Presentation on theme: "Patient Scenario #1 A 45 year old man sought treatment of his snoring, which had been present for many years. His wife slept in another room because the."— Presentation transcript:
1 Obstructive Sleep Apnea and Other Causes of Excessive Daytime Sleepiness
2 Patient Scenario #1A 45 year old man sought treatment of his snoring, which had been present for many years. His wife slept in another room because the snoring “shook the walls”. The patient reports excessive sleepiness (Epworth sleepiness scale score 18/24. Normal is 10 or less), morning headaches and problems concentrating at work. He admits to drinking more than five cups of coffee daily. There was no history of recent weight gain or alcohol use.
3 The Physical Examination Height: 5 feet 10 inchesWeight: 190 pounds; Blood Pressure: 150/90Neck 18 inch circumferenceHEENT: long, edematous uvula, dependent palate (low lying)Chest: clearCardiac: normalExtremities: no edema
4 What is The Next Step?Sleep Apnea is the most common cause of excessive daytime sleepiness and snoring, but there are many other disorders that must be carefully considered.
5 Evaluating Causes of Excessive Daytime Sleepiness (EDS) DisordersEvaluationAll CasesSleep Apnea SyndromesUpper airway resistance syndromesNarcolepsyPeriodic leg (limb)movements in sleepRestless leg SyndromeCircadian Sleep DisordersInsomniaWithdrawal from StimulantsDrug dependence/AbuseMedication side effectsIdiopathic HypersomniaBrain tumorsParasomniasHistorySelf-rating scale of SleepinessSleep-wake diaryPolysomnographySelected CasesMSLTDrug Screen
6 Epworth Sleepiness Scale: Measures average sleep propensity (chance of dozing) over 8 common situations that almost everyone encounters.SituationChance of DozingSitting and readingWatching T.V.Sitting inactive in a public place (i.e., theater, meeting)As a passenger in a car for 1 hour without a breakLying down to rest in the afternoon when circumstances permitSitting talking to someoneSitting quietly after lunch without alcoholIn a car while stopped for a few minutes in trafficTotal0-30-24 (0-10 normal)3= High chance of dozing; 2=moderate; 1=slight; 0=never
7 Stanford Sleepiness Scale: Measures subjective feelings of sleepiness Feeling active and vital; alert, wide awakeFunctioning at a high level, but not peak, able to concentrateRelaxed, awake, not at full alertness, responsiveA little foggy, not at peak, let downFogginess, beginning to lose interest in remaining awake, slowed downSleepiness, prefer to be lying down, fighting sleep, woozyAlmost in reverie, sleep onset soon, lost struggle to remain awake1234567
8 Obstructive Sleep Apnea (O.S.A) OSA is a common disorder occurring in 4% of men and 2% of women.During sleep, closure of the upper airway results in cessation or diminished airflow despite continued respiratory effort. The termination of the apneic event is associated with a brief awakening.These arousals result in sleep fragmentation which reduces the amount of slow wave and REM sleep and causes varying degrees of daytime sleepiness.
9 Risk Factors for Sleep Disordered Breathing Excess body weightLarge neck circumferenceMale genderEthnicityAgeMenopauseAnatomy of airway=soft and hard palate.
10 Indicators for a Polysomnography (PSG) Suspicion of disorders that disturb sleep like sleep apnea, periodic limb disorder, REM behavior disorderEDSObesityInsomnia with daytime sleepinessNocturnal behavioral disorders
11 PolysomnographyMultiple physiologic parameters are measured and compared with the established norms.Electrocardiography (EKG)Electroencephalography (EEG)Electro-oculography (EOG)Electromyography (EMG)Pulse OximetryRespiration:-Effort (chest and abdominal movements)-AirflowSnore sensor/microphoneHeat sensors measure airflow by detecting temperature changes in inspired and expired air*Sleep conditions in the laboratory should be as close to the patients baseline sleep as possible.
12 Human Sleep Architecture WakeNREM sleepStages 1 and 2 (light sleep)Stages 3 and 4 (deep sleep)REM sleep*Recognition of certain characteristic EEG patterns is essential for staging sleep
13 Electroencephalographic Lead Placement CentralOccipitalMastoid*More electrodes can be added if nocturnal seizure is in the differential
14 Monitoring Eye Movements Standard : 2 eye channelsDetecting horizontal/vertical eye movementsDetermining various stages of sleep
15 Electromyography (EMG) Diagnosis of Periodic Limb Movements(PLMS)Chin movementDiagnosis of certain sleep stages
16 Monitoring Respiration During Sleep Apnea – cessation of airflow at the nose and mouth for 10 seconds or longerCentral Apnea – an absence of inspiratory effortObstructive Apnea – absence of airflow despite persistent respiratory effortMixed Apnea – initially no inspiratory effort…then terminates as an obstructive eventHypopnea – reduction in airflow by 30% from baseline for > 10 seconds with > 4 % drop in oxygen saturation (controversial)Respiratory Effort Related Arousals(RERAs) – an event not meeting the above criteria, yet produces an arousal from sleep.
