Common Sleep Disorders Flashcards
COMMON SLEEP DISORDERS
Sleep Apnea
Cheyne-Stoke Breathing
Obesity-Hypoventilation Syndrome
Narcolepsy
Restless Leg Syndrome
is a sleep disorder characterized by the temporary cessation or absence of breathing during sleep for 10 seconds or longer.
SLEEP APNEA
Types of Sleep Apnea
Obstructive Sleep Apnea
Central Sleep Apnea
Mixed Sleep Apnea
-is defined as the cessation of airflow through the nose and mouth with the persistence of the diaphragmatic and intercostal muscle activities.
OBSTRUCTIVE SLEEP APNEA (OSA)
the sleeper attempts to inhale during a period in which the upper airway muscle tone is momentarily absent.
obstructive sleep apnea
The negative pressure generated during inspiration causes the throat to narrow and the tongue to be sucked back into the oropharyngeal area.
obstructive sleep apnea
osa is defined as _____ abnormal obstructed breathing events per hour of sleep and sleepiness.
five or more
-Studies have reported a prevalence of OSAS in _____ of middle-aged men and ____ of middle-aged women.
4%
2%
the upper airway tends to narrow during sleep, resulting in _____, which cause repeated _____ despite continued efforts to breathe.
recurrent closures
apneas
the upper airway tends to narrow during sleep, resulting in recurrent closures, which cause repeated apneas despite continued efforts to breathe. results in
intermittent hypoxemia and frequent arousals
Intermittent hypoxemia and arousals cause an increase in ______, which increases the risk of ______
sympathetic activity
cardiovascular complications and arrhythmia.
Frequent apneas during sleep disturb the sleep architecture, resulting in ____
poor sleep quality and daytime sleepiness.
osa Signs & symptoms
1.Snoring. (not all snorers have OSA); may present with choking attacks during sleep
2.witnessed apnea
3.Decline in mental function
4.mouth breathing with dry mouth and throat on awakening
5.excessive salivation during sleep
6.excessive sweating
7.morning headache
8.nocturnal palpitation
9.unrefreshing sleep excessive daytime sleepiness (EDS)
osa Risk Factors
Obesity
Increased neck circumference
Gender
Age
Craniofacial abnormalities affecting the jaw size
Enlarged tonsils and adenoids
approximately, ____ of OSA patients are obese.
70%
Nevertheless, severe OSA can be seen in non-obese subjects with
craniofacial abnormalities.
Increased neck circumference in osa (____ inches for men and ____ inches in women)
> 17
16
Gender: OSA is more prevalent in
men
Age: osa is more prevalent in
older people
The risk of osa in women increases significantly
post-menopause.
Craniofacial abnormalities affecting the jaw size:
retrognathic and micrognathia
appears as a small mandible and an overbite
retrognathic and micrognathia
Enlarged tonsils and adenoids particularly in ____; nevertheless, occasionally it can be seen in ______.
children
adults
OSA can lead to ______, which increases the risk of motor vehicle and other accidents.
EDS
there is a great link between OSA and cardiovascular and cerebrovascular complications, such as:
Hypertension
ischemic heart disease
Arrhythmias
heart failure
pulmonary hypertension
stroke
The American Academy of Sleep Medicine (AASM) considers ______ to be routinely indicated “Standard” for the diagnosis of sleep disordered breathing
polysomnography
recent studies have shown that ______ can be used in patients with high clinical likelihood of moderate to severe OSA.
level-III portable studies (home sleep testing)
osa is determined by the
number of apneas and hypopneas per hour of sleep
determined by the number of apneas and hypopneas per hour of sleep
apnea hypopnea index (AHI).
apnea hypopnea index (AHI).
Normal = AHI < 5/hour
mild = 5 –15/ hour
moderate = 15 –30/hour
severe = >30/hour
Other parameters that may indicate the severity of OSA include
desaturation index (the number of desaturations with a 4% (or 3%) drop in SpO2 compared of baseline/ hour of sleep) and time spent with SpO2 less than 90%.
gold-standard treatment of osa
positive airway pressure (PAP) therapy
PAP therapy applied non-invasively via an ______ in the form of _____
interfacing mask
continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BPAP)
The AASM considers _______ as the treatment of choice for mild, moderate, and severe OSA.
PAP therapy
-is characterized by the cessation of airflow with no respiratory efforts, that is, both the diaphragmatic and intercostals muscle activities are absent.
CENTRAL SLEEP APNEA (CSA)
-is characterized by an initial cessation of airflow with no respiratory effort (central apnea), followed by a period of upper airway obstruction (obstructive apnea).
MIXED SLEEP APNEA
-defines as a breathing disorder in which there are cyclical fluctuations in breathing, with periods of central apneas or hypopneas that alternate with periods of hyperpnea in a gradual waxing and waning fashion.
