1Andy Veale

Sleep Disorders: 

Sleep Disorders Andrew G Veale

What are the possible causes of this appearance?: 

What are the possible causes of this appearance? RLS Stimulant withdrawal Post ictal Narcolepsy OHS Inadequate sleep OSA

What are his likely co-morbid conditions?: 

What are his likely co-morbid conditions? Diabetes Hyperuricaemia Pulmonary hypertension Hypertension Prostatism Insulin resistance AF CHF cellulitis

What does this show?: 

What does this show?

What is this?: 

What is this?

What about this one?: 

What about this one?

And here?: 

And here?

Which of the following is not an airway dilator?: 

Which of the following is not an airway dilator? Genioglossus Stylohyoid Mylohyoid Geniohyoid Tensor palatini Superior pharyngeal constrictor Gubernaculum

Anatomy: 

Anatomy

Pathophysiology: 

Pathophysiology Abnormally narrowed airway Increased collapsibility Airway collapse – multi-level problem Palate, base of tongue, pharynx, supraglottis or all levels Increased effort Sympathetic outpouring Desaturation Arousal

Presentation: 

Presentation Patient complains of: Poor sleep quality Always tired Impotence Headaches Enuresis GE reflux Wife complains of: Snoring Apnoeas Mood changes Impotence Doctor should notice: Asleep in waiting room Difficult Hypertension Difficult diabetes Congestive cardiac failure Obesity Known associations (Hypothyroidism, Acromegally, Abnormal facies, Ehlers Danlos Syndr. Etc)

Epidemiology - Obstructive Sleep Apnea Syndrome: 

Epidemiology - Obstructive Sleep Apnea Syndrome Reference, Country Methods Subjects, N Age (yr) Criteria Prevalence, % Lavie (1983),163 Israel Questionnaire. PSG 1262 (m) 18-67 AI >10, symptomatic 1.0-5.9 Peter et al. (1985),164 Germany Questionnaire. PSG 354 (m) 25-55 AI >10, symptomatic 2.3 Telakivi et al. (1987),42 Finland Questionnaire. PSG 1939 (m) 30-69 Snoring, EDS, and RDI >10 0.4-1.4 Gislason et al. (1988),41 Sweden Questionnaire. PSG 3201 (m) 30-69 Snoring, EDS, and AHI >10 0.7-1.9 Cirignotta et al. (1989),156 Italy Questionnaire. PSG 1170 (m) 30-39 AI >10, symptomatic 0.2 – 1.0 40-59 AI >10, symptomatic 3.4 – 5.0 60-69 AI >10, symptomatic 0.5 – 1.1 Stradling & Crosby (1991),165 Great Britain Ambulatory oximetry recordings 893 (m) 35-65 ODI4 >20, symptomatic 0.3   ODI4 >10 1.0     ODI4 >5 4.6 Haraldsson et al. (1992),166 Sweden Questionnaire. PSG 846 (m) 30-69 History and PSG 2.8-5.5 Young et al. (1993),32 Wisconsin, USA PSG 352 (m) 30-60 RDI>5 Sleepy 4.0 250 (f) 30-60 RDI>5 Sleepy 2.0 Gislason et al.(1993),167 Iceland Questionnaire. PSG 2016 (f) 40-59 EDS, PSG >2.5 Olson et al. (1995),168 Australia Questionnaire home SS 1233 (m) 35-69 AHI ≥15 4-18   969 (f)  35-69 AHI ≥10 7-35     AHI ≥5 14-69 Bearpark et al. (1995),169 Australia MESAM IV 294 (m) 40-65 RD ≥10 10.0  Subjective EDS and RDI ≥5 ≥3.0 Gislason (1995),49 Iceland Questionnaire. PSG 555 children 6 mo to 6 yr Snoring or apnea & ODI4 > 3 >2.9 Esnaola et al. (1995),170 Spain Questionnaire. PSG 1077 (m) 30-70 AHI ≥5 15.3     AHI ≥10 13.4     AHI ≥5 and EDS 6.5-9.1 hayon et al. (1997),171 Great Britain Telephone (Sleep-EVAL) 2078 (m) 35-64 NA 2.4-4.6 2894 (f) 35-64 NA 0.8-2.2 Kripke et al. (1997),172 San Diego, US Telephone, oximeter, snoring 165 (m) 40-64 ODI4 >20 5.4-13.2 190 (f) 40-64 ODI4 > 20 2.1-8.3 Bixler et al. (1998),38 United States Telephone PSG (sample) 4364 (m) 20-100 AHI > 10 and clinical criteria All: 3.3

