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OVERVIEW OF SLEEP AND SLEEP APNEA

OVERVIEW OF SLEEP AND SLEEP APNEA. David Claman, MD Professor of Medicine Director, UCSF Sleep Disorders Center. SLEEP HYPNOGRAM. SLEEPY FIREFIGHTER?.

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OVERVIEW OF SLEEP AND SLEEP APNEA

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  1. OVERVIEW OF SLEEP AND SLEEP APNEA David Claman, MD Professor of Medicine Director, UCSF Sleep Disorders Center

  2. SLEEP HYPNOGRAM

  3. SLEEPY FIREFIGHTER? • 45 year old firefighter complains of daytime sleepiness; “Doctor: I snore – could I have sleep apnea? I sleep alone so no one can tell me.” • Reports “sleep hours 11 pm – 7 am” • Real schedule is 24 hr at work, then 48 hrs off • At work sleep 2-4 hrs (no reports of apnea) • 1st night after work: 10 pm – 8 am • 2nd nightafter work: 1 am – 5:15 am (up early to drive to work!)

  4. CIRCADIAN RHYTHM DISORDERS • Sunlight is main “Zeitgeber”; meals, exercise, & social activities can also shift sleep rhythms • Internal Clock located in Suprachiasmatic nucleus (SCN) of hypothalamus • Jet lag: light and social stimuli help shift internal biological clock 1-2 hrs / day • Shift work: light and social stimuli are in conflict with work schedule; may lead to poor sleep quality, insomnia and chronic fatigue

  5. JET LAG • Start trip sleep deprived • Dehydration on plane worsened by caffeine and alcohol • Circadian rhythm “out of phase” • Flying West is easier • delay sleep schedule by 1-2 hr/d • Flying East is harder • advance sleep schedule by 0.5-1 hr/d

  6. JET LAG INTERVENTIONS • Avoid sleep deprivation before trip • Consider daytime flight • Avoid important meetings the morning of arrival • Adjust schedule before trip • 1-2 hours per day, for 1-2 days before trip • Avoid alcohol and caffeine • Bright light • In morning when flying east (to advance schedule) • In afternoon/evening when flying west (to delay) • Hypnotic prn (zolpidem or melatonin)

  7. SHIFT WORK DISORDER • Shift Work Disorder (SWD) is characterized by complaints of insomnia, excessive sleepiness and impaired performance that occur when work hours are scheduled during the usual sleep period • 20% of workforce in industrialized countries are shift workers, & 40-80% of night workers report sleep difficulties

  8. SHIFT WORK DISORDER • Most common schedule is to work Mon through Fri nights 11 pm – 7 am, but to sleep during those same hours on Sat / Sun • Since sunlight is strongest stimulus of circadian rhythms, the body’s preferred sleep schedule stays oriented for the hours 11 pm – 7 am

  9. SHIFT WORK DISORDER • Interventions: • Optimal approach is to stay awake at night on non-working days and always sleep on the same schedule • If patient continues to alternate their sleep schedule, try to maximize overlap between weekday and weekday schedules (if 7a-2p weekdays, then 3a-10a weekends) • Avoiding sunlight on drive home at 7 am (using “glacier” sunglasses) may also be helpful

  10. DDx of Insomnia • Psychiatric / psychological • Medical • Drugs (especially caffeine and alcohol) • Psychophysiological insomnia • Somatized tension and anxiety causing insomnia • Poor sleep hygiene • Maladaptive coping mechanisms are common • Circadian rhythm issues

  11. SLEEP HYGIENE • Keep regular bedtime and wake-up time • Keep bedroom quiet, comfortable, & dark • Relaxation technique for 10-30 min before bed • Get regular exercise • Don’t nap • Don’t lie in bed feeling worried, anxious, or frustrated • Don’t lie awake in bed for long periods of time • Don’t use alcohol, caffeine, or nicotine