CHEYNE-STOKES BREATHING (CSB)
-seen mostly in patients with heart failure (HF)
CHEYNE-STOKES BREATHING (CSB)
CHEYNE-STOKES BREATHING (CSB) are -described in patients recovering from:
acute pulmonary edema
advanced renal failure
central nervous system lesions
-is a condition in some obese people in which poor breathing leads to lower oxygen and higher carbon dioxide levels in the blood
OBESITY HYPOVENTILATION SYNDROME
To diagnose OHS, the following criteria must be met:
The presence of hypoventilation during wakefulness (PaCO2> 45 mm Hg) as measured by arterial PCO2, end-tidal PCO2, or transcutaneous PCO2.
Presence of obesity (BMI > 30 kg/m2).
Associated sleep-related breathing disorder
Absence of other known causes of hypoventilation
It is important to note that OSA often coexists with _____, in those cases, the diagnosis of both OSA and OHS should be made.
OHS
About ______ of patients with OHS have coexisting OSA; therefore, symptoms and many of the physical findings of OHS patients are similar to those in patients with OSA,
90%
About 90% of patients with OHS have coexisting OSA; therefore, symptoms and many of the physical findings of OHS patients are similar to those in patients with OSA, such as:
excessive day-time sleepiness
impairments of memory or concentration
Snoring
mood disturbance
choking during sleep
Fatigue
morning headaches
However, when compared to eucapnic OSA patients, those with OHS tend to complain more often of
shortness of breath.
OHS is a diagnosis of
exclusion
many diagnostic tests should be carried out to distinguish OHS from other disorders in which hypercapnia is a common finding, such as
pulmonary diseases, skeletal restriction, neuromuscular disorders, hypothyroidism or pleural pathology.
ohs Tests should include:
ABG
PFT
chest imaging
ABG sampling is a key test since hypercapnia is a fundamental feature of the disorder =reveals _______, which reflects the chronic nature of the disease.
low PaO2 and a high bicarbonate level
PFT are essential to exclude other causes of hypercapnia such as _____. Although PFTs can be normal, they usually reveal______
chronic pulmonary diseases
mild -to-moderate restrictive pattern due to obesity.
Untreated OHS is associated with a
high mortality rate, a reduced quality of life, and numerous morbidities, including hypertension, pulmonary hypertension, right heart failure, angina, and acute hypercapnic respiratory failure.
Although there are no treatment guidelines for OHS, treatment approaches are based on
reversing the underlying pathophysiology of OHS including the reversal of sleep-disordered- breathing, weight reduction, and treatment of comorbid conditions
ohs Management
A.PAP
B.Weight loss
C.Oxygen
_____ is desirable in patients with OHS and will lead to improvement in ______ including improvement in _______
Significant weight loss
pulmonary physiology and function
alveolar ventilation and nocturnal oxyhemoglobin saturation.
it is important to realize that _____ cannot be used as the sole initial treatment in ohs
weight loss
is the mainstay of therapy for OHS.
Application of PAP
It seems reasonable to start with _____ knowing that the majority of OHS patients have coexisting OSA.
CPAP
_____has been shown to be effective in a group of patients with stable OHS, especially in those with severe OSA.
CPAP
There are no clear guidelines on when to start or switch to bi-level PAP (BPAP); however, BPAP should be strongly considered in patients with _____, if CPAP is _______, or if they fail to _____. In addition, BPAP should be used in patients with ______
OHS without OSA, and in patients with OHS and coexisting OSA
insufficient and hypercapnia persists despite being on long- term CPAP
tolerate CPAP
OHS who experience acute-on-chronic respiratory failure
Treatment of OHS with PAP improves ____, this improvement could be achieved in _____
blood gasses
2 to 4 weeks.
in ohs ____ is important and should include ______
early follow-up
repeated measurement of ABG with an assessment of adherence to PAP
patients with OHS commonly suffer from ______during sleep, in addition to ______.
prolonged episodes of hypoxemia
daytime hypoxemia
is needed if hypoxemia persists despite the relief of upper airway obstruction and hypoventilation with _____, in order to prevent the long-term consequences of hypoxemia on pulmonary vasculature and other vital organs
Oxygen therapy
PAP therapy
-Is a relatively rare autoimmune disease and has pentad of clinical features including:
NARCOLEPSY
-Irresistible attacks of sleep, which is usually present in all patients.
NARCOLEPSY
is characterized by sudden “sleep attacks” that often occur several times a day.
narcolepsy
-The narcolepsy attacks last from several seconds to more than
30 minutes.
narcolepsy Is a relatively rare autoimmune disease and has pentad of clinical features including:
-Irresistible attacks of sleep, which is usually present in all patients.
The other feature of narcolepsy is not present in all patients.
Cataplexy
Hypnagogic hallucination\
Sleep paralysis
Interrupted fragmented sleep
characterized by sudden bilateral loss of muscle tone brought on by emotions, which can be limited to certain muscles or generalized, resulting in falling down.
Cataplexy
____ consciousness during cataplexy.
Full
Cataplexy is _____ for narcolepsy and is not present in all narcolepsy patients.
pathognomonic
If cataplexy is present, the patient has
narcolepsy type 1.
is appropriate when excessive daytime sleepiness is present with REM phenomenology (hypnogogic hallucinations and sleep paralysis) but without cataplexy.
