Sleep and Restritive Lung

Question 1

Definition of restrictive lung disease

Answer 1

TLC < 80%. Also low RV, VC and FRC. No Obstruction.

DLCO normal = Chest wall problem. Low DLCO = ILD

Question 2

Causes of restrictive lung disease

Answer 2

Neuromuscular Weakness
Chest Wall Disorders
Pleural Disease
Lung Parenchymal Disease

Question 3

What can cause neuromuscular weakness in respiration?

Answer 3

Spinal cord injury or disease
Anterior horn cell disease (ALS, polio, rabies)
Guillain-Barré Syndrome
Diaphragmatic paralysis
Myasthenia gravis
Botulism
Hereditary and acquired myopathies

Question 4

Underlying causes of ILD

Answer 4

Congenital or acquired
Infections
Tobacco
Medications
Occupational exposures
Environmental exposures
Connective tissue disease
Idiopathic Pulmonary Fibrosis

Question 5

Six categories of ILD etiology

Answer 5

Inflammatory: Sarcoids, vasculitis, pneumonitis
Immunologic
Infiltrative: cancers
Inhalational: asbestos, silicosis, hypersensitivities
Iatrogenic: chemo, amiodarone, cocaine, naproxen, etc.
Idiopathic: IPF, etc.

Question 6

Physical signs of ILD

Answer 6

Clubbing
Crackles - “velcro”
Inspiratory Squeaks
Cyanosis
Cor pulmonale

Question 7

IPF - pathophysiology and physical findings

Answer 7

Unknown etiology
Gradual progression to respiratory failure and death – within 10 years
Physical findings: Clubbing, Bibasilar, late inspiratory, Velcro crackles, Cor pulmonale – end stage

Question 8

Investigations of restrictive lung disease

Answer 8

DLCO/VA - is lung functioning properly
CXR of ILD: Reticular, Nodular or Both
CXR of Sarcoids: bilateral hilar adenopathy, non-caseating granulomas

Question 9

Tx of restrictive lung disease

Answer 9

Sarcoidosis: systemic steroids if severe
ILD: methotrexate…
IPF: usually palliation. Maybe lung transplant

Question 10

Components of sleep history

Answer 10

BEARS
Bedtime
Excessive daytime sleepiness EDS
Awakenings: night wakings, early morning waking
Regularity and duration of sleep
Snoring 
Also get bed partner’s observations

Question 11

Causes of Excessive daytime sleepiness

Answer 11

• Drugs
• Respiratory-Induced: Snoring, Upper Airway Resistance Syndrome, Obstructive sleep apnea, Central sleep apnea, Periodic breathing (Cheyne-Stokes)
• Periodic Leg Movements
• Narcolepsy
• Idiopathic Hypersomnolence

Question 12

Normal Snoring

Answer 12

<5 obstructions per hour is ok. More is concerning.

Question 13

Main symptoms of Sleep disorder

Answer 13

Daytime sleepiness
Waking at night choking
Intellectual impairment
Increased irritability
Sexual impairment
Mood change: Aggressive, Irritable, Bursts of anxiety, Depression
Intellectual impairment: concentration, less flexible, confusion in AM

Question 14

Consequences of EDS

Answer 14

Performance deficits, decreased quality of life, increased morbidities and mortality (diabetes, stroke, MI, accidents)

Question 15

Dx of sleep disorders

Answer 15

Polysomnography/overnight sleep study

Gold standard is going to a sleep lab (level 1). Watch ECG, leg movements, eyes, position.

Question 16

How can you tell apart central and obstructive sleep apnea?

Answer 16

On sleep study, if there is not thoracic/abdominal effort, then it is central.
Can have both = mixed sleep apnea

Question 17

Periodic leg movements

Answer 17

Repetitive, stereotypic, uncontrollable movements of lower limbs
Association with Restless Leg Syndrome, thyroid issues or low Fe.

Question 18

Narcolepsy classic symptoms

Answer 18

Sleeping 12-15 hours per day
“Drop attacks” with laughter (Cataplexy)
Unable to move for 15 minutes after waking
Intense dreams but actually awake/Sleep paralysis

Question 19

Tx of sleep disorders

Answer 19

Behavioral and lifestyle: smoking, EtOH, obesity (but not everyone with sleep problem is overweight)
Pharmacotherapy
Dental appliance
Surgical intervention: uvula and soft palate resection
CPAP/BiPAP