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MD2 Respiratory > Sleep Disorders > Flashcards

Sleep Disorders Flashcards

1
Q

List 4 broad causes of daytime sleepiness, from most common to least common

A 
Lifestyle (not getting enough sleep!)
Drugs/alcohol (e.g. benzodiazepenes, anti-depressants)
Sleep breathing disorders
RLS/periodic limb movement disorder
Neurological disease
Insomnia
Narcolepsy
Idiopathic hypersomnia
Circadian disorders
Psychiatric disorders
Post-viral

Lifestyle (not getting enough sleep)
Conditions disrupting sleep:
Drugs/alcohol
Sleep-related conditions

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2
Q

Distinguishing between sleepiness vs tiredness/lethargy

A

Sleepiness: narrower differential diagnosis

Tiredness/lethargy: broader differential diagnosis (chronic disease)

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3
Q

How can sleepiness be distinguished from tiredness/lethargy?

A

Epworth sleepiness scale: patient is asked what their chance of dozing would be in a number of contexts (normal 15 confers 2x risk of MVA; use in fitness to drive assessments)

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4
Q

Summarise the respiratory control changes at sleep onset

A

Loss of wakefulness drive to breathe and behavioural influences
Down-regulation of respiratory reflexes, chemosensitivity, and upper airway and respiratory pump muscle tone (thereby increasing upper airway resistance)

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5
Q

What is the major regulator of breathing during sleep?

A

Chemical control

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6
Q

What are the cardinal symptoms of OSA?

A

Heavy snoring
Excessive daytime somnolence
Witnessed apnoeas

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7
Q

List some other nocturnal symptoms of OSA

A

Disrupted/restless/unrefreshed sleep
Nocturnal choking and gasping
Nocturia

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8
Q

Mechanism of OSA

A

pO2 starts to fall, pCO2 starts to rise
Individual tries to breathe harder but this increases the negative pressure, causes closing of upper airway
Central drive reaches threshold for waking

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9
Q

List some other daytime symptoms of OSA

A 
Headaches (nocturnal/morning)
Memory/cognitive/concentration deficit
Mood change (depression/irritability)
Sexual dysfunction (decreased libido or impotence)
Uncontrolled HTN
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10
Q

List 5 cardio-respiratory effects of OSA

A 
HTN
Cor pulmonale
MI
Arrhythmias/sudden death
Polycythaemia
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11
Q

List 5 risk factors for OSA

A 
Age
Male gender
Obesity
Alcohol/sedatives
Upper airway morphology including nasal obstruction
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12
Q

What are the criteria for diagnosis of OSA?

A

Apnoea hypopnoea index (AHI) >5 events/hr

5-15 mild, 15-30 moderate, >30 severe (ranges not really useful; better to assess symptoms)

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13
Q

How can OSA be diagnosed?

A

In laboratory OR at home full polysomnography

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14
Q

Define apnoea

A

Complete cessation of airflow for ≥10 secs, regardless of O2 desaturation

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15
Q

Define hypopnoea

A

≥30% reduction in airflow associated ≥3% O2 desaturation or an alpha wave arousal from sleep

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16
Q

What are the 4 options for OSA management?

A

Conservative treatments
CPAP
Oral appliances
Surgery

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17
Q

List 5 options for conservative treatment of OSA

A 
Weight loss
Avoid alcohol, tobacco and sedatives
Body position
Treat nasal congestion
Treat medical disorders
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18
Q

Where might the use of oral appliances be advised?

A

Snoring
Mild to moderate OSA
Failed CPAP treatment

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19
Q

List some contraindications to oral apliances for management of OSA

A 
Dentures or lack of teeth
Periodontal problems
TMJ disorder
Severe nasal obstruction
Severe hypoxia
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20
Q

List some SEs of oral appliances for management of OSA

A

Excessive salivation
Discomfort in the teeth and jaw
Movement of teeth
TMJ dysfunction

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21
Q

List 3 types of sleep disordered breathing

A

OSA
Central sleep apnoea
Sleep hypoventilation

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22
Q

Define central sleep apnoea

A

Apnoeas or hypopnoeas caused by reduction in central respiratory drive

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23
Q

What are the 4 main causes of central sleep apnoea?

