Clinical evaluation of patients with sleep disordered breathing By

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Clinical evaluation of patients with sleep
disordered breathing By

• Ahmad Younis
• Professor of Thoracic Medicine
• Mansoura Faculty of Medicine

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Sleep disordered breathing

• Abnormal breathing pattern apnea hypopnea ,RERA,
  hypo-ventilation
• It lead to
• 1-daytime symptoms and signs
• 2-organ system dysfunction.

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It is difficult to take a history of a sleep
disorder than to inquire about a complaint that
occurs during wake-fullness

• The patient often has a little or no awareness
  of the problem and it is important to obtain the
  bed partner view of the events during sleep and
  during wake-fullness

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The aims are 1- establish whether or not there
is a sleep disorder.

• 2- Assess the relative contribution of
  psychological ,medical and social factors to the
  complaint.

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• Sleep complaints
• 1-Excessive sleepiness
• Sleep disordered breathing
• Narcolepsy
• Idiopathic hypersomnia
• Psychatric disorders
• 2-Insomnia
• 3-Circadian rhythm disorders
• 4- Parasomnia

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Sleep disordered breathing

• Symptoms habitual loud snoring ,EDS ,nocturnal
  choking ,witnessed apnea, morning headaches
  ,un-refreshed sleep.
• Risk factors BMI ,waist and neck circumference
  ,hypothyroidism ,CHF. COPD. stroke.
• Consequences motor vehicle or work accidents
  related to EDS. type 2 DM, HTN,IHD, CVA .

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• Events during sleep wake during sleep, why( pain
  ,anxiety ,nightmares ,choking, heartburn
  ,nocturia, nocturnal wheeze ) ,how long is it
  before sleep is re-entered. Awareness of any
  mental or physical activities , sleep paralysis.
• Events during awakening is sleep refreshing
  ,frontal headache ,level of alertness ,accident
  related to somnolence, naps if refreshing
  ,hallucination ,cataplexy, unpleasant sensation
  in legs relieved by movement

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Sleepiness can be defined as a high physiologic
drive toward sleep

• Excessive daytime sleepiness, defined as
  sleepiness that interferes with daytime
  activities, productivity, or enjoyment, is
  usually abnormal and may reflect insufficient
  sleep, disrupted sleep, or a primary sleep
  disorder .
• Sleepiness following sleep restriction or
  extended wakefulness does not always require
  detailed assessment when the underlying cause is
  identifiable and self-limited.
• Sleepiness that interferes with everyday
  activities or occurs at inappropriate times is
  almost always abnormal, particularly if the
  somnolence is chronic, recurrent, or severe

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• Berlin Questionnaire (Screening test for OSA )
• 1-High risk was defined as persistent symptoms
  (gt3 times/wk) in two or more questions about
  their snoring.
• 2-High risk was defined as persistent (gt3
  times/wk) wake-time sleepiness, drowsy driving,
  or both.
• 3-High risk was defined as a history of high
  blood pressure or a body mass index more than 30
  kg/m2.
• To be considered at high risk for sleep apnea, a
  patient had to qualify for at least two symptom
  categories.

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• Somnolent individuals may complain of
• fatigue, tiredness, lack of energy, inattention,
  impaired concentration, or emotional lability.
• Severely somnolent individuals often appear
  visibly sleepy and in extreme cases stuporous or
  encephalopathic.
• Visible signs of sleepiness on examination may
  include
• drooping of the eyelids, pupillary miosis,
  nodding of the head, or intermittent loss of
  postural tone.
• True hypersomnia (sleep for abnormal long
  duration each 24 h cycle) must be differentiated
  from hypersomnolence (sensation of sleepiness).

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The history alone often allows accurate
assessment of whether a patient's sleepiness is
likely to be the result of sleep derivation
which include insufficient sleep and disrupted
sleep (e.g., secondary to obstructive sleep
apnea, percentages of sleep stages) or a central
nervous system disorder such as narcolepsy.