  12. DEFINITIONS: • Apnea: complete cessation of airflow lasting 10 second or more • Hypopnea: reduced airflow for 10 seconds or more, associated with 4% oxygen desaturation (4% is classical definition) • Apnea-hypopnea index (AHI): average number of apneas & hypopneas per hour of sleep • AHI < 5 is normal • AHI 5-15 is mildly elevated • AHI 15-30 is Moderate • AHI > 30 Severe

  13. CLINICAL PREDICTORS OF OSA • Sleep Heart Health: Clinical predictors of AHI > 15: • Male gender, older age, higher BMI, larger neck girth, snoring & episodes of witnessed apnea • Young T et al. Arch Intern Med 2002 Apr 22;162(8):893-900

  14. Young T et al. Excess weight and sleep-disordered breathing. J Appl Physiol 2005;99(4):1592-9.

  15. Wisconsin OSA prevalence by gender and BMIYoung T. J Appl Physiol 2005;99(4):1592-9

  16. HYPERCAPNIA IN OSA • French Multicenter Study; n=1141 from database • Excluded those with FEV1<80% • Overall prevalence of 11% with PaCO2 >45 • BMI < 30 – prevalence 7.2% • BMI 30-40 – prevalence 9.8% • BMI > 40 – prevalence 23.6% • Laaban J-P et al. Chest 2005;127:710-715

  17. OSA TREATMENT • Weight loss (10% weight loss reduces AHI 25%) • Avoid alcohol and sedatives • Postural training (side sleeping since apnea worse on back) • Nasal patency (treat allergies?) • CPAP (also autoCPAP & Bi-level) • Oral (dental) appliances • ENT surgery: • Tonsillectomy in kids • UPPP in adults 50% success; mandibular surgery 80-90% success • Nasal expiratory resistor (Provent) • Nasal bandaid with microvalve – delivers approx 5 cm pressure

  18. CPAP – Site Non-specific

  19. LONGTERM USE OF CPAPBest compliance if AHI >30 & ESS >10 McArdle N et al. AJRCCM 1999;159:1108-1114

  20. PROFESSIONAL DRIVERS • Hours of Service Rules • 10-11 hr driving limit; 14-15 hr on-duty limit • http://www.fmcsa.dot.gov/rules-regulations/topics/hos/index.htm • Sleep Deprivation • Common in truck drivers; 35% up before 6 am • Sleep Apnea – age and obesity major risks • Effect similar to being over legal alcohol limit in simulator • Pack & Dinges: OSA prevalence • Mild 17%, Moderate 5.8%, Severe 4.7% • www.fmcsa.dot.gov/facts-research/research-technology/tech/Sleep-Apnea-Technical-Briefing.htm

  21. National Transportation Safety Board • Sleep Apnea Alert October 2009 • Recommend “screening” but no regulations in place • Federal Motor Carrier Safety Administration • Trucks, buses, trains • US Coast Guard – ship pilots • FAA – airline pilots

  22. DRIVER SAFETY • In California, if patient has caused an accident by falling asleep at the wheel in the last 3 years, then Dept of Public Health must be notified • If patient reports concerns about sleepiness while driving, chart should document: “Patient was advised not to drive if he / she is drowsy.”

  23. SLEEP HISTORY!!!

  24. REFERENCES • Behavioral and pharmacological therapies for late-life insomnia. CM Morin et al. JAMA 1999;281:991-9 • Cognitive Behavioral Therapy and Pharmacotherapy for Insomnia Jacobs GD; Arch Intern Med 2004;164:1888-1896 • Principles and Practice of Sleep Medicine. 4th Edition. Kryger, Roth, & Dement. 2005 • Jet lag and shift work sleep disorders: How to help reset the internal clock. Kolla BP & Auger RR. Cleveland Clinic J of Med 2011;78(10):675-684 • Circadian Rhythm Sleep Disorders. Lu BS & Zee PC. CHEST 2006;130:1915-1923 • Marin JM et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea: an observational study. Lancet. 2005;365(9464):1046-53

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