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  • 1.  
  • 2. Sleep is as necessary as the air we breathe, the water we drink, and the food we eat.
  • 3. Disorders of sleep are not recognized 50–70 million chronic disorders of sleep 20 million asthma 10-15 million COPD
  • 4. Medical illness disrupts sleep; and problems with sleep cause medical illness. Depression Neurologic Cardiac Respiratory Gastrointestinal Renal Cognitive Cardiovascular Respiratory Metabolic Syndrome Movement Disorder Sleep
  • 5. We need to be alert to problems with sleep in our patients and treat appropriately to help our patients.
  • 6. Public Health Issues Sleep deprivation has a major impact on Public Health. Work absenteeism, industrial and motor vehicle accidents, impaired cognitive and executive function, and increased mortality due to sleep deprivation costs society billions of dollars in related costs.
  • 7. Public Health Concern <ul><li>Prevalence </li></ul><ul><li>Incidence of Sleep Loss in the Population </li></ul><ul><ul><li>28% of normal young adults slept 6.5 hours or less each weeknight </li></ul></ul><ul><ul><li>32% of normal young adults has an MSLT of 5 min or less </li></ul></ul>Bonnet and Arand, 1995
  • 8. Public Health Issues <ul><li>Industrial and Work Accidents </li></ul><ul><li>Sleepiness and Industrial Errors: </li></ul><ul><ul><li>Meter reading </li></ul></ul><ul><ul><li>Chernobyl </li></ul></ul><ul><ul><li>Three Mile Island </li></ul></ul><ul><ul><li>Exxon Valdez </li></ul></ul><ul><li>Sleepiness and Driving: </li></ul><ul><ul><li>Fatigue a factor in 57% of deaths in truck drivers (NTSB) </li></ul></ul><ul><li>Sleepiness and Driving: </li></ul><ul><ul><li>Libby Zion Case </li></ul></ul>Mitler et al, 1988
  • 9. Public Health Issues Industrial Accidents The Exxon Valdez oil tanker left Valdez, Alaska on March 24, 1989, into Prince William Sound. The taker turned out of the shipping chanel, but did not turn back in time. The tanker hit a reef and spilled millions of gallons of crude oil into the Sound. It cost more than $2 billion to clean up the spill and the environmental damages were enormous. Although it was initially thought that the captain was drunk, it was subsequently determined that the cause of the accident was the third mate, who had slept only six hours in the previous 48 and was severely sleep deprived.
  • 10. Public Health Issues Motor Vehicle Crashes Lavie et al 1986, Langlois et al, 1985
  • 11.  
  • 12. Insomnia is Underreported and Undertreated Hatoum et al 1998
  • 13.  
  • 14. Medical Conditions That Can Cause Insomnia <ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><li>Arthritic Conditions </li></ul></ul><ul><ul><li>Chronic Renal Disease </li></ul></ul><ul><ul><li>Chronic Lung Disease </li></ul></ul><ul><ul><li>Heart Failure </li></ul></ul><ul><ul><li>Reflux Esophagitis </li></ul></ul><ul><ul><li>Neurological Disorder </li></ul></ul><ul><ul><li>Hepatic Disease </li></ul></ul>This is not a complete list of medical disorders that can produce sleep disturbance or insomnia. Cardiovascular, cerebrovascular and neurological disorders that affect the control of breathing can have serious consequences and need to be considered in any patient presenting with a complaint of insomnia, especially elderly patients.
  • 15. These graphs are from the National Sleep Foundation survey that illustrate symptoms of individuals without insomnia, occasional insomnia and chronic insomnia patients. Note the higher rate of symptoms in the chronic insomnia group compared with the other groups.
  • 16. Pickwickian Syndrome Obstructive sleep apnea was called the Pickwickian syndrome in the past because Joe the Fat Boy who was described by Charles Dickens in the Pickwick papers had typical features with snoring, obesity, sleepiness and “dropsy”. The term Pickwickian syndrome was originally applied to those patients who had sleepiness, obesity and evidence of right heart failure. Some of the patients probably had central alveolar hypoventilation syndrome and obesity hypoventilation syndrome rather than typical obstructive sleep apnea syndrome as we now know it.
  • 17. But . . . Most OSA patients are thin Obese patients have hypoxemia, obesity hypoventilation, and/or obstructive sleep apnea. A PSG is necessary. But . . . Nasal, pulmonary, and cardiac problems may interfere with diagnosis.