A diagnosis of narcolepsy without cataplexy (Narcolepsy type 2)
Vivid dreams that occur at the transition from wakefulness to sleep or from sleep to wakefulness
Hypnagogic hallucination:
from wakefulness to sleep
hypnagogic
from sleep to wakefulness
hypnopompic
It is a temporary inability to move or speak that happens when the patient is waking up or falling asleep.
Sleep paralysis
Narcolepsy patients may complain of ________ sleep
Interrupted fragmented sleep
gives good clues to diagnose narcolepsy.
History
To confirm the diagnosis, a patient with narcolepsy undergoes an
overnight sleep study (PSG),
To confirm the diagnosis, a patient with narcolepsy undergoes fan overnight sleep study (PSG), followed by ___
multiple sleep latency test (MSLT).
MSLT starts
1.5–2 hours after waking up in the morning.
in mlst The patient is given
4–5 chances to nap separated by 2 hours.
in mslt If the patient falls asleep, he is allowed to sleep for
15 min.
in mlst _______ are monitored.
Sleep latency and sleep onset REM (SOREM)
in mlst The presence of a ________ support the diagnosis of narcolepsy.
short sleep latency (<8 min) and two or more SOREM
are common among patients with narcolepsy.
Periodic leg movement and restless legs syndrome
The management of patients with narcolepsy and cataplexy aims to improve
daytime sleepiness and control cataplexy.
For the irresistible attacks of sleep, _____ are used.
behavioral therapy and medication
in management of narcolepsy ______ are used.
Good sleep hygiene, obtaining enough sleep at night, and strategic naps
entail getting short naps for a few minutes when circumstances allow
Strategic naps
short naps increase alertness in patients with narcolepsy for
1–2 hr
are used to reduce sleepiness
stimulants
The first-line treatment in narcolepsy is
Modafinil.
may be used in patients who do not respond to Modafinil.
Methylphenidate
For cataplexy, _______ are used as first-line treatment.
the Serotonin Reuptake inhibitors (SSRI) Fluoxetine, or the Serotonin-Norepinephrine Reuptake inhibitors (SNRI) Venlafaxine
For difficult cases of cataplexy, _______ can be used.
Sodium Oxybate (Xyrem)
is a sensory-motor disorder characterized by unpleasant “creepy-crawly” sensations in the lower limbs.
RESTLESS LEG SYNDROME (RLS)
Movement of the legs temporarily relieves rls symptoms but disrupts the ability to
stay asleep during the night, resulting in delayed or fragmented sleep.
The major symptoms of RLS are
very disturbing sensations in the limbs (98%), and sleep disturbance is often the primary complaint (95%).
4 diagnostic criteria of rls
I.an urge to move the legs, usually accompanied or caused by an uncomfortable sensation in the legs
II.beginning or worsening of symptoms during periods of rest or inactivity;
III.partial or total relief of symptoms by movement;
IV.symptoms that are worse in the evening or night compared to during the day or that occur only in the evening or night (it follows a circadian rhythm).
have suggested four diagnostic criteria for rls
The International Restless Legs Syndrome Study Group (IRLSSG)
Roughly, _______ of RLS patients are estimated to have a positive family history;
60%
Roughly, _______ of RLS patients are estimated to have a positive family history;
60%
genetic association studies have linked ______ to RLS.
5 genes and 10 different alleles
The symptoms of RLS follow the circadian fluctuation of dopamine in the
substantia nigra and the putamen.
RLS patients have lower dopamine and iron levels in the substantia nigra and, therefore, respond to both
dopaminergic therapy and iron administration.
-RLS can be primary
(idiopathic)
This entity usually has a genetic predisposition and is seen more in young people and is usually more difficult to treat.
RLS can be primary (idiopathic)
RLS has been linked to a number of comorbid conditions, such as
iron deficiency
renal failure (uremia)
diabetes mellitus
neurological disorders = multiple sclerosis and Parkinson’s disease
rheumatologic diseases = rheumatoid arthritis.
specific tests for RLS diagnosis.
none
RLS is a ___ diagnosis based on____
clinical
clinical findings.
is not required to diagnose RLS.
PSG overnight sleep study
If iron deficiency is suspected in rls, _____ should be obtained.
serum ferritin levels
The goal of treatment of patients with RLS is to have
uninterrupted sleep with minimal sleep latency.
In patients with intermittent RLS symptoms that disturb sleep, treatment may be used on an _____
intermittent basis during symptomatic episodes.
In intermittent rls cases, the _______ can use as needed.
dopamine agonist carbidopa-levodopa (Sinemet) at bedtime
For severe persistent RLS, dopamine agonists, such as
pramipexole or ropinirole can be used 1–2 hour before bedtime.
Secondary RLS is dependent on the ______, which once managed, RLS can be cured.
causative conditions
RLS patients with_____, symptoms may remit after treatment or resolution of these conditions.
iron deficiency, pregnancy, and uremia
For rls patients with ______, iron treatment can be initially started and ferritin levels monitored.
ferritin level <112 picomols/L (50 nanograms/mL)
If ferritin levels of rls patient are _______ and symptoms persist, they can be treated based on their severity.
> 112 picomols/L (50 nanograms/mL)
