Sleep & Neuromuscular Flashcards
What medication helps with adherence to CPAP
eszoplicone
N1-NREM
Stage 1
What do we spend most of the night in
NREM Stage 2 (N2)
What waveforms are found in stage 2 sleep
Theta waves: K complexes and spindle
N3 Stage 3 NREM dominant waves
Delta (0.5-3.99 min 75 microvolt) slow
Large triangles, 50 microvault
Awake waves
alpha, but only if eyes are closed
REM waves
looks like awake but with SAWTOOTH
NO K complexes
Look at EOG –> should have Rapid Eye movements
Chin muscle tone should be atonic
75% of sleep is in
NREM sleep
REM sleep - how many percentage of the night
25%
Each sleep cycle lasts
90 minutes
REM occurs when in the night?
last third of the night
When does N3 happen during the night
1st third
Normal respiratory physiological changes in sleep
Decrease in minute ventilation (0.5-1.5L/min) from decrease in tidal volume
No change in resp rate
PaO2 5-8 mmHg DECREASE (1-2% SpO2 decrease)
PaCO2 3-5 mmHg INCREASE
What controls onset of sleeping
medulla
When is breathing most stable in sleep
N3
What happens to tidal volume in REM
decreases by 40%
Definition of Apnea
at least 10 seconds of:
Decrease in airflow sensor amplitude by 90%
Difference between obstructive, central and mixed apnea
Obstructive: inspiratory effort is ALWAYS present
Central: Inspiratory effort is ABSENT throughout event
Mixed: Central event followed by an obstructive event
Definition of “hypopnea”
at least 10 seconds of
reduced nasopharyngeal airflow (at least 30%)
- With 3-4% desaturation
RERA
reduced airflow for >10 seconds ending with disruption in sleep (arousal)
No desat
HSAT Type 3 and 4
Type 3: apnea, hypopnea only (needs technician scoring)
Type 4: WatchPAT/NightOwl, apnea/hypopnea lumped together, RERA can be scored (arousals without 3-4% desat)
Normal AHI
<5
Mild, moderate, severe AHI cut offs
Mild: 5-14 (must have comorbid conditions/sx to get CPAP)
Moderate: 15-29
Severe: >30
patient has resistant HTN, next step ___
Sleep study
Daytime sleepiness and AHI correlation
weak
Who shouldn’t you do a HSAT on?
- people dependent on O2
- ppl with strokes
- hypoventilation sd
- narcolepsy
- people on alpha 1 blockers
- people with complete heart blocks
- people with HFrEF
CPAP use benefits (evidence-based)
Probably yes:
Mortality
BP (only mildly)
Excessive daytime sleepiness
Sleep QOL
MVA
Not proven:
CV, mood, metabolic
Does weight loss completely cure OSA?
no, usually 10% residual
What medication helps to consolidate night sleep and decrease cataplexy
Sodium Oxybate
When are oral appliances indicated
mild-moderate sleep apnea
must have 8 teeth in the upper and lower jaw!
Types of surgery for OSA
Bariatric surgery for obesity
Maxillo-mandibular advancement
Adenotonsillectomy for pediatrcs
Hypoglossal nerve stimulation
How good is hypoglossal nerve stimulation for moderate-severe OSA?
STAR Trial 2014
Outcome:
- AHI <20 per hour
- Reduction in AHI by at least 50% from baseline
- 2/3 of patients benefit
Medications to reduce sleepiness
Modafinil
Armodafinil
Solriamfetal
Etiology of central sleep apnea
- stroke
- opioids
- cheyne stroke breathing (HFrEF)
- PAP emergent
- idiopathic
Definition of central sleep apnea
AHI >5
Central apnea/hypopnea >50% of thotal apneas/hypopneas
Sx of excessive sleepiness or disrupted sleep
Biot’s breathing pattern
2-3 breaths and then pause (looks like two front teeth to me)
related to opioids - dose dependent
Cheyne stokes breathing
33% of people with heart failure
the worse the heart failure the longer the circulation time (end of apnea to nadir of saturation)
cycle length
beginning of apnea to the beginning of the next episode
Circulation time
Starts from the end of the apnea to the nadir of the desaturation
True or false:
Hypocapnia during wakefulness worsens cheyne stokes breathing
true
Etiology of cheyne stokes
Increased chemoreceptor responsiveness to CO2 in medulla
Type of PAP therapy CONTRAINDICATED in Cheyne Stokes breathing
ASV
Adaptive servo ventilation - stops from ventilatory overshoot
Has higher all cause mortality in LVEF <45%
Type of PAP therapy recommended in sleep-disordered breathing in heart failure
CPAP if OSA is predominent (ASV trial recommended)
