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  • Fig 1. Polysomnography of onset of sleepwalking in an 8-year-old child. On the right side of figure are the movement artifacts associated with the arousal and beginning of the parasomnias. The preceding recording segment (left side of figure) shows the abnormal breathing that occurred during SWS. The abnormal breathing can be seen on the nasal cannula/pressure transducer recording (Cannula). There is a flow limitation and very negative peak end inspiratory esophageal pressure (Pes) that resolve with the beginning of the arousal with a reversal of the abnormal respiratory effort (PES signal) and start of the sleepwalking. The patient snores continuously (microphone [MIC] channel) and is a mouth breather with a very good signal obtained from the mouth thermistor (Airflow channel). The child is in stage 3 NREM sleep just before the onset of the event. The drop in the pulse oximeter channel (Spo2) on the right of the figure is related to movement artifacts.
  • screaming, or confused chatter, rapid hear-beat, sweating, etc
  • Bystanders should interfere as little as possible
  • Fig 2. Onset of sleep terror in a 3-year-old boy. The child is in stage 4 NREM sleep with high amplitude slow waves. On the right of the figure, movement artifacts begin. The chin electromyelogram changes abruptly. Before the start of the event, the child presents flow limitation seen on the nasal cannula, with a "flattening" at the top of the "Cannula" signal. Esophageal pressure signal (Pes), indicative of respiratory effort, is abnormally negative at end inspiration, reaching here 20 cm H2O. With the beginning of the confusional arousal, there is a "Pes reversal" with drop in the negativity of the esophageal pressure and a change in the frequency of the high amplitude slow waves on the EEG (C3/A2, C4/A1). Both Figs 1 and 2 indicate presence of abnormal breathing preceding the confusional arousal. They also show that in children, abnormal breathing is often not indicated by an "apnea" but much more commonly by a more discrete polysomnographic pattern. Both children (Figs 1 and 2) were treated with tonsillectomy

Icsdsleepdisorders Pgs[1] Icsdsleepdisorders Pgs[1] Presentation Transcript

  • The International Classification of Sleep Disorders Second Edition Diagnostic & Coding Manual American Academy of Sleep Medicine
  • Introduction
    • Sleep disorders are classified in the newly revised International Classification of Sleep Disorders, Second Edition (ICSD-2)
      • Revision involved >100 members of sleep community in USA and other countries
      • Divided into eight categories
      • Each category was assigned a task force consisting of leading sleep professionals
  • AGENDA
    • Categories of sleep disorders
    • Symptoms and underlying pathology
    • PSG Findings
    • Treatment
  • OVERVIEW
    • Insomnias
    • Sleep Related Breathing Disorders
    • Hypersomnia of Central Origin
      • Not due to other causes
    • Circadian Rhythm Sleep Disorders
    • Parasomnias
    • Sleep Related Movements Disorders
    • Isolated symptoms, Apparently Normal Variants and Unresolved Issues
    • Other Sleep Disorders
  • INSOMNIAS
    • Repeated difficulty with sleep initiation, duration, consolidation or quality.
      • With adequate sleep opportunity, persistent sleep difficulty and associated daytime dysfunction
    • Symptoms depend on age and severity
      • Mild: fatigue, decreased mood or irritability, general malaise and cognitive impairment
      • Chronic Adult: impaired social or vocational functioning, reduced quality of life
        • May include physical symptoms of GI upset or headache
        • Increased traffic and work place accidents
        • Psychiatric disorders
        • Concerns or worries about sleep
      • Children: Poor school performance
  • 11 categories of INSOMNIA
    • Adjustment Insomnia
    • Psychophysiological Insomnia
    • Paradoxical Insomnia
    • Idiopathic Insomnia
    • Inadequate Sleep Hygiene
    • Behavioral Insomnia of Childhood
    • Insomnia due to Drug or Substance abuse
    • Insomnia Due to Medical Condition
    • Insomnia Due to Substance
    • Known physiological condition or Unspecified (Non-organic Insomnia)
    • Physiological (Organic) Insomnia, Unspecified
  • Adjustment Insomnia (Acute Insomnia)
    • Essential feature is association with a stressor that can be identified
      • Disappears when stressor is resolved
    • Short duration (few days to few weeks)
      • lasts no more than few months
    • Occurs at any age
      • More often in woman than men
    • PSG Findings: (based on experimental models only) prolonged sleep latency, increased arousals and awakenings and decreased sleep efficiency. Reduced REM and SWS with increased stage 1 and 2.
