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PULMONARY BOARDS > Sleep & Neuromuscular > Flashcards

Sleep & Neuromuscular Flashcards

1
Q

What medication helps with adherence to CPAP

A

eszoplicone

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2
Q

N1-NREM

A

Stage 1

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3
Q

What do we spend most of the night in

A

NREM Stage 2 (N2)

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4
Q

What waveforms are found in stage 2 sleep

A

Theta waves: K complexes and spindle

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5
Q

N3 Stage 3 NREM dominant waves

A

Delta (0.5-3.99 min 75 microvolt) slow
Large triangles, 50 microvault

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6
Q

Awake waves

A

alpha, but only if eyes are closed

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7
Q

REM waves

A

looks like awake but with SAWTOOTH

NO K complexes

Look at EOG –> should have Rapid Eye movements

Chin muscle tone should be atonic

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8
Q

75% of sleep is in

A

NREM sleep

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9
Q

REM sleep - how many percentage of the night

A

25%

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10
Q

Each sleep cycle lasts

A

90 minutes

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11
Q

REM occurs when in the night?

A

last third of the night

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12
Q

When does N3 happen during the night

A

1st third

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13
Q

Normal respiratory physiological changes in sleep

A

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

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14
Q

What controls onset of sleeping

A

medulla

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15
Q

When is breathing most stable in sleep

A

N3

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16
Q

What happens to tidal volume in REM

A

decreases by 40%

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17
Q

Definition of Apnea

A

at least 10 seconds of:

Decrease in airflow sensor amplitude by 90%

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18
Q

Difference between obstructive, central and mixed apnea

A

Obstructive: inspiratory effort is ALWAYS present

Central: Inspiratory effort is ABSENT throughout event

Mixed: Central event followed by an obstructive event

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19
Q

Definition of “hypopnea”

A

at least 10 seconds of

reduced nasopharyngeal airflow (at least 30%)
- With 3-4% desaturation

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20
Q

RERA

A

reduced airflow for >10 seconds ending with disruption in sleep (arousal)

No desat

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21
Q

HSAT Type 3 and 4

A

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)

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22
Q

Normal AHI

A

<5

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23
Q

Mild, moderate, severe AHI cut offs

A

Mild: 5-14 (must have comorbid conditions/sx to get CPAP)
Moderate: 15-29
Severe: >30

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24
Q

patient has resistant HTN, next step ___

A

Sleep study

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25
Q

Daytime sleepiness and AHI correlation

A

weak

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26
Q

Who shouldn’t you do a HSAT on?

A
  • people dependent on O2
  • ppl with strokes
  • hypoventilation sd
  • narcolepsy
  • people on alpha 1 blockers
  • people with complete heart blocks
  • people with HFrEF
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27
Q

CPAP use benefits (evidence-based)

A

Probably yes:
Mortality
BP (only mildly)
Excessive daytime sleepiness
Sleep QOL
MVA

Not proven:
CV, mood, metabolic

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28
Q

Does weight loss completely cure OSA?

A

no, usually 10% residual

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29
Q

What medication helps to consolidate night sleep and decrease cataplexy

A

Sodium Oxybate

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30
Q

When are oral appliances indicated

A

mild-moderate sleep apnea

must have 8 teeth in the upper and lower jaw!

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31
Q

Types of surgery for OSA

A

Bariatric surgery for obesity

Maxillo-mandibular advancement

Adenotonsillectomy for pediatrcs

Hypoglossal nerve stimulation

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32
Q

How good is hypoglossal nerve stimulation for moderate-severe OSA?

A

STAR Trial 2014

Outcome:
- AHI <20 per hour
- Reduction in AHI by at least 50% from baseline
- 2/3 of patients benefit

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33
Q

Medications to reduce sleepiness

A

Modafinil
Armodafinil
Solriamfetal

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34
Q

Etiology of central sleep apnea

A
  • stroke
  • opioids
  • cheyne stroke breathing (HFrEF)
  • PAP emergent
  • idiopathic
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35
Q

Definition of central sleep apnea

A

AHI >5
Central apnea/hypopnea >50% of thotal apneas/hypopneas
Sx of excessive sleepiness or disrupted sleep

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36
Q

Biot’s breathing pattern

A

2-3 breaths and then pause (looks like two front teeth to me)

related to opioids - dose dependent

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37
Q

Cheyne stokes breathing

A

33% of people with heart failure

the worse the heart failure the longer the circulation time (end of apnea to nadir of saturation)