If CSA is predominant, CPAP trial to see if AHI <15, can also use O2 supplement, if not ASV trial is recommended (NOT FOR LVEF <45)
BPAP with backup rate
Avoid autotitrating devices
For whom is transvenous phrenic nerve stimulation indicated and what are the benefits
- effective for idiopathic CSA
- ok to use for those with pacemakers
Benefit: improved nocturnal hypoxemic burden
What do you do with treatment emergent CSA
wait, it will get better
or ASV (contraindicated in HFrEF <45%)
Definition of obesity hypoventilation syndrome
BMI > 30
Awake pCO2 >45
Diagnosis of exclusion
Similar in F and M
Probable REM related hypoventilation
SpO2 goes down and STAYS down
What improves mortality in OHS
discharging from hospital on PAP
When to check serum HCO3 vs. PaCO2 if suspecting OHS
high pretest probability:
PaCO2
Low pretest prob: check HCO3, if >27 can check PaCO2
Should OHS be treated with NIV or CPAP
first line: CPAP (90% has OSA)
Some may need Bilevel
VAPS also an option (little data to show it is advantageous over BPAP)
Two drivers of sleep-wake pattern
- Process S (the more you are awake, the sleepier you get)
- Process C (circadian - increasing alert at night, reduces in the early morning 3AM)
Where are the sensors that make you awake from light
Retina –> retinohypothalamic tract –> SUPRACHIASMATIC NUCLEUS –> superior cervical ganglion –> PINEAL GLAND (where melatonin is secreted when sun goes down)
Who should be given tasimelteon
blindness
66yo man who wakes up too early in the morning
Dx?
Advanced sleep phase syndrome
“larks” early bedtime and early wake time, shorter sleep time in general
Management of “larks”
bright light therapy in early evening
33yo who stays on his computer/phone to late night, with insomnia
Dx? and managemnt?
Delayed sleep phase syndrome
(has longer circadian clock)
Timed early morning light
melatonin in early evening
Chronotherapy (progressive phase delay or advancement)
55yo F s/p eye enucleation and macular degeneration with erratic sleep
Dx and treatment?
Free-running circadian disorder
Tx: evening administration of melatonin or tasimelteon (approved melatonin receptor agonist)
88yo with Alzheimer’s with inconsistent sleep
Dx and Tx?
Irregular sleep-wake circadian rhythm
Tx: bright light and activity during the day, evening administration of melatonin. Maintain schedule
Definition of Insomnia
3x a week
for at least 3 mo
PSG definition:
1. Sleep onset latency >30 min
- Wake after sleep onset >30 min
- Sleep Efficiency is <85%
- Total Sleep Time <6-6.5 hrs
Narcolepsy is a deficiency in this hormone (in type 1)
Hypocretin
Tx for insomnia
- CBT-I
- Brief behavioral therapy
- hypnotics
When is Ramelteon contraindicated
concurrent use of fluvoxamine and hepatic impairment
Safer options for insomnia (sleep onset AND maintenance)
eszopiclone (lunesta)
zaleplon (sonata)
zolpidem
reduce dose in women
less mucle relaxant effect, anticonvulsant, or anxiolytic properties
Orexin receptor meds for reducing wake drive (DORA)
Suvorexant
Lemborexant
Daridorexant
“exant” rhymes with orexin-ish
Treats insomnia
Can make you have REM dyscontrol
Definition of Excessive Daytime sleepiness
Inability to sustain wakefulness and alertness to accomplish tasks of daily living
microsleep episodes
frequent napping
hyperacitivity in children
automatic behavior
Diagnostic test for excessive sleep disorder
Sleep diary +/- Actigraphy for 7 days
PSG to exclude OSA and PLMD
MSLT:
**mean SOL <8 minutes (sleep onset REM periods)
MWT: Mean SOL <40 min (mean wakefulness test)
MSLT, what does it consist of and what are the diagnostic cut offs
4-5 nap opportunities q2h
Narcolepsy dx:
*Must have 6 hours of sleep night before (documented with PSG)
*Start 2 hours after last awakening
Must have sleep onset REM periods (x2) and sleep latency test average < 8 min over 5 tests
Dx of Narcolepsy type I
must have HYPOCRETIN/OREXIN <110 deficiency (acts on orexin receptors)
OR cataplexy PLUS MSLT + (2x sleep-onset REM periods and avg SLT <8 min over 5 tests)
Narcolepsy type II dx criteria
NORMAL hypocretin lvl or not checked
NO cataplexy
Only MSLT +
Idiopathic hypersomnia dx criteria
Routine sleep >11 hrs/d (>660 min)
OR
normal hypocretin/orexin or not checked, no cataplexy, and + MSLT with 0-1 sleep-onset REM periods
