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Pulmonary Review > Sleep > Flashcards

Sleep Flashcards

1
Q

This is the constant sleep that you get during the sleep perisod becuase of falling circadian alertness opposing any decrease in homeostatic sleep drive

A

Sleep homeostasis

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2
Q

This is the biologic alerting rhythm that consists of one oscillarion every 24.2 hours

A

Circadian system

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3
Q

What are Zeitgebers?

A

They are cues that syncrhonize the circadian rhythm to the external 24-hour period.

Can be photic (light) or nonphotic (eating times)

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4
Q

This is the cognitive impairment present immediately on awakening from sleep

A

Sleep inertia

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5
Q

When is sleep inertia most pronounced?

A

15-30mins after wakening

This is why you go crazy on call when paged and have no idea how to think.

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6
Q

This is the master circadian rhythm generator in mammals.

A

Suprachiasmatic nuceleus

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7
Q

Where in the brain is the suprachiasmatic nucleus?

A

Hypothalamus

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8
Q

When is the suprachiasmatic nucleus active?

A

Active during the day, consolidates at night.

Peaks in late morning and early evening. Dips in the early morning and early afternoon (coffee times)

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9
Q

What is the connection of the suprachiasmatic nucelus to light? (mainly blue-blue green light)

A

Retinohypothalamic tract

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10
Q

Function of the following sleep neurotransmitter:

GABA

A

CNS inhibition

benzos, alcohol

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11
Q

Function of the following sleep neurotransmitter:

Glutamate

A

CNS excitation

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12
Q

Function of the following sleep neurotransmitter:

Serotonin

A

CNS excitatory

Activity increases during wake and decreases during sleep

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13
Q

Function of the following sleep neurotransmitter:

NE

A

CNS excitation

Increases during wake and decreases during sleep

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14
Q

Function of the following sleep neurotransmitter:

Dopamine

A

Agonists promote wakefulness

This is why Haldol makes you sleep and amphetamines make you awake for 3 days

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15
Q

Function of the following sleep neurotransmitter:

Histmaine

A

1st generation antagonists promote sleep (Benadryl)

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16
Q

Function of the following sleep neurotransmitter:

Ach

A

REM sleep neuroteansmitter

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17
Q

Function of the following sleep neurotransmitter:

Hypocretin

A

Deficiency in this results in narcolepsy with cataplexy

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18
Q

Function of the following sleep neurotransmitter:

Adenosine

A

Decrease in acitivity promotes wakefulness

Caffeine blocks adenosine receptors!!!

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19
Q

This hormone is synthesized in the pineal gland and influences the circadian sleep-wake cycles

A

Melatonin

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20
Q

When is melatonin secreted the most? Day or Night?

A

Night

It’s inhibited by light.

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21
Q

If you have problems falling asleep too early in the evening (phase DELAY circadian sleep-wake rhythm), when should you take melatonin?

A

Early morning

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22
Q

If you have problems falling asleep too late in the evening (phase ADVANCE circadian sleep-wake rhythm), when should you take melatonin?

A

Early EVENING

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23
Q

Which increases in the autonomic nervous system during sleep, sympathetic or parasympathetic?

A

Parasympathetic

REST and digest

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24
Q

What happens to the cardiovascular system during non-REM and REM sleep?

A

NREM: ↓HR, ↓CO, ↓BP

REM: ↑HR, ↑CO, ↑BP

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25
Q

What happens to the renal system during sleep?

A

Decrease in urine output:

↑water reabsorption, renin, ADH

↓GFR

This is why you can not pee at night for 8 hours but during the day barely last more that 3 hrs before having to pee.

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26
Q

Which of the following hormones are increased during sleep?

GH, PRL, PTH, Testosterone, Cortisol, Insulin, TSH

A

GH, PRL, PTH, Testosterone

There is ↓ Cortisol, Insulin, TSH

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27
Q

When is your body the hottest and coldest during the day?