Symptoms, Risk Factors: 

Symptoms, Risk Factors Source: Random sample of 10,000 NZ adults aged 30-60 yrs, 71% response rate Data courtesy of Dr Ricci Harris

4% O2 Desaturations / Hour: 

4% O2 Desaturations / Hour Random sample from electoral roll, 30-60 years 169 Maori, 195 non-Maori Overnight MESAM4 monitoring at home Data courtesy of Kara Mihaere

Hypertension: 

Hypertension STUDY Age N RDI <1 RDI 1-4.9 RDI 5-14.9 RDI > 15 RDI >30 WSCS 30-65 709 1.0 1.2 2.0 2.9 SHHS 40-97 6132 1.0 1.1 1.2 1.3 1.4 S Penn 20-100 1741 2.3 6.9 Vitoria 30-70 552 1.0 2.5 1.3 2.3

Slide16: 

Figure 100-1 Ambulatory blood pressure during presleep, sleep, and postsleep by apnea-hypopnea index (AHI) category (the line with triangles shows AHI 5, number of patients = 537; the line with squares shows AHI &#8805; 5, number of patients = 231); Wisconsin Sleep Cohort Study. A shows systolic blood pressure and B shows diastolic blood pressure. Mean blood pressure values are adjusted for age, sex, and body mass index. Downloaded from: Principles and Practice of Sleep Medicine (on 4 August 2005 12:48 PM) © 2005 Elsevier

Hypertension treatment: 

Hypertension treatment Prospective study 420,000 over 10 years Reduction of BP Reduction in Stroke Reduction in CAD 5mHg 34% 21% 7.5mmHg 46% 29% 10mmHg 56% 37% CPAP reduction 5 – 10 mmHg

Slide18: 

Figure 100-2 Treatment with therapeutic continuous positive airway pressure (CPAP) decreased systemic blood pressure, whereas use of subtherapeutic CPAP failed to decrease blood pressure. (From Becker HF, Jerrentrup A, Ploch T, et al: Effect of nasal continuous positive airway pressure treatment on blood pressure in patients with obstructive sleep apnea. Circulation 2003;107:68-73.) Downloaded from: Principles and Practice of Sleep Medicine (on 4 August 2005 12:48 PM) © 2005 Elsevier

Pulmonary Hypertension: 

Pulmonary Hypertension Study N Criteria Prevalence Chaouat 220 AHI > 20 17% PAP > 20 Laks 100 AHI > 20 42%PAP > 20 (20-52) Sanner 92 AHI > 10 (10-100) 20% PAP > 20 8 had increased PCWP all were hypertensive Pre-capillary factors Hypoxia, hypercapnia, Intrathoracic pressure changes, Endothelial damage. Capillary factors Reduction of capillary bed from co-morbidities. Post-capillary factors Increased LVEDP

Atrial Fibrillation: 

Atrial Fibrillation Cardioverted patients with OSA Untreated - 82% recurrence @ 12 mths CPAP treated - 42% recurrence @ 12 mths Non OSA Pts - 53%

Sudden death: 

Sudden death 46% OSA patients die between 12mn and 8am 21% in people without OSA RDI >40 have a 40% greater risk of nocturnal death than RDI 5-39 5 to 7% risk in non snorers 12%risk in habitual snorers 20% risk in OSA OR 3.6 OR 1.4 in SHHS

Slide22: 

Figure 101-1 Incidence of cardiovascular disease during a 7-year follow-up in middle-aged men otherwise healthy at baseline. Fraction of individuals with incidence of cardiovascular disease, hypertension, coronary artery disease (CAD), and cardiovascular event (stroke, myocardial infarction [MI], or cardiovascular death). Depicted are data from patients without OSA (non OSA) as well as from those incompletely or efficiently treated for their sleep and breathing disorder. (Reprinted from Peker Y, Hedner J, Norum J, et al: Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: A seven-year follow-up. Am J Respir Crit Care 2002;166:159-165.) Downloaded from: Principles and Practice of Sleep Medicine (on 4 August 2005 12:48 PM) © 2005 Elsevier

Heart Failure: 

