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Sleep Disorders – Overview and Pitfalls.pptx
This document provides an overview of sleep disorders including sleep related breathing disorders, movement disorders, insomnias, parasomnias, hypersomnias, and circadian rhythm disorders. It discusses obstructive sleep apnea (OSA) in detail including its pathophysiology, risks of untreated OSA, diagnostic polysomnography, and treatment options like CPAP and surgery. It also covers some pitfalls in diagnosing and treating sleep disorders and highlights the importance of considering sleep-related issues in other medical specialties.
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Sleep Disorders – Overview and Pitfalls.pptx
- 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. Sleeprelated breathing disorders 2. Sleep related movement disorders 3. Insomnias 4. Parasomnias 5. Hypersomnias 6. Circadium rhythm sleep-wake disorders
- 9. Sleep related breathingdisorder • 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 sleepdisorder 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? OSAis 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 Interplaybetween three important factors • Anatomic Structural narrowing of airway • Neurologic Inadequate upper airway dilator muscle function • Mechanical Altered upper airway collapsibility
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- 18. Primary events Secondary events Clinical consequences • Vibration ofsoft 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 • Countnumber 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
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- 23. EEG Potentials generated bythe cerebral cortex
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- 25. Sleep staging • Rechtschaffenand Kales (R and K) 1967 stage W,N1-4 & R • AASM 2007stage W,N1-3 & R
- 27. Hypnogram in normaladult
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- 29. Awake Alpha rhythm-trains ofsinusoidal 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 eyemovements: conjugate, regular , sinusoidal eye movement with initial deflection >500 msec vertex sharp waves low amplitude 4-7 Hz/ mixed frequency activity
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- 32. Sleep Spindles • SleepSpindle – 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% DeltaActivity ( .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 suddenlybecomes 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 EMGPlacements • E1 • M1 • M2 • E2 • CHIN EMG
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- 43. Obstructive Apnea Acomplete 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
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- 46. Hypopnea This isan 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 MildModerate Severe AHI 5-15 15-30 >30 RDI 15-20 20-40 >40
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- 49. 5 Questions toMonitor CPAP • Snoring despite CPAP? • Weight change since CPAP started? • When was equipment last checked? • Still symptomatic? • Problems?
- 50. CPAP Compliance -Widely variablerates 50-70% overall –-Probably need >4 hrs. nightly for response –-Compliance determined early on
- 51. CPAP Compliance • Manor 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-AdjustingCPAP • 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 levelsof 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
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- 56. Sleep related disordersin other specialities
- 58. VPC, tachycardia inOSA pt
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- 61. CSR • If thereis 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.
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- 65. • Psychiatry – ADHD –Depression – Bipolar disorders – Alcoholism – PTSD • Gastro – GERD • Dental – Bruxism
- 66. Pitfalls 1. Artifacts 2. Misdiagnosis 3.Superadded apnoea 4. Inadequate relief
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- 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!