  • Psychophysiologic Insomnia (Conditioned Insomnia)
    • Symptoms present for > 1 month
    • Conditioned arousals
      • “ racing mind” common
      • May report sleeping better away from their own bedrooms and away from their usual routine
    • PSG Findings
      • Increased sleep latency and increased WASO
        • Exceeds 30 minutes
      • Increased stage 1 and decrease in slow-wave sleep
      • May show reverse first-night effect
  • Paradoxical Insomnia (Sleep State Misperception)
    • Complaints of severe insomnia without objective evidence to support it.
    • Report daytime symptoms
      • Severity of nocturnal complaints not matched with evidence for pathologic sleepiness
        • MSLT latencies of <5 minutes are not evident
    • PSG Findings: Normal latencies and sleep times.
      • Estimated sleep times are at least 50% less than actual
      • Estimated onset latencies and wake after onset at least 1.5 times actual amount
      • Some evidence of increased EEG frequency in sleep reported in recent research
  • Idiopathic Insomnia (Childhood-Onset Insomnia)
    • Lifelong sleep difficulty
      • Onset in early childhood
      • Absence of factors associated with onset
    • PSG Findings
      • Prolonged sleep latency and increased WASO
      • Reduced total sleep time and sleep efficiency
      • Increased stages 1 and 2, decrease in 3 and 4
      • Increased EEG frequency reported during sleep
        • Not specific to idiopathic insomnia
  • Insomnia Due To Mental Disorder
    • Insomnia caused by underlying mental disorder
      • Diagnosed only when severe enough to warrant independent treatment
    • Associated features
      • Difficulty falling asleep in anxiety disorders
      • Frequent nighttime and early morning awakenings in depression
    • PSG findings same as with other types of insomnia
      • Decreased sleep efficiency and increase in sleep latency
      • Early REM latency and increased REM density in depression
  • Inadequate Sleep Hygiene (sleep incompatible behaviors)
    • Associated with daily routines that are incompatible with sleep (5-10% of insomnias)
      • Behaviors are under the individuals control
      • Contribute to mood and motivational disturbance, reduced attention, vigilance and concentration and daytime fatigue or sleepiness.
      • Preoccupation with sleep disturbance common
    • Recording in sleep lab may correct some inadequate hygiene practices and mask severity of the problem.
  • Behavioral Insomnia of Childhood (limit-setting sleep disorder)
    • Difficulty falling asleep and/or staying asleep related to an identified behavioral etiology.
      • Seen in 10-30% of children
    • Inappropriate sleep associations
      • Dependency on specific stimulation, objects or settings for initiating or returning to sleep.
    • Inadequate limit-setting (by care giver)
      • Bedtime stalling or refusal
  • Sleep Related Breathing Disorders
    • Central Sleep Apnea
    • Obstructive Sleep Apnea
    • Sleep Related Hypoventilation/Hypoxemic Syndromes
    • Sleep Related Hypoventilation/Hypoxemia Due to Medical Condition
      • Due to pulmonary parenchymal or vascular pathology
      • Due to lower airways obstruction
      • Due to neuromuscular & chest wall disorders
    • Other Sleep Related Breathing Disorders
      • Sleep apnea/Sleep related breathing disorder, unspecified
  • Central Sleep Apnea
    • Primary Central Apnea
    • Central Apnea Due to Cheyne Stokes Breathing
    • Central Apnea Due to High Altitude Periodic Breathing
    • Central Apnea Due to Medical Condition Not Cheyne Stokes
    • Central Apnea Due to Drug or Substance
  • Primary Central Sleep Apnea
    • Recurrent cessation of breathing in sleep with no ventilatory effort ( at least 5 per hr .)
    • C/O of frequent awakenings, excessive daytime sleepiness, insomnia or awakening short of breath
    • Caused by instability of the respiratory control system in the transition from wakefulness to sleep
    • Tend to occur in patients with high ventilatory responsiveness to CO 2
      • lower PaCO 2 levels exist (close to apnea threshold)
  • Cheyne Stokes Breathing Pattern
    • Recurrent central apneas and hypopneas, alternating with periods of prolonged crescendo-decrescendo pattern of tidal volume
      • Usually in NREM, better in REM
    • Seen in males, >60 yrs.
