Mod 4 Sleep Disorders Flashcards
1
Q
What is the definition of sleep according to Merck?
A
A reversible behavioural state w/varying degrees of unconsciousness and reactive inactivity
2
Q
What are the 2 major sleep cycles?
A
- Non-rapid eye movement (non-REM) sleep
- Rapid eye movement (REM) sleep
3
Q
What is Rapid Eye Movement (REM) Sleep?
A
Active or dreaming sleep
- Increased EEG activity
- Lengthens as sleep progresses
- Contributes to psychological rest and long term emotional well being
4
Q
What is Non-Rapid Eye Movement (non-REM) Sleep?
A
Quiet or slow-wave sleep
- Has 4 sub-stages
5
Q
What are the 5 stages of sleep?
A
- W: Wakefulness
- N1: non-REM 1
- N2: non-REM 2
- N3: non-REM 3
- R: REM
6
Q
What are the 4 sub-stages of non-REM sleep?
A
N1, N2, and N3 (N3 has 2 levels)
7
Q
What is non-REM Sleep?
A
Typically the first stage of sleep
- Contributes to physical rest and may bolster the immune system and the digestive system
- Occurs every 60-90 mins increasing in duration across the night, each period lasts 5-10 mins
8
Q
When is the majority of sleep spent?
A
N2
9
Q
which stage of sleep has the largest cycle?
A
N2
10
Q
Which stage of sleep is described as the more chaotic?
A
N1 and N2
11
Q
Which stage of sleep is more regular?
A
N3
12
Q
Why is non-rem Sleep important?
A
Interruptions in these stages of sleep can interfere with normal growth patterns, healing, and immune response, especially in kids.
- N3 is crucial for development and growth.
13
Q
How are stages of sleep determined?
A
Electrophysiological monitoring
- EEG
- EOG
- EMG
14
Q
Why is REM sleep important?
A
REM sleep contributes to psychological rest and long-ter emotional well being
- may bolster memory
15
Q
What is REM sleep signified by?
A
Increased EEG activity
16
Q
How long does REM sleep last?
A
5-40 mins; lengthening as the sleep progresses.
17
Q
What is REM Sleeps role in Sleep Disordered breathing?
A
Muscle atonia in REM worsens airway collapse = more obstruction (affects arms, legs, intercostals, and upper airway muscles). No affect on diagram.
- Sleep related hypoventilation and apnea are frequent due to variable autonomic input (central control of breathing)
- Reduced response to hypoxia and hypercapnia.
- Apnea and hypopnea events are more frequent and prolonged
18
Q
Is non-REM sleep longer than REM sleep?
A
Yes, REM sleep is shorter than non-REM
19
Q
What are abnormalities of respiratory pattern?
A
Pauses in breathing
20
Q
What is Sleep-Disordered Breathing (SDB)?
A
A group of disorders characterized by pauses in breathing, or the amount of ventilation during sleep.
21
Q
What are 3 types of Sleep Apnea?
A
- Obstructive Sleep Apnea
- Central Sleep Apnea
- [Hypopnea, Upper Airway Resistance Syndrome (UARS)] -> Decreased # of breaths
22
Q
What is the continuum of sleep Apnea?
A
23
Q
What is Hypopnea?
A
Significant decrease in breathing w/o complete cessation of airflow.
- Decreases in SpO2 and/or sleep arousal are key features
- 30% decrease in airflow w/4% O2 desat
24
Q
What is Upper Airway Resistance Syndrome (UARS)
A
Increased airway resistance results in an extra effort to breathe
- can cause arousals and increase in BP
- Identified as 10 or more apneas lasting < 10 secs per hour
25
What is the continuum of Upper Airway Resistance Syndrome?
Snoring -> UARS -> OSA
(Least severe - Most severe)
26
What is the clinical definition of Apnea?
The cessation of breathing for 10 seconds or longer (may even exceed 100 seconds!)
27
When is Sleep Apnea diagnosed?
When more than 5 apneas per hour are occurring, over a 6 hour period with apneas > 10 seconds
28
When can Apneas occur?
In either non-REM or REM sleep
- More frequent and more severe in REM and when in a supine body position
29
When is sleep apnea most severe?