17 Important Sleep Parameters on PSG Sleep stages (percentage)Sleep efficiencyApnea Hypopnea index (AHI), Respiratory Disturbance Index (RDI), paradoxical respiration; desaturations and cardiac arrhythmias
19 Diagnosis of OSAThe Apnea + Hypopnea Index (AHI) a.k.a Respiratory Disturbance Index (RDI) = The Number of Apneas + hypopneas Per Hours of Sleep
20 Treatment of OSA Obesity- Diet and behavior modification Positional Therapy-non-supine sleep (pillow, etc.)-raise the head of the bedNasal CPAP, BiPAP, Auto CPAPOral appliancesSoft tissue surgery or UPPP (Uvulopalatopharyngoplasty)Skeletal surgeryTracheotomy
21 Significance of Sleep Disordered Breathing Risk factor for strokeRisk factor for cardiac arrhythmiasRisk factor for CAD and M.I.Risk factor for pulmonary hypertension and right heart dysfunctionCause of hypertension
22 Patient Scenario #2A 40 year old man was referred because his wife complained that he kicked in his sleep and constantly disturbed her. The patient remembered awakening several times each night, but never noticed any discomfort at those times. He admitted that at bedtime he did have an irresistible urge to move his legs and he described a feeling of “pins and needles.” However this delayed his sleep only rarely. His Epworth Sleepiness Scale was 15/24 (sleepy).PSG shows: Periodic leg movements in sleep (PLMS) – 20% of these events were associated with arousals.
23 Periodic Leg Movement in Sleep (PLMS) PLMS are repetitive, stereotypic dorsiflexion movements of the toes, ankles, knees and thighs that recur at regular intervals. They occur most commonly in stages 1 and 2 but can occur less commonly in other stages. Patients are rarely aware of the leg movements themselves and complaints are usually from bed partners.
24 Periodic Leg Movement Disorder PLMD This is a syndrome of leg movements + symptoms (ie. insomnia or excessive daytime sleepiness.This is a polysomnographic diagnosis; but, it is often incorrectly used interchangeably with Restless Leg Syndrome.International Classification of Sleep Disorders Criteria for PLMS SeveritySeverityPLM Index/HourPLM Arousal Index/HrMild5 - 24Not specifiedModerateSevere> 50> 25/ hour
25 Restless Leg Syndrome (RLS) Characterized by abnormal and uncomfortable sensations in the limbs that compel the person to move to relieve the sensation and these movements are exacerbated by rest. The symptoms occur primarily in the evening or at night.
26 International RLS Study Group Criteria for Diagnosis of RLS Primary FeaturesAssociated FeaturesUnpleasant limb sensations: desire to move the limbs usually associated with paresthesias/dysesthesias (abnormal/unpleasant sensations)Motor restlessness: patient is compelled to moveSymptoms precipitated by rest and relieved by activity: symptoms are worse or exclusively present at rest (i.e., sitting or lying with at least partial and temporary relief by activitySymptoms worse in the evening or at nightSleep disturbance and consequences: difficulty initiating or maintaining sleep; less commonly, excessive daytime sleepinessInvoluntary movements during wake or sleep (PLMS)Normal neurologic exam in primary RLS; in secondary forms, possible evidence of neuropathyClinical course: onset any age, usually chronic and progressive, remissions may occur, can be exacerbated by or exclusively during pregnancyFamily history: sometimes present; suggestive of autosomal dominant pattern
27 PSG : Quasi-periodic movements of the legs during wakefulness with a prolonged sleep latency. After sleep, PLMs are noted in 70 –90% of PatientsPLMsRLS
28 Differential Diagnosis of RLS NeuropathyClaudicationPainful toes and moving leg syndrome (lumbrosacral radiculopathy)Neuroleptic akathesia
29 Causes and associations of PLMs Any cause of RLSWithdrawal of anti-convulsant, barbiturates, hypnoticsAssociated with narcolepsy, OSA, CPAP titrationCauses of RLS/PLMDPrimary RLSSecondary RLSFe deficiency anemiaESRDPregnancyMedications-caffeine-TCA’sCause unknown? If there’s an abnormality in Fe (iron) transport into the CNS or a defect in the use of Fe as it relates to dopaminergic neurons.-SSRI’s-Dopamine blockers
30 Treatment options for RLS/ PLMs Nonpharmacologic-avoid etoh, caffeine, do light stretching, exercise, warm bathsDopaminergic agents (ie, Sinemet)-Treats PLMs and improves sleep qualityDopamine agonistsBenzodiazepinesNarcotics (usually reserved for severe cases)
31 Patient Scenario #3A 30 year old woman was evaluated for excessive daytime sleepiness of 5 year duration. There was no history of snoring or observed apnea. The patient recalled having difficulty holding her head up when she laughed or was embarrassed. The patient’s husband reported that sometimes she kicked the covers at night. Rarely, the patient felt she could not move for a while as she was falling asleep at night.
