1. Sleep Disorders Part II - Hypersomnia Amr A. Jamal, MBBS Family Medicine Senior Resident Department of Family and Community Medicine King Abdulaziz Medical City Riyadh, Saudi Arabia

2. Differential Diagnosis Hypersomnia Intrinsic Causes Narcolepsy Recurrent Hypersomnia Syndrome Menstrual-related Hypersomnia Idiopathic Hypersomnia Post-traumatic Hypersomnia Sleep apnea syndromesPLMS Extrinsic CausesCircadian Rhythm DisordersMedical DisordersPsychiatric DisordersMedication Related

3. Obstructive Sleep Apnea

4. Key points The most common respiratory condition Prevalence: 2% of middle aged men 1% of middle aged women Cardinal symptoms: Snoring excessive daytime sleepiness Witnessed apneas Major risk factor for RTA Risk factor for HTN It is Treatable

5. Knowledge and attitude of primary health care physicians towards OSA in Riyadh 40% felt that sleep disorders are common medical problems based on their practice Recognition of consequences of OSA motor vehicle accidents (63%) ischemic heart disease (40%) hypertension (50%) pulmonary hypertension (13%)

6. What is it? Apneas may be “central”, in which there is cessation of inspiratory effort “obstructive”, in which inspiratory efforts continue but are ineffective because of upper airway obstruction.

7. What is it? obstruction occurs at the pharyngeal level due to the dilator muscles relaxing Obeseity micro- or retrognathia pharyngeal obstruction leads to: Asphyxia drop in arterial oxygen saturations rise in PaCO 2 levels intrathoracic pressure swings as inappropriate

8. What is it? arousal sufficient to increase the pharyngeal tone and re-opens the airway sudden inflow of air rise in oxygen saturations This cycle then often repeats almost immediately leading to fragmented and unrefreshing sleep difficulty concentrating at work or while driving

9. What is it? repetitive narrowing and closure of the pharynx during sleep sleep fragmentation and repeated oxygen desaturations Excessive somnolence Impaired alertness Poor cognition.

10. Who gets it? More in men Snores Overweight Genetic acquired

11. Prevalence 2-3% of Children 4-7 % of Middle Aged Adults 10-15% > 65 years The prevalence is likely to rise as obesity rates continue to increase.

12. Risk factors Major risk factors Being a middle aged man overweightsnoringcollar size >43 cm craniofacial abnormalities minor risk factors Large tonsilsHypothyroidismNeuromuscular diseaseneuron disease Rare causes MucopolysaccharidosesAcromegalyCushing's syndromeMarfan's syndromeDown's syndrome.

13. Snoring Snoring is common and may be a serious medical problem. The family doctor and his team should be aware of the condition, using simple screening test such as ESS, improves the patient care, and finding of suspected cases.

14. How is my sleep? Epworth Sleepiness Scale Never High Chance 1. Sitting and Reading 0123 2. Watching T.V. 0123 3. Sitting, inactive in a public place (e.g. Theatre or a Meeting) 0123 4. As a passenger in a car for an hour without a break 0123 5. Lying down to rest in the afternoon when circumstances permit 0123 6. Sitting and talking to someone 0123 7. Sitting quietly after a lunch without alcohol 0123 8. In a car, while stopped for a few minutes in the traffic 0123 A total score of 10 or more suggests that you may need further evaluation by a physician to determine the cause of your excessive daytime sleepiness and whether you have an underlying sleep disorder

15. Hypoxic Periodic Breathing

16. http://www.sleepeducation.com

17. How should I diagnose it? Excessive sleepiness, measured by the Epworth Sleepiness Score (>9 is abnormal, >15 is severely abnormal) Loud snoring, witnessed apnoeas, and choking noises Feeling unrefreshed on waking Poor concentration Mood swings, personality changes, or depression Nocturia. Less common symptoms are: Nocturnal sweating Reduced libido Oesophageal reflux.

19. Examination Neck circumference Oropharynx Teeth Nasal patency Respiratory function Blood pressure Evidence of endocrine abnormalities Evidence of neuromuscular disorders Evidence of heart failure

20. Investigations Routine haematology and biochemistry Thyroid function tests Cholesterol, fasting triglycerides, glucose, and folate Arterial or capillary blood gas

21. Sleep studies

22. Overnight oximetry

24. Respiratory polysomnography Limited sleep studies assess some or all of: Snoring Body movements Heart rate Oro-nasal flow Chest and abdominal movements Leg movements.

25. Full polysomnography in addition to the above: EEG electro-oculogram EMG

26. Proforma for assessing patients who snore Sleepiness Does the patient feel sleepy? Major symptoms Does the patient have one or more of: Witnessed apneas? Choking during sleep? Obesity Minor symptoms Does the patient have two or more of: Hearing the end of their own snore? Having to sleep sitting up? Nocturia? may need to be referred

27. Medical History Have possible respiratory failure awake hypoxia (SaO 2 <94%), ankle oedema professional driver whose job is at risk.

28. How should I treat it? Not all patients with OSA need treatment Determine treatment upon: significant daytime symptoms that warrant intervention patient's occupation Patient’s desire severity of their condition determined by a sleep study

30. A 40 year old man presents with snoring of new onset. Which one of the following statements is correct? Excessive alcohol intake is not relevant A neck circumference of >17 inches carries a low risk of obstructive sleep apnoea Testing thyroid function would not be useful You should consider carrying out an Epworth Sleepiness Score You should refer the patient to a sleep specialist for a full polysomnography

31. Which one of the following statements about obstructive sleep apnoea is correct? Tracheostomy is not beneficial Vivid disturbing dreams are a prominent feature of this disorder The problem is caused by absent or reduced ventilatory drive due to an abnormality in the brainstem Rare causes of obstructive sleep apnoea include acromegaly It is a rare disorder that usually affects women

32. Which one of the following statements is correct about investigating patients with obstructive sleep apnea? Referral to an ENT surgeon is essential An arterial blood gas often shows daytime hypercapnia Overnight oximetry is all that is required to diagnose obstructive sleep apnoea A fasting glucose level and cholesterol level may be helpful Full lung function tests are always needed

34. Which one of the following statements about mandibular advancement splints is correct? They are safe if the patient has poorly controlled epilepsy They are useful for treating snoring They are available only from sleep clinics They are effective at controlling severe obstructive sleep apnoea