• Patients with excessive sleepiness commonly
  exhibit identifiable symptoms that help identify
  specific underlying causes. Such symptoms include
  snoring or observed apnea during nighttime sleep,
  restlessness or jerking of the legs, hypnagogic
  or hypnopompic hallucinations, sleep paralysis,
  automatic behavior, cataplexy, and other
  constitutional symptoms

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• Epworth sleepiness scale
• The chance to doze off or fall asleep in the
  following situation
• 1-sitting and reading
• 2- watching TV
• 3- sitting inactive in public place
• 4-as a passenger in a car for an hour without a
  break
• 5-lying down to rest in the afternoon when
  circumstances permit
• 6-sitting and talking to someone
• 7- sitting quietly after a lunch without
  alcohol. 8- in a car while stopped for few
  minutes in traffic

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• Stanford sleepiness scale
• Describe the patients current state of alertness
• It is limited in usefullness due to lack of
  reference values
• It is more sensitive to sleep deprivation than
  ESS
• Visual analog scale
• Most simple
• Designate degree of alertness sleepiness on a
  10-cm scale.

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Severity of daytime sleepiness

• Mild infrequent, at times of day when sleep
  should be expected (2-4pm or late in the evening
  or at rest or in passive environment)
• Severe frequent, at any time of the day ,occur
  despite stimulating circumstances (while talking
  ,eating ,walking (

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Cyclical sleepiness

• Weekly catch up their sleep debt at week end due
  to intermittent sleep deprivation.
• Monthly premenstrual sleepiness
• Elimination of sleepiness when sufficient sleep
  is allowed as in holidays suggest that sleep
  deprivation rather than a primary sleep disorder
  is the cause.

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Snoring and Other Obstructive Symptoms during
Sleep

• Loud snoring is a cardinal symptom of OSA and
  upper airway resistance syndrome and may be
  accompanied by mouth breathing, unusual body
  positions, or visible restlessness during sleep.
• Respiratory pauses are sometimes witnessed by bed
  partners or family members, sometimes terminating
  with a snort or gasp when breathing resumes. Such
  symptoms are most informative when present
• conversely, the absence of observed apnea and
  even snoring does not rule out the possibility of
  an obstructive SRBD.

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Nocturnal choking

• SAHS
• GERD
• Vocal cord adduction
• Panic attacks

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Hypnagogic or Hypnopompic Hallucinations

• Hypnagogic (at sleep onset) and hypnopompic (at
  waking) hallucinations are brief, dreamlike
  episodes that last seconds to minutes.
  Hallucinations are often vivid and distressing
  despite their brevity.
• Although these hallucinatory episodes are often
  reported by patients with narcolepsy, they have
  also been reported in association with a variety
  of psychiatric conditions, and as a medication
  side effect.

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Cataplexy

• Cataplexy is characterized by paroxysmal episodes
  of bilateral muscle weakness or paralysis,
  triggered by laughing or emotion. The phenomenon
  reflects muscle atonia, which is normally
  restricted to REM sleep but, in this condition,
  is inappropriately expressed during wakefulness.
• The duration of cataplexy is usually ranging from
  seconds to minutes, but successive attacks
  precipitated by extreme emotional stimuli (status
  cataplecticus) may rarely last as long as 1 hour.
  
• Mild attacks may consist only of a brief
  sensation of weakness without externally visible
  manifestations.
• Severe episodes may be characterized by complete
  paralysis, sparing only respiration, eye
  movements, and sphincters.

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Sleep Paralysis

• Sleep paralysis is a condition in which muscle
  atonia, normally restricted to REM sleep, instead
  occurs at the interface between sleep and
  wakefulness. Sleep paralysis may be total or
  partial and may coincide with hypnagogic
  hallucinations.
• Although episodes typically last for only a few
  minutes, they may be extremely frightening to
  affected patients and accompanied by sensations
  of suffocation.

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Other Constitutional Symptoms and Signs
Associated with Specific Causes of Sleepiness

• Lethargy, weight gain, and unsteady gait may
  accompany somnolence in patients with
  hypothyroidism, who are at increased risk for
  OSA.
• Morning headache or other neurologic complaints
  are nonspecific symptoms sometimes associated
  with sleepiness secondary to structural pathology
  within the central nervous system.
• Hypersomnia can occur in individuals with
  depression, in whom associated symptoms of
  anhedonia, fatigue, or intermittent mania may be
  apparent

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Social history

• Shift work
• Cross time zones frequently through travel
• Bedroom environment
• Pet animal

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Family history

• Snoring
• OSAS
• Narcolepsy
• RLS
• Bed partner have a sleep problem which disturb
  the patient

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• Signs
• 1-BP
• 2-Neck circumference
• 3-Central cyanosis
• 4-Upper airway examination
• 5-Chest and heart examination
• 6-Neurological examination
• 7- Endocrinal examination

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• Modified Mallampati classification
• Categorize the severity of posterior pharyngeal
  narrowing
• It is a weak predector of OSAS

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• Chronic tonsillar enlargement

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• Sleep diary
• The time when you go bed for the night
• Your estimate of approximately when you go to
  Sleep
• Note each time that you wake up during the night
• If you must leave your bed, note the time and
  duration
• Medicines and doses taken.
• Note the time that you wake up in the morning
• Note whether or not you needed an alarm clock to
  awaken you.
• Note every nap that taken during the day, when
  you went to Sleep, and when you awakened
• Make a note of how you felt during times of the
  day. Note if you felt groggy, drowsy, or tired
  and what time .