A

Annual variation is due to bikini season, but on a day to day basis, peak temperature is early evening and nadir is 2 hours prior to usual wake (4-5am)

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28
Q

Which neurotransmitter is responsible for REM

A

Ach

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29
Q 
19-year-old woman
sleeps from 3 am until 11
am daily. She starts
college in 1 month and has
7 am classes. What
circadian rhythm sleep
disorder does she have?
When would you give her
melatonin?
A 
She has a delayed sleep
phase disorder; should
receive melatonin early in
the night to help her fall
asleep earlier.
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30
Q 
76-year-old man sleeps
from 7 pm until 4 am once
a day. He wants to join his
local Bingo group that
meets at 8 pm, and he
would like to stay up longer
at night. What circadian
rhythm sleep disorder does
he have, and when would
you give him melatonin to
treat it?
A 
He has advanced sleep
phase disorder, and he
should receive melatonin in
the early morning, after
being cautioned that
melatonin can cause
drowsiness
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31
Q

This test can be used to diagnosed sleep disordered breathing (SDB), efficacy of trreatment for SDB, use of PAP titration, and diagnosis of non-respiratory sleep disorders (limb movement disorders, narcoleps, parasomnias, nocturnal seizures, REM disorders)?

A

Polysomnography (PSG)

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32
Q

Which waveform on PSG occurs when you’re alert and awake (>13 Hz)?

A

Beta waves

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33
Q

Which waveform on PSG occurs when you’re drowsy with eyes closes (8-13 Hz)?

A

Alpha waves

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34
Q

Which waveform on PSG occurs when you’re in N1, N2, and REM (4-7 Hz)?

A

Theta waves

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35
Q

Which waveform on PSG occurs when you’re in N3 sleep (<4 Hz)?

A

Delta waves

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36
Q

This EEG waveform are sharp negative waves in the theta range frequency, and usually occurs during the latter part of sleep stage 1

A

Vertex waves

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37
Q

This EEG waveform are sharp negative waves followed by slower postiive component, usually seen in stage 2?

A

K-complex

Like a EEG PVC

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38
Q

This EEG waveform is a cluster of short rhythmic waves in the 12-14 Hz range, seen in stage 2

A

Sleep spindles

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39
Q

What EEG waveforms are only seen in REM?

A

Sawtooth waves

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40
Q

What hormone increases during sleep, ghrelin or leptin?

A

Ghrelin increases (grow), leptin decreases (lean)

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41
Q

What stage of sleep is this based on the characteristics of PSG?

Chin EMG tone high, low voltage mixed frequency pattern, fast eye movements and eye blinks

A

Wake

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42
Q

What stage of sleep is this based on the characteristics of PSG?

Low amplitude, mixed frequency, K-complexes and/or sleep spindles

A

N2

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43
Q

What stage of sleep is this based on the characteristics of PSG?

Alpha activity diminished or disappeared, low amplitude mixed frequency waves, slow rolling eye movements, possible vertex waves, chin EMG levels lower than wake

A

N1

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44
Q

What stage of sleep is this based on the characteristics of PSG?

low amplitude, mixed frquency waves, low chin EMG, rapid eye movements

A

REM

Lol it’s in the question stem

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45
Q

What stage of sleep is this based on the characteristics of PSG?

> 20% of epoch occupied by low-frequency, high amplitude delta waves

A

N3

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46
Q

Apnea on the PSG is defined by what criteria on the thermal sensor?

A

decrease in theraml sensor amplitude by >90% of baseline for >10 sec

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47
Q

How is hypopnea defined by PSG?

A

decrease in nasal pressure by >30% for >10 sec with a >4% drop in oxygen saturation

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48
Q

How often do you have to move your legs to be defined has having periodic leg movement disorder (PLM)?

A

> 4 consecutive leg movements for 0.5-10sec each

5-90 sec between movements

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49
Q

Define normal, mild, moderate, and severe SDB using AHI

A

Normal 0-5
Mild 5-15
Moderate 15-30
Severe >30

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50
Q

This is the number of apneas + number of hypopneas + respiratory effort-related arrousals per hour of sleep

A

Respiratory disturbance index

Classified by the same #'s as AHI:
Normal 0-5
Mild 5-15
Moderate 15-30
Severe >30
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51
Q

This is an 8-item questionairre that evaluates the chances of dozing off to sleep on the scale of 0 to 3 uncer certain circumstances

A

Epworth sleepiness scale

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52
Q

What score on the Epworth sleepiness scale determines excessive daytime sleepiness?

