1. 1 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Chapter 19 Assessment of Sleep and Breathing

2. 2 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives After reading this chapter you will be able to:  Describe the RT’s role in assessment of patients for sleep-disordered breathing  Identify the number of Americans affected by sleep disorders  Describe expected findings in assessment of patients with sleep-disordered breathing

3. 3 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Explain correlation between sleep apnea, snoring, and excessive daytime sleepiness  List the criteria used with the Epworth Sleepiness Scale and the Berlin Questionnaire surveys in assessing the presence of a sleep disorder

4. 4 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe normal stages of sleep with associated physiological changes in the cardiopulmonary system  List clinical and assessment criteria for obstructive, central, and mixed sleep apnea  Describe the role of a polysomnogram in providing a differential diagnosis for sleep- disordered breathing

5. 5 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Learning Objectives (cont’d)  Describe typical physiologic parameters monitored on a polysomnogram montage  List criteria to classify sleep apnea as mild, moderate, or severe  Identify the symptoms and assessment characteristics for children with sleep apnea

6. 6 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction  Approximately 40 million Americans have sleep disorders  Almost half of these have sleep apnea  RTs should be able to recognize symptoms of sleep disorders  RTs comprise a major portion of the workforce performing polysomnograms (PSGs)

7. 7 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction (cont’d)  Sleep is composed of two phases  Non–rapid eye movement (NREM )  Rapid eye movement (REM)  NREM sleep is made up of three phases; each representing progressively deeper stages of sleep

8. 8 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction (cont’d)  Sleep varies between NREM and REM in 60- to 90-minute cycles  NREM  Restorative sleep  Occupies about 75% of sleep cycle  Stage 3 NREM is associated with: Increased Pa CO 2 (2-4 mm Hg) Decreased V E (13% to 15%) Decreased BP (8% to 14%)

9. 9 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Introduction (cont’d)  REM  Dreaming occurs  Skeletal muscle semiparalysis This further reduces V E ; may be associated with hypoxemia and hypercapnia May result in upper airway obstruction  Heart rate varies and arrhythmias are seen  BP becomes variable and elevated compared with NREM

10. 10 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment of Sleep-Disordered Breathing (SDB)  Physical exam results are nonspecific and often unremarkable; patients commonly present with:  Obesity  Symptoms of excessive daytime sleepiness  CHF in severe cases

11. 11 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment of Sleep-Disordered Breathing (SDB) (cont’d)  Patient/family interview commonly reveals:  Sleep apnea: cessation of airflow for >10 seconds Excessive daytime sleepiness (EDS) and excessive snoring are the two most common signs of SDB and apnea

12. 12 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment of Sleep-Disordered Breathing (SDB) (cont’d)  Epworth Sleepiness Scale (ESS) assesses EDS  Essential for initial screening of sleep disorders  Composed of 8 questions Each rated 0 to 3 on chance of dozing Score of >9, patient should see sleep specialist

13. 13 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Assessment of Sleep-Disordered Breathing (SDB) (cont’d)  Berlin Questionnaire identifies sleep apnea risk factors  10 items in three categories  High risk of sleep apnea if qualify in two categories

14. 14 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Polysomnography (PSG)  Diagnostic sleep study: provides tracings of various physiologic parameters  Four EEG tracings: identify NREM/REM sleep  Right and left eye movement  Chin movement or tension  Right and left leg movement  Snoring and airflow  Thoracic and abdominal movement  Sp O 2 and heart rate  Body position

15. 15 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

16. 16 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Classifying Sleep Apnea  Apnea-hypopnea Index (AHI) defines number of hypopneas and apneas per hour of sleep time  AHI classifies sleep disorder severity  Normal: AHI <5  Mild SDB: AHI of 5-20  Moderate: AHI of 20-40  Severe:AHI >40

17. 17 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Obstructive Sleep Apnea (OSA)  Etiology of OSA is anatomic and may include:  Enlarged tonsils, macroglossia, micrognathia, deviated septum, or retrognathia When tied with paralysis of REM complete or partial airway obstruction may occur

18. 18 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Obstructive Sleep Apnea (OSA) (cont’d)  OSA occurs when obstruction prevents airflow into the lungs while the efforts to breathe continue  The Sa O 2 will fall causing EEG arousal, which causes the patient gasp and sit up

19. 19 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

20. 20 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

21. 21 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Central Sleep Apnea (CSA )  Sleep apnea with lack of effort for >10 seconds due to a lack of central drive to breathe  <10% of all adults with SDB

22. 22 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Central Sleep Apnea (CSA) (cont’d)  Etiology of CSA is complex but may include:  Stroke or brainstem lesion  Encephalitis or neurodegeneration  Radiation treatments to the cervical spine  CHF

23. 23 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Central Sleep Apnea (CSA) (cont’d)  Signs and symptoms of CSA include:  Lack of restorative sleep, frequent awakenings  Often associated with neurologic issues Difficulty swallowing Change in voice Body weakness/numbness  Common sign is Cheyne-Stokes breathing Periods of waxing and waning breathing with apneas  Each cycle lasts from 30 seconds to 2 minutes

24. 24 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Mixed Sleep Apnea (MSA)  Combines aspects of OSA and CSA  Without a PSG study MSA is virtually impossible to detect  Often the PSG study shows CSA first followed by OSA  Once CPAP pressures are adequate to prevent OSA events then the CSA can be addressed

25. 25 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Polysomnography  PSG results establish and differentiate between types of SDB  OSA shows no airflow while respiratory efforts continue and then a sudden arousal  CSA shows a lack of airflow and respiratory effort  MSA reflects episodes of CSA and OSA

26. 26 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Sleep Apnea in Children  Children and infants with OSA  Primary symptom is snoring  Presentation may confuse parents/teachers Sleepy or hyperactive, and social withdrawal Poor attention span and academic performance Aggressive behavior  Common in premature infants (<37 wk gestation)  SIDS may be due to CSA but no evidence to support

27. 27 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Summary  Sleep apnea a common problem in the United States  Obesity is the most common cause of obstructive sleep apnea  RTs are employed in sleep labs to perform polysomnograms as part of the sleep assessment process

28. 28 Mosby items and derived items © 2010 by Mosby, Inc., an affiliate of Elsevier Inc. Summary  Patients with severe sleep apnea obtain very little restorative sleep at night and are at high risk for accidents related to excessive daytime sleepiness  The RT will help identify the best level of CPAP during sleep to eliminate OSA