1. Sleep Disorders MODULE F

2. Types of Sleep Disorders Obstructive Sleep Apnea Central Sleep Apnea Mixed Hypopnea

3. Polysomnography Early 1980’s sleep disorders were acknowledged by the medical community. Sleep apnea Apnea during sleep for periods of 10 seconds or longer with an apnea index of 5/hour. Patient often has 30 or more episodes over a 4-6 hour period. Apnea may last 20 – 90 seconds.

4. Hypopnea Decreased rate and depth of breathing. Monitor Respiratory Disturbance Index (RDI). Number of respiratory events per hour of sleep Includes both apneas and hypopneas. Usually 10 – 15 events/hour is significant.

6. Stages of Sleep 5 stages of sleep Non-Rapid eye movement (Non-REM) Stages 1-4 Quiet or slow wave sleep Rapid eye movement (REM) Stage 5 Active or dreaming sleep

7. Stages of Sleep Each stage is associated with characteristic: Electroencephalographic (EEG) Patterns Electro-oculographic Patterns (EOG) Electromyographic Patterns Behavioral Patterns Breathing Patterns

8. Non-REM Sleep 4 Stages Each progressing into a deeper sleep Lasts 60 – 90 minutes Most of the time is spent in phase 2

9. REM Sleep – Stage 5 Burst of fast alpha rhythms in the EEG tracing. Respiratory rate decreases and Vt becomes shallow. Hypoventilation and apnea. Decrease in both the hypoxic and hypercapnic ventilatory response during REM. Constitutes 20 – 25% of sleep time.

10. REM Sleep Rapid eye movement. HR becomes irregular. Dreaming occurs. Paralysis of movement. Arms, legs, intercostal & upper airway muscles. Loss of muscle tone in the upper airway results in airway obstruction.

11. REM Sleep REM lasts 5 – 40 minutes and recurs every 60 –90 minutes. More difficult to awake a person in REM.

12. 40 Million People Suffer from Abnormal Sleep Narcolepsy Parasomnias Nocturnal leg cramps (restless leg syndrome) REM Behavior Disorders Insomnia Sleep Apnea

13. Polysomnography Overnight test done in a sleep clinic. 6 ½ to 7 hours Multiple monitors are used to assess the patient. Patients are often videotaped.

14. Monitoring Respirations (nasal air-flow) SpO 2 Respiratory Effort Inductive plethysmography or esophageal balloon Brain wave activity Eye movement – electro-oculogram Heart activity Body position

20. Summary of Results # of apneas and hypopneas are summed and averaged over the night-time to calculate the average number of respiratory disturbances per hour. Respiratory Disturbance Index SpO 2 levels below 85% are indicative of sleep apnea.

21. Consequences of Sleep Apnea Increase MVA’s Increase work related accidents Poor job performance Depression/Inability to concentrate Family Discord Decreased quality of life

22. Obstructive Sleep Apnea Most common of the sleep apneas. Partial or complete obstruction of the upper airway during sleep. Absence of airflow at the nose/mouth but inspiratory efforts are present; O 2 desaturation. Can develop Cor Pulmonale.

25. Obstructive Sleep Apnea Symptoms Loud habitual snoring, choking/gasping/snorts Morning headaches Daytime sleepiness (hypersomnolence) Obesity Hypertension Nocturnal enuresis Impotence Personality changes/depression

27. Obstructive Sleep Apnea Profile Upper body obesity Neck size #17 or larger in men Neck size #16 or larger in women Hypertension C/O daytime sleepiness

28. Pickwickian Syndrome Obesity Excessive daytime sleepiness Sleep apnea Decreased pulmonary function Chronic ventilatory failure Hypoxic drive

29. Central Sleep Apnea Respiratory centers of the medulla fail to send signals to the respiratory muscles Cessation of airflow at the nose and mouth, no inspiratory efforts & desaturation of Hb Associated with CNS disorders Accounts for 10% of all sleep apneas

32. Mixed Apnea Combination of Obstructive and Central Begins as central apnea followed by obstructive apnea Down’s Syndrome

35. Hypopnea No apnea Decreased depth and rate of breathing

36. Screening History Examination of neck and upper airway Spirometry – flow volume loop ABG Hb Thyroid Function Chest x-ray EKG Sleep Study CT scan of upper airway or head

38. General Management Weight Reduction Behavior modification Avoid alcohol, sedation, smoking Sleep Posture Oxygen therapy Oral Appliance

39. General Management Surgical Procedures Laser-assisted Uvulopalatopharynoplasty (LAUP) or UPPP Mandibular advancement Nasal operation Tonsillectomy Tracheostomy

41. General Management Non-invasive Ventilation CPAP – most frequently prescribed therapy BiPAP NPV – Central Apnea Continuous mechanical ventilation Medication – REM Inhibitors Phrenic Nerve Pacemaker – Central Apnea