A

Cardiac failure (Cheyne-Stokes respiration; main cause)
High altitude
CNS disorders (e.g. CVA)
Idiopathic

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24
Q

How is central sleep apnoea managed?

A

Depends on underlying causes (e.g. for Cheynes-Stokes, manage heart failure)

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25
Q

List some causes of hypoventilation

A 
Reduced respiratory centre activity
Neuromuscular disease
Chest wall deformity
Obesity
Increased ventilatory requirements
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26
Q

Victorian requirements for driving

A

AHI >35

ESS >15

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27
Q

55 year old male, 110 kg, taxi driver
Fell asleep at the wheel and was woken by passenger
Long Hx of snoring, sleeps alone
Driving 15 hours per day; says he sleeps on the rank
6 hours per night in bed
Likely Dx?

A

OSA

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28
Q

Is OSA more common in males or females?

A

Males

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29
Q

List 5 neuropsychological effects of OSA

A 
Excessive sleepiness
Psychological problems
Stroke
Dementia
In children: behavioural problems, poor school performance, ADHD
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30
Q

Describe 4 factors contributing to the pathogenesis of OSA

A

Anatomically narrow upper airway
Upper airway muscle weakness
Poor respiratory control (with propensity to develop cyclical breathing)
Reduced arousal threshold (leading to cycling)

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31
Q

What are the diagnostic criteria for OSA?

A

AHI >5 events per hour (events/total sleep time)

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32
Q

How is the severity of OSA graded?

A

Mild: 5-15
Moderate: 15-30
Severe: >30

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33
Q

How effective is weight loss as a treatment for OSA?

A

10% weight loss results in a 26% reduction in AHI

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34
Q

Adaptive Servo-Ventilation (ASV)

A

Uses an algorithm which detects significant reductions or pauses in breathing and intervenes with just enough support to maintain the patient’s breathing at 90% of what had been normal prior to decreased breathing
Algorithm is based off a set rate of breaths per minute that the patient should be taking; when the patient’s breathing dips below these rates, the ASV delivers just enough air pressure to keep the patient breathing regularly

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35
Q

How is Cheyne-Stokes breathing managed?

A

Treat HF
CPAP
?O2
Adaptive Servo-Ventilation (ASV)

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36
Q

How is idiopathic CSA treated?

A

?O2

?NIV

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37
Q

Describe the “balance of forces” in respiration

A

Pro-respiratory: respiratory drive, nerve integrity, muscle integrity, “bellows” structure
Anti-respiratory: upper and lower airway resistance, elastance, gas exchange requirements

38
Q

22 year old male, difficulty sleeping since early teens, mainly due to sleep onset insomnia
Once asleep sleeps well, but has to get up for work after 4/24
Describes that he “cannot get comfortable” in bed
Non-snorer, thin
Minimal alcohol, no illicit drugs, 1 coffee daily
What aspects of Hx would be consistent with a diagnosis of chronic insomnia?

A

Subjective dissatisfaction with sleep quality or duration, difficulty falling asleep at bedtime, waking up in the middle of the night or too early in the morning, or non-restorative or poor quality sleep
Associated daytime symptoms and functional impairments

39
Q

Is chronic insomnia more common in females or males?

A

Females

40
Q

What is “primary” insomnia?

A

A disorder of “hyperarousal”

41
Q

List 6 changes seen in primary insomnia which may be associated with its pathophysiology

A 
Increased anxiety
Increased HPA axis activity
Increased HTN
Increased ANS activity in sleep
Changes in sleep EEG with more faster frequency waves
Increased brain glucose uptake in sleep
42
Q

List 8 disorders which may contribute to the onset of insomnia

A 
OSA
Circadian disorders
Restless legs
Psychiatric disorders
Substance abuse
Pain
Urinary problems
Rx
43
Q

How can insomnia be assessed/monitored?