- During REM
- When in a supine body position
30
Age group affected by Apnea?
All age groups
- it may play a role in SIDS for infants
31
What is Obstructive Sleep Apnea caused by? (OSA)
- Categories?
Caused by small or unstable pharyngeal airway
1. Anatomical (Excess soft tissue)
2. Neurological (Decreased muscle tone)
32
What is the most common type of sleep apnea?
Obstructive Sleep Apnea (OSA)
33
What is Obstructive Sleep Apnea (OSA)?
Characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation or arousal from sleep.
- This disturbance results in fragmented, nonrestorative sleep
34
What is Obstructive Sleep Apnea Anatomical (OSA) caused by?
Excess soft tissue because of:
- Obesity (not everyone)
- Tonsillar hypertrophy (mostly PEDS)
35
What is Neurological Obstructive Sleep Apnea (OSA) caused by?
Decreased muscle tone
- While awake the pharyngeal tone is maintained by increased activity of the airway dilator muscles. This activity is lost during sleep and narrowing and/or closure of the airway results
- cause is not well understood
36
How does Obstructive Sleep Apnea (OSA) present?
Pts initially appear quiet and still while sleeping.
- Followed by an **increased effort** to inhale, often resulting in **snoring**
37
How do severe cases of Obstructive Sleep Apnea (OSA) present?
- Suddenly awaken
- Sit upright in bed
- Gasp for air
- people feel like they're being suffocated
- some patients aren’t sleep during the day and sometimes their score is over 100 an hour
38
Do symptoms of sleep apnea always indicate the severity of sleep apnea?
No, Symptoms of sleep apnea are not always an indication of the severity of the sleep apnea!
39
What is Enuresis?
Bed wetting.
40
What are hallmark signs/symptoms of Obstructive Sleep Apnea (OSA)
- **excessive daytime sleepiness**
- Hypertension
- Nocturnal Enuresis (bed wetting)
41
What are risk factors associated w/Obstructive Sleep Apnea (OSA)?
- Neck Size
- Type 2 diabetes
- Family hx (similar anatomical shapes of airways)
- Smoking residue can make upper airways stickier
- Older than 65 years
- Men
- post-menopausal women
42
What is the "STOP BANG" questionnaire?
S = Snoring
T = Tiredness
O= Observed apneas/gasping
P = Pressure (as in high BP)
B = BMI
A = Age
N = Neck circumference
G = Gender
43
Why are headaches associated with Sleep Apnea?
Trying to compensate for not breathing.
- Low blood pressures = headaches
44
What is observed apnea?
Bed partner seeing person not breathing
45
How is the STOP BANG Questionare scored?
- what is its purpose?
Screens individuals who may be at a higher risk of having obstructive sleep apnea (OSA). Helps w/further treatments.
- Scored out of 8
- Every yes = 1 point
- If you answer yes to 3 ore more then you have a high risk of OSA
46
What STOP BANG score suggests OSA?
If you answer yes to **3 or more** then you have a high risk of OSA
47
What are the consequences of untreated Obstructive Sleep Apnea (OSA)?
- Hypertension (50%)
- **Cardiovascular disease** (MI or stroke)
- Diabetes
- Neurocognitive and performance deficits
- Automotive accidents
- Deterioration in QOL, family life
48
What is Central Sleep Apnea (CSA)?
Pts display a periodic breathing pattern.
- Waxing and waning of respiratory drive
- **Cheyne-stokes** is a severe type of periodic breathing, often associated w/CHF
- Heterogenous group of disorders (Has several root causes)
- **your brain doesn’t send the signal to breath**
- **there is no effort** they just don’t breath for a long time
49
When does Central Sleep Apnea (CSA) occur?
When resp. centers of the medulla fail to send signals to the respiratory muscles.
- Characterized by cessation of airflow at the nose and mouth w/absence of diaphragmatic excursions.
- **your brain doesn’t send the signal to breath**
- **there is no effort** they just don’t breath for a long time
50
Clinical disorders associated with central sleep apnea
- CHF (cheyne stokes resp)
- Metabolic alkalosis
- Encephalitis (brain swelling)
51
What is Mixed Sleep Apnea?
