiness);
sleep apnea and other disorders.
• Narcolepsy: to confirm diagnosis and
determine the severity before stimulant
therapy.
• Insomnia with daytime sleepiness.
• Circadian rhythm disorders
MSLT
Testing
Consists of 4-5 naps at 2
hour intervals conducted
in the daytime
commencing 1.5-3 hours
after waking from the
PSG.
Scoring and Interpretation
A mean sleep latency of <5
minutes and 2 or more
naps with REM sleep.
Treatment of Narcolepsy
•Sleep hygiene
•Optimizing the amount of sleep
•If able, regularly schedule naps during the day (if restorative)
Tx of Daytime Sleepiness
• Stimulants are working to
increase the availability of
NE/DA
• Largest doses should be given 1
– 2 hours before the periods of
maximum sleepiness
methylphenidate
dextroamphetamine
selegiline
modafinil
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Tx of Cataplexy/Hallucinations
TCA’s
Venlafaxine (Effexor)
Tegretol
GHB (Xyrem)
Insomnia
Patient Scenario #4
A 30 year old Female is referred for complaints of
inability to sleep for more than 10 years. The patient
reports it usually takes her 2 to 3 hours to fall asleep
after going to bed. She also finds herself awakening 3
to 4 times during the night. She reports that it takes at
least 30 minutes to fall back asleep after each
awakening. Alcohol and over the counter medications
sometimes helped. During the day, fatigue, but not
definite sleepiness was noted. Her husband denied that
she snores, kicks, or jerks during sleep.
Sleep onset insomnia
Insomnia
Sleep maintenance insomnia
Early morning awakening
Non-restorative sleep
Common Causes of Insomnia
Primary Insomnia
• Psychophysiological
Acute (adjustment sleep
disorder)
Chronic
• Idiopathic
• Sleep state misperception
Secondary Insomnia
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Sleep disorders (sleep apnea,
PLMD, RLS)
Psychiatric disorder(depression,
panic attacks)
Inadequate sleep hygiene
Environmental sleep disorder
Drugs (nicotine, ethanol, caffeine)
Medical conditions/medications
o Fibromyalgia and chronic
pain syndromes
o COPD and other respiratory
disorders
o Medications (beta blockers,
theophylline)
o Circadian disorders
Delayed sleep phase syndrome
Advance sleep phase syndrome
Shift work or jet lag syndrome
Insomnia History
• Nature and Duration
of problem
• Sleep habits
– Time in bed, lights out,
sleep onset, wake time
– Bedroom environment
– Timing and duration of
naps
– Changes on weekends
• Effects of a new sleep
environment
(vacation)
• Medication/beverage
history
• Symptoms of
depression. History of
leg jerks, restless leg
syndrome, snoring,
apnea
Diagnosis of the cause of Insomnia based on:
•Careful History
•Review of Patient’s sleep diary
PSG: Typically normal and may not be beneficial unless
there’s a suspicion of another underlying sleep disorder
Or
Insomnia is severe and doesn’t respond to empiric
therapy.
Treatments for Insomnia
• Optimize sleep hygiene
• Behavioral techniques
relaxation therapy
stimulus control therapy
Sleep restriction therapy
Cognitive behavioral treatment
• Combined behavioral and pharmacological treatment
Benzodiazepines
BZ receptor agonists (ie ambien, sonata)
• Sedating anti-depressants
Patient Scenario #4A
-Same as previous patient. She averages 4 hours/night of
sleep with EDS
-On weekends able to sleep in and get 7 to 8 hours of
sleep and awake feeling refreshed.
Sleep Disorders Associated with
Alterations in Circadian Rhythm
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Delayed sleep phase syndrome
Advance sleep phase syndrome
Time zone change (jet lag) syndrome
Shift work sleep disorder
Irregular sleep wake pattern
Non-24-hour sleep –wake disorder
• Circadian rhythms are generated
by an internal pacemaker in the
suprachiasmatic nucleus (SCN) of
the hypothalamus
• The main role of the SCN is to
synchronize bodily functions with
the light – dark cycle.
Diagnosis: History
Sleep Diary
Treatment:
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Chronotherapy (progressive phase delay)
Bright light therapy
Melatonin
Short-acting hypnotics
Parasomnias: A motor, verbal, or
experiential phenomenon that
occurs during sleep and is often
undesirable
Differential Diagnosis of Unusual Behavior
Associated With Sleep
Diagnosis
Usual Sleep Stage
Normal Sleep Phenomena
Sleep starts (hypnic jerks)
Sleep onset
Nightmares (REM anxiety attacks)
REM>>NREM
Parasomnias
Sleep walking (somnabulism)
NREM
Sleep terrors
NREM
Confusional arousal
NREM
Sleep talking (somniloquy)
REM behavior disorder
NREM and REM
REM
Parasomnia overlap disorder
NREM and REM
Bruxism
NREM (stage 2)
Enuresis
NREM and REM (random)
Psychiatric Disorders
Panic attacks
NREM (transition stage 2 to stage 3)
Posttraumatic stress syndrome
REM and NREM
Seizure Disorders
Nocturnal seizures
NREM>Wake>REM
Possible seizure Disorders
Nocturnal paroxysmal dystonia
Episodic nocturnal wandering