Sleep Medicine

Question 1

True or False: Hypertension can be secondary to OSA

Answer 1

T

Question 2

True or False: Sleep disorders are underdiagnosed

Answer 2

T

Question 3

What special history acronym is part of sleep history?

Answer 3

BEARS
Bedtime
Excessive daytime sleepiness
Awakenings: night wakings
                        early morning waking
Regularity and duration of sleep
Snoring

Question 4

What are some questions to ask a partner of whom sleep disorder is in question?

Answer 4

Bed partner’s observations
Snoring
leg movements

Question 5

What are some medical conditions that should be asked to a patient suspected of sleep disorder?

Answer 5

Asthma
Reflux
Angina

Question 6

What are causes of excessive daytime somnolence?

Answer 6

1. sleep deprivation
2. fragmented sleep
3. primary sleep disorder

Question 7

How to diagnose a sleep disorder?

Answer 7

Overnight sleep study = Polysomnography

Question 8

What does the polysomnography record?

Answer 8

Sleep stage, breathing, oxygen and heart rate +
Leg movements
ECG
Video camera

Question 9

What are some etiologies of EDS?

Answer 9

• Drugs
  Hypnotic-dependent sleep disorder
  Stimulant-dependent sleep disorder
  Alcohol-dependent sleep disorder

- Respiratory-Induced:
Snoring
Upper Airway Resistance Syndrome
Obstructive sleep apnea
Central sleep apnea
Periodic breathing  (Cheyne-Stokes)

• Periodic Leg Movements
• Narcolepsy
• Idiopathic Hypersomnolence

Question 10

What are some characteristics of UARS?

Answer 10

Snoring, large pleural pressure swings

Question 11

What is obstructive sleep apnea on polysomnograph?

Answer 11

A complete blockage of the airway despite efforts to breath. Notice the effort gradually increasing ending in airway opening.

Question 12

What is hypopnea on polysomnograph?

Answer 12

This is an 18 second hypopneic event. The airflow signal is reduced by approximately 50% during this event.

Question 13

What is normal snoring?

Answer 13

Fewer than 5 obstructions (apneas + hypopneas) per hour

Question 14

T or F: OSA affects all ages

Answer 14

T

Question 15

What are causes of sleep apnea?

Answer 15

Imbalance in pressures keeping airway open

Pharynx collapses with breath

Anything which narrows airway makes sleep apnea more likely.

Anything which causes loss of muscle tone increases risk of sleep apnea.

Question 16

What are some anatomical causes of sleep apnea?

Answer 16

Abnormal anatomy of head and neck
Retorgnathia 
Obesity
Family history
Ethnicity

Question 17

What are the symptoms of sleep apnea?

Answer 17

Daytime sleepiness
Waking at night choking
Intellectual impairment
Increased irritability
Sexual impairment

Question 18

What are some heart complication as a result of

Answer 18

Increased risk of hypertension
Increased risk of MI
Increased risk of stroke
Excess mortality is due to cardiovascular causes

Question 19

What are some treatments for sleep apnea?

Answer 19

Nasal CPAP (the gold standard)

Dental appliance

Surgery:
UPPP
Cricoid resuspension
Mandibular advancement

Question 20

What is central apnea on polysomnograph?

Answer 20

A complete cessation of airflow resulting from a Reduction in respiratory effort . The upper airway is patent, but the respiratory center temporarily fails to trigger.

Question 21

What is mixed sleep apnea?

Answer 21

OSA + CSA = mixed sleep apnea

Question 22

T or F: CSA is more common than /oSA

Answer 22

F: OSA is more common

Question 23

What is the treatment for CSA?

Answer 23

Identify and treat reversible risk factors

BPAP with back-up rate

Question 24

How to diagnose Periodic Leg Movements (PLMS)?

Answer 24

Diagnosed by polysomnography EMG

Question 25

What is PLMS?

Answer 25

Repetitive, stereotypic, uncontrollable movements of lower limbs
Association with Restless Leg Syndrome
Incidence increasing with age

Question 26

What confirms narcolepsy?

Answer 26

MSLT confirmatory:
4 of 5 naps showed sleep onset REM
Sleep latency 2-3 minutes

Question 27

What are symptoms of narcolepsy?

Answer 27

Sleepiness
Cataplexy
Sleep paralysis
Hypnagogic hallucinations

Question 28

What is cataplexy?

Answer 28

• Loss of muscle tone
  REM intrusion
  Often brought on by emotions
• Severe fall to the ground
  only respiratory muscles spared
• More usually just momentary laps
  head sags
  knees buckle
• Dominant inheritance with variable penetrance
  Half relatives have sleepiness

Question 29

What are the treatments for narcolepsy?

Answer 29

Stimulants:
Dextroamphetamine
Methamphetamine
Modafanil**

Tricyclic Antidepressants:
Protriptyline
Imipramine
Fluoxetine **

Question 30

What is an AHI index?

Answer 30

The AHI is the number of apneas or hypopneas recorded during the study per hour of sleep. It is generally expressed as the number of events per hour.

Question 31

What are the classes based in AHI?

Answer 31

None/Minimal: AHI < 5 per hour
Mild: AHI ≥ 5, but < 15 per hour
Moderate: AHI ≥ 15, but < 30 per hour
Severe: AHI ≥ 30 per hour

Question 32

What is MSLT?

Answer 32

The multiple sleep latency test (MSLT) tests for excessive daytime sleepiness by measuring how quickly you fall asleep in a quiet environment during the day.

Question 33

MSLT is used to diagnose which diseases?

Answer 33

MSLT is the standard tool used to diagnose narcolepsy and idiopathic hypersomnia

Question 34

What are the stages in sleep an in order?

Answer 34

Usually sleepers pass through four stages: 1, 2, 3, and REM (rapid eye movement) sleep. These stages progress cyclically from 1 through REM then begin again with stage 1. A complete sleep cycle takes an average of 90 to 110 minutes, with each stage lasting between 5 to 15 minutes. The first sleep cycles each night have relatively short REM sleeps and long periods of deep sleep [stage 3] but later in the night, REM periods lengthen and deep sleep time decreases.

Question 35

What is the distribution of sleep stages?

Answer 35

In adults, approximately 5% of the total sleep time is Stage N1; 50% Stage N2; and 20% is Stage N3 sleep. The remaining 25% is REM stage sleep