Inv sleep 2012

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25/3/2012
Ix of sleep disorders by dr.Jaidaa Mekky

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  • NREM sleep is divided into 4 stages. Stages 1 and 2 are characterized by low arousal thresholds and are considered light sleep. Stages 3 and 4 are characterized by high arousal thresholds and are considered deep or “slow wave” sleep. All 4 of these stages can be differentiated by electroencephalography (EEG). Stage 1 is marked by low voltage, mixed frequency EEG. Stage 2 is marked by the presence of K complexes and sleep spindles on EEG recordings. Both stages 3 and 4 are marked by delta waves, which have a voltage of 75 microvolts or more and a frequency range of 0.5 to 4 hertz, but differ in composition. Stage 3 is defined as sleep consisting of 20-50% delta waves and stage 4 as sleep consisting of more than 50% delta waves. REM sleep is characterized by minimal movement, low muscle tone, activation of cortical activity, and rapid eye movements accompanied by vivid dreams. [Text: Comella, p. 18-B; Pace-Schott, p. 600. Figure: Pace-Schott, p. 600] Comella CL, Walters AS, Hening WA. Sleep and wakefulness. In: Goetz CG, Pappert EJ, eds. Textbook of Clinical Neurology . Philadelphia: WB Saunders Company; 1999:18-27. Pace-Schott EF, Hobson JA. The neurobiology of sleep: genetics, cellular physiology and subcortical networks. Nat Rev Neurosci . 2002;3:591-605. Scammell TE. The regulation of sleep and circadian rhythms. Sleep Med Alert. 2004;8:1-6.
  • Inv sleep 2012

