Sleep and Breathing

1. Sleep and Breathing Davina Lovegrove Senior Scientist & Training Coordinator Respiratory and Sleep Specialists

2. Sleep – Why do we need it? • Restorative function for brain • Learning and memory • Repair of cells and healing • Hormone secretions • Energy conservation

3. How much is enough? • Children and teenagers • average of 10 hours per night • Adults • Average of 8 hours per night Hours of sleep /night 4 5 6 7 8 9 10 11 12

4. Consequences of reduced sleep • Day time tiredness • Reduced reaction times • Mood disturbances • Fatigue & muscle weakness • Headaches • Double vision • Reduced motivation……..

5. Sleep Hygiene What is sleep hygiene? • Sleep quantity • Bedroom / sleep routine • Regular bedtimes • Routine before bed * • Dark environment • No bright lights • No pets in the room • No TV, computers & work in bed • Caffeine intake

6. Sleep Disorders • Sleep Apnoea • Insomnia • Narcolepsy • Periodic Limb Movements • Insufficient sleep syndrome • Post Traumatic Hypersomnia • Obesity Hypoventilation • Respiratory Failure • Night Terrors • REM Behaviour Disorder • Nocturnal Epilepsy

7. Obstructive Sleep Apnoea What is OSA? • repeated obstruction of the upper airway during sleep causing; • reduction in blood oxygen saturation • frequent sleep disturbance Phillips & Naughton, 2004

8. How do we diagnose OSA? • Risk factors • Obesity • Family history • Age • Smoking • Alcohol / sedative use • Questionnaires • Epworth sleepiness scale • Overnight sleep study (PSG)

9. How do we diagnose OSA? Clinical Examination – risk factors

10. What happens when an individual obstructs? Normal Airway

11. What happens when an individual obstructs? Snoring

12. What happens when an individual obstructs? Apnoea

13. Slide courtesy of Dr Darren O’Brien

14. Consequences of OSA • Sleep disruption • Headaches • Hypertension • Heart disease (heart failure, CAD) • Type 2 diabetes / insulin resistance • Increased risk of stroke • Heart arrhythmias • Intellectual deterioration • Frequent urination at night • Personality changes

15. SpO2 BP Airflow Resp. effort

16. Treatment options Lifestyle changes • Weight loss • Drugs, alcohol, smoking • Sleep hygiene Positional therapy Surgery • Tracheostomy • Uvulopalatopharyngoplasty • Gastric, bariatric Sx Oral appliances CPAP/APAP/Bilevel Slide courtesy of Dr Darren O’Brien

17. CPAP • Gold Standard treatment • How it works • Air passes through a mask into your nose and/or mouth then into your throat, where the slight pressure acts as a splint to keep your airway open and prevent apnoeas, hypopnoeas and snoring.

18. CPAP Sullivan et.al., Lancet 1981 First Patient on CPAP, RPAH, 1980. Slide courtesy of Dr Darren O’Brien

19. 10 cm H2O Fixed Pressure CPAP Devices CPAP machines provide a single, fixed pressure through out the night. The intent of CPAP is to splint open the upper airway to prevent obstruction. Fixed pressure throughout the night

20. 4 cm H2O Auto Pressure CPAP Devices Auto pressure devices automatically adjust the pressure in response to changes in the patients airway. Results in lower overall mean pressure. ?increased comfort for patient. Varying pressure throughout the night in response to events Beginning of obstruction

21. Bi-level Devices(NIV) • Bi-level systems deliver two different pressures • a higher pressure on inspiration (IPAP) • a lower pressure on expiration (EPAP) • Acts as a non-invasive VENTILATOR (NIV) Inspiration 10 cm H2O Expiration 4 cm H2O

22. Why do we need bi-level? • Breathing basics…. In order to breath IN our diaphragm and accessory chest muscles must contract to cause expansion of our rib cage and therefore air enters our lungs

23. When do we need bi-level? • When our diaphragm cannot contract due to • Muscle weakness • Greatly increased load on the muscles • Restricted movement

24. Breathing basics – gas exchange • With each breath our lungs transfer • Oxygen (O2) from the air into our blood stream • Carbon dioxide (CO2) from our blood into the air • When we don’t breath adequately • Blood oxygen levels drop (hypoxia) • Blood carbon dioxide levels increase (hypercapnia) O2 O2 CO2 CO2

25. Breathing basics • Not breathing adequately is called HYPOVENTILATION • Hypoventilation hypoxia + hypercapnia • Hypoxia + hypercapnia = respiratory failure = hospital admission

26. How does bi-level help? • Assist and support patient’s own breathing efforts • Rest fatigued respiratory muscles • Improve gas exchange by increasing tidal volume • Prevent nocturnal hypoventilation • Increase nocturnal O2 levels • Reduce nocturnal CO2 levels • Improve daytime blood gases • Stabilise upper airway

27. Case study • Chest wall restriction secondary to Poliomyelitis • Undergoing a split night sleep study • ½ night as a diagnostic study • ½ night as a bi-level study

28. Dx NIV

32. Research • Simonds et al 1995: • Outcomes of patients on home NIV were assessed over 5 years in 180 patients with chronic respiratory failure • NIV very well tolerated in post-polio patients: • 100% (n=30) of patients were still compliant at 5 year follow-up (ie 100% survival at 5 years) • Blood oxygen (O2) and carbon-dioxide (CO2) levels were improved and maintained at 5 years

33. Research • Leger et al. 1994 • NIV improved quality of life • NIV reduced number of days in hospital (from an average of 34 days per year to 7 days per year) • NIV improved sleep quality in 70% of patients • Buyse 2002 • NIV is more beneficial in terms of survival, blood gases, and lung function compared with long term oxygen alone in patients with kyphoscoliosis

34. Why use NIV as treatment? • Improved sleep quality • Improved quality of life • Less hospital admissions • Improved blood gases (CO2 and O2) • Improved lung function