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Respiratory > Sleep Medicine > Flashcards

Sleep Medicine Flashcards

1
Q

Risk factors for OSA

A
  • High BMI
  • Male gender
  • Older age
  • Increased neck circumference
    Males >43cm, Females >37cm
  • Snoring
  • Witnessed apnoea
  • Menopause
  • Craniofacial abnormalities
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2
Q

Screening questionnaires for OSA

A 
STOP-BANG
- Snoring
- Tiredness
- Observed apnoea
- Blood pressure
- BMI
- Age
- Neck circumference 
- Gender 
Score /8
Intermediate to high risk of OSA if score ≥3/8
OSA50 
- Obesity
- Snoring
- Apnoeas
- >50 
>5/10 score

Epworth Sleepiness Scale

STOP Bang and berlin questionnaires have the highest sensitivity + specificity

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3
Q

Diagnosis of OSA

A 
Via polysomnography (PSG)
AHI (apnoea/hypopnoea index)

AHI > 5/hr + symptoms OR
AHI > 15/hr +/- symptoms

Normal <5
Mild 5-15/hr
Moderate 15-30/hr
Severe 30+/hr

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4
Q

Complications of OSA

A
  • Motor vehicle accidents - 4x increased risk with moderate/severe OSA
  • Cardiovascular disease: HTN, CAD, CCF, AF, CVA
  • Pulmonary HTN
  • Metabolic dysregulation - increased risk of DM
  • All cause mortality

Most common to least:

  • AF
  • Depression
  • CCF
  • Stroke
  • HTN
  • CAD
  • Diabetes
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5
Q

Characteristics of obesity hypoventilation syndrome

A

Obesity Hypoventilation Syndrome (OHS) consists of a triad of:
• Awake hypercapnia (PaCO2 >45mmHg)
• BMI >30
• Sleep disordered breathing when other causes of hypoventilation excluded (eg: lung disease, neuromuscular disease)

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6
Q

How does obesity and OSA cause hypercapnia?

A

Obesity –> leptin resistance or increased mechanical load –> blunted ventilatory response –> chronic hypercapnia

OSA –> acute hypercapnia during sleep –> decreased compensatory hyperventilation or decreased HCO3 excretion rate –> increased serum HCO3 –> chronic hypercapnia

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7
Q

Conditions associated with OSA

A
  • Increased mortality
  • COPD
  • Heart failure
  • Diabetes
  • CKD
  • GORD
  • NASH
  • Systemic HTN is more common in patients with OSA than those without OSA
  • Increased OSA severity corresponds to increased likelihood of systemic HT
  • CPAP reduces BP but not as much as medication
  • Consider OSA in patients with resistant HTN
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8
Q

Cardiovascular consequences of OSA

A
  • Hypertension
  • Pulmonary HTN
  • Arrhythmias
  • Diabetes
  • CAD
  • Stroke
  • Dyslipidaemia
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9
Q

Women with OSA present differently to men

What are the main symptoms and risk factors of OSA in women

A

Higher prevalence symptoms

  • Insomnia
  • Depression, irritability, mood changes
  • Anxiety
  • Non-restorative sleep, lethargy, fatigue

RF

  • PCOS
  • Pregnancy
  • Menopausal state
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10
Q

Efficacy of OSA treatment

A

(a) Symptoms - improve, residual sleepiness
(b) Hypertension - improve depending on patient and severity of htn
(c) Reduce incidence of cardiovascular disease and mortality
(d) Some studies suggest improvement in insulin resistance in non-diabetics + improve glycemic control in t2dm

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11
Q

Oral appliances vs CPAP for OSA

A

Reduction in AHI greater with CPAP

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12
Q

Surgery for OSA

A

Evidence primarily from case series

  • Maxillo-mandibular advancement: high success rate reported in selected patients
  • Bariatric surgery: improvements in AHI
  • Hypoglossal nerve stimulation improves apnoea hypopnoea index, oxygen desaturation index, epworth sleepiness scale, QOL, reduced snoring
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13
Q

What is the difference between obstructive sleep apnoea and central apnoea

A

Two main types of sleep apnea include obstructive sleep apnea (most common) and central sleep apnea.