32 7 of 9 patients with narcolepsy had low orexin levels in their CSF. Narcolepsy is related to abnormal regulation of REM sleep and inappropriate intrusion of REM sleep physiology into wakefulness.1998 Hypocretin/orexin (2 peptides) secreted by the hypothalamus and other brain areas.2 major pathways:-hypothalamus cortex-hypothalamus Brain stem-locus ceruleus- NE secreting neurons important in maintaining wakefulness7 of 9 patients with narcolepsy had low orexin levels in their CSF.Other studies have shown an absence of orexin-secreting neurons in the hypothalamusAntigen DQB1* 0602 is the most sensitive marker for narcolepsy across all ethnic groups
33 Narcolepsy is a Neurological Disorder Characterized by: PathognomonicPrevalenceSymptoms100%70%66%60%Excessive daytime sleepiness (EDS); sleep attacksCataplexy-loss of muscle tone during periods of high emotionHallucinations: Hypnagogic (dreaming at sleep onset)/hypnopompic (dreaming just after awakening)Sleep paralysis-loss of muscle tone at sleep onset or on awakeningDisrupted nocturnal sleepAutomatismsCan be followed years later by the other SX’s
34 NarcolepsyPrevalence of disorder is % in the general populationAdolescence is the common age of onsetSecond peak at about 40 years of age(5% of cases start after age 50)
35 Secondary Narcolepsy Head Trauma Stroke MS Neurodegenerative Disorders Brain tumorsCNS infectionsPSG Findings:Short REM Latency (low sleep efficiency) Sleep fragmentation; reduced slow wave sleep; +/- PLMs
36 Indications for a Multiple Sleep Latency Test (MSLT) Unexplained hypersomnolence (sleepiness); sleep apnea and other disorders.Narcolepsy: to confirm diagnosis and determine the severity before stimulant therapy.Insomnia with daytime sleepiness.Circadian rhythm disorders
37 MSLT Scoring and Interpretation Testing Consists of 4-5 naps at 2 hour intervals conducted in the daytime commencing hours after waking from the PSG.A mean sleep latency of <5 minutes and 2 or more naps with REM sleep.
38 Treatment of Narcolepsy Sleep hygieneOptimizing the amount of sleepIf able, regularly schedule naps during the day (if restorative)Tx of Daytime SleepinessStimulants are working to increase the availability of NE/DALargest doses should be given 1 – 2 hours before the periods of maximum sleepinessmethylphenidatedextroamphetamineselegilinemodafinilTx of Cataplexy/HallucinationsTCA’sVenlafaxine (Effexor)TegretolGHB (Xyrem)
39 Insomnia Patient Scenario #4 A 30 year old Female is referred for complaints of inability to sleep for more than 10 years. The patient reports it usually takes her 2 to 3 hours to fall asleep after going to bed. She also finds herself awakening 3 to 4 times during the night. She reports that it takes at least 30 minutes to fall back asleep after each awakening. Alcohol and over the counter medications sometimes helped. During the day, fatigue, but not definite sleepiness was noted. Her husband denied that she snores, kicks, or jerks during sleep.
41 Common Causes of Insomnia Primary Insomnia Secondary InsomniaPsychophysiologicalAcute (adjustment sleep disorder)ChronicIdiopathicSleep state misperceptionSleep disorders (sleep apnea, PLMD, RLS)Psychiatric disorder(depression, panic attacks)Inadequate sleep hygieneEnvironmental sleep disorderDrugs (nicotine, ethanol, caffeine)Medical conditions/medicationsFibromyalgia and chronic pain syndromesCOPD and other respiratory disordersMedications (beta blockers, theophylline)Circadian disordersDelayed sleep phase syndromeAdvance sleep phase syndromeShift work or jet lag syndrome
42 Insomnia History Nature and Duration of problem Sleep habits Time in bed, lights out, sleep onset, wake timeBedroom environmentTiming and duration of napsChanges on weekendsEffects of a new sleep environment (vacation)Medication/beverage historySymptoms of depression. History of leg jerks, restless leg syndrome, snoring, apnea
43 Diagnosis of the cause of Insomnia based on: Careful History Review of Patient’s sleep diaryPSG: Typically normal and may not be beneficial unless there’s a suspicion of another underlying sleep disorderOrInsomnia is severe and doesn’t respond to empiric therapy.
44 Treatments for Insomnia Optimize sleep hygieneBehavioral techniquesrelaxation therapystimulus control therapySleep restriction therapyCognitive behavioral treatmentCombined behavioral and pharmacological treatmentBenzodiazepinesBZ receptor agonists (ie ambien, sonata)Sedating anti-depressants
45 Patient Scenario #4A-Same as previous patient. She averages 4 hours/night of sleep with EDS-On weekends able to sleep in and get 7 to 8 hours of sleep and awake feeling refreshed.
46 Sleep Disorders Associated with Alterations in Circadian Rhythm Delayed sleep phase syndromeAdvance sleep phase syndromeTime zone change (jet lag) syndromeShift work sleep disorderIrregular sleep wake patternNon-24-hour sleep –wake disorder
47 Circadian rhythms are generated by an internal pacemaker in the suprachiasmatic nucleus (SCN) of the hypothalamusThe main role of the SCN is to synchronize bodily functions with the light – dark cycle.