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Sleep Apnea:. C Tyler. Sleep Apnea. Kaiser SF Sleep Lab a.k.a. ‘ apnea clinic ’ Part 1 C Tyler, Sep 2016 Medical Director Kaiser, San Francisco. OSA. What are we going to cover?. Brief History of Sleep Neuroanatomy Neuro transmitters
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Sleep Apnea: • C Tyler
Sleep Apnea Kaiser SF Sleep Lab a.k.a. ‘apnea clinic’ Part 1 C Tyler, Sep 2016 Medical Director Kaiser, San Francisco
What are we going to cover? • Brief History of Sleep • Neuroanatomy • Neuro transmitters • Importance of Consolidated Sleep – conversely the importance of staying awake… • The History of Sleep Apnea • Physiology of Sleep Apnea • Modern Definitions (criteria) of Sleep Apnea • Risk Factors • Prevalence • Diagnosis • Treatment • …a quiz
We sleep so we can be awake:Excess Daytime Sleepiness (EDS) • Exxon Valdez • Three Mile Island and Chernobyl • Union Carbide at Bhopal • 100,000 MVAs annually due to driver drowsiness or fatigue • $3,000,000,000 / year • Libby Zion 1965-1984 • Phenylzine (Nardil) MAO-I + Meperidine + Haldol -> Seratonin Syndrome • International Classification of Sleep Disorders (ICSD) • 88 sleep-related disorders
Sleep in other Species • Humans: 8 h • Duck 10.8 h • Horse: 2.9 h • Dolphins: Put half a brain to sleep at a time • Fruit Flies: • Herbivors need time to forage • Predators eat huge meals • Birds don’t go limp during REM sleep • Flamingos sleep on one foot, bats hang upside-down
History of Sleep Medicine • 1875 Electrical activity in brains of animals – Caton • 1880 Narcolepsy described – Gelineau • 1929 ‘Electroencephalogram of man’ – Berger • 1937 NREM described - Loomis • 1951 REM Sleep described – Kleitman • 1960 Sleep-onset REM in narcoleptics – Vogel • 1964 First Narcolepsy Clinic (Stanford) • 1972 Destruction of SCN eliminates circadian rhythms • 2007 RLS in 6% of population but 34% in iron deficient patients • 1989 Sleep deprivation results in death of rats - Rechtschaffen et al. • 1989 First Fellowship Training Programs • 1991 American Board of Sleep Medicine
Deep Brain Structures and Sleep • 1920s: • Diabetes Insipidus caused by Hypothalamic lesions • (sleepiness coincided)
The Isolated Forebrain:Frederick Bremer 1892-1982cerveau isolé • complete midbrain transection • EEG slow waves and spindles • structures below midbrain facilitate wake-state • Hypothesis: ‘wake’ d/t spinal sensory stimuli • mid-pontine transection (lower) ‘cerveauencephali’ • activated / wakelike forebrain EEG • structures between midpons and upper midbrain generating a wake state
What is Sleep? • complex reversible state characterized by: • behavioral quiescence • diminished responsiveness to external stimuli • maintained by • CNS networks • Specific neurotransmitters
The Earth’s spin rate is slowing down • The earth spins once every 24 hr w.r.t. the Sun • …every 23h, 56min, 4 sec w.r.t. the Stars • Today is 1.7 milliseconds longer • than this day one century ago • Requires a‘Leap Second’ every 2 years or so
Biological Clocks: • What for? • Why not just stay awake permanently?
Theories of sleep • Restorative and somatic growth theory • Facilitation of anabolic processes • Metabolic theory • energy conservation • Survival theory • protective and adaptive behavior • Neural growth and processing • neuronal synaptic plasticity • brain development • restoration, learning, and memory consolidation • Evolutionary Specialization to unique environmental circumstances
Why do we Sleep? • Brain recuperation: • Adaptation to special circumstances: • Activity of pray and predators • Non-competitive adaptation • Energy Conservation: • Hibernation • Adaptation to habitat: • Light/Dark • Hot/Cold
Neural Control of Sleep Wake, NREM sleep, and REM sleep • generated/maintained by different neurons, networks, neurotransmitters • Primary Sleep and Wake Neurotransmitters • Glutamate: Primary excitatory neurotrans • ACh: main REM neurotrans • GABA: main NREM neurotransmitter • Wake Neurotransmitters • Glutamate PRINCIPAL (ARAS, RHT) • acetylcholine basal forebrain, PPT/LDT • dopamine subst nigra, BrStm, vntrl tgmnt • histamine tuberomammillary nucleus • hypocretin (orexin) lat hypothal prefornical • norepinephrine locus ceruleus • serotonin Raphe nuc, thalamus • Sleep Neurotransmitters • GABA, gamma-amino-butyric acid prinicple NREM VLPO, Thal, Hypothal, basal forebrain, cortex • acetylcholine principle REM sleep transmitter • adenosine (homeostatic generator) basal forebrain • Glycine: spinal cord (inhib motor)
The seductive call of sleep: • More powerful than hunger • More powerful than sex • More powerful than money