Sleep is as necessary as the air we breathe, the water we drink, and the food we eat.
Disorders of sleep are not recognized 50–70 million chronic disorders of sleep 20 million asthma 10-15 million COPD
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
We need to be alert to problems with sleep in our patients and treat appropriately to help our patients.
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.
Public Health Concern
Incidence of Sleep Loss in the Population
28% of normal young adults slept 6.5 hours or less each weeknight
32% of normal young adults has an MSLT of 5 min or less
Bonnet and Arand, 1995
Public Health Issues
Industrial and Work Accidents
Sleepiness and Industrial Errors:
Three Mile Island
Sleepiness and Driving:
Fatigue a factor in 57% of deaths in truck drivers (NTSB)
Sleepiness and Driving:
Libby Zion Case
Mitler et al, 1988
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.
Public Health Issues Motor Vehicle Crashes Lavie et al 1986, Langlois et al, 1985
Insomnia is Underreported and Undertreated Hatoum et al 1998
Medical Conditions That Can Cause Insomnia
Chronic Renal Disease
Chronic Lung Disease
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.
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.
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.
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.
Obstructive Sleep Apnea Syndrome
Symptoms of Sleep Apnea Syndrome
Obstructive Sleep Apnea Syndrome
Choking or Gasping in Sleep
Tiredness upon Awakening
Features of Excessive Sleepiness
Motor vehicle crashes
Work related accidents
Impaired school or work performance
Memory and concentration difficulties
Impaired quality of life
Quality of Life in OSA
Polysomnograpy An Episode of Obstructive Sleep Apnea
Upper Airway Resistance Syndrome
Prevalence of Sleep-Disordered Breathing Young et al, 1993
Treatment of Obstructive Sleep Apnea Syndrome
Oral Appliance Treatment
Attain an ideal body weight
Sleep on the side
Avoid sedative medication before sleep
Avoid being sleep deprived
Avoid alcohol before sleep
Elevate the head of the bed
Promptly treat colds and allergies
Avoid large meals before bedtime
Weight Loss Response after 1 year of CPAP therapy
Improves oxygen saturation during sleep
May prolong apneic episodes
Reduces cardiac arrythmias
Useful additive treatment with CPAP
Rarely reduces apneic episodes
Can improve daytime sleepiness
May cause CO2 retention
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
BiLevel Pressure Devices
Patient Quality of Life After nCPAP
Crashes before/after CPAP therapy
Turbinectomy / septal reconstruction
Laser-assisted uvulopalatoplasty (LAUP)
Lingual tonsillectomy / Laser midline glossectomy
Hyoid myotomy and suspension
Tongue base suspension
This section edited by: Aaron E. Sher MD Albany Medical College Albany, New York
Adverse Effects of Tonsillo-adenoidectomy Verse et al, 2000
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.
Systemic Hypertension 33 % of OSA patients have systemic hypertension 33% of Hypertensive patients have OSA
Systemic Hypertension Worsnop et al, 1998
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.
Oxygen Desaturation and Atherosclerosis Hayashi M et al, 2003
Sudden Death Rossner et al, 1991
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
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