Coexisting Chapter 1 - Sleep

Question 1

Narcolepsy

Answer 1

Lots of boundaries between the three distinct states of : 1)wakefulness:
2) NREM sleep, and REM sleep.

Question 2

Parasomnias

Answer 2

Admixture of wakefulness with either NREM sleep or REM sleep

Wakefulness+NREM = Confusional arousal, sleep tower, and sleep acting( talking, walking)
Or
Wakefulness+REM =REM nightmares, REM sleep behavior disorder ( REM without usual Atonia ) allowing physical enactment of dreams which can result in injury to self or others

Question 3

Opioids increase hypoxia with OSA. True or False

Answer 3

True

Question 4

Sleep effects of prazosin

Answer 4

Resolves nightmare

Question 5

Sleep effects of clonidine

Answer 5

Induces nightmare

Question 6

Sleep effects of Beta Blockers

Answer 6

Increase daytime sleepiness
Induce nightmares
Insomnia

Question 7

Effects of statins

Answer 7

Insomnia and sleep disruption

Question 8

Lithium

Answer 8

Increased effects on slow wave sleep

Sleep walking

Question 9

MAOIs

Answer 9

Almost zero effect on REM

Question 10

Amphetamines

Answer 10

Bruxism

Question 11

TCAs

Answer 11

Increase periodic limb movements, RLS

Question 12

Mallampati predicts 2 things

Answer 12

Difficult Tracheal intubation

Risk of OSA: for every 1 point of Mallampati , odds of OSA increased by 2.5

Question 13

What factors predispose to OSA

Answer 13

Cigarette smoking
Obesity
Non - Caucasian 
Male 
Narrowing of upper airway 
Genetic inheritance 
Menopause 
Use of alcohol and sedative

Question 14

What is Central sleep apnea

Answer 14

Sleep apnea that is not associated with respiratory efforts during the apnea event

Question 15

Primary/idiopathic CSA is

Answer 15

Cause unknown
You see:
Periodic breathing with a cycle length of apnea followed by hyperpnea

Question 16

Is the most common form of secondary CSA

Answer 16

Narcotic induced CSA
1/2 the pts on chronic opioids
You see:
Biot ’ s breathing or irregular ataxic breathing

Question 17

What was the first form is of he sleep relate in breathing disorder described

Answer 17

CSA with Cheyen-stokes breathing

Question 18

Three conditions during which CSA with Cheyne-stockes breathing is encountered

Answer 18

CHF
Stroke
Afib

Question 19

What are the four cyclical components of cayenne Stokes reading

Answer 19

Hypopnea
apnea
hypoxia
hyperventilation

Question 20

OSA’s Immediate consequences on the heart

Answer 20

Hypoxemia
Hypercarbia

Arousal

Reduced pleural pressure

Question 21

Cardiovascular Intermediate term consequences of OSA

Answer 21

Decreased O2 delivery
Oxidative Stress
Inflammation
Hypercoagulopathy

Sympathetic activation
Parasympathetic inactivation

Increases transmural pressure on heart and great vessels

Question 22

Long term effects of OSA on heart

Answer 22

Cardiac dysfunction ; endothelial dysfunction ; Increased RV afterload ; Right ventricular hypertrophy

Tachycardia 
Hypertension 
Increased LV afterload 
Increased myocardial O2 consumption 
Myocardial toxicity 
Dysrhythmias 

Increased Rt and Left Ventricular afterload
Dysrhythmias
Aortic dilation
Increased Lung water

Question 23

30 to 50% of patients with poly cystic ovarian syndrome also have what condition ?

Answer 23

OSA

Question 24

OSA is encountered in 50% or patients with NASH. True or False

Answer 24

True

Non Alcoholic Steatohepatitis

Question 25

What EEG changes are seen due to OSA ?

Answer 25

Overall slowing of EEG Decrease in deeper sleep stages Compensatory Increase in light sleep

Question 26

What metabolic changes seen due to OSA ? Pathophysiological mechanism of these changes specifically

Answer 26

``` Hypoxic injury Systemic Inflammation Increased sympathetic activity Alterations in hypothalamic pituitary adrenal function Hormonal changes ```

Question 27

The metabolic DERANGEMENTS seen with OSA include :

Answer 27

Insulin resistance Glucose intolerance Dyslipidemia

Question 28

The metabolic DISORDERS seen with OSA include

Answer 28

Central Obesity Metabolic syndrome Type 2 Diabetes Mellitus

Question 29

OSA is the result of what 3 events :

Answer 29

Apnea episodes Arousals Increased Respiratory efforts

Question 30

What can Apneic and hypoapneic episodes lead to ?

Answer 30

OSA induced hypoxia + reoxygenation cycles >>activation of : redox-sensitive genes oxidative stress , inflammatory process, SNS, coagulation cascade = endothelial dysfunction =>> systemic HTN + Pulm HTN + Atheroslerosis + Rt/ Lt ventricular systolic/diastolic dysfunction + CAD + CHF + Afib + stroke + sudden death

Question 31

What do arousal episodes lead to ?

Answer 31

Increased sympathetic system activity + Decreased PSNS = increased : HR , LV afterload , Myo O2 consumption , dysrhythmias, Myo toxicity , apoptosis . Sleep deprivation = increased SNS , inflammation and hypermetabolic state Increased inspiratory efforts = large swing in neg intrathoracic pressure >>transmitted to heart/lung/great vessels

Question 32

Are Central Sleep apnea events associated with increased Resp effort ?

Answer 32

No . That would be OSA | But still. Hypoxia occur

Question 33

90% of Obesity Hypoventilation Syndrome (OHS) also have

Answer 33

OSA

Question 34

Other name for OHS

Answer 34

Pickwickian syndrome

Question 35

Other name for Central Alveolar Hypoventilation syndrome

Answer 35

Onldine’ s curse

Question 36

Clinical feature of OHS (8)

Answer 36

1) marked obesity 2) Somnolence 3) Twitching 4) Cyanosis 5) periodic respiration 6) secondary polycythemia 7) Right ventricular hypertrophy 8) Right ventricular failure/cor pulmonale

Question 37

Define OHS , what are the characteristic of OHS

Answer 37

Hypoventilation during wakefulness | Worsens in the supine position and during sleep

Question 38

Which is more common ? Primary or comorbid form of sleep related Hypoventilation ?

Answer 38

Comorbid form

Question 39

What are the major consequences of hypoxia and hypercarbia ?

Answer 39

Pulm HTN Cor Pulmonale Increased sudden unexplained nocturnal death

Question 40

Most common category of sleep disorder is insomnia. What is the second most common ?

Answer 40

Sleep related breathing disorder ! 90 % of that is OSA And Snoring is more common than OSA

Question 41

CSA is not common. But 1/2 of CSA pts have what condition ?

Answer 41

CHF