Combination of obstructive and central sleep apnea
- usually begins as central sleep apnea, followed by ventilatory efforts w/o airflow (OSA)
52
How is mixed sleep apnea handled clinically?
Classified and treated as OSA
53
What is Overlap Syndrome?
When OSA and COPD co-exist (lots of types)
- bad prognosis
- Hypoventilation at night causing high CO2 and bicarb going up
- Worse ABG abnormalities than simple OSA
54
How do you diagnose/predict Sleeping Disorders?
Many ways, the gold standard is the Epworth Sleepiness scale.
55
What is Narcolepsy?
Chronic neuro condition that affects the brains ability to control sleep-wake cycles
56
What is the Epworth sleepiness scale?
- Used to measure excessive daytime sleepiness
- Validated for OSA
- Has patient rate how likely they are to fall asleep in different situations
- **Repeated after beginning treatment w/CPAP** (or bipap) to see if symptoms have improved
57
What do ranges on the Epworth Sleepiness scale indicate?
- What is normal?
- what is abnormal?
- 0-9 is normal
- 10-24 indicates need for expert med advice
- (>16) indicates possibility of severe sleep apnea or narcolepsy
58
What does a range of 0-9 indicate on the Epworth sleepiness scale?
Normal range
59
What does a range of 10-24 indicate on the Epworth sleepiness scale?
Need for expert med advice
60
What does a range of >16 indicate on the Epworth sleepiness scale?
Severe sleep apnea or narcolepsy
61
What are the 2 ways Sleeping disorders are diagnosed?
Level 1 sleep study (PSG)
Level 3 Sleep Study (home or bedside)
62
What are Level 1 study sleep studies?
Polysomnograms (PSG), You want a baseline blood gas before sleep to see how bad their sleep apnea is.
- Done in hospital or sleep lab
- Diagnoses all sleep disorders
- able to sleep
- uses 16 channels to gather info
63
What do you want for a Level 1 sleep study (PSG)
You want a baseline blood gas before sleep to see how bad their sleep apnea is.
64
How many channels are used to gather info for a level 1 sleep study (PSG)?
- what are they?
16 Channels
SpO2, snoring, airflow, EMG, respiratory effort, limb movement, EOG, ECG, EEG
65
What are Level 3 study sleep studies?
Level 3 is for uncomplicated straight up obstructive sleep apnea
- osa only uncomplicated
- remmers sleep recorder
- Uses 6 channels to gather info
66
How many channels are used to gather info for a level 3 sleep study (PSG)?
- what are they?
6
- SpO2, snoring, airflow, respiratory effort (optional), body position and heart rate
67
What is the Apnea Hypopnea Index (AHI)?
Average number of apneas and hypopneas the Pt has per hour of sleep
- AHI = ([#Apneas + #Hyponeas]/sleep time in minutes) *60 (to convert to hours)
- <5 Normal
68
What are the Apnea Hypopnea Index (AHI) severity categories?
An AHI >15 is significant
- Normal— < 5
- Mild—5 to 15
- Moderate—15 to 30
- Severe— >30
69
What is the Respiratory Disturbance Index (RDI)
- What is a clinically significant event?
**Total of everything the patient experiences at night**
- **Any sleep disturbances**
- Number of apnea events/hour plus the number of hypopnea events/hours plus the number of resp-effort related arousals (RERA) per hour of sleep
- RDI > 15 needs to be treated
70
What a normal Apnea Hypopnea Index (AHI)?
Less than 5
71
What a mild Apnea Hypopnea Index (AHI)?
5-15
- mild aren't treated for their sleep apnea
- they'd have high epworth, so they'd likely still be treated
72
What a moderate Apnea Hypopnea Index (AHI)?
15-30
- needs to be treated
73
What a severe Apnea Hypopnea Index (AHI)?
AHI > 30
74
What are clinically significant scores for AHI and RDI?
Any score > 15
75
What is the gold standard Sleep Studies?
PSG (aka level 1 sleep study)
- Can detect OSA that HSAT misses
- Done on all Pts suspected of having "complicated OSA" (or any unstable co-morbidity like **hypertension** or sleeping disorders like **CSA**)
76
What do Home Sleep Apnea Tests (HSAT) tell us?
- when are they used?
