Anatomy of the Upper Airway - PowerPoint PPT Presentation

1 / 68
About This Presentation
Title:

Anatomy of the Upper Airway

Description:

SDB: Diagnostic criteria (AASM Task Force, Sleep 1999) ... Disagreeable leg sensations that usually occur prior to sleep onset and cause ... – PowerPoint PPT presentation

Number of Views:531
Avg rating:3.0/5.0
Slides: 69
Provided by: wendyj5
Category:
Tags: airway | anatomy | upper

less

Transcript and Presenter's Notes

Title: Anatomy of the Upper Airway


1
SLEEP DISORDERS
Esra Tasali, MD
March 4th, 2003
2
The National Sleep Foundations 1999 Omnibus
Sleep in America Poll
  • 62 of adult Americans report having sleep
    problems
  • Only 4 of these adults with sleep problems are
    seeing a doctor or other health care provider for
    advice or treatment

3
International Classification of Sleep Disorders
  • Dyssomnias
  • Excessive sleepiness or difficulty in
    initiating or maintaining sleep
  • - Intrinsic sleep disorders OSA,
    narcolepsy, insomnia, RLS/PLMD
  • - Extrinsic sleep disorders
  • - Circadian rhythm sleep disorders
    DSPS, ASPS
  • Parasomnias
  • Undesirable physical phenomena predominantly
    during sleep
  • - Arousal disorders sleep walking,
    sleep terrors
  • - Sleep-wake transition disorders
    sleep talking
  • - Parasomnias usually associated with
    REM sleep nightmares, RBD
  • - Other parasomnias sleep bruxism
  • Sleep Disorders Associated with Mental,
    Neurologic, and Other Medical Disorders
  • Proposed Sleep Disorders

4
Prevalence of Sleep Disorders
5
Sleep Disordered Breathing /Sleep Apnea
6
Sleep Disordered Breathing (SDB)
Definition Increasingly common chronic condition
characterized by recurrent episodes of partial or
complete upper airway obstruction during sleep
7
SDB a public health concern
  • Associated with increased cardiovascular
    morbidity
  • - systemic hypertension, left
    ventricular hypertrophy
  • - myocardial ischemia, cardiac
    arrhythmias
  • - pulmonary hypertension
  • - stroke
  • Many have features of metabolic syndrome
  • central obesity, hypertension, insulin
    resistance,
  • dyslipidemia (syndrome Z )

8
SDB syndrome definitions
  • Obstructive sleep apnea hypopnea syndrome
  • Central sleep apnea-hypopnea syndrome
  • Cheyne-Stokes breathing syndrome
  • Sleep hypoventilation syndrome
  • Upper airway resistance syndrome
  • Simple snoring

AASM Task Force, Sleep 1999
9
SDB risk factors
  • Obesity (particularly central), increased
    visceral fat
  • Male gender, African American race
  • Craniofacial abnormalities ( mandibular/maxillary
    hypoplasia )
  • Increased pharyngeal soft or lymphoid tissue
    including tonsillary hypertrophy
  • Increased neck circumference ( gt 40cm )
  • Nasal obstruction
  • Familial history
  • Endocrine abnormalities hypothyroidism,
    acromegaly
  • Aggravated by alcohol, sedatives, sleep
    deprivation, supine position, respiratory
    allergies, nasal congestion

10
SDB symptoms
11
Normal
12
Obstructive Apnea

Airway obstructs
Airway opens
Exhale
Effort gradually increases
Inhale
Paradoxing
Paradoxing ends
Desaturations
13
Mixed Apnea

ECG
Airway opens
No airflow
Exhale
Airflow
Respiratory effort
Inhale
no effort
Thor. Effort
Paradoxing
Abd. Effort
Paradoxing ends
14
SDB Diagnostic criteria (AASM Task Force, Sleep
1999)
  • Apnea-hypopnea index (AHI) number of apneas and
    hyponeas per hour of sleep
  • Respiratory events should last at least 10 sec
    in duration

