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1. Sleep disorders – overview and pitfalls
Dr. Aditya Jindal
Interventional Pulmonologist & Intensivist, sleep specialist
Jindal Clinics
SCO 21, Sec 20D, Chandigarh
DM Pulmonary and Critical Care Medicine (PGI Chandigarh),
FCCP

8. Sleep disorders
1. Sleep related breathing disorders
2. Sleep related movement disorders
3. Insomnias
4. Parasomnias
5. Hypersomnias
6. Circadium rhythm sleep-wake disorders

9. Sleep related breathing disorder
• Central sleep apnea due to drug or substance
• Primary sleep apnea of infancy
• Obstructive sleep apnea
• Sleep-related nonobstructive alveolar
hypoventilation, idiopathic
• Primary central sleep apnea
• Central sleep apnea due to Cheyne Stokes
breathing pattern
• Central sleep apnea due to medical condition
not Cheyne Stokes

10. Spectrum of sleep disorder breathing
• Obesity-hypoventilation syndrome
• Severe obstructive sleep apnea
• Moderate obstructive sleep apnea
• Mild obstructive sleep apnea
• Upper airways resistance syndrome
• Chronic, heavy snoring
• Intermittent snoring
• Quiet breathing

11. What is OSA?
OSA is a syndrome characterized by frequent
episodes of upper airway obstruction during
sleep, associated with recurrent arousals,
oxygen desaturation, and daytime symptoms

12. Pathophysiology of OSA
Interplay between three important factors
• Anatomic Structural narrowing of
airway
• Neurologic Inadequate upper airway
dilator muscle function
• Mechanical Altered upper airway
collapsibility

13. Veasey, CCNA 2003

17. Risk of Untreated OSA

18. Primary
events
Secondary
events
Clinical
consequences
• Vibration of soft palate • Snoring
• Pulmonary arterial
vasoconstriction
• Pulmonary hypertension
• Right heart failure
• Systemic arterial
vasoconstriction • Systemic hypertension
• Vagal bradycardia
• Cardiac ischemia and
irritiability
• Cardiac arrhythmias
• Sudden unexplained
cardiac death
• Cerebral vascular
dilatation • Morning headache
• Hypothalamic-pituitary-
testicular dysfunction
• Reduced libido
• Impotence
• Stimulation of
erythropoeisis • Polycythemia
• Cerebral impairment
and/or damage
• Excessive daytime
sleepiness
• Intellectual deterioration
• Behavioural disorders
• Sleep fragmentation
• Loss of deep sleep
• Excessive motor activity • Nocturnal “epilepsy”
Sleep onset
Upper airway
narrowing
Obstructive apnea
ipO2,hpCO2,ipH
Arousal from sleep
Airflow resumption
Return to sleep

19. Sleep studies
• Count number of respiratory events and
divide by hours of sleep to generate AHI
Overnight polysomnography
is the ‘gold standard’ for
diagnosis of OSA

20. Sleep staging
Oronasal Flow
Snoring
Rate, rhythm
Respiratory
effort
Body position
Leg movement
SaO2
EEG
EOG
Flow sensor
EMG
Microphone
ECG
Thoracic
Abdominal
Position
EMG
Oximeter

21. Diagnosis

22. Types of PSG

23. EEG
Potentials generated by the
cerebral cortex

24. 10-20 electrode placement

25. Sleep staging
• Rechtschaffen and Kales (R and K) 1967
stage W,N1-4 & R
• AASM 2007stage W,N1-3 & R

27. Hypnogram in normal adult

28. Hypnogram in OSA pt

29. Awake
Alpha rhythm-trains of sinusoidal 8-13 activity over occipital region ; attenuating
with eye opening
Eye blinks- conjugate vertical eye movementsat a frequency of .5-2hz
REM may be seen with initial deflection lasting < 500msec
Submental EMG - relatively high tone

30. NREM 1
slow eye movements: conjugate, regular , sinusoidal eye movement with
initial deflection >500 msec
vertex sharp waves
low amplitude 4-7 Hz/ mixed frequency activity

31. NREM 2

32. Sleep Spindles
• Sleep Spindle – 11-16 Hz
• .5 second spindles - 6-7
cycles
• Central - vertex region
• >.5 second in duration

33. K Complexes
• Sharp, slow waves, with a negative then
positive deflection
• No amplitude criteria
• >.5 second in duration
• Central in origin

34. NREM 3
•>20% Delta Activity ( .5-2 Hz with amplitude >75 uV)is
seen over frontal region
•no eye movements
•EOG leads will only pick up the EEG activity
•about thirty to forty five minutes after sleep onset
•far more difficult to awaken