Tx of narcolepsy or excessive daytime sleepiness despite good CPAP effect
Solriamfetol (Dopamine and Norepi uptake inhibitor)
Pitolisant (inverse agonist of H3 histamine receptor
modafanil
armodafanil
In severe cases: amphetamine or methylphenidate
Sodium Oxybate - improves sleep
Secondary disorders that cause hypersomnia
Parkinsons
PTSD
Genetic disorders (Prader Willi, myotonic dystrophy)
CNS disorder (stroke)
Metabolic encephalopathy
Most common cause of excessive daytime sleepiness
insufficient sleep
APAP vs. CPAP benefit
associated with lower mean airway pressure than CPAP
helps people use it by 15 min a night
In patients with ALS, if they cant do a good seal to do VC measurement use ____
SNIP (max sniff inspiratory pressure) - doesnt require mouth piece
Diagnostic criteria for Periodic Limb Movement of sleep Syndrome OR disorder (3)
PLM/h = index
- At least 4 in a row
- Period length between 5-90s
- repetitive and stereotyped movement lasting 0.5-10s
Abnormal if >5 in children, >15 in adults
It is a DISORDER if there is sleep disturbances and daytime function and >15 leg movements /hour
Cataplexy treatment
Sodium oxybate
Pitolisant
SSRIs
Parasomnias
During sleep
NREM Sleep - (sleep terrors, sleep walking, confusional arousals)
REM sleep: nightmares, REM sleep behavior disorder
Indications for NIV in ALS and Deuchenne (6 criteria)
- VC <50% OR SNIP <40 cmH2O
- Orthopnea
- MIP <60 cmH2O
- Peak cough flow <270
- Abnormal nocturnal oxymetry SpO2 <95%
- pCO2 >45 mmHg
Do you need a blood gas to start NIV on ALS and Deuchenne?
NO
can use transcutaneous CO2 monitor
Sleep disorder associated with Parkinson’s, multisystem atrophy or lewy body dementia
REM sleep behavior disorder
RLS
NREM parasomnias are at what stage of sleep
N3 (delta waves)
Genetic component of NREM Parasomnias
(not sure we need this for boards)
HLA-DQB1*o5
Which type of parasomnias do you always have dream recall?
REM
NREM is limited or none
Tx of parasomnia
avoid sleep deprivation
provide safe environment
Meds: clonazepam or melatonin at bedtime
Dx of Restless Leg Syndrome
(can be other body parts)
URGE
Urge to move
Rest induced
Gets better with activity
Evening and night accentuation
Tx of RLS and PMLD
Treat underlying cause (like iron deficiency)
OR
First line: gabapentinoid meds
Second line: Ropinirole, pramipexole, rotigone (DA agonist)
3rd line: consider opioid monotherapy
Tingling from taking ropinirole for a long time is due to ____. How do you deal with it
augmentation
change to a diff drug in same class
When to iron supplement with RLS
Ferritin <50
Do you have to treat Periodic limb movement syndrome?
No- it is asymptomatic
When can PMLD not be diagnosed
OSA, Parkinson’s RLS
Does pre-op CPAP help
no studies
How does mild OSA affect post-operative outcomes
it doesn’t significantly affect it
Cut off for STOP-BANG for mod-severe sleep apnea
5 or more
OHS phenotype that can benefit from tracheostomy
severe OSA AHI >30
High altitude effect on OSA and what is the management
worsening from CENTRAL sleep apnea
acetazolamide 250 mg bid
What stage of sleep is primary CSA improved and worst in
Improved during REM
Worse during transitions into and out of sleep (NREM)
Risk factors of opioid-induced sleep apnea
- low BMI
- higher opioid dose
Exploding head syndrome
benign parasomnia
lol
Hypnic headache syndrome
headache in older individuals occurring 4-6 hours after sleep onset
Who is a good candidate for hypoglossal nerve stimulation
mod-severe OSA
BMI <32
NO central crowding on drug-induced sedation endoscopy
In insomnia, always do this diagnostic workup ___
psychiatric eval
As we age, there is less which stage
N3 (deep sleep)
On EPOCH
E means ___
Odd number ___
Even number ___
E means eye
Odd left
Even right
on EPOCH with deflections pointing at each other means ___
rapid eye movement
How do you calculate respiratory disturbance index (RDI)
apneas + #hypopneas + respiratory effort-related arousals PER HOUR
young person with central apnea, headaches, next step and likely dx?
MRI
arnold chiari
Sleep deprivation would increase (blood test)
TSH (usually low throughout the day, increased in evening, peaking before sleep)