15
(No Transcript)
16
(No Transcript)
17
Hypoxic stress / Sympathetic overactivity
Somers et al, J Clin Invest 1995
18
State of sleep debt
Sleep Disordered Breathing
19
SDB Treatment of choice CPAP
General measures - Weight reduction -
Sleep hygiene - Positional therapy -
Avoiding alcohol, smoking
20
SDB Alternative treatments
21
Narcolepsy
22
(No Transcript)
23
The narcolepsy tetrad
  • Excessive daytime sleepiness
  • Cataplexy
  • Hypnagogic hallucinations
  • Sleep paralysis
  • ( Disrupted nocturnal sleep)

24
Excessive daytime sleepiness (EDS)
  • Continuous subjective feeling of sleepiness
    or irresistible sleep attacks
  • Duration of sleep attacks is usually lt 20 min, a
    refractory period of 1 to several hours before
    the next episode occurs
  • Usually they wake up feeling refreshed
  • Not only during passive activities but also in
    situations when the subject is fully involved in
    a task

25
Differential diagnosis of EDS
  • Sleep deprivation
  • Another sleep disorder (OSA, RLS)
  • Poor sleep quality due to medical illness (CHF)
  • Medications, drugs,toxins
  • Depression
  • Delayed sleep phase syndrome
  • Idiopathic hypersomnia

26
Cataplexy
  • Sudden bilateral loss of muscle tone, provoked by
    strong emotions, most typically by laughter
  • Jaw sags, head falls forward, arms drop to the
    side, knees unlock or buckle
  • Consciousness is preserved, eye movements and
    respiration are not compromised
  • Few seconds to a couple of minutes

27
Hypnagogic hallucinations
  • Vivid dream like experiences that occur during
    sleep onset
  • Usually content is bizarre and frightening
  • Visual imagery is predominant
  • Auditory and tactile components are present
  • Lasts less than 10 minutes
  • May occur with sleep paralysis

28
Sleep Paralysis
  • Inability to move the limbs, to open the eyes, to
    speak or even to breath deeply
  • Occurs either on falling asleep or awakening and
    the patient is fully aware of the condition
  • People are usually terrified during an attack,
    particularly the first time
  • Up to 10 min and ends spontaneously or after mild
    sensory stimulation ( shake out of it)
  • Can occur in 15 of otherwise normal persons,
    with familial clustering and association with
    sleep loss

29
Other associated features
  • Automatic behavior
  • Memory disturbances
  • Tiredness or fatigue
  • REM behavior disorder (RBD)
  • Depression
  • Obesity
  • Hypothyroidism

30
Evaluation of sleepiness
  • Subjective scales
  • - Stanford Sleepiness Scale
  • - Epworth Sleepiness Scale
  • Objective testing
  • - Multiple Sleep Latency Test (MSLT)
  • - Maintenance of Wakefulness Test (MWT)

31
Multiple Sleep Latency Test (MSLT)
Roth T Roehrs T, 2000
32
PSG and MSLT findings in narcolepsy
  • PSG Sleep latency lt10 min
  • PSG REM latency lt 20 min
  • MSLT mean sleep latency lt 5min
  • MSLT ? 2 sleep onset REM periods

33
(No Transcript)
34
Narcolepsy diagnostic criteria (ICSD)
  • Recurrent daytime naps or lapses into sleep
    occurs almost daily for at least 3 months
  • cataplexy

Excessive sleepiness or sudden muscle
weakness Associated features sleep paralysis,
hypogogic hallucinations, automatic behaviors,
disrupted major sleep episode ? 1 PSG or
MSLT findings
35
Narcolepsy pathophysiology
  • REM dysregulation inappropriate intrusions of
    REM sleep into wakefulness
  • HLA-DQB10602 (gt 90 with narcolepsy-cataplexy )
    is the best HLA marker
  • Recent studies have shown that narcolepsy with
    cataplexy is usually caused (gt90) by the lack of
    two related brain chemicals called "hypocretin-1"
    and "hypocretin-2"

