Sleep Medicine

Question 1

What is VOTE in DISE? How are the subsites classified?

Answer 1

Velum, oropharynx, tongue base, epiglottis. They are classified as No Obstruction (<50% and no vibration), partial obstruction (50-75%/vibration), or complete obstruction (>75%/collapse), or not visualized.

Question 2

Which of the following items from a level I sleep study is included in a level III sleep study?

EEG
EOG
ECG/Heart rate
Chin/Limb EMG
Respiratory effort at thorax and abdomen
Nasal airflow
Pulse Oximetry
Body Position 
Snoring Sound

Answer 2

ECG, SaO2, nasal airflow (CMS guidelines)

ECG, body motion, snoring, and chest movement (KJ Lee)

Question 3

What is an optimal Friedman stage (tonsil and palate) for UPPP?

Answer 3

Stage 1. Tonsils 2-4 with tongue 1-2 and a non-morbidly-obese BMI

Question 4

What is the definition of CPAP adherence?

Answer 4

> 4 hours/night for 70% of nights in a 30-day period (or ~20h/week).

Question 5

Definitions - hypopnea; parasomnias (hypnopompic vs hypnogogic); UARS

Answer 5

Hypopnea- decrease in airflow by 30% for 10 sec w 4% SpO2 decrease

Parasomnias – EEG changes/arousals w/o airflow changes

Hypnopompic – hallucinations as you are waking up; hypnoGOgic – as you are GOing to sleep

UARS – high RERAs/RDI, normal AHI (common in skinny men)

Question 6

What waves are associated with which sleep stages?

Answer 6

Stage 1 – Theta; 2 – spindle and K; 3 – delta (shitty mnemonic- TSK’d)

Question 7

What are the cut-off values on these risk factors for OSA: BMI, neck collar size (inches per gender)

Answer 7

BMI >35; neck 17” men, 16” women

Question 8

In which stage do most apneas and hypopneas occur?

Answer 8

REM

Question 9

Which stage do we spend the largest % of sleep in?

Answer 9

Stage 2 (3 is next most %)

Question 10

What happens if CPAP titration is too low? Too high?

Answer 10

Too low - ineffective. Too high = central apneas.

Question 11

What is the definition of surgical success for OSA?

Answer 11

50% reduction and into the normal range (<20 AHI)

Question 12

What is the most important muscle targeted with the Inspire?

Answer 12

Genioglossus

Question 13

Define: snoring, UARS, OSA, obesity-hypoventilation syndrome.

Answer 13

Snoring = upper airway resistance/sounds without increase in resp effort. UARS = resistance + incr resp effort without meeting the definition of OSA. OSA = sufficient objective apneas+hypopneas nightly to meet diagnostic criteria. obesity-hypoventilation syndrome = BMI >30, sleep-disordered breathing, daytime hypercapnia > 45mmHg

Question 14

What are the 4 stages of sleep and what EEG waves are associated with each?

Answer 14

Stage 1- theta (NREM). Stage 2 - K complexes + sleep spindles (NREM). Stage 3 - delta (NREM). REM = beta waves.

BATS Drink Blood 
Beta- awake
Alpha - falling asleep
Theta- Stage 1
Sleep spindles - Stage 2
Delta -Stage 3
Beta - REM

Question 15

In which stage do we spend most of our time asleep? In which stage are respiratory events least common?

Answer 15

~50% is Stage 2. Respiratory events least common in stage 3.

Question 16

Approximately how many cycles of NREM-REM occur in one night?

Answer 16

We have 3 to 5 cycles nightly.

Question 17

What is different about respiratory events occurring in REM (eg duration and severity)?

Answer 17

Longer duration and increased severity

Question 18

How well do daytime sleepiness/QOL correlate with frequency and severity of respiratory events?

Answer 18

Poorly

Question 19

Most common cardiac arrhythmia seen with OSA?

Answer 19

Brachycardia-tachycardia. Brady at cessation of breathing. Tachy upon resumption

Question 20

Difference between Mallampati and Friedman scoring?

Answer 20

Mallampati with tongue stuck out, Friedman with tongue resting. Otherwise the same

Question 21

What is the Mueller maneuver?

Answer 21

Pinch your nose and close your mouth, breathe in against a closed airway. Do it while being scoped sitting and supine

Question 22

Cutoffs for neck circumference as OSA risk factors in men and women?

Answer 22

17cm in men, 15cm in women

Question 23

What are level I through 4 polysomnography?

Answer 23

level I - all the works + attended. level II - all the works unattended. level III - unattended + 3 metrics (air flow, SpO2, HR). level IV - unattended + 1-2 metrics (like O2Sat)

Question 24

Name 3 behavioral modifications for management of OSA.

Answer 24

weight loss, positional therapy, sleep hygiene, alcohol/sedative cessation

Question 25

What is a split night study?

Answer 25

Measure AHI/sleep for first two hours, then titrate CPAP rest of the night.

Question 26

Definition of CPAP compliance?

Answer 26

CPAP compliance = 4h a night for 70% of the night (4h for 5 nights a week).

Question 27

What is a ramp setting in CPAP management and when would it be used?

Answer 27

Ramp setting is starting with very low pressures and then slowly increasing to therapeutic - useful for patients who have trouble falling asleep with CPAP pressures

Question 28

Name 2-3 procedures for palatal collapse.

Answer 28

Palatal collapse: palatoplasty, UPPP, palatal advancement.

Question 29

Name 2-3 procedures intended to improve the hypopharyngeal airway.

Answer 29

Hypopharynx: tongue base reduction, tongue suspension, hyoid suspension.

Question 30

What is the most effective surgery for OSA?

Answer 30

Most effective surgery: maxillomandibular advancement

Question 31

Define: apnea

Answer 31

apnea = cessation of airflow for 10 seconds.

Question 32

What is normal sleep latency?

Answer 32

10-15 minutes

Question 33

Define hypopnea

Answer 33

hypopnea = decrease in flow >30% for 10 seconds with at least 4% reduction in SpO2.

Question 34

Define central apnea, obstructive apnea, RERA

Answer 34

Central apnea = apnea without resp effort. Obstructive apnea = apnea with resp effort. RERA = respiratory effort related event; events that do not meet definition of apnea/hypopnea.

Question 35

Define RDI.

Answer 35

RDI = respiratory disturbance index, hypopnea + apnea + RERA.