Clinical evaluation of patients with sleep disordered breathing By

1. Clinical evaluation of patients with sleep disordered breathing By Ahmad Younis Professor of Thoracic Medicine Mansoura Faculty of Medicine

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

3. 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

4. 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.

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

6. 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 .

7. 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

8. 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

9. Berlin Questionnaire (Screening test for OSA ) 1-High risk was defined as persistent symptoms (>3 times/wk) in two or more questions about their snoring. 2-High risk was defined as persistent (>3 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.

10. 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).

11. 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

12. 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

13. 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.

14. 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 (

15. 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.

17. 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.

18. Nocturnal choking • SAHS • GERD • Vocal cord adduction • Panic attacks

19. 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.

20. 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.

21. 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.

22. 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

23. Social history • Shift work • Cross time zones frequently through travel • Bedroom environment • Pet animal

24. Family history • Snoring • OSAS • Narcolepsy • RLS • Bed partner have a sleep problem which disturb the patient

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

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

27. Chronic tonsillar enlargement

28. 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 .

29. 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 you’re 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 body’s clock running smoothly.

30. Rules: 6-Sleep a full night on a regular basisGet 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

31. 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.  

32. 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.

33. 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 <10 hours.

34. 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 .

35. 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