36
What are hypocretin (orexin) molecules?
  • Were found on hypotalamus and some resemblance to
    gut secretin
  • Also found to stimulate food intake orexin A,
    orexin B
  • Small neuronal group with dense projections to
    cortex and to brain stem
  • Excitatory stimulus to locus coeruleus

37
The discovery of the hypocretin/orexin peptides
38
Hypocretin/orexin in human narcoleptics
  • Undetectable levels of hypocretin in CSF
  • ( Lancet, 2000)
  • Absence of hypocretin neurons in the hypotalamus
    by histopathologic examination of brains of
    narcoleptic patients
  • ( Nature Med, 2000 Neuron, 2000)

39
Narcolepsy Treatment
  • Nonpharmacologic
  • - Regular timing of nocturnal sleep, avoiding
    shifts
  • - Avoid heavy meals and alcohol intake
  • - Scheduled naps 15 min at lunch time and at
    530pm
  • Pharmacologic
  • For sleepiness Stimulants ( Modafinil,
    Methylphenidate )
  • For cataplexy TCA, SSRI , sodium oxybate
    (Xyrem)

40
Restless Leg Syndrome / Periodic Limb Movement
Disorder
41
Restless Leg Syndrome Disagreeable leg
sensations that usually occur prior to sleep
onset and cause almost an irresistible urge to
move the legs
Periodic Limb Movement Disorder Periodic
episodes of repetitive and highly stereotyped
limb movements that occur during sleep
42
Pathogenesis of RLS
  • Primary or idiopathic
  • - no identifiable predisposing factor
  • - tends to occur in families ( genetic?)
  • Secondary
  • - Iron deficiency anemia
  • - Uremia ( 15-40 of dialysis patients)
  • - Pregnancy
  • - Neuropathies
  • - Drug induced (TCA, SSRI, lithium,
    neuroleptics)
  • - Diabetes, Parkinson disease, Rheumatoid
    Arthritis

43
RLS essential features (IRLSSG criteria)
  • Desire to move the limbs usually associated with
    paresthesias or dysesthesias
  • Motor restlessness
  • Symptoms worse at rest partially relieved by
    activity
  • Symptoms worse in the evening or at night

44
Uncomfortable Sensations
  • Creepy, crawly, tingly
  • Like worms or bugs crawling under the skin
  • Painful, burning, achy, itchy
  • Like water running over the skin
  • Sometimes indescribable

45
RLS additional common features
  • Sleep disturbance and its consequences (EDS)
  • Involuntary movements while awake and at rest,
    disappearing when patient gets up to walk
  • Usually chronic course but spontaneous remissions
    relapses may occur
  • Circadian variability symptoms typically peak
    between midnight and 4 am
  • Periodic limb movement disorder (PLMD)

46
(No Transcript)
47
(No Transcript)
48
Management of RLS
49
Insomnia
50
Insomnia
The perception of insufficient, disturbed or
non restorative sleep
  • Medical
  • Psychiatric
  • Pharmacologic
  • Primary sleep disorder
  • Genetic (Fatal Familial Insomnia)
  • Tobacco/ Alcohol

51
Transient Insomnia (Short term )
  • Environment related ( noise,temperature,sleep
    surface, sleep position, altitude )
  • Stress-related
  • Sleep schedule related ( jet lag, shift work)
  • Drug discontinuation or initiation

52
(No Transcript)
53
  • Primary Insomnia
  • Psychophysiological insomnia
  • Sleep-state misperception
  • Idiopathic insomnia

54
Insomnia Management
  • Behavioral therapy
  • - Relaxation techniques
  • - Sleep restriction
  • - Stimulus control
  • Sleep Hygiene
  • Medications

