OVERVIEW OF SLEEP AND SLEEP APNEA by HkPa6Naw

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									OVERVIEW OF SLEEP
 AND SLEEP APNEA
           David Claman, MD
          Professor of Medicine
 Director, UCSF Sleep Disorders Center
SLEEP HYPNOGRAM
 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!)
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
           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
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)
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
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
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
          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
             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
         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
    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
Young T et al. Excess weight and sleep-disordered breathing. J Appl
                   Physiol 2005;99(4):1592-9.
Wisconsin OSA prevalence by gender and BMI
      Young T. J Appl Physiol 2005;99(4):1592-9
     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
          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
CPAP – Site Non-specific
LONGTERM USE OF CPAP
Best compliance if AHI >30 & ESS >10




              McArdle N et al. AJRCCM 1999;159:1108-1114
   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
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
       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.”
  SLEEP
HISTORY!!!
              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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