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Sleep Related Breathing Disorders
Elisabeth Brandauer, MD Department of Neurology, Innsbruck Medical University, Austria
Movement Disorders in SleepBarcelona, Jan 30-31
Abnormalities of respiration during sleep
Possible location of respiratorydisturbances :
• Central respiratory drive• Oropharyngeal muscles• Respiratory muscles• Ventilation
Possible consequences:
• Snoring• Apneas, Hypopneas• Hypoxemia• Hypercapnia
Apnea: drop in the peak thermal sensor excursion by >90% of baseline, duration at least 10 sec.
– obstructive apnea– central apnea– mixed apnea
Definitions
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Hypopnea:• The nasal pressure signal excursion drop by >30% of baseline, duration at least
10 sec.• There is a >3% oxygen desaturation from pre-event baseline or the event is
associated with arousal
Oxygen desaturation index(ODI):� number of desaturation per
hour of sleep
Apnea-hypopnea index (AHI):� Number of apneas and
hypopneas per hour of sleep
Classification
Obstructive Sleep ApneaDisorders
• Obstructive Sleep Apnea, Adult• Obstructive Sleep Apnea, Pediatric
Central Sleep Apnea Syndromes• Central Sleep Apnea with Cheyne-Stokes
Breathing• Central Apnea Due to a Medical Disorder
without Cheyne-Stokes Breathing• Central Sleep Apnea Due to High Altitude
Periodic Breathing• Central Sleep Apnea Due to a Medication
or Substance• Primary Central Sleep Apnea• Primary Central Sleep Apnea of Infancy• Primary Central Sleep Apnea of
Prematurity• Treatment-Emergent Central Sleep Apnea
Sleep Related Hypoventilation Disorders
• Obesity Hypoventilation Syndrome • Congenital Central Alveolar Hypoventilation
Syndrome • Late-Onset Central Hypoventilation with
Hypothalamic Dysfunction• Idiopathic Central Alveolar Hypoventilation• Sleep Related Hypoventilation Due to a
Medication or Substance• Sleep Related Hypoventilation Due to a
Medical Disorder
Sleep Related HypoxemiaDisorder
• Sleep Related Hypoxemia
Isolated Symptoms and Normal Variants
• Snoring• Catathrenia
Obstructive Sleep Apnea
�A. The presence of one or more of the following:
�The patient complains of sleepiness, nonrestorative sleep, fatigue, or insomniasymptoms�The patient wakes with breath holding, gasping or choking.�The bed partner or other observers reports habitual snoring, breathinginterruptions, or both during the patients sleep.�The patient has been diagnosed with hypertension, a mood disorder, cognitivedysfunction, coronary artery disease, stroke, congestive heart failure, atrialfibrillation, or type 2 diabetes mellitus
• (A and B) or C satisfy the criteria
�B. Polysomnography (PSG) or OCST (out-of-center sleep testing) demonstrates:
�Five or more predominantly obstructive respiratory events (obstructive and mixedapneas, hypopneas, or respiratory effort related arousals (RERAs) per hour of sleepduring PSG or per hour of monitoring in OCST
�C. PSG or OCST demonstrates:. The presence of one or more of the following:
�Fifteen or more predominantly obstructive respiratory events per hour of sleep duringa PSG or per hour of monitoring
International Classification of Sleep Disorders 3rd
American Academy of Sleep Medicine, 2014
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Predisposing Factors: � Obesity
� Male>female� Prevalence increases with age with a plateau reached app. at age 65
� Alcohol consumption and sedating medication� menopause
� Endocrine disorders (hypothyroidism, acromegaly)
� Maxillomandibular malformation, adenotonsillar enlargement� First degree relatives of OSA patients are twice as likely to have OSA
Demographics:� 9% of females and 24% of males between 30-60 years with criterion
AHI>5/h;
2% of females and 4% of males using the criterion AHI>5/h plus exzessive daytime sleepiness (Young et al. 1993)
� 3-7% of adult males, 2-5% of adult females (Punjabi 2008)
International Classification of Sleep Disorders 3rd
American Academy of Sleep Medicine, 2014
Pathophysiology:
� Reduced cross sectional area of the upper airway lumen due toexcessive bulk of soft tissues or craniofacial anatomy
� During inspiration negative pressure is generated in the lumen of theupper airway
� Activity of pharyngeal dilating muscles becomes insufficient in OSA
� Further reduction of activity in these muscles in REM sleep
� Event termination may occur with or without arousal:
� Some events resolve with augmentation of muscle tone fromchemical and mechanical stimuli
� Others resolve with arousals
Graduation: � Mild OSA: AHI > 5/h� Moderate OSA: AHI 15-30/h� Severe OSA: AHI > 30/h
International Classification of Sleep Disorders 3rd
American Academy of Sleep Medicine, 2014
� Clinical history
� Scales (e.g. Epworth Sleepiness Scale)
� OCST (out of center sleep testing)
� Polysomnography
� Testing daytime symptoms� Neuropsychological testing systems� Multiple Sleep Latency Test
Diagnostic steps
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OCST
Polysomnography
� Excessive daytime sleepiness, reduction in quality of life
� Risk of accidents sixfold higher (Teran-Santos et al. 1999)
� Cognitive impairment, depression
� Cardiovascular risks: systemic hypertension („non dipping“),coronary artery disease, congestive heart failure, stroke, cardiac arrhythmias,
