Sleep Disorders MODULE F Types of Sleep Disorders

Sleep Disorders MODULE F

Types of Sleep Disorders • • Obstructive Sleep Apnea Central Sleep Apnea Mixed Hypopnea

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.

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.

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

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

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

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.

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.

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

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

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.

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

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 • Sp. O 2 levels below 85% are indicative of sleep apnea.

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

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.

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

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

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

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

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

Hypopnea • No apnea • Decreased depth and rate of breathing

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

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

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

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