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38
Q

cycle length

A

beginning of apnea to the beginning of the next episode

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39
Q

Circulation time

A

Starts from the end of the apnea to the nadir of the desaturation

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40
Q

True or false:
Hypocapnia during wakefulness worsens cheyne stokes breathing

A

true

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41
Q

Etiology of cheyne stokes

A

Increased chemoreceptor responsiveness to CO2 in medulla

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42
Q

Type of PAP therapy CONTRAINDICATED in Cheyne Stokes breathing

A

ASV
Adaptive servo ventilation - stops from ventilatory overshoot

Has higher all cause mortality in LVEF <45%

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43
Q

Type of PAP therapy recommended in sleep-disordered breathing in heart failure

A

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

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44
Q

For whom is transvenous phrenic nerve stimulation indicated and what are the benefits

A
  • effective for idiopathic CSA
  • ok to use for those with pacemakers

Benefit: improved nocturnal hypoxemic burden

45
Q

What do you do with treatment emergent CSA

A

wait, it will get better

or ASV (contraindicated in HFrEF <45%)

46
Q

Definition of obesity hypoventilation syndrome

A

BMI > 30
Awake pCO2 >45

Diagnosis of exclusion
Similar in F and M

47
Q

Probable REM related hypoventilation

A

SpO2 goes down and STAYS down

48
Q

What improves mortality in OHS

A

discharging from hospital on PAP

49
Q

When to check serum HCO3 vs. PaCO2 if suspecting OHS

A

high pretest probability:
PaCO2

Low pretest prob: check HCO3, if >27 can check PaCO2

50
Q

Should OHS be treated with NIV or CPAP

A

first line: CPAP (90% has OSA)

Some may need Bilevel
VAPS also an option (little data to show it is advantageous over BPAP)

51
Q

Two drivers of sleep-wake pattern

A
  • Process S (the more you are awake, the sleepier you get)
  • Process C (circadian - increasing alert at night, reduces in the early morning 3AM)
52
Q

Where are the sensors that make you awake from light

A

Retina –> retinohypothalamic tract –> SUPRACHIASMATIC NUCLEUS –> superior cervical ganglion –> PINEAL GLAND (where melatonin is secreted when sun goes down)

53
Q

Who should be given tasimelteon

A

blindness

54
Q

66yo man who wakes up too early in the morning

Dx?

A

Advanced sleep phase syndrome

“larks” early bedtime and early wake time, shorter sleep time in general

55
Q

Management of “larks”

A

bright light therapy in early evening

56
Q

33yo who stays on his computer/phone to late night, with insomnia

Dx? and managemnt?

A

Delayed sleep phase syndrome

(has longer circadian clock)

Timed early morning light
melatonin in early evening
Chronotherapy (progressive phase delay or advancement)

57
Q

55yo F s/p eye enucleation and macular degeneration with erratic sleep

Dx and treatment?

A

Free-running circadian disorder

Tx: evening administration of melatonin or tasimelteon (approved melatonin receptor agonist)

58
Q

88yo with Alzheimer’s with inconsistent sleep

Dx and Tx?

A

Irregular sleep-wake circadian rhythm

Tx: bright light and activity during the day, evening administration of melatonin. Maintain schedule

59
Q

Definition of Insomnia

A

3x a week
for at least 3 mo

PSG definition:
1. Sleep onset latency >30 min

  1. Wake after sleep onset >30 min
  2. Sleep Efficiency is <85%
  3. Total Sleep Time <6-6.5 hrs
60
Q

Narcolepsy is a deficiency in this hormone (in type 1)

A

Hypocretin

61
Q

Tx for insomnia

A
  1. CBT-I
  2. Brief behavioral therapy
  3. hypnotics
62
Q

When is Ramelteon contraindicated

A

concurrent use of fluvoxamine and hepatic impairment

63
Q

Safer options for insomnia (sleep onset AND maintenance)

A

eszopiclone (lunesta)
zaleplon (sonata)
zolpidem

reduce dose in women

less mucle relaxant effect, anticonvulsant, or anxiolytic properties

64
Q

Orexin receptor meds for reducing wake drive (DORA)

A

Suvorexant
Lemborexant
Daridorexant
“exant” rhymes with orexin-ish

Treats insomnia
Can make you have REM dyscontrol

65
Q

Definition of Excessive Daytime sleepiness

A

Inability to sustain wakefulness and alertness to accomplish tasks of daily living

microsleep episodes
frequent napping
hyperacitivity in children
automatic behavior

66
Q

Diagnostic test for excessive sleep disorder

A

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)

67
Q

MSLT, what does it consist of and what are the diagnostic cut offs

A

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

68
Q

Dx of Narcolepsy type I

A

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)

69
Q

Narcolepsy type II dx criteria

A

NORMAL hypocretin lvl or not checked
NO cataplexy

Only MSLT +

69
Q

Idiopathic hypersomnia dx criteria

A

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

70
Q

Tx of narcolepsy or excessive daytime sleepiness despite good CPAP effect

A

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

71
Q

Secondary disorders that cause hypersomnia

A

Parkinsons
PTSD
Genetic disorders (Prader Willi, myotonic dystrophy)
CNS disorder (stroke)
Metabolic encephalopathy