      • Atrial fib and hypocapnea frequently seen
        • Awake PaCO 2 of 38 mm/Hg or less
        • Moderate oxygen desaturations
          • drops in SpO 2 to 80-85%
    • Seen in CHF, CVA or renal failure
  • Cheyne Stokes Breathing
  • Obstructive Sleep Apnea, Adult
    • Repetitive episodes of complete (apnea) or partial (hypopnea) airway obstruction in sleep
      • Events 10-30 sec. long but can be a minute or more
    • Events occur in NREM (stages 1 &2) or REM
      • Associated with desats from 1% to >40%
      • Longer in duration and more severe desats in REM
    • Snoring and excessive daytime sleepiness
      • Worse with alcohol consumption & increase in weight
      • At risk for systemic hypertension and type II diabetes
  • Obstructive Apnea, Pediatric
    • May have cyclic episodes of obstructive apneas or UARS similar to that of adults
    • Many (esp. younger) have prolonged hypoventilation associated with hypercarbia and or oxygen desaturations
    • Sleep architecture is usually normal may be due to higher arousal threshold
    • Large tonsils and adenoids; craniofacial abnormalities (micrognathia, nasal atresia, etc.); midface hypoplasia and associated hypotonia; Down syndrome; neuromuscular diseases; cerebral palsy; infants with gastroesophogeal reflux leading to edema of upper airway
  • Hypersomnias of Central Origin Not Due to Circadian Rhythm Disorder, SRBD or other cause of disturbed nocturnal sleep
    • Narcolepsy
    • Recurrent Hypersomnia
    • Idiopathic Hypersomnia
    • Behaviorally induced insufficient sleep syndrome
    • Hypersomnia due to a medical condition
    • Hypersomnia due to drug or substance
    • Hypersomnia not due to substance (non-organic)
    • Physiological (organic) Hypersomnolence
  • Narcolepsy with Cataplexy
    • Excessive daytime sleepiness with repeated episodes of naps or lapses into sleep across the daytime
      • Short sleep latencies and positive MSLT
    • Cataplexy : loss of muscle tone provoked by strong emotions
      • Ranges in mild sensation of weakness to complete postural collapse
      • Sleep paralysis, hypnogogic hallucinations, and nocturnal sleep disruption are common
    • Genetic link : associated with human leukocyte antigen (HLA) subtypes DR2/DRB1*1502 and DQB1*0602
      • Always found together in Caucasians and Asians (not African Americans)
      • Associated with loss of hypothalamic neurons containing neuropeptide hypocretin
        • Assessed by measuring CSF levels of hypocretin-1
  • Narcolepsy without Cataplexy
    • HLA typing is never used for diagnosing
    • Measuring CSF hypocretin-1 levels rarely helpful
      • May be helpful in SRBDs, PLMD and RBD
    • PSG shows short sleep latency ( 10 min) and sleep onset REM period ( SOREMP)
    • MSLT shows mean sleep latencies of less than 5 min. and SOREMP in 2 or more naps
      • Same findings in narcolepsy with cataplexy
  • Recurrent Hypersomnia Kleine-Levin Syndrome
    • Recurrent bouts of sleepiness occurring weeks or months apart
      • May have flu like symptoms prior to 1 st episode
    • Occurs in adolescents, mostly male (4:1)
    • During sleepy phase may sleep 18-20 hrs
      • Behavioral abnormalities may be present with binge eating, hypersexuality, irritability and aggressiveness
    • PSG shows low voltage slow EEG or diffuse alpha
    • MSLT shows reduced sleep latencies and REM onset in one or more naps
  • Parasomnias
  • Parasomnias
    • Disorders of Arousal (NREM Sleep)
      • Confusional Arousals
      • Sleep Walking
      • Sleep Terrors
    • Parasomnias Usually Associated with REM
      • REM Behavior Disorder
      • Recurrent isolated sleep paralysis
      • Nightmare Disorder
    • Other Parasomnias
      • Sleep Related Dissociative
      • Sleep Enuresis
      • Sleep Related Groaning
      • Exploding Head Syndrome
      • Sleep Related Hallucinations
      • Sleep Related Eating Disorder
      • Parasomnia, Unspecified
      • Due to Drug or Substance
      • Due to Medical Condition
  • Confusional Arousals
    • Episodes of mental confusion following arousal from sleep
      • Typically from slow wave sleep in 1 st third of night
      • Sleep talking and occasional shouting is common
      • Last 5-15 mins (can last as long as 30-40 min)
    • Prevalent in children and adults <35 yr.
      • 17% of children 3-13 yrs.
  • Confusional Arousal
  • Disorders of arousal
    • Impaired arousal from sleep, usually occur in SWS.
      •   awake enough to act out complex behaviors but still asleep (not aware or able to remember these actions).