A

> 10

53
Q

This si teh test that measures tendency to fall asleep in quiet settings, where patients are told to try to fall asleep

A

Multiple sleep latency test (MSLT)

Requires PSG the night prior, discontinue any offending meds, and 4-5 20 min nap opportunities at 2 hour intervals with focus on sleep latency and presence or absence of REM sleep onset periods

54
Q

What is the MSLT used to diagnose?

A

Narcolepsy

Also used to evaluate unexplained hypersomnia

55
Q

On the MSLT, what causes short sleep onset latency (SOL) <8 mins?

A 
Narcolepsy
Idiopathic hypersomnia (IH)
Sleep deprivation
OSA
PLMD
Acute stimulant agent withdrawal
56
Q

On the MSLT, what things cuases >2 sleep onset REM sleep periods (SOREMPs)?

A 
Narcolepsy
Sleep deprivation
OSA
Alcohol withdrawal
REM sleep suppressant withdrawal (antidepressants)
57
Q

This SDB has the risk factors for age, male, obesity, ethnicity (black, Asian, Hispanic), and medical comorbidities (heart failure, history of CVA, renal failure)

A

OSA

58
Q

What are two defining
characteristics of
narcolepsy on PSG with
MSLT?

A

Decreased SOL and ≥ two

SOREMPs on MSLT

59
Q

Whats the god standard for diangosing OSA?

A

In-lab PSG

60
Q

What do patients NOT have in order to do portable sleep studies?

A

Co-morbidities such as CAD, CVA, COPD, hypoventilation syndromes

61
Q

Untreated OSA puts you at an increased risk of what bad things?

A 
MI
CVA
Pulm HTN
HTN
Sudden death
Worsened DM and CHF
Increases pro-inflammatory immune mediators
MVAs
Cognitive problems
62
Q

What is the mainstay of treatment for OSA?

A

CPAP

63
Q

When is CPAP indicated based on AHI?

A

Moderate-severe OSA (>15 AHI) regardless of symptoms

Mild OSA (AHI >5) with symptoms/comorbidities

64
Q

What is deemed “compliant” with CPAP?

A

> 4 hours at least 70% of observed nights

65
Q 
What is the #1 reason for
residual daytime
sleepiness in patients who
are on CPAP therapy for
SDB?
A

CPAP noncompliance

66
Q

What intervention is as effective as CPAP for improving daytime sleepiness but less effective than CPAP for improving oxygenation and AHI?

A

Oral appliances

67
Q

What surgery improves SDB but does not result in resolution of sleep apnea?

A

Bariatric surgery

68
Q

What surgery is the reduction or removal of portions of the soft palate and uvula, is UNsuccessful in resolving OSA, and is NOT recommended?

A

UPPP

Name is too long to type

69
Q

What surgery moves the upper and lower jaw forward, and is noted to be successful in resolving OSA?

A

Maxillomandibular advancement

70
Q

What surgery is a last resort for refractory OSA in patients intolerant of CPAP?

A

Tracheostomy

71
Q

What surgery is effective in children and infants for OSA?

A

Adenotonsillectomy

72
Q

Which outcome is the most
likely to improve with use
of CPAP in OSA?

A

Daytime sleepiness

73
Q

This is the loss of ventilatory effort during sleep resulting in repetitive cessation of airflow

A

Central sleep apnea (CSA)

74
Q

This is the normal or low PaCO2 and increased ventilatory response to hypercapnea in CSA

A

Nonhypercapnic CSA

75
Q

This type of breathing in CSA is characterized by crescendo-decrescendo periodic breathing

A

Cheyne-stokes breathing

76
Q

What is the pathophysiology for cheyne-stokes breathing?

A

↑ CO2 sensitivity
↑ ventilatory drive
↑ circulatory time secondary to decreased CO
↓ oxygen reserve

77
Q 
74-year-old man with
heart failure (LVEF 20%)
and atrial fibrillation is
referred for frequent
nocturnal desaturations
noted during a recent
hospitalization. What type
of SDB would you be
concerned about?
A

Cheyne stokes breathing

78
Q

What sleep stages does cheyne stokes breathing occur in?