  • 18. Obstructive Sleep Apnea Syndrome
  • 19. Symptoms of Sleep Apnea Syndrome
  • 20. Obstructive Sleep Apnea Syndrome <ul><ul><li>Symptoms </li></ul></ul><ul><ul><li>Excessive Sleepiness </li></ul></ul><ul><ul><li>Snoring </li></ul></ul><ul><ul><li>Apneic Episodes </li></ul></ul><ul><ul><li>Choking or Gasping in Sleep </li></ul></ul><ul><ul><li>Nocturia </li></ul></ul><ul><ul><li>Tiredness upon Awakening </li></ul></ul>
  • 21. Features of Excessive Sleepiness <ul><ul><li>Motor vehicle crashes </li></ul></ul><ul><ul><li>Work related accidents </li></ul></ul><ul><ul><li>Impaired school or work performance </li></ul></ul><ul><ul><li>Marital problems </li></ul></ul><ul><ul><li>Memory and concentration difficulties </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Impaired quality of life </li></ul></ul>
  • 22. Quality of Life in OSA
  • 23. Polysomnograpy An Episode of Obstructive Sleep Apnea
  • 24. Upper Airway Resistance Syndrome
  • 25. Prevalence of Sleep-Disordered Breathing Young et al, 1993
  • 26. Treatment of Obstructive Sleep Apnea Syndrome <ul><ul><li>Behavioral Treatment </li></ul></ul><ul><ul><li>Medical Treatment </li></ul></ul><ul><ul><li>Oral Appliance Treatment </li></ul></ul><ul><ul><li>Surgical Treatment </li></ul></ul>
  • 27. Behavioral Treatments <ul><ul><li>Attain an ideal body weight </li></ul></ul><ul><ul><li>Sleep on the side </li></ul></ul><ul><ul><li>Avoid sedative medication before sleep </li></ul></ul><ul><ul><li>Avoid being sleep deprived </li></ul></ul><ul><ul><li>Avoid alcohol before sleep </li></ul></ul><ul><ul><li>Elevate the head of the bed </li></ul></ul><ul><ul><li>Promptly treat colds and allergies </li></ul></ul><ul><ul><li>Avoid large meals before bedtime </li></ul></ul><ul><ul><li>Stop smoking </li></ul></ul>
  • 28. Medical Treatments <ul><ul><li>Weight loss </li></ul></ul><ul><ul><li>Pharmacological </li></ul></ul><ul><ul><li>Oxygen therapy </li></ul></ul><ul><ul><li>Nasopharynegeal intubation </li></ul></ul><ul><ul><li>Nasal CPAP </li></ul></ul><ul><ul><li>BiLevel CPAP </li></ul></ul><ul><ul><li>Automatic CPAP </li></ul></ul><ul><ul><li>Oral Appliances </li></ul></ul><ul><ul><li>Atrial Pacing </li></ul></ul>
  • 29. Weight Loss Response after 1 year of CPAP therapy
  • 30. Oxygen Therapy <ul><ul><li>Improves oxygen saturation during sleep </li></ul></ul><ul><ul><li>May prolong apneic episodes </li></ul></ul><ul><ul><li>Reduces cardiac arrythmias </li></ul></ul><ul><ul><li>Useful additive treatment with CPAP </li></ul></ul><ul><ul><li>Rarely reduces apneic episodes </li></ul></ul><ul><ul><li>Can improve daytime sleepiness </li></ul></ul><ul><ul><li>May cause CO2 retention </li></ul></ul>
  • 31.  
