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In Service Exam > Sleep > Flashcards

Sleep Flashcards

1
Q

Ideal length of sleep

A

Infants: 14-16 hours
Children: 9 hours
Adults; 7-8 hours

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2
Q

Factors that determine sleep length

A

Circadian rhythm, genets, voluntary control (i.e. alarm clock)

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3
Q

Stages of sleep

A 
Non REM (N1 - transition to sleep 2-5%, N2 - sleep 45-55%, N3 - deep sleep 15-20%)
REM
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4
Q

Aging and sleep stages

A

Young infants and children: increased REM and N3

Elderly: decreased N3

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5
Q

Sleep waves

A 
Beta: 13-30Hz (wakefullness)
Alpha: 8-12 Hz (relaxed wakefullness)
Theta: 4-8Hz (N1 and REM)
Delta: 1-4 Hz (N3)
K complex (N2)
Vertex sharp waves (N1)
Sleep spindle (N2)
Sawtooth waves (REM)
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6
Q

Sleep wake cycles

A 
Homeostatic drive (process S; increasing sleep propensity with wakefullness)
Circadian rhythm (Process C; internal sleep/wake cycle)
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7
Q

Sleep centers of the brain

A

Reticular activating system
Hypothalamus
Basal forebrain
Thalamus

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8
Q

Sleep related brain nuclei

A
  • Locus coeruleus
  • Substantia nigra
  • Ventral tegmental region
  • Laterodorsal tegmental nuclei
  • Pedunculopontine nuclei
  • Dorsal raphe nucleus
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9
Q

Hormones related to sleep function

A
  • Cortisol (rises at night and peaks in the morning)
  • TSH (circadian regulated, rise and fall with sleep)
  • Growth hormone (increased initially during sleep and then decrease throughout the night, association with slow wave sleep)
  • Prolactin (increases with sleep and is sleep modulated)
  • Glucose/insulin (increase during sleep)
  • Hypocretins/orexins
  • Melatonin (rises and falls with sleep)
  • Leptin
  • Ghrelin
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10
Q

Muscles that maintain airway patency

A
  1. Tensor veli palatini
  2. Pterygoid
  3. Genioglossus
  4. Geniohyoid
  5. Sternohyoid
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11
Q

Apnea

A

> 90% cessation of airflow by the nose or mouth lasting 10 seconds or longer

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12
Q

Hypopnea

A

Decrease in airflow >30% for at least 10 seconds with >4% o2 desaturation or a reduction in airflow >50% for 10 seconds and an o2 desat >3%

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13
Q

RERA

A

10 seconds or more of increasing respiratory effort leading to arousal that does not meet criteria for apnea or hypopnea

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14
Q

Types of apneas

A

Obstructive, central, mixed

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15
Q

Nonsurgical management of snoring

A
  • Weight loss
  • Eliminate alcohol, tobacco, caffeine and sedatives
  • Positioning while asleep
  • Medically treat reflux, sinusitis, nasal polyps
  • Nasal breathing strips
  • Oral appliance
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16
Q

Surgical management of snoring

A
  • Septoplasty/turbinate reduction
  • Radiofrequency palatoplasty
  • Palatal implants
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17
Q

Upper airway resistance syndrome

A
  • 15 or more RERAs per hour
  • Characterized by excessive daytime somnolence but normal sleep studies. Esophageal pressure monitoring shows increased negative intrathoracic pressure leading to increased work of breathing and sleep arousals
  • Associated with crescendo snoring
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18
Q

Risk factors for upper airway resistance syndrome

A
  • Female
  • nonobese
  • Younger age
  • Nasal obstruction
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19
Q

OSA diagnosis

A
  • > 5 respiratory events an hour with respiratory effort and symptoms OR
  • > 15 respiratory events with respiratory effort without symptoms
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20
Q

OSA pathophysiology

A
  • Upper airway collapse
  • Inability for airway dilators to respond
  • Decreased sensitivity of chemoreceptors
  • Decreased central respiratory drive
  • Defective ventilatory response
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21
Q

OSA risk factors

A
  • Obesity
  • Family history
  • Anatomy (maxillary hypoplasia, retrognathia)
  • Increased age
  • Allergies
  • Postmenopausal
  • Sedatives and alcohol
  • Smoking
22
Q