A

Sleep diary

Actigraphy

44
Q

8 treatment strategies for insomnia

A 
Treat comorbid disorders
Stimulus control therapy
Sleep restriction
Relaxation
Biofeedback
Paradoxical intention
Sleep hygiene
Short term hypnotics
45
Q

What pharmacological treatments are used for insomnia?

A 
Benzodiazepines
Non-benzodiazepines
Antidepressants
Valerian
Antihistamines
46
Q

What principles must be considered when deciding whether to manage insomnia pharmacologically?

A

Hypnotic medications should not be the first choice of treatment
Rx should be used in short term management of idiopathic or psychophysiological insomnia
Rx should be combined with non-pharmacological measures when tapering the dose

47
Q

List 7 circadian disorders

A 
Delayed sleep phase syndrome
Advanced sleep phase syndrome
Non-24 hr circadian rhythm
Free-running rhythm
Jet lag
Shift work disorder
Seasonal affective disorder
48
Q

In what % of the population does restless legs syndrome occur?

A

5-15%

Increases with age

49
Q

List the 4 International Restless Legs Study Group Criteria

A

Desire to move the extremities often associated with parasthesias or dysaesthesias
Motor restlessness
Worsening of symptoms at rest with at least partial and temporary relief during activity
Worsening of symptoms in the evening or at night

50
Q

List 5 secondary causes of restless legs syndrome

A 
Iron deficiency
Renal failure
Peripheral neuropathy
Lumbosacral radiculopathy
Pregnancy
51
Q

How is familial restless legs syndrome inherited?

A

AD

52
Q

List 5 consequences of restless legs syndrome

A 
Sleep disturbances
Tiredness or fatigue during daytime
Reduced emotional well-being/QOL
Avoidance of social activities
Possibly higher incidence of CVS risk factors/CVS disease
53
Q

What is periodic limb movement disorder?

A

Repetitive movements of the limbs (usually legs) that occur during sleep and may be associated with arousal

54
Q

How is periodic limb movement disorder diagnosed?

A

PLM index on polysomnography

55
Q

What is the relationship between RLS and PLM?

A

80% with RLS have PLM

>50% PLM have RLS

56
Q

What is narcolepsy?

A

Disorder of sleep regulation, with an intrusion of some REM sleep into wakefulness and abnormal regulation sleep timing

57
Q

What is the pathophysiology of narcolepsy?

A

Deficiency in the neurotransmitter orexin

58
Q

When is the typical onset of narcolepsy?

A

Begins in teens and 20s (but can occur after 40)

59
Q

What is the inheritance pattern of narcolepsy?

A

AD with incomplete penetrance

Associated with HLA-DQB1*0602

60
Q

What are the main features of narcolepsy?

A

Excessive daytime sleepiness

Manifestations related to REM sleep

61
Q

What are the features of excessive daytime sleepiness seen in narcolepsy?

A

“Sleep attacks”, ESS>15, refreshed following nap
Abnormally timed REM sleep
Abnormal result on a multiple sleep latency test (MSLT)

62
Q

What manifestations related to REM sleep may be seen in narcolepsy?

A

Hypnagogic/hypnopompic hallucinations
Sleep paralysis (complete inability to move for 1-2 minutes after awakening)
Cataplexy

63
Q

Cataplexy

A

A medical condition in which strong emotion or laughter causes a person to suffer sudden physical collapse though remaining conscious

64
Q

What are the criteria for a diagnosis of narcolepsy?

A

Excessive daytime sleepiness
Cataplexy
MSLT (mean sleep latency

65
Q

SOREM

A

Sleep-onset rapid eye movement

66
Q

How can narcolepsy be treated?

