Sleep and Breathing by ert554898


									Sleep and Breathing

              Davina Lovegrove
   Senior Scientist & Training Coordinator
     Respiratory and Sleep Specialists
       Sleep – Why do we need it?

•   Restorative function for brain
•   Learning and memory
•   Repair of cells and healing
•   Hormone secretions
•   Energy conservation
                            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
    Consequences of reduced sleep
•   Day time tiredness
•   Reduced reaction times
•   Mood disturbances
•   Fatigue & muscle weakness
•   Headaches
•   Double vision
•   Reduced motivation……..
               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
                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
         Obstructive Sleep Apnoea
  What is OSA?
• repeated obstruction of the upper airway during sleep
   – reduction in blood oxygen saturation
   – frequent sleep disturbance

                      Phillips & Naughton, 2004
      How do we diagnose OSA?
• Risk factors
  – Obesity
  – Family history
  – Age
  – Smoking
  – Alcohol / sedative use
• Questionnaires
  – Epworth sleepiness scale
• Overnight sleep study (PSG)
             How do we diagnose OSA?
Clinical Examination – risk factors


What happens when an individual obstructs?

What happens when an individual obstructs?

What happens when an individual obstructs?

Slide courtesy of Dr Darren O’Brien
           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


Resp. effort
                          Treatment options
     Lifestyle changes
          – Weight loss
          – Drugs, alcohol, smoking
          – Sleep hygiene
     Positional therapy
          – Tracheostomy
          – Uvulopalatopharyngoplasty
          – Gastric, bariatric Sx
     Oral appliances
Slide courtesy of Dr Darren O’Brien
• 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.
                                              Sullivan, Lancet 1981

      First Patient on CPAP, RPAH, 1980.

Slide courtesy of Dr Darren O’Brien
            Fixed Pressure CPAP Devices
                                                Fixed pressure
                                             throughout the night

10 cm H2O

   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.
            Auto Pressure CPAP Devices
                                                Varying pressure throughout the
                                                  night in response to events

 4 cm H2O

                            Beginning of

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.
                          Bi-level Devices

10 cm H2O

4 cm H2O

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

                          CO2   CO2

• When we don’t breath adequately
  – Blood oxygen levels drop (hypoxia)
  – Blood carbon dioxide levels increase (hypercapnia)
             Breathing basics
• Not breathing adequately is called

• Hypoventilation       hypoxia + hypercapnia

• Hypoxia + hypercapnia = respiratory failure
             = hospital admission
         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
                  Case study
• Chest wall restriction secondary to
• Undergoing a split night sleep study
  – ½ night as a diagnostic study
  – ½ night as a bi-level study
Dx   NIV
• Simonds et al 1995:
• Outcomes of patients on home NIV were assessed
  over 5 years in 180 patients with chronic respiratory
• 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
• 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
       Why use NIV as treatment?
•   Improved sleep quality
•   Improved quality of life
•   Less hospital admissions
•   Improved blood gases (CO2 and O2)
•   Improved lung function

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