  • OSA is where your upper airway gets partially or completely blocked while you sleep.
  • Central sleep apnea (CSA), cessation of respiratory drive results in a lack of respiratory movements
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14
Q

What is central apnoea?

A

Absent inspiratory effort for the duration of the apnoea

PSG finding: absence of airflow and thoraco-abdominal excursion >10s
- Central apnoea index > 5 events/hour and >50% of respiratory events are central

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15
Q

Types of central sleep apnoea

A 
(A) Eucapnic or Hypocapnic CSA 
- High or irregular drive to breathe
- No daytime hypoventilation 
- Examples
Heart failure 
Post stroke 
Chronic renal failure, dialysis 
High altitude
Idiopathic 
Treatment emergent CSA when starting PAP therapy 
(B) Hypercapnic CSA
- Low drive to breath 
- Nocturnal and daytime hypoventilation 
- Examples 
Neuromuscular disorders
Pulmonary disorders
Opioids
Central congenital alveolar hypoventilation syndromes
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16
Q

Sleep disordered breathing in CCF

A
  • Common in HFrEF, HFpEF
  • OSA and CSA often co-exist
  • RF: male, >60yo, AF, LVEF, daytime hypocapnia PaCO2 <38
  • Associated with poor prognosis
17
Q

Sleep disordered breathing treatment in CCF

A

OSA
- CPAP has been shown to improve symptoms and LVEF

Central Sleep Apnoea

  • Medical management of CCF
  • ?CPAP - improves AHI, oxygenation, ejection fraction by 4%, exercise capacity
  • ?ASV (adaptive servoventilation) - increased mortality with EF < 45%
18
Q

Diagnostic criteria for restless leg syndrome

A

All 3 need to be met

  1. An urge to move the legs, usually accompanied by or though to be caused by uncomfortable and unpleasant sensations in the legs
  2. Not due to another medical or behavioural condition
  3. Affection function

Essential:
URGE
- Urge to move limb: unpleasant and uncomfortable
- Rest (inactivity) worsens or precipitates symptoms
- Getting up and moving improves symptoms
- Evening (or bedtime) worsens or precipitates symptoms

Non-Essential

  • Family hx (increase 3-5 times)
  • Response to dopaminergic therapy
  • Sleep disturbance
  • PLMS or PLMW (periodic limb movement during sleep/wakefulness)
19
Q

Causes and risk factors of restless leg syndrome

A

Primary Causes

  • Early onset
  • Younger, slowly progressive, family history, idiopathic

Secondary Causes:

  • (brain) Iron deficiency - leading to reduced CNS dopamine as iron is dependent for dopamine synthesis
  • ESRF
  • Pregnancy
  • Medication induced: antidepressants, antihistamines, lithium, D2 receptor blockers (antipsychotics)
20
Q

Treatment for restless leg syndrome

A

Non Pharm

  • Mental alerting activities
  • Abstinence from caffeine, nicotine, alcohol
  • Iron replacement if ferritin <50
  • Evaluate medications that may worsen RLS

FIRST LINE
1. Dopamine Agonist: pramipexole (renally excreted), ropinirole (hepatic excreted), rotigotine patch (hepatic excreted)
SE: sleepiness, impulsive behaviours, augmentation (paradoxical worsening of RLS)

  1. Alpha delta ligands
    - Pregablin, gabapentin
    - SE: suicide ideation, weight gain, sleepiness

SECOND LINE

  • Opioids: oxycodone (targin)
  • Benzodiazepines

Correction of nutritional deficiences: Iron

21
Q

Augmentation with the use of dopamine agonist in restless legs syndrome

A

(1) Augmentation (worsening of symptoms) are common
(a) Development of worsening RLS with increased doses of dopamine agonists
- Earlier onset of symptoms (2-4 hours +)
- Spread to arms or trunk
- Shorter duration of reponse to medications

(b) RF for augmentation
- Increasing total agonist dose
- Increasing duration of symptoms + treatment
- Lower iron stores
- Greater severity of symptoms pre-treatment
- Risk greater for levodopa than agonists and possibly more for intermediate compared to long acting agonists