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• Sleep hygien your personal collection of habits
  that determine the quality of your sleep.
• Rules
• 1-Wait until you are sleepy before going to
  bed If youre not sleepy at your regular
  bedtime, do something relaxing read a book,
  listen to music, or do some other activity that
  relaxes, not stimulates you.  This will relax
  your body and distract your mind to remove your
  worries about sleep.
• 2-Pre-sleep rituals help to initiate relaxation
  each night before bedA warm bath, light snack,
  or a few minutes of reading or listening to music
  can initiate good sleep.  Avoid eating heavy
  meals near bedtime.
• 3-If you're not asleep in 20 minutes, get out of
  bed, leave your bedroom and find something else
  that will relax you enough to help make you
  sleepy.
• 4-Try to keep a regular sleep/wake scheduleWake
  up at the same time each day, even on weekends
  and holidays.
• 5-Keep a regular daily scheduleMaintaining a
  regular schedules for  meals, medications, and
  other activities helps keep your bodys clock
  running smoothly.

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• Rules
• 6-Sleep a full night on a regular basis Get
  enough sleep every day so that you feel
  well-rested.
• 7-If possible, avoid naps If you have to take a
  nap, try to keep it to less than one hour and
  avoid taking a nap after 3 pm.
• 8-Do not read, eat, watch TV, talk on the phone,
  or play board games in bed
• 9-Avoid caffeine after lunch
• 10-Avoid alcohol of any type within six hours of
  your bedtime
• 11-Do not smoke or ingest nicotine within two
  hours of your bedtime
• 12-Exercise regularly but avoid strenuous
  exercise within six hours of your bedtimeRegular
  exercise is good, but do it earlier in the day
• 13-Avoid sleeping pills, or use them cautiously.
• 14-Try to clear your mind of things that make you
  worry

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• Rules
• 16-Maintain a quiet, dark and cool bedroom
  environment
• 17-Every person has his or her own personal
  preference as to the ideal sleep environment. 
  Extremes should be avoided.  If you need noise,
  use white noise or soft music.  If you need
  light, use off-light such as a night light in the
  bathroom or down the hall.  Temperature is highly
  subjective.be comfortable.  

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Idiopathic Hypersomnia with Long Sleep Time

• Idiopathic hypersomnia with long sleep time is
  characterized by pervasive daytime sleepiness
  despite longer-than-average nighttime sleep.
  Prolonged nighttime sleep of 10 or more hours
  with few or no awakenings still leave affected
  patients un-refreshed or confused (sleep
  drunkenness) on waking in the morning
• Daytime naps of these patients tend to be longer
  and less refreshing than those of the patients
  with narcolepsy.

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• Idiopathic Hypersomnia without Long Sleep Time
• Although the severe, pervasive daytime somnolence
  and un-refreshing naps seen in this condition are
  identical to those seen in idiopathic hypersomnia
  with long sleep time, the nighttime sleep period
  is lt10 hours.

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Behaviorally Induced Insufficient Sleep Syndrome

• Excessive daytime sleepiness often results solely
  from habitually insufficient nighttime sleep.
• Review of a sleep diary or sleep history of the
  affected patients usually reveals a chronically
  shortened nighttime sleep period that is either
  less than the patient's pre-morbid baseline or
  less than normal for age.
• Symptoms remit with lengthening of the nighttime
  sleep period ,for example, on weekends .

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Hypersomnia due to Medical Condition

• Neurologic conditions may include stroke, brain
  tumor, encephalitis, head trauma, and Parkinson
  disease.
• Genetic conditions sometimes associated with
  sleepiness most notably include Prader-Willi
  syndrome and myotonic dystrophy.
• Endocrine and toxic metabolic causes include
  hypothyroidism, hypo-adrenalism, hepatic
  encephalopathy, and renal failure.
• Drug-induced and psychiatric causes

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