    • Mental confusion & disorientation.
    • Relative non-reactivity to external stimuli.
    • Retrograde amnesia for many intercurrent events
    • Fragmentary or no recall of dream mentation
    • Poor response to efforts to provoke behavioral wakefulness
  • Sleepwalking (Somnambulism)
    • Series of complex behaviors that are initiated during slow wave sleep & result in walking during sleep.
      • Occur in first half of the night
    • Usual duration of an episode is 1-5 minutes.
    • Difficult to awaken
      • once aroused, shows mental confusion with amnesia for the event.
  • Copyright ©2003 American Academy of Pediatrics Guilleminault, C. et al. Pediatrics 2003;111:e17-e25 PSG of Onset of Sleepwalking in a 8-year-old child
  • Features of sleepwalking
    • Most common in children aged 4-6 years
      • Frequently disappears during adolescence.
      • Adult cases are not infrequent.
    • Strong family history is common
      • often family or personal history of other arousal disorders from SWS
        • specifically sleep terrors & confusional arousals
  • PSG Findings
    • Sleep lightens from SWS to stage 1 or 2 patterns 
    • On nights without episodes, PSG often shows 3 or more direct slow-wave-wakefulness transitions, an infrequent findings in normal subjects.
    • More frequent & higher amplitude delta bursts during incomplete arousals from non-REM sleep
    • Higher frequency of brief micro-arousals.
  • Differential Diagnosis
    • Psychomotor epilepsy.
    • REM sleep behavior disorders.
    • Nocturnal eating syndrome.
  • Sleep Terrors
    • Characterized by:
      • sudden arousal from slow wave sleep
      • a piercing scream or cry
      • accompanied by autonomic ( part of the nervous system that regulates motor functions of the heart, lungs, etc.) and behavioral manifestations of intense fear.
  • Sleep Terrors: Associated symptoms
    • PSG demonstrates the onset of episodes during SWS (stage 3 or 4 sleep)
    • Tachycardia usually occurs in association with the episodes.
    • Other medical disorders are not the cause of the episode, (i.e., epilepsy)
    • Other sleep disorders can be present
      • nightmares, sleep panic attacks, sleep apnea.
  • How serious are Sleep Terrors?
    • Some adults have episodes of night terror that may occur less than once per month, and do not result in harm to the individual or others.
    • Some adults experience episodes less than once per week, and it does not result in harm to the individual or others.
    • In its severest form, the episodes occur almost nightly, or are associated with physical injury to the individual or others.
    • Night terrors in adults is not normal.
      • Children generally have them, but tend to grow out of it.
  • Copyright ©2003 American Academy of Pediatrics Guilleminault, C. et al. Pediatrics 2003;111:e17-e25 Onset of Sleep Terror in a 3-year-old boy
  • REM Behavior Disorder
    • Predominantly male after 50 yr. of age
      • Often with underlying neurological disorder such as Parkinsonism, narcolepsy and stroke
      • Medication use common (venlafaxine, SSRI, mirtazapine)
    • Intermittent loss of REM EMG atonia
    • Exaggerated motor activity with dreams
    • PSG shows increased chin EMG in REM with prolonged limb movements
      • Increase in REM density and SWS time
  • SLEEP RELATED MOVEMENT DISORDERS
    • Restless Leg Syndrome
    • Periodic Limb Movement Disorder
    • Sleep Related Leg Cramps
    • Sleep Related Bruxism
    • Sleep Related Rhythmic Movement Disorder
    • SRMD, Unspecified
    • Due to Drug or Substance
    • Due to Medical Condition
  • Restless Leg Syndrome
    • Disagreeable leg sensations prior to sleep onset
      • Creeping, crawling, tingling, aching or itching
      • Feelings abate with leg movement
      • Complaints of inability to fall asleep
    • Iron, dopamine and genetics are factors in pathology
      • Serum ferritin levels <50
    • PSG: Prolonged sleep latency.
  • Periodic Limb Movement Disorder
    • Onset at any age but increases with age ( 34% >60 yr )
    • Iron deficiency may play role
      • Also seen with RLS, RBD and narcolepsy
    • Symptoms include leg cramps & insomnia
    • May be precipitated or aggravated by medications
      • tricyclic antidepressants, SSRIs, lithium and dopamine-receptor antagonists
    • PSG: periodic EMG bursts lasting 0.5-5 secs
      • 20-30 secs apart (4 movements in 90 sec)
      • Sleep fragmentation and prolonged latencies
  •