(2) Impulse control disorders
- Pathological gambling
- Compulsive shopping
- Hypersexuality

22
Q

Other therapies for restless leg syndrome

A
  • Pregablin and gabapentin - a2delta Ligands
  • iron replacement aim ferritin >100
  • benzodiazepines especially clonazepam
  • Opioids
23
Q

Difference between dyssomnias and parasomnia

A

Dyssomnia: a group of primary sleeping disorders characterized by difficulty falling/staying asleep or hypersomnia (excessive daytime sleepiness)
EG: OSA, central sleep apnoea, narcolepsy, insomnia, hypersomnolence disorder

Parasomnia: a group of primary sleeping disorders characterized by abnormal behaviors or experiences that occur while falling asleep, during sleep, or while waking up
EG:
(a) NREM-related parasomnia: a group of parasomnias characterized by repeated episodes of brief but incomplete awakenings that typically occur during the first third of sleep: Sleepwalking disorder, Sleep terror disorder
(b) REM-related parasomnias: a group of parasomnias characterized by a dissociation between REM sleep and the awake state: Nightmare disorder, REM sleep behavior disorder, Recurrent isolated sleep paralysis,
(c) Restless legs syndrome

24
Q

Nightmare disorder vs sleep terror disorder

A

I REMember my NIGHTMARE, and there were NO memorable TERRORists:” Nightmare disorder occurs during REM sleep and the experience is remembered, while sleep terror disorder occurs during non-REM sleep and is not remembered.

What is the biggest differences between night terrors and nightmares?
One of the biggest differences between nightmares and night terrors is the awareness on the part of the child. With nightmares, children can often recall the experience in vivid detail. With night terrors, they usually have no recollection of the event at all the next morning

25
Q

What is the normal sleep cycle?

A
  • Consists of 4-5 sleep cycles of 90-120 minutes each
  • Every cycle consists of 3 NREM sleep stages and 1 REM sleep stage with the percentage of REM sleep gradually increasing as the night progresses
25
Q

What is the normal sleep cycle?

A
  • Consists of 4-5 sleep cycles of 90-120 minutes each
  • Every cycle consists of 3 NREM sleep stages and 1 REM sleep stage with the percentage of REM sleep gradually increasing as the night progresses
26
Q

Non-REM + REM sleep

A

NON-REM SLEEP
- 80% of total sleep time
- Divided into N1/N2/N3 - progressively “deeper” sleep
N1: light sleep lasting for 5-10 mins, sloe eye movements
N2: body prepares to enter deep sleep, muscle relaxation, decreased body temp, reduced HR
N3 (slow wave sleep): mostly occurs in first half of the night, deep sleep stage and where restorative effects of sleep occur
- Body build bone + muscle, repairs + regenerates tissues, strengthen immune system
-As you age, you get LESS non-REM sleep - older adults get less deep sleep than younger people

REM SLEEP

  • 20% of sleep time
  • Brain activity increases again and sleep is not as deep
  • Increased brain activity, increased heart rate, vivid dreams occur
  • Characterised by atonia (EMG), tonic/phasic eye movements
  • Narcolepsy: intrusion of REM in wakefulness
27
Q

Normal changes in sleep with aging

  • What is increased
  • What is decreased
A

Increased

  • Nocturnal awakenings
  • Daytime napping
  • Nocturnal sleep latency - takes longer to fall asleep
  • Snoring

Decreased

  • Total sleep time
  • Sleep efficiency
  • REM latency - time to get to REM sleep is shorter
  • Percentage of time in REM
28
Q

What is apnoea and what is hypopnoea

A
  • Apnoea: cessation of airflow for ≥ 10s

- Hypopnoea: Reduction in airflow by 30% for ≥ 10s (mouth or nose) followed by 4% oxygen desaturation or EEG arousal

28
Q

What is apnoea and what is hypopnoea

A
  • Apnoea: cessation of airflow for ≥ 10s

- Hypopnoea: Reduction in airflow by 30% for ≥ 10s (mouth or nose) followed by 4% oxygen desaturation or EEG arousal

29
Q

What are the waves?

