Sleep Flashcards
Definitions of apnea adult vs pediatric
Adult: Apnea is defined by cessation of air movement for at least 10 seconds.
Pediatric: Cessation of air movement over two breath cycles.
Definitions of hypoventilation
Sleep related hypoventilation is defined as >10 mmHg increase in pCO2 compared to awake for at least 10 minutes OR rise in pCO2 > 55 mmHg for at least 10 minutes.
Definition of hypopnea
Decrease of air movement >/_ 30% for OVER 10 seconds, WITH at least 3% decrease in O2 sats (4% for medicare) (over 10 seconds for adults, over 2 breaths for kids)
Definition of arousal
Defined by an abrupt shift of EEG >16 Hz lasting at least 3 seconds.
What is the Mueller maneuver?
Performed with patient awake sitting up or supine. Patient asked to perform a valsalva while scope assess the degree of retropalatal or retrolingual collapse.
Sleep terror vs nightmare?
Sleep terrors - Occur in 1st third of night, non REM. Usually in kids, wake up scared, confused (don’t necessarily remember).
Nightmare - Occur during REM sleep. Patient wake up and can remember their dream (not confused).
What test to use for narcolepsy and results interpretation? ALSO type I vs type II narcolepsy?
MSLT < 8 minutes and rapid onset of REM (during PSG) are characteristic for narcolepsy.
Increased stage I sleep
Type I: WITH cataplexy, LOW CSF hypocretin
Type 2: WITHOUT cataplexy, NORMAL CSF hypocretin –> MOST COMMON TYPE!
What is periodic limb disorder?
Periodic limb disorder refers specifically to repetitive movement of anterior tibialis muscle.
What is RDI?
Respiratory disturbance index: apnea + hypopnea plus RERAs divided by total sleep time
What is OSAHS score?
Calculated by adding grades for BMI, tonsil size and Friedman tongue size. Scores of 8 or more have 90% chance of having at least moderate OSA.
Findings for Awake, REM, N1, N2, N3, and OSA on sleep study?
Awake - beta waves (beta off awake)!
Relaxed wakefulness - Alpha waves
REM - Sawtooth, rapid eye movements, 25% of sleep
N1 - Vertex sharp waves
N2 - K complexes and sleep spindles,** 50% of night**, 2nd half of night
N3 - Delta (Deepest sleep, 1st half of night)
OSA - Irregularity/flattening on PTAF and airflow tracings
Current criteria for INSPIRE?
Age >18
AHI 15 to 65, non-obstructive events <25% of total events, BMI<35 (although many commercial insurers use BMI<32), CPAP intolerance
Absence of complete concentric collapse at the velum on DISE.
What is periodic limb movement disorder defined as (PLMI) and first line treatment?
PLMI > 5/h and TX: Iron, dopamine agonists (pramipexole)
Definition of Apnea Index? Apnea Hypopnea Index?
Apnea Index: Apnea/Hr
Apnea Hypopnea Index: Apnea + Hypopnea/Hr
Indications for PSG in a pediatric patient?
-Confirm OSA prior to T&A
-POST OP PSG indicated in those who had preoperative evidence of moderate to severe OSA; obesity; craniofacial anomalies obstructing the upper airway; or neurologic disorders, such as Down syndrome, Prader-Willi syndrome, and myelomeningocele.
-PSG should be considered in children with chronic asthma, cystic fibrosis, pulmonary hypertension, bronchopulmonary dysplasia, or chest wall abnormality if there is clinical suspicion of an accompanying sleep-related breathing disorder.
***
What muscles do you include and exclude in INSPIRE?
Include the genio muscles and C1 (branch to geniohyoid)
Exclude styloglossus and hyoglossues (they retract the tongue)
Periodic Limb Movement Disorder Criteria for adults vs children?
Adults: 15 or greater movements/hour
Kids: 5 or greater movements/hour
What does expansion pharyngoplasty entail?
Tonsillectomy/UPPP + rotation of the palatopharyngeal muscle (tunnel reaches hamulus of medial pterygoid).
Of note - a LATERAL pharyngoplasty involves the superior constrictor muscles instead.
VOTE Scoring for DISE
Velum, Oropharynx, Tongue base, Epiglottis
0 - No collapse
1- Partial collapse
2- Complete collapse
(Specify AP, lateral or concentric collapse)
What is the STOP BANG score?
Snoring, Tiredeness, observed apneas, increased blood pressure
BMI > 35, Age > 50, neck circumferance > 40 cm, male gender
One point for each, score of 3 or higher = high risk for OSA.
What is upper airway resistance syndrome?
15 or more RERAs per hour
(Seen in younger non obese females)
When is in lab PSG (type I) indicated over home sleep study?
In patient with: significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular conditions, awake hypoventilation or suspicion of sleep-related hypoventilation, chronic opioid medication use, history of stroke, or severe insomnia.
Types I-4 sleep study features and most common?
Type I: In lab
Type II: HOME with at least 7 channels including EEG
Type III: HOME with at least 4 channels (MOST COMMON)
Type IV: HOME with at least 3 channels, not used often
Treatment for narcolepsy?
Stimulants such as modafinil. TCAs + SSRI can also help with cataplexy.
Gamma hydroxybutuerate also approved for narcolepsy with cataplexy
1st stage of stanford protocol and 2nd stage?
1st: UPPP, genioglossus advancement, hyoid suspension
2nd: Maxillomandibular advancement
*UPPP + tongue suspension = better results than UPPP alone
*Maxillomandibular advancement = comparable effects on AHI as CPAP
What facial features increase risk of OSA?
Decreased maxillary and mandibular projection, low hyoid, INCREASED vertical facial length, increased tongue size, increased length + width of soft palate
What sleep stages are increased with OSA?
What sleep stages decrease with age?
OSA: INCREASED Stage 1 and 2, DECREASED Stage 3 + REM
Aging: Decreased Stage 3