    1. 1. Investigations of sleep disorders BY Dr.Jaidaa Mekky Lecturer of Neuropsychiatry Sleep Medicine ConsultantMember of the American Academy of Neurology Member of the American Academy of Sleep Medicine Faculty of Medicine Alexandria University
    2. 2. Background• One-half to one-third of life asleep• Sleep medicine relatively new field• Sleep is a co-morbidity in a long list of diseases• It was mentioned in the holy Quran 9 times, describing the sleep fnctions and stages  ‫وقال إن أبقراط قال: إذا كان النوم فى المراض المزمنة يس ّب وجعً، فذلك‬ ‫ا‬ ‫ب‬ ‫. من علمات الموت‬
    3. 3. Milestones• 1837 – Dickens – describes overweight/hypersomnolent boy in the Posthumous Papers of the Pickwick Club (term “pickwickian” used by Osler)• 1875 – Caton – EEG in dogs• 1928 – Berger – Human EEG alpha waves• 1937 – Loomis – EEG Sleep stages described
    4. 4. Milestones• 1953 – Aserinsky & Kleitman – REM sleep• 1970s – Polysomnography• 1972 – Guilleminault – coins term OSA• 1990 – International Classification of Sleep Disorders
    5. 5. Sleep Physiology• What is Sleep? – “a reversible behavioral state of perceptual disengagement from and unresponsiveness to the environment”• 75% in Non-REM sleep• 25% REM sleep – muscle atonia, autonomic activation
    6. 6. Sleep Architecture: NREM & REM Sleep Pace-Schott EF, Hobson JA. Nat Rev Neurosci. 2002.
    7. 7. Biological rhythms (periodic physiological fluctuations)Types of rhythms3. Ultradian (Basic Rest-Activity Cycle)4. Circadian (sleep-wake cycle)5. Infradian (menstrual cycle)6. Circannual (annual breeding cycles)
    8. 8. A major input to the relay and reticular nuclei of the thalamus (yellow pathway) originates from cholinergic (ACh) cellgroups in the upper pons, the pedunculopontine (PPT) and laterodorsal tegmental nuclei (LDT). These inputs facilitatethalamocortical transmission. A second pathway (red) activates the cerebral cortex to facilitate the processing of inputsfrom the thalamus. This arises from neurons in the monoaminergic cell groups, including the tuberomammillary nucleus(TMN) containing histamine (His), the A10 cell group containing dopamine (DA), the dorsal and median raphe nucleicontaining serotonin (5-HT), and the locus coeruleus (LC) containing noradrenaline (NA). This pathway also receivescontributions from peptidergic neurons in the lateral hypothalamus (LHA) containing orexin (ORX) or melanin-concentrating hormone (MCH), and from basal forebrain (BF) neurons that contain γ-aminobutyric acid (GABA) orACh. Note that all of these ascending pathways traverse the region at the junction of the brainstem and forebrain wherevon Economo noted that lesions caused profound sleepiness.
    9. 9. Sleep architecture over the lifespan
    10. 10. The main sleep c/o:• Insomnia• EDS• Parasomnia• Symptoms of SDB(snoring)
    11. 11. ApproachSleep history( SLEEP LOG)( from the patient & bed partner)Medications ( hypnotic dependant sleep disorder)Medical history( COPD, Hypothyroidism, end organ failure)Neurological ( Parkinson,s disease, dementia)Psychiatric ( depression, anexiety)Social history( marital ,social & occupational functioning)
    12. 12. Sleep Diary
    13. 13. Sleep Log
    14. 14. Epworth sleepiness scaleSituation Chance of dozingSitting and reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Watching TV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sitting, inactive in a public place (e.g. a theatre or a meeting) . . . . . . .As a passenger in a car for an hour without a break . . . . . . . . . . . . . . .Lying down to rest in the afternoon when circumstances permit . . . . .Sitting and talking to someone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Sitting quietly after a lunch without alcohol . . . . . . . . . . . . . . . . . . . . .In a car, while stopped for a few minutes in the trafficTotal . . . . . . . . . . . . . . . . . . . . . . . . :Score Normal range 0-10  Borderline 10-12 pathological 12-24
    15. 15. Examination• Body habitus( obesity, poor hygiene)• Neck( circumference ,thyroid etc.)• Craniofascial abnormalities (retrognathia, craniosynsitosis)• Otolaryngeal examination( nasal mucosa, tongue ,uvula)• Pulmonary & cardiac examination• Neurological & Psychiatric assessment
    16. 16. Mallampati classification
    17. 17. InvestigationsLaboratory Tests:Thyroid functionSerum ferritin, hemoglobinHLA typing(HLA DQB1*0602 )Toxocological screeningLiver & kidney function
    18. 18. Investigations( cont.)Neurologic Assessment:Videomonitored EEGImaging Studies: CT& / MRI
    19. 19. Assessment of the upper airway• Fluoroscopy• Nasopharyngoscopy• Cephalometry• CT, Volumetric reconstruction• MRI
    20. 20. Investigations( cont.)Sleep Tests•Overnight Polysomnography(Videomonitored )•MSLT•MWT•Actigraphy•OSLER test
    21. 21. PolysomnographyPolysomnography is a simultaneous recording of multiple physiologic parameters related to sleep and wakefulness – EEG – EOG – EMG
    22. 22. Aapplication
    23. 23. Parameters monitored:1-Four (EEG) channels2-Two  (EOG) channels 3-One (EMG) channel4-Airflow( nasal and  oral) for the detection  of apnea 5-Sound recordings to  measure snoring      
    24. 24. 6-ECG 7-Pulse oximetry  8-Respiratory effort (Thoracic  and abdominal belts)9- Tibialis anterior EMG10-Detector of the body  position 11-Esophageal manometry
    25. 25. Videomonitored PSG
    26. 26. Neurologic monitoring Techniques• Extended EEG ( 12-36) channel• Repeated studies ,video monitoredDD:• Nocturnal seizures• Parasomnias• REM behavioral disorders
    27. 27. HypnogramStandard Hypnogram
    28. 28. S taging M ove m e nt T im e Awak e RE M S tage 1 S tage 2 S tage 3 S tage 4 11 Õ 12 ã 01 ã 02 ã 03 ã 04 ã 05 ã 06 ãPos ition Le ft R ight S upine P rone U prightPL MS With Arou s al W/O Arou s al Respiratory E vents Mixe d Apne a O bs tructive Apne a C e ntral Apne a Hypopne a
    29. 29. The main data presented in PSG are:• 1) Total sleep time, wake time, total recording time;• 2) Sleep efficiency (total sleep time/total recording time);• 3) Latency for sleep onset, latency for REM sleep and other sleep stages.• 4) Duration (in minutes) and proportion of total-sleep-time sleep stages (5) Frequency of apneas and hypopneas per hour of sleep• 6) Saturation values and events of oxyhemoglobin desaturation• 7) Total number and index of periodic lower limb movements per hour of sleep.• 8) Total number and index of micro-arousals per hour of sleep and their relationship with breathing events or lower limb movements;• 9)Esophageal ph anormalities• 10)Penile tumecence
    30. 30. Portable PSG
    31. 31. MSLT -MWT• 4-6 naps with 2h interval• Parameters monitored:• EEG(4channel)• EOG• Chin EMG• ECG• Respiratory flow (if needed)• Microphone (if needed)
    32. 32. GERD
    33. 33. Actigraphy
    34. 34. Actigraphy• Cost efficient• Records motor movements• Aallows estimates for several days, avoiding the sampling error of NPSG• It gives an idea about TST,SL, Nocturnal arousals• It is superior to sleep log
    35. 35. Uses:• Used in assessment of Insomnia• Useful in children and old age• Circadian rhythm disorders• Epidemiologic sleep studiesLimitations:• It is not standardized yet for diagnosing PLMS,SDB or RBD.
    36. 36. Osler testThe Oxford Sleep Resistance Test
    37. 37. Sleep tight

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