Heart Failure 40 – 80% LVF Patients have SDB 5-30% OSA 30-60% CSA SDB independent predictor of death in LVF Nasal CPAP increases EF Reduces sympathetic outflow Reduces inflammatory markers

Slide24: 

Figure 102-3 Effects of supplemental nasal oxygen on apnea-hypopnea index in patients with systolic heart failure. Downloaded from: Principles and Practice of Sleep Medicine (on 4 August 2005 12:49 PM) © 2005 Elsevier

Slide25: 

Figure 86-2 Intermediate pathways linking sleep apnea, glucose intolerance, and insulin resistance. Downloaded from: Principles and Practice of Sleep Medicine (on 4 August 2005 12:48 PM) © 2005 Elsevier

Slide26: 

Figure 96-2 The mechanisms by which sleep apnea may result in endothelial dysfunction and cerebrovascular and cardiovascular disorders. CBF, coronary/cerebral blood flow; Do2, oxygen delivery; HPT, hypertension; &#8593;, increase; &#8595;, decrease. (Adapted from Javaheri S: Heart failure and sleep apnea: Emphasis on practical therapeutic options. Clin Chest Med 2003;24:207-222.) Downloaded from: Principles and Practice of Sleep Medicine (on 4 August 2005 12:48 PM) © 2005 Elsevier

Treatments: 

Treatments Improve the upper airway Nasal steroid / anti-histamine Nasal surgery Tonsillectomy Conservative treatment Weight loss, stop smoking, stop drinking, sleep apart Nasal CPAP Dental devices Surgery UPPP, LAUP. Tracheostomy Maxillofacial surgery Novel Approaches RF Tissue reduction Injected sclerosants Singing

Normal Sleep: 

Normal Sleep Non-REM Stage 1 Onset theta activity slow rolling eye movements Stage 2 Spindles and K complexes Stage 3 Delta waves (Slow waves) Stage 4 More delta waves REM Periodicity Circadian rhythm Quantum of sleep

Sleep Stages: 

Sleep Stages

Sleep stages: 

Sleep stages

Abnormal Sleep: 

Abnormal Sleep Disorders of the initiation & maintenance of sleep (DIMS) Insomnia 1o or 2o (medical / psychiatric conditions) PAS PDS Disorders of excessive sleepiness (DOES) Not enough Obstructive sleep apnoea Narcolepsy RLS/PLMS Abnormal behaviors during sleep (Parasomnias) NREM Sleep walking/talking/night terrors REM REM Behavior disorder

Easy: 

Easy

30 year old man with sleepiness and episodes of dropping thingsY/N: 

30 year old man with sleepiness and episodes of dropping things Y/N He will have HLA DQB1*0602 His identical twin will have the same disorder He will have low hypocretin levels in CSF He will have high orexin CSF levels He should be treated with clonazepam Modafinil is firstline treatment His MSLT shows 2 SOR periods does this mean Narcolepsy

70 year old man present with abnormal bed movements. His wife is frightened.: 

70 year old man present with abnormal bed movements. His wife is frightened. He has OSA with arousals He has a slow wave parasomnia He has nocturnal frontal lobe epilepsy He will respond to clonazepam Ropinerol has less side effects than pergolide He should stop using viagra

40 year woman on dialysis. Can’t sleep doctor: 

40 year woman on dialysis. Can’t sleep doctor She needs treatment with a sleeping tablet She should have her iron level measured She needs her renal replacement adjusted She may have recently started an SSRI for the depression that “was causing her sleepiness. She may benefit from Sinemet One of her treatments has been shown to cause valvular heart disease

22 year old comes with complaints of being fired from his job having crashed his car.: 

22 year old comes with complaints of being fired from his job having crashed his car. He is likely to go to bed late. He will have lots of SWS He needs a alarm on the morning His body temperate will be lowest about 6am He needs morning bright light exposure He needs night bright light exposure at 7pm He should be exposed with red light He is normal

Slide37: 

Question 1. Last night your teenage son set his alarm for 7:00 am. This morning he woke up at 10:00 am. Which of the following explanations is likely? He had actually set the alarm for 7:00 pm instead of 7:00 am. He woke up at 7:00 am, went to the school bus stop, returned home, and then went back to sleep and forgot. He did not wake up when the alarm went off at 7:00 am because his arousal threshold was too high. His alarm went off at 7:00. He woke up and turned the alarm off and fell right back to sleep. When he woke up at 10:00, he forgot that he had turned off the alarm.