睡眠醫學的最新進展

1. 睡眠醫學的最新進展 新光醫院胸腔內科 美國史丹佛大學睡眠研究中心 林嘉謨醫師

2. 演講內容大綱 • 介紹 • 睡眠呼吸問題 • 睡眠呼吸問題與疾病的關係 • 兒童睡眠呼吸問題 • 猝睡症 • 肢動症 • 失眠症的行為治療 • 討論

3. 白天嗜睡的主要原因 • 睡眠的質或量不夠如睡眠時間不足或間斷性的睡眠(睡眠呼吸中止症或身心症) • 中枢神經病変 • 生理時鐘與環境的互動失調 • 藥物的影響

4. 正常睡眠的階段 • 非快速動眼期(Non-REM)睡眠--較規則的呼吸,較理性化的夢境, stage 1,2,3,4. ( stage 3+4=slow wave sleep, SWS) • 快速動眼期(REM)睡眠--較不規則的呼吸,較情緒化的夢境,呼吸驅動力較弱,較易缺氧 • 一個典型夜晚的睡眠是以70-90分鐘的非快速動眼期睡眠開始,然後進入約十分鐘的快速動眼期睡眠,如此重複循環整個夜晚

5. 阻塞性睡眠呼吸中止

6. 睡眠呼吸中止症之上呼吸道特徵 • 鼻腔阻塞 • 扁桃腺(tonsil), 咽扁桃腺(nasal adenoid)肥大 • 咽顎帆區(velopharyngeal space)淺而狹窄 • 舌頭肥大(Macroglossia) • 下顎狹小, 後縮(Micro,retro-gnatia) • 上呼吸道感覺神經異常

7. Signs and symptoms suggestive of sleep apnea Atul et al. Lancet 2002; 360:237-45 • Snoring • Witnessed apneas, gasping, or both • Obesity (especially neck circumference) • Hypertension • Excessive daytime sleepiness • Family history • Nocturia • Non-restorative sleep

8. Are Far-East Asian More Prone to have Sleep Apnea?

9. 亞洲人與美洲人睡眠呼吸中止症候群病人的比較亞洲人與美洲人睡眠呼吸中止症候群病人的比較 • 亞洲的睡眠呼吸中止症候群的病人較瘦,沒有像美洲的病人那麼胖 • 亞洲人先天上顱骨底面積較美洲人小,所以亞洲人上呼吸道會比美洲人更小,更容易有睡眠呼吸問題

10. 行為治療 • 維持理想體重 • 側睡 • 避免睡前鎮靜藥物 • 避免睡眠不足 • 避免睡前喝酒 • 床頭搖高(肥胖特別是肚子大的人） • 感冒及過敏一定要治好 • 睡前避免吃太多 • 戒菸

11. Medical Treatment of OSAS • Respiratory Center Stimulants (?) Medroxyprogesterone Acetate Acetazolamide Clomipramine Hydrochloride Theophylline • Neuroactive Drugs (?) Protriptyline Strychnine Modafinil • Oxygen therapy (avoid CO2 retention) • Intranasal steroid or radiofrequency • Tongue Retaining Device (Oral appliant) (only mild OSA, need follow up sleep study) • Nasal CPAP-gold standard of treatment)

12. Surgical Treatment of OSAS • Tracheostomy-100% success rate but…. • Removal of the underlying obstruction---enlarged tonsils, adenoid, thyroid.etc • Tonsillo-adenoidectomy • Palatopharyngoplasty (PPP) • Uvulopalatopharyngoplasty (UPPP) • Laser-assisted Uvulopalatoplasty (LAUP) • Genioglossal advancement • Radiofrequency palatoplasty and tongue base ablation • Mandibular Osteostomy & Hyoid Bone Advancement (Phase II)

13. Radiofrequency Usage in OSAS

14. Child OSAS

15. 猝睡症(Narcolepsy)

16. The Narcolepsy “Tetrad” • Excessive daytime sleepiness (sleep attack) • Cataplexy (sudden loss of muscle tone) • Hypnogogic hallucination (vivid dream-like images just before sleep onset) • Sleep paralysis (muscle paralysis on morning awakening) • Disrupted nocturnal sleep?

17. Periodic Leg Movement

18. Restless Leg Syndrome

19. RLS Epidemiology • 10-15% of the responders (in 2019 subjects) • Similar prevalence among male and female • The mean age of onset was found to between 27.2 and 41.0 years • Two large survey found that 38.3 and 45% of RLS patients, respectively, experienced their first symptoms before the age of 20

20. Periodic Legs Movements Definition • Originally called “nocturnal myoclonus”, PLMS is best described as rhythmical extensions of the big toe and dorsiflexions of the ankle with occasional flexions of the knee and hip, each movement lasting approximately 0.5 to 5.0 sec with a frequency of about one every 20 to 40 sec • The prevalence of PLMS is correlate with age, rarely diagnosed in <30 years p’t, 5% 30-50 years, 29% >50 years, 44% >65 years. • A PLMS index (number of the PLMS per hour of sleep) >5 for the entire night of sleep is considered pathological.

21. Secondary RLS due to Underlying Conditions • Iron-deficiency anemia • Uremia (20-40% of dialysis patients) • Pregnancy (up to 27%) • Fibromyalgia and rheumatoid arthritis (30%) • Diabetes & parkinson’s disease • Neurological lesions • both spinal cord and peripheral nerve lesions • Drug-induced (include withdrawal) • tricyclics, SSRI’s, lithium, dopamine • blockers (e.g., neuroleptics), xanthines, beta-blockers, caffeine, alcohol, and histamine blockers

22. Insomnia Defined • Insomnia is characterized by any of the following: • Difficulty falling asleep • Difficulty staying asleep • Early morning awakening • Feeling unrefreshed in the morning

23. Insomnia Epidemiology • Approximately 35% adults population is afflicted with insomnia during the course of a year. • 9-12 % of the population occur on a regular basis (chronic insomnia) • Both the incidence and the complaint of insomnia increase across the life cycles

24. Complications of Insomnia • Insomnia is a frequent symptom of psychiatric disorders and is often a risk factor for future psychiatric illness -Depression -Anxiety -Alcohol abuse -Drug abuse

25. Diagnosing Insomnia • Complete sleep history • Medical and psychiatric assessment --substance use • Alcohol, caffeine, and concomitant medication • Prescription and / or OTC medication • Drugs • Sleep diary • Polysomnography

26. Non-pharmacological Insomnia Treatment/Cognitive Behavioral Therapy (CBT) Outcome • Reduce sleep latency • Decrease frequency and duration of arousal • Increase sleep quality • Decrease sleep-related anxiety • Improve daytime function and mood

27. Procedure of CBT • Comprehensive evaluation • Overnight sleep study • Individual of group format • Weekly session (6-8 weeks) • Daily sleep logs • Multiple component approach • Concomitant drugs treatment

28. Indications of CBT • Persistent difficulty falling asleep • Psychogenic insomnia • Inadequet sleep hygiene • Circadian rhythm disorder • Long term sleep medication treatment failure • Secondary or residual insomnia complaints

29. Discussion