72
Q

Most common cause of excessive daytime sleepiness

A

insufficient sleep

73
Q

APAP vs. CPAP benefit

A

associated with lower mean airway pressure than CPAP

helps people use it by 15 min a night

74
Q

In patients with ALS, if they cant do a good seal to do VC measurement use ____

A

SNIP (max sniff inspiratory pressure) - doesnt require mouth piece

75
Q

Diagnostic criteria for Periodic Limb Movement of sleep Syndrome OR disorder (3)

A

PLM/h = index

  1. At least 4 in a row
  2. Period length between 5-90s
  3. 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

76
Q

Cataplexy treatment

A

Sodium oxybate
Pitolisant
SSRIs

77
Q

Parasomnias

A

During sleep

NREM Sleep - (sleep terrors, sleep walking, confusional arousals)

REM sleep: nightmares, REM sleep behavior disorder

78
Q

Indications for NIV in ALS and Deuchenne (6 criteria)

A
  1. VC <50% OR SNIP <40 cmH2O
  2. Orthopnea
  3. MIP <60 cmH2O
  4. Peak cough flow <270
  5. Abnormal nocturnal oxymetry SpO2 <95%
  6. pCO2 >45 mmHg
79
Q

Do you need a blood gas to start NIV on ALS and Deuchenne?

A

NO

can use transcutaneous CO2 monitor

80
Q

Sleep disorder associated with Parkinson’s, multisystem atrophy or lewy body dementia

A

REM sleep behavior disorder

RLS

81
Q

NREM parasomnias are at what stage of sleep

A

N3 (delta waves)

82
Q

Genetic component of NREM Parasomnias

(not sure we need this for boards)

A

HLA-DQB1*o5

83
Q

Which type of parasomnias do you always have dream recall?

A

REM

NREM is limited or none

84
Q

Tx of parasomnia

A

avoid sleep deprivation

provide safe environment

Meds: clonazepam or melatonin at bedtime

85
Q

Dx of Restless Leg Syndrome

(can be other body parts)

A

URGE

Urge to move
Rest induced
Gets better with activity
Evening and night accentuation

86
Q

Tx of RLS and PMLD

A

Treat underlying cause (like iron deficiency)
OR
First line: gabapentinoid meds
Second line: Ropinirole, pramipexole, rotigone (DA agonist)
3rd line: consider opioid monotherapy

87
Q

Tingling from taking ropinirole for a long time is due to ____. How do you deal with it

A

augmentation

change to a diff drug in same class

88
Q

When to iron supplement with RLS

A

Ferritin <50

89
Q

Do you have to treat Periodic limb movement syndrome?

A

No- it is asymptomatic

90
Q

When can PMLD not be diagnosed

A

OSA, Parkinson’s RLS

91
Q

Does pre-op CPAP help

A

no studies

92
Q

How does mild OSA affect post-operative outcomes

A

it doesn’t significantly affect it

93
Q

Cut off for STOP-BANG for mod-severe sleep apnea

A

5 or more

94
Q

OHS phenotype that can benefit from tracheostomy

A

severe OSA AHI >30

95
Q

High altitude effect on OSA and what is the management

A

worsening from CENTRAL sleep apnea

acetazolamide 250 mg bid

96
Q

What stage of sleep is primary CSA improved and worst in

A

Improved during REM

Worse during transitions into and out of sleep (NREM)

97
Q

Risk factors of opioid-induced sleep apnea

A
  1. low BMI
  2. higher opioid dose
98
Q

Exploding head syndrome

A

benign parasomnia

lol

99
Q

Hypnic headache syndrome

A

headache in older individuals occurring 4-6 hours after sleep onset

100
Q

Who is a good candidate for hypoglossal nerve stimulation

A

mod-severe OSA
BMI <32
NO central crowding on drug-induced sedation endoscopy

101
Q

In insomnia, always do this diagnostic workup ___

A

psychiatric eval

102
Q

As we age, there is less which stage

A

N3 (deep sleep)

103
Q

On EPOCH
E means ___
Odd number ___
Even number ___

A

E means eye
Odd left
Even right

104
Q

on EPOCH with deflections pointing at each other means ___

A

rapid eye movement

105
Q

How do you calculate respiratory disturbance index (RDI)

A

apneas + #hypopneas + respiratory effort-related arousals PER HOUR

106
Q

young person with central apnea, headaches, next step and likely dx?

A

MRI
arnold chiari

107
Q

Sleep deprivation would increase (blood test)

A

TSH (usually low throughout the day, increased in evening, peaking before sleep)

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