A

N1 and N2

79
Q

What is the best treatment for cheyne-stokes respirations?

A

Optimize heart failure
Adaptive servo-ventilation
Supplemental oxygen

80
Q

Would a patient with cheyne stokes respirations be hypercapnic, hypocapnic, or eucapnic on a daytime arterial blood gas?

A

Hypocapnic

81
Q

This type of complex sleep apnea occurs predmoninantly during non-REM sleep, in high altitudes over 2500 meters, caused by enhanced ventilatory response to hypoxemia, and trreated with oxygne and acetazolamide

A

High-altitude periodic breathing

82
Q

This type of complex sleep apnea occurs because of fluctuations in PaCO2 above and below the apneic threshold as sleep onset occurs, resolves as sleep progresses, and does not need therapy?

A

Sleep-onset central sleep apnea

83
Q

This condition is characterized by elevated awake PaCO2 > 45 and BMI >30

A

OHS

84
Q

Treatment of OHS?

A

CPAP +/- oxygen

BiPAP for persistent hypoxemia

85
Q

What conditions can lead to congential central hypoventilation due to lack of responsiveness to O2 and CO2, possibly due to mutation in the PHOX2B gene?

A

Autonomic dysfunction
Hirschsprung disease
Neural crest tumors

86
Q

This diagnosis causes dyspnea at night due to increased vagus nerve tone, circadian variability with decreased FEV1, and increased inflammatory agents (eosinophils) during early morning hours (3-6am)

A

Nocturnal asthma

87
Q

True or False: nocturnal hypoxemia can be diagnosed in COPD using portable PSG

A

FALSE

Don’t use ambulatory sleep tests in pts with underlying co-morbidities

88
Q

What are the indications for nocturnal oxygen therapy for COPD patients?

A

Either:

PaO2 <55 mmHg
SaO2 <88%
Fall of PaO2 > 10mmHg during sleep
Fall of SaO2 > % during sleep

89
Q

This condition is characterized by excessive daytime sleepiness, cataplexy, sleep paralysis, and sleep hallucinations

A

Narcolepsy

90
Q

What neurotransmitter is specifically low in narcolepsy patients?

A

Orexin (AKA hypocretin)

91
Q

What is the normal function of orexin?

A

Fucntions to heighten alertness and inhibits REM sleep through orexin-mediated nerve conduction in the lateral hypothalamus

92
Q

True or False: sleep and daytime naps are refreshing in narcolepsy

A

TRUE

This is what distinguishes narcolepsy from idiopathic hypersomnia, where sleep is not refreshing

93
Q

This is the sudden loss of muscle tone, usually triggerred from strong emotions

A

Cataplexy

Patognomonic of narcolepsy

94
Q

When do sleep hallucinations in narcolepsy occur, when falling asleep or awakening?

A

At sleep onset (hypnogogic)

95
Q

What test is useful for diagnosing narcolepsy?

A

MSLT

96
Q

What times of non-pharmacologic treatment should be administered for narcolepsy?

A

Structured sleep schedule
Scheduled naps
No drama in life

97
Q

What medications can be used to treat the hypersomnolence with narcolepsy?

A

Stimulants (modafinil, armodafinil)

Amphetamines (methylphenidate, dextremphetamine)

98
Q

What medications can be used to treat the cataplexy with narcolepsy?

A

SSRIs

Sodium oxybate

99
Q

What medications can be used to treat the sleep fragmentation with narcolepsy?

A

Hypnotics (zolpidem, eszopiclone)

Sodium oxybate

100
Q

Treatment for idiopathic hypersomnia?

A

Modafinil or armodafinil

101
Q

Based on the following characteristics, is this more suggestive of narcolepsy or idiopathic hypersomnia (IH)?

Continuously sleepy throughout the day

A

IH

102
Q

Based on the following characteristics, is this more suggestive of narcolepsy or idiopathic hypersomnia?

Naps are refreshing

A

Narcolepsy

103
Q

Based on the following characteristics, is this more suggestive of narcolepsy or idiopathic hypersomnia?

Presence of cataplexy

A

Narcolepsy

104
Q

Based on the following characteristics, is this more suggestive of narcolepsy or idiopathic hypersomnia?