Clinical consequences of OSA

A
  • Sleep related: daytime somnolence, fatigue, morning headaches, car accidents, poor job performance, depression, stress
  • Cardiovascular: HTN, CAD, arrhythmias, CVAs
  • Pulmonary: pulmonary HTN, cor pulmonale
  • Shorter life expectancy
23
Q

Physical exam findings of OSA

A
  • Neck circumference (> 17 in males and > 15.5 in females)
  • waste/hip ratio (> 0.9 males, >0.85 females
  • Cricomental distance (> 15mm excludes OSA)
  • Kyphosis
  • Micro/retrognathia
  • Enlarged tonsils
  • High arched palate
  • Maxillary retrusion
  • Tracheo/laryngomalacia
  • Enlarged tongue
24
Q

Evaluation of maxillary retrusion

A
  • Line dropped from nasion to the subnasale should be perpendicular to the frankfurt plane
25
Q

Evaluation of retrognathia

A
  • Line bisecting vermillion border of the lower lip with the pogonion should be perpendicular to the frankfurt plane
26
Q

PSG parameters

A
  • EEG (allows sleep staging from brain regions)
  • Electrooculum
  • Electromyogram
  • ECG
  • Oronasal airflow
  • Respiratory effort (chest effort, abdominal effort)
  • Oximetry
  • Vital signs
  • Snoring volume
27
Q

PSG report

A
  • Sleep latency
  • Sleep efficiency
  • Sleep architecture
  • Types of respiratory disturbances
  • Volume/presence of snoring
  • Effect of position on airflow
  • Effect of sleep stage on airflow
  • Number/severity of desaturation episodes
  • Percentage of sleep time above 90% SaO2
  • Lowest O2 level
28
Q

Categories of sleep tests

A

Type 1 : in lab sleep study with sleep technologist
Type 2: home sleep test with minimum of 7 channels including EEG
Type 3: home sleep test, minimum of 4 channels including respiratory airflow, respiratory effort, EKG and oxygen saturation
Type 4: typically only measures oxygen saturation

29
Q

Management sequence of OSA

A
  • Behavioral (weigh loss, limit alcohol, tobacco, caffeine and sedatives)
  • Medical management (nasal blockage, reflux)
  • CPAP/BiPAP
  • Oral or nasal appliances
  • Mandibular repositioning
  • Surgery
30
Q

Increase CPAP patient compliance

A
  • Humidity
  • Treat nasal congestion/obstruction
  • Desensitization
  • Reassess mask
  • Chin strap for mouth leak
  • Pressure reduction
  • Brief trial of hypnotic medication while adjusting to device
  • Trial of auto PAP
31
Q

BiPAP indications

A
  • Pressure support for obesity hypoventilation
  • COPD
  • Hypoxemic patients
  • Respiratory muscle weakness
  • Neurologic dysfunction
  • Poor CPAP compliance because of high PAP pressures (>16 cm H20)
32
Q

CPAP/BiPAP Contraindications

A
  • No respiratory drive
  • Risk of aspiration
  • Hypotension
  • CSF leak
  • Bullous lung disease
  • Pneumocephalus
  • Pneumothorax
  • Skull base surgery
33
Q

Pathogenesis of sleep apnea in children

A
  • Adenotonsillar hypertrophy
  • Poor muscle tone
  • Upper airway narrowing
  • Syndromic
34
Q

Signs and symptoms of sleep apnea in children

A
  • Snoring
  • Witnessed apneas
  • Restless sleep
  • Enuresis
  • Hyperactivity
  • Chronic mouth breathing
35
Q

Central sleep apnea types

A
  • Primary CSA
  • Cheyne stokes breathing
  • High altitude CSA
36
Q

Cheyne stokes breathing

A
  • Three cycles of crescendo and decrescendo breathing and lasting 10 minutes or associated with 5+ central apneas/hypopneas and associated with heart failure
37
Q

Causes of hypoventilation syndrome

A
  • Obesity
  • Interstitial lung disease
  • Pulmonary HTN
  • Sickle cell anemia
  • Myxedema
38
Q

Sleep related movement disorders

A
  • Restless leg (subjective complaint)
  • Periodic limb movement (repetitive contraction of anterior tibialis)
  • rhythmic movement disorder
  • Nocturnal leg cramps
  • Excessive fragmentary myoclonus
  • Bruxism
39
Q