A

“For BETTER (read “beta”) WAVES, Ask The Silent Surfer Dozing at the Beach:” Beta waves while awake; Alpha waves with eye closure; Theta waves during N1; Sleep spindles during N2; Delta waves during N3; Beta waves during REM sleep).

30
Q

NREM Parasomnia

  • Definition
  • Pathogenesis
  • RF
  • Types
A

Definition: undesirable behaviour or phenomenon occuring during NREM sleep

Pathogenesis:

  • Partial arousal from sleep
  • State instability
  • HLADQB1 increases susceptibility

RF

  • Sleep deprivation/emotional stress
  • Drugs - sedative
  • Sleep disorders that increase arousals - OSA< PLMS

Types

  • Sleep walking
  • Confusional aorusals
  • Sleep terrors
31
Q

NREM Parasomnia treatment

A
  • Reduce sleep deprivation
  • Safe environment
  • Pharmacotherapy - clonazepam, topiramide
  • Relaxation/mindfulness/hypnotherapy
32
Q

REM sleep behaviour disorder (REM parasomnias) are associated with which neurodegenerative diseases

A

a-synucleinopathies (PALM)
Parkinson disease
Lewy body dementia
Multisystem atrophy

Also associated with narcolepsy

  • Involves both RSWA (REM sleep loss of muscle atonia) and dream enactment behaviours (DEB)
  • Mx: clonazepam, melatonin
  • Avoid antidepressants (TCA, SSRI)
  • Neurology assessment
33
Q

Narcolepsy

A

• Narcolepsy is a central disorder of hypersomnolence
Hypersomnia is characterized by recurrent episodes of excessive daytime sleepiness or prolonged nighttime sleep
• Cataplexy: sudden and transient episode of muscle weakness associated with conscious awareness usually triggered by emotions eg laughing

It is characterised by severe, irresistible daytime sleepiness and often by cataplexy (sudden loss of muscle tone following emotional or other provocation). Sleep monitoring shows
rapid sleep onset (latency) and rapid onset of shortened rapid eye movement (REM) sleep

Type 1
- With cataplexy
- Low CSF HYPOCRETIN (lateral hypothalamus)
- Genetic predisposition - HLADQB1*06.02
- Etiological homogeneity
- Tx: amphetamine
Cataplexy - antidepressant (venlafaxine), sodium oxybate

Type 2:

  • Without cataplexy
  • More heterogeneous
  • Spontaneous improvement 15%

Secondary Narcolepsy (rare) - CNS trauma, genetic disorders, MD, brain lesions

34
Q

Clinical features of narcolepsy

A
  1. Daily sleepiness
    Normal: 1hr –> REM
    Narcolepsy: minutes –> REM
  2. Cataplexy: episodes of muscle weakness triggered by strong emotions
  3. Inability to move at the start or end of sleep
  4. Vivid hallucinations
  5. Fragment sleep
35
Q

Diagnostic criteria for narcolepsy type 1

A
  • Daily periods of irrepressible need to sleep or daytime lapses into sleep occurring for at least 3 months
  • The presence of 1 or both of the following
    (a) Cataplexy and a mean sleep latency of < 8 minute and two or more SOREMPs
    (b) CSF hypocretin conc <110pg/ml or <1/3 of mean values

Sleep onset REM periods (SOREMPs) are REM sleep periods that occur within 15 minutes of sleep onset.

36
Q

PSG Features of

  • OSA
  • Central sleep apnoea
  • Nocturnal hypoventilation
  • Cheyne Stokes Respiratory
A

(a) OSA: cessation of airflow with PERSISTING respiratory effort followed by an oxygen desaturation and arousals
(b) Central sleep Apnoea: cessation of airflow with NO respiratory effort followed by oxygen desaturation and arousal
(c) Nocturnal Hypoventilation: severe nocturnal hypoxemia with sustained oxygen desaturation associated with rise of TCO2 especially in REM
(d) Cheynes Stokes Respiration: crescendo decrescendo respiration

Respiratory (10 decks)

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