10% of cases remit spontaneously

A

IH

Narcolepsy is life-long

105
Q

Based on the following characteristics, is this more suggestive of narcolepsy or idiopathic hypersomnia?

Treatments include other agents such as SSRIs and zolpidem in addition to modafinil

A

Narcolepsy

106
Q

This condition is characterized by uncomfortable sensation in the legs at rest which are relieved with movement

A

RLS

107
Q

Deficiency in which substance can cause RLS due to ineffective dopamine synthesis?

A

Iron

108
Q

First line agents for treatment for RLS?

A

Dopamine agonists (pramipexole, ropinirole)

109
Q

Second line agents for treatment of RLS?

A

Gabapentin, opioids, carbidopa/levodopa

110
Q

This group of diagnosis is characterized by abnormal or complex body movement during sleep, and include sleep terrors, sleep walking, sleep talking, and sleep eating.

A

Parasomnias

111
Q

Do parasomnias occur during REM or NREM sleep?

A

NREM

112
Q

This diagnosis is characterized by presence in childhood, child will sit of screaming or mumbling, appearing panicked, amnesia to event

A

Night terrors

113
Q

Treatment of night terrorss?

A

Supportive unless frequent and disruptive, in which benzos or TCAs may be beneficial

114
Q

This parasomnia occurs in older male patients in REM sleep, where dreams are acted out, memories of event are present, and often associated with Parkinsons

A

REM sleep behavior disorder

115
Q

Treatment for REM sleep behavior disorder?

A

NONPHARMACOLOGIC first (mattress on floor, sleep in separate beds, eetc) –> Clonazepam

116
Q

Treatment for delayed sleep phase syndrome?

A

Bright light in the morning, melatonin at night to promote sleep

117
Q

Treatment for advanced sleep phase syndrome?

A

Bright light at night, melatonin in the morning

118
Q

Treatment for shift work sleep disorder (if unable to change jobs)?

A

Bright light while at work to suppress melatonin, can use modafinil or armodafinil, use dark glasses when driving home and block sun when sleeping during the day

119
Q

Treatment for free running disorder (non-24-hour syndrome) in blind patients??

A

Maltonin at night, alarm clocks

120
Q

This is the inability to initiate or maintain sleep despite adequate time and opportunity to do so

A

Insomnia

121
Q 
32-year-old woman
reports sleeping only 3
hours per night for many
years. She reports good
sleep quality, denying any
daytime impairment,
sleepiness, or distress.
Does this patient have
insomnia?
A 
No because the patient is
not experiencing
impairment or distress as a
result of the short sleep
duration
122
Q

What is the gold standard for treatmnet for insomnia?

A

Cognitive behavior therapy (CBT)

This is a systematic approach that addresses cognitive stress that exacerbates insomnia, and the maladaptive behaviors that perpetuate further sleep disturbances. Equally effective as meds!

123
Q

This medication for insomnia is a selective GABA agonist, lasts 4-5 hours, used for sleep initiation insomnia, and can cause side effects such as sleep eating, depression, headaches, and fatigue?

A

Zolpidem

124
Q

This medication for insomnia is a benzodiazepine, lasts 6-8 hours, used short term (7-10 days) for sleep initiation insomnia, and causes side effects such as respiratory depression, fatigue, dependency, or dizziness?

A

Temazepam

125
Q

This medication for insomnia is a selective GABA agonist that lasts 6-8 hours, used for sleep initiation and maintenance insomnia, and can cause side effects such as depression, headaches, dizziness, and unpleasant metallic taste?

A

Eszopiclone

126
Q

This medication for insomnia is a melatonin receptor agonist, lasts 4-5 hours, used for sleep initiation insomnia, and can cause side effects such as depression, headaches, and fatigue?

A

Ramelteon

127
Q

This medication for insomnia that is a selective GABA agonists, lasts 1-2 hours, used for sleep initiation insomnia, and can cause depression, headaches, dizziness, and amnesisa?

A

Zaleplon

128
Q

This medication for insomnia that is an SNRI, lasts 3-5 hours, used for sleep maintenance insomnia, and can cause side effects such as fatigue, nausea, and depression?

A

Doxepin

Pulmonary Review (14 decks)

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