� Hints on elevated levels of circulating inflammatorymediators related to repetitive episodes of oxygendesaturation and increased sympathetic nervous systemactivity
Complications
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� Weight reduction, prevention of alcohol andsedative medication
� Prevention of back position
� Positive airway pressure therapy
� Mandibular advancement devices
� Surgery (UVPP, surgery of tongue, tonsillectomy, hypoglossal nerve stimulation)
Therapy
� CPAP (continous positve airway pressure)� APAP (automatically adjusting positive
airway pressure)
Positive airway pressure therapy
Effect of CPAP therapy
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Central Sleep Apnea Syndromes
� Central Sleep Apnea with Cheyne-Stokes Breathing
� Central Apnea Due to a Medical Disorder withoutCheyne-Stokes Breathing
� Central Sleep Apnea Due to High Altitude PeriodicBreathing
� Central Sleep Apnea Due to a Medication orSubstance
� Primary Central Sleep Apnea
� Primary Central Sleep Apnea of Infancy
� Primary Central Sleep Apnea of Prematurity
� Treatment-Emergent Central Sleep Apnea
International Classification of Sleep Disorders 3rd
American Academy of Sleep Medicine, 2014
Common features
– AHI > 5/h– Number of central apneas/hypopneas > 50%
Abb: central apneas, Polysomnography
Central Sleep Apnea with Cheyne-Stokes breathing
– Presence of atrial fibrillation/flutter, congestiveheart failure or a neurological disorder
– Therapy: adaptive Servo-ventilation
Central Sleep Apnea Syndromes
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Central Sleep Apnea Syndromes
Due to medication orsubstances:� e.g opioids
Primary Central Sleep Apnea� rare� Arterial pCO2 drops below the hypocapnic apnea treshold� Frequent arousals from sleep predispose to central apneas
Treatment Emergent Central Sleep Apnea� Central apneas due to CPAP
treatment
Sleep Related Hypoventilation Disorders
� Obesity Hypoventilation Syndrome � Congenital Central Alveolar Hypoventilation Syndrome
� Late-Onset Central Hypoventilation with Hypothalamic Dysfunction
� Idiopathic Central Alveolar Hypoventilation
� Sleep Related Hypoventilation Due to a Medication or Substance� Sleep Related Hypoventilation Due to a Medical Disorder
Common features:� Insufficient sleep related ventilation, resulting in abnormally
elevated PaCO2
� Oxygen desaturation may be present, not necessarily
� Scoring Hypoventilation: rise of pCO2 > 55mmHg for> 10min orrise of pCO2 during sleep> 10mmHg and pCO2>50mmHg for>10min
International Classification of Sleep Disorders 3rd
American Academy of Sleep Medicine, 2014
Sleep Related Hypoventilation Disorders
Obesity Hypoventilation Syndrome
� Presence of hypoventilation during wakefulness(PaCO2>45mmHg)
� Obesity (BMI>30kg/m2)
� Hypoventilation is not primarily due to other disease
� OSA is often present (80-90%)
� Symptoms like in OSA, hypersomnolence is common
� Therapy: CPAP, adaptive Servoventilation
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Congenital Central Alveolar Hypoventilation (Ondine´s curse)
� Sleep related hypoventilation
� Mutation of gene PHOX2B
� Some central apneas may occur, but the predominant pattern isreduced flow/tidal volume
� Some patients may present phenotypically later in life
Sleep Related Hypoventilation Disorders
Sleep Related Hypoventilation due to a Medical Disorder
� Lung parenchymal or airway disease, pulmonary vascularpathology, chest wall disorder, neurologic disorder, muscleweakness
� Usually most severe in REM sleep
Sleep Related Hypoventilation Disorders
Sleep Apnea in Movement Disorders
� Parkinson´s Disease
� Multiple System Atrophy� Occurence of OSA, central sleep apnea, irregular and apneustic
breathing, Cheyne Stokes breathing pattern, stridor
� Due to damaged brainstem structures controlling respiration
� OSA occurs more frequently than central sleep apnea
Caig and Iranzo, 2012
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Sleep Apnea in Parkinsons disease
• Controversial results on prevalence of SDB in PD
n Manifest or subclinical sleep breathing disorders in 50% of PD patients, but
sleep structure not normalized with nCPAP treatment (Schäfer 2001)
• Moderate or severe obstructive sleep apnea syndromes in 20%(Arnulf 2002)
• 43 % sleep apnea syndrome, mostly mild or moderate with little oxygendesaturations (Diederich 2005)
• Significant correlation of heavy snoring and ESS in PD and controls• (Högl et al 2003, Braga Neto 2006)
• Sleep apnea in PD less frequent than in sick in hospital controls (Arnulf 2009)
Sleep Apnea in Parkinsons disease
• Pathophysiology: Upper airway obstruction present in 24-65% of PD
patients, thought to be related to hypokinesia and rigidity involving
the upper airway (Sabate 1996, Shill 2002)
• PD patients might be protected from OSA due to lower body weight
and muscle atonia during REM sleep
• Review of da Silva-Junior 2014: neither obstructive nor central
disordered breathing events were more frequent in PD patients
Sleep Apnea in Parkinsons disease
• Excessive daytime sleepiness does not correlate with AHI in
PD patients (da Silva-Junior 2014, review)
• SDB in PD does not seem to be a disease related process,
more an aging related conditon (da Silva-Junior 2014, review)
• CPAP treatment should be done when necessary, and it is
effective (Neikrug 2014)