  • 32. Continuous Positive Airway Pressure (CPAP Representation of the effect of CPAP on the upper airway in obstructive sleep apnea syndrome. The first panel of inspiration shows the development of the negative inspiratory pressure, muscle tone is required to prevent collapse of the upper airway. The second panel shows collapse when the inspiratory negaive pressure exceeds the counteracting muscle tone that is maintaining airway patency. The third panel shows the application of a positive airway pressure through the nares which overcomes the negative inspiratory pressure and improves airway patency. Sullivan et al, 1981
  • 33. CPAP Compliance <ul><ul><li>Improved Masks </li></ul></ul><ul><ul><li>Nasal Pillows </li></ul></ul><ul><ul><li>Chin Strap </li></ul></ul><ul><ul><li>Humidifier </li></ul></ul><ul><ul><li>BiLevel Pressure Devices </li></ul></ul><ul><ul><li>Ramping </li></ul></ul><ul><ul><li>Nasal Decongestants </li></ul></ul>Improvement Strategies
  • 34. Patient Quality of Life After nCPAP
  • 35. Crashes before/after CPAP therapy
  • 36. Surgical Treatment <ul><li>Turbinectomy / septal reconstruction </li></ul><ul><li>Tonsillo-adenoidectomy </li></ul><ul><li>Uvulopalatopharyngoplasty </li></ul><ul><li>Laser-assisted uvulopalatoplasty (LAUP) </li></ul><ul><li>Lingual tonsillectomy / Laser midline glossectomy </li></ul><ul><li>Genioglossal advancement </li></ul><ul><li>Hyoid myotomy and suspension </li></ul><ul><li>Maxillomandibular advancement </li></ul><ul><li>Radiofrequency palatoplasty </li></ul><ul><li>Tongue base suspension </li></ul><ul><li>Hyoidplasty </li></ul><ul><li>Tracheostomy </li></ul><ul><li>Gastroplasty </li></ul>This section edited by: Aaron E. Sher MD Albany Medical College Albany, New York
  • 37. Adverse Effects of Tonsillo-adenoidectomy Verse et al, 2000
  • 38. Gastroplasty Efficacy Verse et al, 2000
  • 39. Pharmacological Therapy Protriptyline Medroxyprogesterone Fluoxetine Antihistamines Nasal Steroids Theophylline Acetazolamide Modafinil Magalang UJ et al, 2003
  • 40. Conclusion Obstructive sleep apnea syndrome is an important medical disorder that warrants active investigation by means of a clinical evaluation and polysomnographic sleep studies. Treatment is essential, not only to improve the symptoms that include sleepiness, but also to prevent the development of cardiovascular complications. Effective treatments exist that include behavioral, medical and surgical means; dramatic improvements in patient wellbeing can result.
  • 41. Cardiovascular Consequences Systemic hypertension Pulmonary hypertension Cor pulmonale Brady-tachycardia Sinus arrest Complete heart block Atrial and ventricular arrhythmias Myocardial infarction Sudden death
  • 42. Cardiovascular Disease Zaninelli A. et al, 1991
  • 43. Systemic Hypertension 33 % of OSA patients have systemic hypertension 33% of Hypertensive patients have OSA
  • 44. Systemic Hypertension Worsnop et al, 1998
  • 45. Ambulatory Blood Pressure in OSA This illustration shows hourly blood pressure values (mean +- SEM) during ambulatory BP recordings before (closed circles) and after successful treatment of OSA with nCPAP (open circles). Lower levels of blood pressure are found during nCPAP treatment.
  • 46. Oxygen Desaturation and Atherosclerosis Hayashi M et al, 2003
  • 47. Sudden Death Rossner et al, 1991
  • 48. Untreated OSA is associated with an increased risk of cardiovascular mortality in patients with coronary artery disease (CAD). Over a five year follow-up of 19 patients with CAD, 6 of 16 patients with OSA died compared with 4 of 43 without OSA. Peker et al, 2000
  • 49. There is a high rate of sleep apnea in survivors of myocardial infarction. Because of the cardiovascular effects of obstructive sleep apnea syndrome it is suspected that individuals with sleep apnea have an increased risk of developing ischemic heart disease and myocardial infarction. This chart shows a greater rate of apneas in patients who are survivors of myocardial infarction that in a control group. Hung et al, 1986
  • 50. Crashes before/after CPAP therapy
  • 51. NEXT
  • 52. Changes in Sleep with Age
  • 53. Factors Affecting Sleep in the Elderly <ul><li>1. Circadian rhythm disturbances </li></ul><ul><li>2. Primary sleep disorders </li></ul><ul><li>3. Medical illness </li></ul><ul><li>5. Medications/polypharmacy </li></ul><ul><li>5. Dementia </li></ul>
  • 54. Consequences of Sleep Disturbances <ul><li>-Difficulty sustaining attention </li></ul><ul><li>-Slowed response time </li></ul><ul><li>-Difficulty with memory </li></ul><ul><li>-Decreased performance </li></ul><ul><li>MAY all be misinterpreted as dementia </li></ul>
  • 55. Health Care Workers <ul><li>1. Know the diseases which interfere with sleep . </li></ul><ul><li>DIMS insomnias </li></ul><ul><li>DOES sleep related breathing disorders </li></ul><ul><li>Parasomnias hypersomnia of central origin </li></ul><ul><ul><ul><ul><ul><li>Circadian rhythm sleep disorders </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>parasomnias </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>sleep-related movement disorders </li></ul></ul></ul></ul></ul>
  • 56. HEALTH CARE WORKERS <ul><li>2. Ask , patients will not volunteer! </li></ul><ul><ul><li>How did you sleep last night? </li></ul></ul><ul><ul><li>Was the sleep refreshing? </li></ul></ul><ul><ul><li>Do you snore? </li></ul></ul><ul><ul><li>Does your sleep partner complain? </li></ul></ul>

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