Sleep DOs Flashcards
Manifestations of sleep d/o
- Inadvertently fall asleep or fight to stay awake during quiet or passive activities
- Intentional naps
- Experience short repetitive lapses while doing monotonous tasks
- Lost productivity
- Accidents
Test used to show sleep apnea
Nocturnal polysomnography
Characteristics of pts w/sleep apnea
- Obese > non obese
- Middle aged men
- Women approaching menopause
- Snore
- Excessive daytime somnolence
- Neck size men >17, women >16
- Oral anatomy: narrow airway, stretched uvula, erythema
Conservative tx for OSA
- Positional: raise HOB, tennis ball in t-shirt, wedge
- Avoid etoh and sedatives
- Wt loss: lifestyle, bariatric surgery
Non-conservative Tx for OSA
- Mechanically stent upper airway: nasal cpap, BiPAP, AutoCPAP, oral devices
- Alter upper airway: soft tissue surgery, skeletal surgery
- Bypass upper airway: tracheostomy
- CPAP is mainstay!
Central sleep apnea
- Not obstructive, no waking up gasping
- Brain decides not to breathe
- Usually cardiac: Cheyne-Stokes, Neuro: stroke, trauma, Secondary to opiate use
- Tx underlying cause
Classic tetrad of symptoms for narcolepsy
- Excessive daytime sleepiness***, sleep attacks
- Cataplexy (triggered by anger, surprise, awake but no muscle tone)
- Sleep paralysis
- Hallucinations
- Fragmented nocturnal sleep
***only necessary symptom for Dx
Not always have tetrad
How to diagnose narcolepsy
Daytime sleep study: Multi-sleep latency test – objective test of daytime sleepiness
Tx of narcolepsy
- Education: sleep patterns, naps, psychosocial complications, risks
- Med therapy: goal to control sx, balance w/SEs. CNS stimulants – caffeine, methamphetamine, dextroamphetamine
- Can try indirect sympathomimetics, TCAs
Sx idiopathic hypersomnia
- Resembles narcolepsy
- Dx of exclusion
- EDS of unknown etiology, naps are not refreshing (narcolepsy tend to feel better)
Typical age of idiopathic hypersomnia
15-30yo
Testing for idiopathic hypersomnia
MSLT – shows pathologic sleepiness but no SOREM
Tx for idiopathic hypersomnia
Disabling – stimulants not that effective
Often end up w/amphetamines
What is REM sleep behavior disorder
- Loss of voluntary muscle atonia during REM
- Excessive motor activity while dreaming (have lost atonia)
- Behaviors frequently result in injury
Characteristics of patients w/REM sleep behavior DO
- More common in the elderly
- Post traumatic stress disorder
- Associated with neurodegenerative disease
Dx of REM sleep behavior DO
Diagnosis: Nocturnal Polysomnography: also to r/o apnea, which can cause acting out of dreams
Tx of REM sleep behavior DO
- Safety
- Clonazepam
- Avoid stress/sleep deprivation
RLS definition
- characterized by an almost irresistible urge to move, usually associated with disagreeable leg sensations (creepy crawly, etc) , worse during inactivity, and often interfering with sleep.
- May also c/o excessive daytime somnolence and insomnia
- Is a symptom – may be Periodic Leg Movements
PLM diagnosis
- In sleep lab via electromyography
- 30% have RLS symptoms
Secondary causes of RLS
IDA, uremia, pregnancy, neuro lesions, drugs (TCAs, SSRIs, lithium, dopamine blockers, xanthines)
Conditions associated w/RLS
Diabetes, Parkinson’s, RA
Acute vs chronic insomnia
Acute insomnia
- Up to 1 week in duration
- Often caused by situational stress
- May be recurrent with new stresses
Chronic insomnia
- Symptoms persist for 1 month or longer
Should be evaluated and treated
Types of insomnia / Dx
Many! But most importantly, they must have next day consequences for it to be insomnia
Tx for insomnia
- Sleep hygiene, OTC meds (melatonin, Benadryl), antiDs, non-BDZ hypnotics, benzos
- If circadian rhythm disturbance, try w/o meds first, or w/benzo/non-benzo short term to re-establish
- typically hypnotics for short term while starting CBT. Initial agents: zolpidem, zaleplon, eszopiclone
- If underlying affective DO: short term hypnotics and longterm AntiD or anxiolytic
Oral airway classes
Questionnaires for assessing sleep apnea
- STOP Bang & Epworth sleepiness scale
- Snoring
- Tired
- Observed (gasping/stop breathing)
- Pressure (HTN)
- BMI >35
- Age >50
- Neck size large (male >17 collar, female >16 collar)
- Gender male
Low risk: 0-2, Intermediate: 3-4, High: 5-8
Apnea vs hypopnea
- Apnea: stop breathing at least 10 seconds, associated with a decrease in blood oxygenation.
- Hypopnea:disruption of air flow of at least 30% during sleep or an arousal during sleep.
combo causes the blood level of CO2 to increase and the blood level of O2 to decrease –> disrupted sleep pattern
What is needed for CPAP?
- PSG in sleep lab needed for titration to determine optimal level of CPAP
- Usually 1 night for Dx, 2nd night for titration (can do split night)
- Adherence is biggest issue – need good fit
- Must be able to exhale against pressure
- Preferred in OSA: most evidence of success
How does CPAP work?
delivers a fixed mild positive pressure during inspiration and expiration to maintain airway openness.
How does BiPAP work?
delivers a higher pressure during inspiration and a lower pressure during exhalation - if cannot tolerate CPAP
How does APAP work?
variable inspiratory and expiratory pressures as it continuously monitors the patient’s breathing pattern and delivers pressures accordingly
How is CPAP delivered?
mask or through nasal pillows (plastic inserts placed directly under the nose and held in place by straps that cover less of the face than the mask)
Nasal pillows might be the better choice for patients who find the CPAP mask too uncomfortable or unattractive, or who find that their mask leaks air.
CPAP: nasal complaints and what to do about it
- Complaints: congestion, rhinorrhea, sneezing, or other nasal symptoms
- Tx:
- Humidification of the CPAP air
- nasal saline or nasal decongestants including nasal steroids.
- persistent nasal symptoms: refer to a sleep specialist or to a specialized respiratory therapist for reevaluation of the PAP setting and mask fittings.
CPAP: mask / air swallowing complaints and what to do about it
mask allergies: always assess for latex allergy!
Skin irritation: try nasal pillows
Air swallowing: decrease pressure (sleep specialist), lower HOB, PPI
CPAP: no improvement in Sx: what to do
Have patient keep sleep diary to document:
- tolerance
- side effects (e.g., nasal symptoms)
- daytime symptoms (e.g., sleepiness)
- nocturnal awakening
Encourage CPAP compliance and discuss with sleep specialist
OSA and pharm therapy
- NOT recommended until r/o other causes of failure, including comorbidities. Nothing approved/effective for tx of OSA itself.
- Only two drugs are FDA-approved for the treatment of residual daytime somnolence: modafinil and armodafinil. Should be used w/PAP tx
- Consider CV health, effect on cognition, habit forming, reduced effectiveness of OCPs
Measuring outcomes of OSA tx
Always!
Indicators
- Resolution of daytime sleepiness
- Improvements on Epworth Sleepiness Scale and/or other objective tests
- Patient self-reports of increased alertness/wakefulness during day
- Bed-partner reports of less snoring, less restlessness, and fewer nighttime awakenings by patient
- Adherence to therapy
- Weight loss
- Avoidance of factors exacerbating OSA, such as smoking and alcohol