55
Circadian Disorders of Sleep-Wake Cycle
56
Sleep wake cycle in circadian sleep phase
disorders
CLOCK TIME
12
14
16
18
20
22
24
02
04
06
08
10
12
Advanced sleep phase syndrome
Typical sleep phase
Delayed sleep phase syndrome
57
  • Delayed Sleep Phase Syndrome (DSPS)
  • - onset is often during adolescence
  • - poor school or job performance
  • - may report a history of prolonged
    sedative-hypnotic use, bedtime use of alcohol,
    behavioral interventions, psychotherapy,
    depression, personality disorders
  • Advanced Sleep Phase Syndrome (ASPS)
  • - mostly older than 50 years
  • - genetic studies

58
Management
  • Chronotherapy
  • Successive advancement or delay of sleep times
    by 3h daily over a 5-6 day period until the
    desired sleep time is achieved
  • Light therapy
  • Melatonin
  • Physical exercise

59
Light Therapy
  • Light at sunset (dusk)/ light at the end of the
    day
  • - clock slows down
  • - phase delay
  • Light at sunrise (dawn)/ light at the beginning
    of the day
  • - clock speeds up
  • - phase advance

60
Behavioral Parasomnias
61
  • Wake-to-sleep transition disorders
  • - Intensified Sleep Starts (Hypnic Jerks)
  • - Rhythmic Movement Disorder (Jactatio Capitis
    Nocturna)

NREM sleep disorders (SWS arousal disorders) -
Sleep Walking (Somnambulism) - Sleep Terrors
REM sleep disorders - Nightmares (Terrifying
Dreams ) - REM sleep behavior disorder (RBD)
Light sleep stage (stage 1,2) disorders - Sleep
Talking - Bruxism
62
Intensified Sleep Starts (Hypnic Jerks)
  • Otherwise normal physiological event, often
    self-limiting
  • Principally involve legs
  • Usually are brief muscle jerks at sleep onset
  • The intensity of the contraction may cause an
    abrupt expiratory cry
  • Sometimes related to intake of stimulants
    (caffeine, nicotine, intense evening exercise,
    stress)
  • Tx avoidance of precipitating factors or
    irregular sleep schedule

63
Rhythmic Movement Disorder (Jactatio Capitis
Nocturna)
  • Repetitive stereotyped movements involving large
    body areas (head banging, body rocking)
  • Typically just before sleep onset
  • Common in infants and young children who are
    otherwise normal
  • Male predominance
  • Self limiting, disappears before late childhood
  • Parents need to be reassured restraining is
    generally ineffective, padding in bed area or
    protective helmet may be useful

64
Sleep Walking (Somnambulism)
  • Without awakening, exhibit complex automatic
    behaviors
  • Child crawling into parents bed, adult trying to
    prepare meals,mumbling even comprehensible
    speech,rarely, eating or aggression
  • Communication with them is difficult or
    impossible
  • Typically 1-5 min duration
  • Commonly in children aged 4-6 years, in adults
    with strong family history
  • Parents need to be reassured, frequently
    disappears during adolescence, avoidance of
    precipitating factors, minimize injury,
    clonazepam, TCA

65
(No Transcript)
66
REM Sleep Behavior Disorder (RBD)
  • Explosive, violent movements that appear to be
    dream enactment with markedly increased muscle
    tone during REM sleep
  • May reappear in cyclic fashion (every 90 min)
  • Injury to self or bed partner is common
  • Violent nocturnal behavior is typically
    discordant with dreamers daytime personality
  • Elderly with history of dementia, SAH, Parkinson
    disease, MS, chronic alcoholism, idiopathic (60
    )
  • Treatment is with medication clonazepam

67
Stage REM
EOG 1
EOG 2
EEG
EEG
EMG
ECG
  • EEG Low voltage, mixed frequency, Sawtooth
    waves, theta (3-7cps)
    activity
  • EOG Phasic rapid eye movements
  • Submental EMG lowest tonic activity, phasic
    twiches

68
REM behavior sleep disorder in a 64-year old
man
Write a Comment
User Comments (0)
About PowerShow.com