A

General measures

Pharmacologically

67
Q

List 5 general measures used to manage narcolepsy

A 
Avoid shifts in sleep schedule
Avoid heavy meals and alcohol intake
Regular timing of nocturnal sleep
Strategically timed naps, if possible (e.g. 15 mins at lunchtime, 15 mins at 5.30pm)
Career counselling
68
Q

List 2 types of pharmacological treatments used to manage narcolepsy

A

Stimulants (e.g. modafinil, amphetamines)

REM-suppressing drugs (e.g. SSRIs, tricyclics)

69
Q

2 examples of amphetamines used in the treatment of narcolepsy

A

Dexamphetamine

Methylphenidate

70
Q

2 examples of SSRIs used in the treatment of narcolepsy

A

Fluoxetine

Venlafaxine

71
Q

List 5 diagnostic criteria for idiopathic hypersomnia

A

DIAGNOSIS OF EXCLUSION:
Complaint of EDS and prolonged, often unrefreshing naps
Difficulty waking up in the morning or after a nap (sleep drunkenness)
Insidious onset prior to age 30
Duration of at least 6 months
Exclusion of conditions that may cause the same symptoms on polysomnogram and MSLT (i.e. latencies between 5-10 mins, no SOREMs)

72
Q

Describe the pathogenesis of idiopathic hypersomnia

A

Unknown

73
Q

How is idiopathic hypersomnia treated?

A

Stimulants

1/4 spontaneously improve

74
Q

What is a parasomnia?

A

Undesirable behaviour or experiences in sleep or in transition to or from sleep

75
Q

List 3 disorders of arousal (from non-REM sleep)

A

Confusional arousals
Sleepwalking
Sleep terrors

76
Q

List 3 parasomnias usually associated with REM sleep

A

REM sleep behaviour disorder
Recurrent isolated sleep paralysis
Nightmare disorder

77
Q

List 6 other types of parasomnias

A 
Sleep-related dissociative disorder
Sleep enuresis
Sleep-related groaning
Exploding head syndrome
Sleep-related hallucinations
Sleep-related eating disorder
78
Q

When do disorders of arousal typically occur?

A

When arising from slow wave sleep (is a mixed state between sleep and wakefulness)
Usuaully occurs in the first 1/3 of night

79
Q

What factors may exacerbate disorders of arousal?

A

Factors which deepen sleep

Factors which disturb sleep

80
Q

How do disorders of arousal present?

A

Confusion when woken and mentation slow

Complex activity possible

81
Q

At what stage of life are disorders of arousal more common?

A

In childhood

82
Q

Do disorders of arousal have a familial component?

A

Yes

83
Q

What is the main DDx for a disorder of arousal?

A

Seizure disorder

84
Q

List 8 points of management for disorders of arousal

A 
Reassurance
Alter sleep environment for safety
Avoidance of precipitants
Treat stress
Sleep extension
Scheduled wakenings
Clonazepam/tricyclics
L-tryptophan for sleep terrors
85
Q

Clonazepam

A

Benzodiazepine (also used for seizures)

86
Q

What is the rationale behind the use of L-tryptophan for sleep terrors?

A

It is converted into serotonin

87
Q

List 3 types of REM parasomnias

A

REM behaviour disorder
Frequent nightmares
Isolated sleep paralysis

88
Q

Who is the typical demographic affected in REM behaviour disorder?

A

Elderly men predominantly (0.5% prevalence)

Association with neurodegenerative disorders

89
Q

What is REM behaviour disorder characterised by?

A

Dream enactment behaviour (often violent)

Failure of REM atonia/locomotor quiescence

90
Q

What different forms of REM behaviour disorder are there?

A

Idiopathic/secondary forms

91
Q

What may precipitate the acute form of REM behaviour disorder?

A

Injury
CVA
SSRI

92
Q

How is REM behaviour disorder managed?

A

Treat associated conditions
Stop causative medications
Consider use of clonazepam (80-90% respond), melatonin

MD2 Respiratory (9 decks)

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