Changes in Sleep: Endocrine 1. Increased levels in sleep 2. Decreased levels in sleep

1. GH, prl, parathyroid, testosterone 2. cortisol, insulin, TSH

Sleep Flashcards by nathan tobey

Hypopnea

> 30% decrease from pre-event baseline in peak signal excursions using nasal PRESSURE transducer. Duration > or = 10s and >3 or 4% oxygen desat from baseline (usually occurs after the event)

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Apnea

decrease in peak signal excursion by >90% or pre-event baseline using oronasal THERMAL sensor (not pressure)

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RERA

> 10s of breathing characterized by increasing respiratory effort in thoracic/abdominal channels, leading to arousal from sleep where resp event does not meet criteria for apnea or hypoponea

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Master circadian rhythm generator in mammals

suprachiasmatic nucleus

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CNS inhibitory neurotransmitter

GABA

2. Adenosine (caffeine blocks adenosine receptors)

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CNS excitatory neurotransmitters

Activity increases during wake and decrease in sleep:
1. Glutamate (GABA blocks glutamate)
2. Serotonin
3. Norepinephrine
4. Dopamine (Haldol is antago)
5. Hypocretin (deficiency results in narcolepsy with cataplexy)
Histamine (antagonist promotes sleep)

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Deficiency of this results in narcoleps with cataplexy

Hypocretin

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REM sleep neurotransmitter

Acetylcholine

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Changes in sleep:Resp System

decreased PaO2, SaO2, increased PaCO2; decrease Vt, decreased minute vent
Irreg respirations during REM

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Changes in sleep: CV

NREM: Dec HR, Dec CO, Dec BP

REM (compared to NREM and wake): Increased HR, Increased CO, increased BP

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Changes in Sleep: Endocrine

Increased levels in sleep
Decreased levels in sleep

GH, prl, parathyroid, testosterone

2. cortisol, insulin, TSH

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Changes in sleep: Thermoregulation

Core body temp peaks early evening (6-8pm), falls at onset of sleep, nadir 2 hr prior to waking (4-5am)
-sleep occurs during falling phase of temp rhythm, wake occurs during rising phase of temp rhythm

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Sleep deprivation on Ghrelin

and Leptin

Increased

Leptin is decreased

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Various EEG patterns:

Beta- >13 Hz, alert and awake
Alpha- 8-13 Hz- Drowsy with eyes close
Theta- 4-7Hz- charac of N1, N1 and REM sleep
Delta- <4 Hz, N3 sleep

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K complex

sharp negative and slower positive component, stage 2 sleep (PVC of EEG)

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Sleep Spindle

Short rhythmic waveform, 12-14 Hz, characteristic of stage 2 sleep

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Characteristic findings of N2 sleep

Low amplitude, K complex and sleep spindle

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Characteristic findings of N3 sleep

Low frequency, high amplitude delta waves (VT)

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Diagnosis: Narcolepsy

MSLT with mean latency <8 minutes and at least 2 SOREMPs

PSG preceeding this test to assess for confounding conditions like OSA
sleep deprivation can lead to abnormal MSLT

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How to clinically distinguish Narcolepsy from IH?

Naps not refreshing to patients with IH but are to narcoleptics

Psycho-physiologic Insomnia

Starts as stressor to emotionally distressing event. Response is anxiety about inability to fall asleep leading to insomnia.
Treatment: with sleep restriction

Idiopathic Hypersomnia

Excessive daytime sleepiness, usually not refreshed by sleep. MSLT with sleep latency <8min but 0-1 (<2) SOREMPs.

Narcolepsy type 1

Narcolepsy with cataplexy

Narcolepsy type 2

Narcolepsy without cataplexy

Long sleeper vs Idiopathic Hypersomnia

Sleep >10h but feel refreshed (as opposed to IH where still feel excessively sleepy)

AHI: Normal Severity

0-5 is normal mild 5-15 moderate 15-30 Severe >30

Use of ASV led to increased CV mortality in patients with:

symptomatic CHF | LVEF

Defn: SOREMP

onset of REM within 15min of sleep

Qualify for bronch LVRS

FEV1 15-45%, heterogeneous emphysema, hyperinflation and air trapping (TLC >100%, RV >150%)

Wake:

>50% of epoch has alpha, chin EMG tone high, fast eye movement

Sleep N1

Alpha activity diminished or disappears, low amplitude/mixed frequency, slow rolling/roaving eye movements, chin EMG lower than wake

Characteristic EEG of REM

Low amplitude, mixed frequency, low chin EMG, REM

In whom to consider hypoglossal nerve stimulation?

- AHI 20-65 - BMI < or = 32 - AP collapse of soft palate (on DISE) -contraindications- concentric collapse of soft palate, BMI >32

Cheyne Stokes Respirations (CSR)

Normal or low PaCO2, increased vent drive to hypercapnia - Increased chemoreceptor sensitivity to CO2 - Increased circulation time secondary to decreased CO

CSR during sleep stages

occurs in N1 and N2, improves with REM

ASV in Cheyne Stokes Respir:

with symptomatic CHF and LVEF <45%, increased CV mortalitity

CPAP in CSA with CHF:

modest improvement in LVEF but does not improve survival (CANPAP)

Congenital Central Hypoventilation associated with mutation in gene:

PHOX2B - alveolar hypovent - autonomic nervous system dysregulation- esophageal dysmotility, Hirschsprung, neural crest tumors

OSA by sleep stage:

- goes away in N3 | - worse in REM

Treatment of Narcolepsy:

1. Nonpharm- structure sleep, scheduled naps 2. Pharm- stimulant (modafinil) first-line treatment for excessive daytime sleepiness 3. Cataplexy: -mild- SSRI -GHB (sodium oxybate) for cataplexy and EDS

RLS related to:

Low CNS iron stores. Fe is cofactor for tyrosine hydroxylase, rate-limiting step for dopamine synthesis.

Tx for RLS

-dopamine agonist (pramipexole, ropinirole) Tx Fe-defic anemia Side effect: increased impulsive behaviors Second line: gabapentin, opioids

Tx for REM related behavioral disorder

Keep partner and patient safe. - Benzo - Melatonin is second line

Tx of insomnia in COPD: preferred agent

Ramelteon- melatonin (MT1/MT2) agonist -safe and effective in COPD -CBT- longterm effects are better - avoid nicotine - tx concurrent OSA, PLM

Zalepelon- mechanism

Short-acting benzo receptor agonist | -use for sleep onset insomnia (short-acting)

Features suggesting GBS;

Ascending paralysis - neuropathic pain - autonomic dysfunction

Botulism: - present - treatment

- descending weakness | - tx with IVIG

Typical PFT findings in obesity:

Decreased: ERV, FRC RV is spared FEV1 and FVC both reduced but FEV1:FVC preserved