Restless leg risk factors

A
  • Female
  • Family history
  • BTBD9 gene
40
Q

Restless leg diagnosis

A
  • URGE
  • Urge to move legs, Rest makes worse, Gets betters with activity, Evening and nighttime symptoms
  • Labs: ferritin, renal function, flucose, anemia, thyroid, B12, Mg, ANA, RF
  • CSF transferrin levels
41
Q

Tx of restless leg

A
  • Address secondary causes (iron deficiency, renal failure, pregnancy, peripheral neuropathy, medications - dopamine antagonist meds)
  • Behavior modifications
  • Dopamine agonists (ropinirole, pramipexole)
42
Q

Non obstructive Pediatric sleep disorders

A
  • Sleep terrors: during slow wave sleep, first part of the night, usually have autonomic response
  • Somnambulism - sleep walking during slow wave sleep
  • Confusional arousals
  • Nightmares - during REM sleep, early hours of the morning
  • Sleep paralysis
  • REM sleep behavior disorder
  • Bruxism
  • Somniloquy- sleep talking during REM and NREM
  • Nocturnal enuresis
  • Rhythmic movement disorders- benign, goes away by early childhood, including body rocking, head banging and head rolling, tx with safe environment
43
Q

Describe the Mueller maneuver?

A

Endoscopic evaluation during maximal inspiration against closed nose and mouth at various levels to attempt to identify anatomical regions of obstruction

44
Q

Epworth Sleepiness Scale

A 
A validated questionnaire for daytime sleepiness. Questions rated 0-3 of likelihood a person would doze off. 8 questions. Maximal score of 24 
0-5: supernormal
5-10: normal
10-15: sleepy
15-20: very sleepy
> 20: dangerously sleepy

Questions:
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g., a theater or
a meeting)
As a passenger in a car for an hour without a
break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic

45
Q

Potential complications or sequelae of UPPP

A

Persistent snoring or OSA, bleeding, nasopharyngeal regurgitation of liquids, oropharyngeal dryness, oropharyngeal dysphagia, globus, pharyngeal stenosis

46
Q

What does the Friedman staging system assess

A

It is used as a clinical predictor of which patients may have successful improvement of their OSA after UPPP surgery.
Stage I patients have an 80% chance of success following a UPPP (greater than 50% reduction in preoperative AHI or a postoperative AHI < 20)

Table 1. Friedman staging system as determined by
Friedman tongue position (FTP), tonsil size, and BMI
Stage FTP Tonsil size BMI
I I, II 3 or 4 <40
II I, II 0, 1, or 2 <40
III or IV 3 or 4 <40
III III or IV 0, 1, or 2 <40
IVa I–IV 0–4 >40
a All patients with significant craniofacial or other anatomic abnormalities.

47
Q

What craniofacial syndromes are closely associated with snoring and sleep apnea?

A

Achondroplasia, Pierre Robin sequence, Treacher-Collins, Crouzon, Down syndrome, Prader-Willi, Apert syndrome

48
Q

OSAHS score

A

Developed by Friedman et al as a tool for predicting a diagnosis of OSAHS based on physical examination characteristics alone.

  • Calculated by adding the numerical values obtained for FTP (I-IV), tonsil size (0-4), and BMI grade (1-4). The minimum OSAHS score is 2 and the maximum is 12.
  • Score of 8+ have a 90% chance of having moderate OSA and 74% chance of having severe OSA
  • Score less than 4 have a 67% chance of not having moderate/severe OSA
49
Q

What cephalometric findings are associated with OSA

A
  • Large tongue
  • Decreased maxillary and mandibular projection
  • Elongated palate (increased length and width of soft palate)
  • Low hanging hyoid
  • Increased vertical facial length
50
Q

CPAP compliance

A

Usage for at least 4 hours a night for 5+ nights a week

51
Q

Friedman tongue position vs mallampati score

A

FTP is the evaluation of the tongue’s position
relative to the tonsils/pillars, uvula, soft palate,
and hard palate. It is based on Mallampati stages,
which are used in the field of anesthesiology in the
context of difficult endotracheal intubation.
The Mallampati system has 3 grades and
evaluates the palate with the tongue protruded. Modified mallampati which is now routinely used has 4 grades.

52
Q

Differences between adult and pediatric OSA

A

Adults: greater male predominance, more common to have nocturnal arousals, daytime hypersomnolence and obesity

Pediatrics: mouth breathing and adenotonsillar hypertrophy more common

In Service Exam (16 decks)

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