Sleep Disorders Part II - Hypersomnia Amr A. Jamal, MBBS Family Medicine Senior Resident Department...
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Transcript of Sleep Disorders Part II - Hypersomnia Amr A. Jamal, MBBS Family Medicine Senior Resident Department...
Sleep DisordersPart II - Hypersomnia
Amr A. Jamal, MBBSFamily Medicine Senior ResidentDepartment of Family and Community Medicine King Abdulaziz Medical City Riyadh, Saudi Arabia
Differential DiagnosisHypersomniaIntrinsic Causes
Narcolepsy
Recurrent Hypersomnia Syndrome
Menstrual-related Hypersomnia
Idiopathic Hypersomnia
Post-traumatic Hypersomnia
Sleep apnea syndromes
PLMS
Extrinsic Causes
Circadian Rhythm Disorders
Medical Disorders
Psychiatric Disorders
Medication Related
Obstructive Sleep Apnea
Key points
The most common respiratory condition Prevalence:
2% of middle aged men 1% of middle aged women
Cardinal symptoms: Snoring excessive daytime sleepiness Witnessed apneas
Major risk factor for RTA Risk factor for HTN It is Treatable
Knowledge and attitude of primary health care physicians towards OSA in Riyadh
40% felt that sleep disorders are common medical problems based on their practice
Recognition of consequences of OSA motor vehicle accidents (63%) ischemic heart disease (40%) hypertension (50%) pulmonary hypertension (13%)
What is it?
Apneas may be • “central”, in which there is cessation of
inspiratory effort• “obstructive”, in which inspiratory efforts
continue but are ineffective because of upper airway obstruction.
What is it?
obstruction occurs at the pharyngeal level due to the dilator muscles relaxing
Obeseity micro- or retrognathia
pharyngeal obstruction leads to: Asphyxia drop in arterial oxygen saturations rise in PaCO2 levels intrathoracic pressure swings as inappropriate
What is it?
arousal sufficient to increase the pharyngeal tone and re-opens the airway sudden inflow of air rise in oxygen saturations
This cycle then often repeats almost immediately leading to fragmented and unrefreshing sleep difficulty concentrating at work or while driving
What is it?
repetitive narrowing and closure of the pharynx during sleep
sleep fragmentation and repeated oxygen desaturationsExcessive somnolence Impaired alertness Poor cognition.
Who gets it?
More in menSnoresOverweightGenetic acquired
Prevalence
2-3% of Children4-7 % of Middle Aged Adults10-15% > 65 years
The prevalence is likely to rise as obesity rates continue to increase.
Risk factors
Being a middle aged man
overweight
snoring
collar size >43 cm
craniofacial abnormalities
minor risk factors
Large tonsils
Hypothyroidism
Neuromuscular disease
neuron disease
Rare causes
Mucopolysaccharidoses
Acromegaly
Cushing's syndrome
Marfan's syndrome
Down's syndrome.
Snoring
Snoring is common and may be a serious medical problem.
The family doctor and his team should be aware of the condition, using simple screening test such as ESS, improves the patient care, and finding of suspected cases.
How is my sleep?Epworth Sleepiness Scale
Never High Chance1. Sitting and Reading
0 1 2 32. Watching T.V.
0 1 2 33. Sitting, inactive in a public place (e.g. Theatre or a Meeting)
0 1 2 34. As a passenger in a car for an hour without a break
0 1 2 35. Lying down to rest in the afternoon when circumstances permit
0 1 2 36. Sitting and talking to someone
0 1 2 37. Sitting quietly after a lunch without alcohol
0 1 2 38. In a car, while stopped for a few minutes in the traffic
0 1 2 3
A total score of 10 or more
suggests that you may need
further evaluation by a physician to
determine the cause of your
excessive daytime
sleepiness and whether you have
an underlying sleep disorder
Hypoxic Periodic Breathing
http://www.sleepeducation.com
How should I diagnose it?
Excessive sleepiness, measured by the Epworth Sleepiness Score (>9 is abnormal, >15 is severely abnormal)
Loud snoring, witnessed apnoeas, and choking noises
Feeling unrefreshed on waking Poor concentration Mood swings, personality changes, or
depression Nocturia. Less common symptoms are: Nocturnal sweating Reduced libido Oesophageal reflux.
Examination
Neck circumference Oropharynx Teeth Nasal patency Respiratory function Blood pressure Evidence of endocrine
abnormalities Evidence of neuromuscular
disorders Evidence of heart failure
Investigations
Routine haematology and biochemistry
Thyroid function tests Cholesterol, fasting
triglycerides, glucose, and folate
Arterial or capillary blood gas
Sleep studies
Overnight oximetry
Overnight oximetry
Respiratory polysomnography
Limited sleep studies assess some or all of: Snoring Body movements Heart rate Oro-nasal flow Chest and abdominal movements Leg movements.
Full polysomnography
in addition to the above:EEGelectro-oculogram EMG
Proforma for assessing patients who snore
SleepinessDoes the patient feel sleepy?
Major symptomsDoes the patient have one or more of:Witnessed
apneas ?Choking during
sleep ?Obesity
Minor symptomsDoes the patient have two or more of:
Hearing the end of their own
snore ?Having to sleep
sitting up ?Nocturia ?
may need to
be referred
Medical History
Have possible respiratory failureawake hypoxia (SaO2
<94%), ankle oedema
professional driver whose job is at risk.
How should I treat it?
Not all patients with OSA need treatmentDetermine treatment upon:
significant daytime symptoms that warrant intervention
patient's occupation Patient’s desire severity of their condition determined by a
sleep study
A.
B.
C.
D.
E.
A 40 year old man presents with snoring of new onset. Which one of the following statements is correct?
Excessive alcohol intake is not relevant
A neck circumference of >17 inches carries a low risk of obstructive sleep apnoea
Testing thyroid function would not be useful
You should consider carrying out an Epworth Sleepiness Score
You should refer the patient to a sleep specialist for a full polysomnography
A.
B.
C.
D.
E.
Which one of the following statements about obstructive sleep apnoea is correct?
Tracheostomy is not beneficial
Vivid disturbing dreams are a prominent feature of this disorder
The problem is caused by absent or reduced ventilatory drive due to an abnormality in the brainstem
Rare causes of obstructive sleep apnoea include acromegaly
It is a rare disorder that usually affects women
A.
B.
C.
D.
E.
Which one of the following statements is correct about investigating patients with obstructive sleep apnea?
Referral to an ENT surgeon is essential
An arterial blood gas often shows daytime hypercapnia
Overnight oximetry is all that is required to diagnose obstructive sleep apnoea
A fasting glucose level and cholesterol level may be helpful
Full lung function tests are always needed
QUESTIONS?
A.
B.
C.
D.
E.
Which one of the following statements about mandibular advancement splints is correct?
They are safe if the patient has poorly controlled epilepsy
They are useful for treating snoring
They are available only from sleep clinics
They are effective at controlling severe obstructive sleep apnoea