Sleep Disorders Flashcards
2 things that differentiate N1 sleep pattern from REM pattern on sleep study
Rapid eye movements and flat chin waveform
Normal
N1
N2
N3
% of sleep that is REM
15-20%, stays constant as we age
Change in minute ventilation with sleep
Decreases 1-2L/min
Stage of sleep where breathing is most stable
N3
Sleep stage that lessens as we age
N3
Reduction of tidal volume in REM
40%
REM sleep occurs in cycles of how many minutes
90 minutes or so
What key feature must occur to classify an event as an obstructive apnea?
Must have a continued effort throughout the event
Obstructive apnea
Mixed Apnea
Hypopnea
3 Criteria for hypopnea
- Drop of signal by 30%
- Drop lasts for 10 seconds
- 3% or more drop in sats or an arousal
- Government payers say 4% or more only, no arousal
4 Criteria for RERA (respiratory effort related arousal)
- 10 seconds or more
- Increased respiratory effort or flattening of inspiration portion
- leads to an arousal
- Does not meet criteria for apnea or hypopnea
2 criteria for apnea
- Decrease in amplitude by 90%
- Lasts for 10 seconds
Definition of apnea index
of apneas per hour of sleep
Definition of Apnea/Hypopnea index (AHI)
of apneas and hypopneas per hour of sleep
Definition of respiratory disturbance index (RDI)
apneas, hypopneas, and RERAs per hour
Definition of respiratory events index (REI)
apneas, hypopneas per hour of recorded time (Home studies)
Normal AHI
< 5
Mild apnea AHI
5-14
(CMS also requires a comorbid condition or symptom)
Moderate apnea AHI
15-29
Severe apnea AHI
30 or more
% of those with severe OSA who are not sleepy
50%
How does severity of PHTN correlate with OSA
OSA will cause mild PHTN but not moderate or severe
Positive predictive value of snoring and witnessed apneas for OSA
64%
4 Medical disorders requiring an inlab sleep study
- CHF
- Hypoventilation syndromes
- COPD
- Stroke
3 Sleep disorders that require an inlab sleep study
- Insomnia
- Restless leg syndrome
- Narcolepsy
2 methods of diagnosing OSA that are NOT recommended
- Autotitrating CPAP
- Overnight pulse ox
Why can you not do a home sleep study in pregnancy?
No data on home study accuracy in pregnancy
How does data on PAP therapy show impact on CV disease?
Not a great reduction except HTN and maybe CVA
3 things that will improve CPAP adherence
- Heated humidification
- Education
- CBT
What do patient’s with an oral device for OSA treatment need after the device has been fitted?
Repeat sleep study (only about 70% effective)
What surgery is not recommended anymore for OSA?
Laser assisted uvuloplasty (LAUP)
What are the 4 surgical options for OSA treatment?
Bariatric surgery
Maxillo-mandibular advancement (MMA)
Hypoglossal nerve stimulator
Adenotonsilectomy for pediatrics
Breathing pattern associated with opioid use
Ataxic breathing pattern (Biot’s)
Rule of 3rds in CHF sleep disorders
1/3 will have OSA
1/3 will have CSA
1/3 will have neither
WIth central sleep anea and HF, what is a contraindication to adaptive servoventilation
EF < 45%
(SERVE-HF trial showed increased mortality)
2 criteria for diagnosis of OHS
- BMI > 30
- Awake PCO2 > 45
- Must be a diagnosis of exclusion
Which drive is the process is the sleep drive
Process S
Which process is the circadian rhythm drive?
Process C
Term for sleep diary
Actigraphy
Questionnaire used in circadian rhythm sleep disorders
Owl - Lark Questionnaire
Advanced sleep phase syndrome
Goes to bed early and gets up early
Gene associated with familial form of advanced sleep phase syndrome
Per2 gene mutation
Treatment for advanced sleep phase syndrome
Early evening bright light therapy
Delayed sleep phase syndrome
Night owls, go to bed late and get up late
Free running circadian disorder
AKA non-24 hour sleep/wake disorder
Major sleep period “marches” throughout the day
Other than melatonin, drug treatment for Non-24 circadian disorder
Tasimelteon
Irregular sleep wake circadian rhythm disorder
NO real circadian rhythm
Variable periods of sleepiness and wakefullness
10 D’s of excessive daytime sleepiness
- Deprivation
- Disorders of sleep
- Delayed sleep phase disorder (morning sleepiness)
- Depression
- Disease (liver failure, thyroid disorders)
- Dope (Illegal drugs)
- Drugs (prescription drugs)
- Drinking (ETOH abuse)
- Delirium
- Drama (malingering)
4 clinical characteristics of narcolepsy type 1
- Excessive sleepiness for at least 3 months
- Cataplexy
- Mean sleep latency < 8 mins + 2 sleep onset REM periods (SOREMP) OR
- CSF hypocretin/orexin level < 110
2 differences in Narcolepsy type 2 as compared to type 1
CSF Hypocretin/orexin level > 110
NO cataplexy
Drug used to treat cataplexy in narcolepsy
Sodium oxybate
Diagnostic criteria for idiopathic hypersomnia
Sleep latency test (MSLT) showing < 8 minutes
< 2 Sleep onset REM periods (SOREMP)
Definition of insomnia
difficulty falling asleep at least 3 times per week for > 3 months
Insomnia drug contraindicated in patients using fluvoxamine or with liver impairment
Ramelteon
Non-benzodiazepine benzo receptor antagonists
Eszopiclone
Zaleplon
Zolpidem
Hypocretin/orexin receptor antagonist drug in insomnia. Cateplexy rarely described.
Suvorexant
Parasomnia associated with lewy body dementia
REM sleep behavior disorder
3 Parasomnias associated with NREM sleep
Confusional arousals
Sleep terrors
Sleepwalking
Characteristic REM sleep behavior disorder
Violent movements during REM usually associated with unpleasant or action filled dreams
Drug used to treat all parasomnias
Clonazepam
(Can use melatonin for RBD)
URGE mnemonic for RLS
Urge to move
Rest induced
Gets better with activity
Evening and night accentuation
What lab test should be considered in patients with RLS or periodic limb movements
Ferretin
Side effect of dopaminergic meds (ropinirole) in RLS treatment
Impulse disorders
Threshold for periodic limb movements to be abnormal
> 15 in adults
2 Charateristics that are unfavorable for hypoglossal nerve stimulators
Concentric collapse of the pharangeal airway
Large tonsils
Drug shown to improve CPAP adherance in short term use
Eszopiclone