Gives RDI score
- only used when Pt is suspected of having a uncomplicated OSA
- Positive = OSA
- Negative = Pt needs PSG to rule out OSA
- Remmers (level 3)
77
Do negative RDI scores from a Home Sleep Apnea Test (HSAT) rule out sleep apnea?
No, a level 1 is needed to rule it out for sure.
78
What do waveforms and lines represent on a Polysomnography?
- How do you read sleep studies?
- Flat lines for airflow = apnea
- Effort = obstructive sleep apnea
79
Management of Sleeping Disordered Breathing?
The usual include
- lifestyle modifications
- physical interventions (positive airway pressure and oral appliances)
- surgical interventions
80
What are alternative treatments for sleep apnea?
- Positional therapy
- Pharmaceutical
- Neurostimulation
- Oropharyngeal exercises
81
What are lifestyle changes would aid in the management of Sleep Disordered breathing?
- Weight loss/maintain healthy BMI
- Good sleep hygiene
- Avoidance of alcohol
- Work with physician to change/alter schedule of sedatives
- Avoid excessive fatigue
- Smoking cessation
82
What methods could be used to admin Positive Airway Pressure for Sleep Disordered Breathing?
- CPAP and APAP (auto-CPAP)
- BiPAP
- AVAPS/VPAP
83
What is Auto-CPAP (APAP)
- Auto-adjusting CPAP, within a set range
- Thought to result in a lower failure rate
- Special modes (“C-Flex”) may decrease the CPAP level during expiration to ease exhalation; “A-flex” does both inspiration and expiration
84
What range of pressures can you use for APAP (auto-cpap)?
5-15 cmH2O
- Machine adjusts water to make sure airways stay open
85
What should you keep in mind when managing Sleep Disordered Breathing with CPAP?
level determined by repeated sleep studies while on CPAP
- you increase pressures if problems don't resolve
86
When would you use BiPAP to manage Sleep Disordered Breathing?
When there is a component of hypoventilation.
- **Always set back up rate bc they are usually chronic**
87
What are 3 types of patients that would need bipap
Any that have a component of hypoventilation
1. Neuromuscular Pts
2. Nocturnal hypoventilation (Pickwickian Syndrome)
3. CSA
88
When would you use AVAPS/VPAP to manage Sleep Disordered Breathing?
Severe OSA or a central component
89
why would you use AVAPS/VPAP to manage Sleep Disordered Breathing?
Allows volume targeting and minimal min volumes (like PRVC)
- Need to set target Vt
- Target Vt 500
- Machine does what needs to get in (like PRVC)
90
What is BUR and when do you need it?
BUR = Back up rate
- Need to set on BiPAP
91
Why do patients with COPD have better outcomes with BiPAP at night?
- Clears CO2 at night
- a lot of COPD exacerbations is bc they wake up at night and struggle to breath
- BiPAP supports their breathing and clears CO2 over night while they sleep
92
What mode of positive airway pressure is best suited for a patient with COPD?
BiPAP
- helps them clear CO2 at night
93
What oral appliances used for in Sleep Disordered Breathing?
Typically for snoring, UARS, mild-mod OSA
94
What oral appliances can be used for sleep disordered breathing like snoring, UARS, and mild-mod OSA?
- Tongue Retaining device (TRD)
- Mandibular Advancement Device (MAD)
95
How does a Tounge Retaining Device (TRD) work?
Holds the tongue forward
96
How does a Mandibular advancement device (MAD) work?
- holds the lower jaw forward to maintain
- May be used in conjunction with CPAP
- OTC and custom made
- Looks like a mouth guard
97
What are surgical interventions for the management of Sleep Disordered Breathing?
- Nasal surgery (septoplasty, turbinate reduction…)
- Tonsillectomy
- UPPP (Uvulopalatopharyngoplasty)
- Genioglossal advancement
- Mandibular advancement
98
what is positional therapy?
- what methods are used?
The use of devices to encourage sleeping on the side (as snoring is worse on back)
- effective w/positional SDB (only when supine)
- Methods: Backpacks, shirts, tennis ball tech
99
What is the success rate of Surgical Interventions for Sleep Disordered Breathing?
Varying levels of success, sometimes it doesn’t work
100