35. Stage R
•Brain suddenly becomes much more active.
•REM-conjugate, irregular, sharply peaked eye movements with initial
deflection< 500 msec
•Low chin EMG activity
•Sawtooth waves- low amplitide sharply contoured or triangular (2-
6hz); over central head regions

36. EOG and EMG Placements
• E1
• M1
• M2
• E2
• CHIN EMG

37. Corneoretinal potential

38. EMG placement

39. Leg EMG

40. Position sensor

41. Thoraco-abdominal movements

42. Flow tracing

43. Obstructive Apnea A complete blockage of the airway despite
efforts to breath. Notice the effort gradually increasing ending
in airway opening.
Blood oxygen levels
reduce to < 3% of
basline value
Inhale
Exhale Airway obstructs Airway opens
Paradoxing
Paradoxing Ends
EKG
Airflow
Thoracic
effort
Abd.
effort
SAO2
Effort gradually increases

44. Central Apnea
Airflow
Thor.
Effort
Abd.
Effort
SAO2
ECG

45. Mixed Apnea
EKG
Airflow
Thoracic Effort
Abdominal Effort
SAO2

46. Hypopnea This is an 18 second hypopneic event. The airflow
signal is reduced by approximately 50% during this event.
Airflow reduction
SAO2 desaturation
> effort with paradox Paradox ends
Inhale
Exhale

47. Scoring SDB
Severity Mild Moderate Severe
AHI 5-15 15-30 >30
RDI 15-20 20-40 >40

48. OSA Treatment: CPAP

49. 5 Questions to Monitor CPAP
• Snoring despite CPAP?
• Weight change since CPAP started?
• When was equipment last checked?
• Still symptomatic?
• Problems?

50. CPAP Compliance
-Widely variable rates 50-70% overall
–-Probably need >4 hrs. nightly for
response
–-Compliance determined early on

51. CPAP Compliance
• Man or Machine?
– Man
• -Monitoring- Compliance feedback
• -Education/Reassurance/Reevaluation
• -Partner involvement
– Machine
• -Humidification- Warm Vs. Cold
• -Mask- Nasal Pillows, Full Face, Other
• -Blower- Bi-level, Auto-titration
• Berry RB. Sleep Med (1): 175; 2000

52. Practice points: Auto-Adjusting CPAP
• Auto-CPAP offers no benefit over fixed CPAP in terms of
efficacy on the AHI
• It has not been established that unattended auto-CPAP
titration is safe without a previous diagnostic PSG
• Some, but not all, studies indicate auto-CPAP results in a
lower cumulative CPAP level. However, the importance of the
amount of applied pressure on CPAP adherence is not
consistently demonstrated
• Auto-CPAP has variable effects on adherence

53. OSA Treatment: Surgery
• Laser-assisted uvulopalatoplasty (LAUP)
– AASM: not advised for OSA
• Uvulopalatopharyngoplasty (UPPP)
– 40% patients achieve AHI < 5
• Somnoplasty or Radiofrequency volumetric tissue
reduction (RFVTR)
– Role has yet to be fully defined
• Maxillofacial surgery
– Infrequently performed, but can be very effective

54. Radiofrequency Ablation
-Programmable levels of
radiofrequency energy delivered
by a proprietary disposable
device into upper airway
structures causing tissue necrosis
and fibrosis
-Less painful; ambulatory
procedure
-Unlikely to be singularly effective
for most OSA
-May be effective in combination
procedures
-Minimal peer-reviewed data

55. Oral Appliances
Tongue advancing
device

56. Sleep related disorders in other
specialities

58. VPC, tachycardia in OSA pt

59. After CPAP

61. CSR
• If there is at least 3 consecutive cycles of cyclical crescendo
and decrescendo change in breathing amplitude
• + atleast one of the below :
1. 5 or more central apnea / hypopnea per hr of sleep.
2. The cyclic cresendo and decresendo change in breathing
amplitude has a duration of atleast 10 consecutive mins.
CSR has variable cycle length that is most commonly in the
range of 60 seconds.

62. Nocturia

63. Erectile
dysfunction

65. • Psychiatry
– ADHD
– Depression
– Bipolar disorders
– Alcoholism
– PTSD
• Gastro
– GERD
• Dental
– Bruxism

66. Pitfalls
1. Artifacts
2. Misdiagnosis
3. Superadded apnoea
4. Inadequate relief

67. POPPING ARTIFACT

68. MOISTURE ARTIFACT

69. Equipment malfunction

70. Oximetry probe malfunction

71. ECG artifact

72. Eye movement artifact

73. Complex sleep apnea

74. Kapur et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep
apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep
Med. 2017

76. Take home message
1. Have a high index of suspicion
2. In hospital/ clinic study (both diagnostic & titration)
is recommended
3. Use home sleep testing only if parameters are met
4. Be aware of sleep related non-respiratory disorders
5. Be ready to tackle problems!