Essentials of Sleep Medicine (eBook)

Preface 6
Contents 8
Contributors 10
Chapter 1: Normal Sleep 14
Normal Sleep Stages and Architecture 14
Breathing During Sleep: Ventilation and the Upper Airway 17
Summary of Normal Breathing and Ventilation During Sleep 17
Effect of Sleep on Control of Breathing 18
Effect of Sleep on Upper-Airway Structure and Function 18
Cardiovascular Function During Sleep 22
Endocrine Function During Sleep 23
Gastrointestinal Function During Sleep 23
Summary of Keypoints 24
References 25
Chapter 2: Pharmacology of Sleep 29
Introduction 29
Sleep-Promoting Drugs 30
Benzodiazepines 30
Nonbenzodiazepine Receptor Agonists (NBRA) 32
Barbiturates Derivatives 39
Melatonin Receptor Agonists 39
Ramelteon 39
Tasimelteon 40
Melatonin 43
Antidepressants and Antipsychotics 43
Trazodone 43
Tricyclic Antidepressants (TCA) 44
SSRI and SNRI 44
Other Antidepressants 47
Antipsychotic Agents 47
Other Sedating Drugs 47
Newer Sedatives Under Development 48
Almorexant 48
Agomelatine 48
Stimulants/Wake-Promoting Drugs 49
Amphetamine-Like Substances 49
Modafinil 49
Armodafinil 53
Sodium Oxybate 54
Drugs of Abuse 55
New Drugs Under Development 57
Summary of Keypoints 57
References 58
Chapter 3: Obstructive Sleep Apnea: Diagnosis with Polysomnography and Portable Monitors 67
Introduction 67
Prevalence and Epidemiology 68
Risk Factor 68
Clinical History 69
Physical Exam 72
Diagnosis of OSA 72
Overnight Polysomnography (PSG) 72
Split Night Study (Diagnosis Combined with Titration) 75
Portable Monitoring (PM) 76
Types of PMs (Type II–IV) 76
When Should PM Be Considered for Diagnosis of OSA? 77
Current Roles of Autotitrating Positive Airway Pressure (APAP) 78
Cost Effectiveness of PSG vs. PM 79
Utilities of Multiple Sleep Latency Test (MSLT) in OSA 79
Future Outlook 80
Summary Outline 80
References 81
Chapter 4: Approach to Hypersomnia 85
Introduction 85
Determinants of Daytime Sleepiness 86
Sleep Factors 86
Quantity of Sleep 86
Quality of Sleep 86
Circadian Rhythm 87
Medications 87
Demographic Factors 88
Age 88
Gender 88
Race 88
Obesity 88
Pathology of the Central Nervous System 89
Measurement of Daytime Sleepiness 89
Multiple Sleep Latency Test (MSLT) 89
Maintenance of Wakefulness Test (MWT) 90
Epworth Sleepiness Scale (ESS) 91
Summary of Measurements of Excessive Daytime Sleepiness 93
Differential Diagnosis 93
Approach to the Sleepy Patient 95
Summary of Keypoints 97
References 97
Chapter 5: Obstructive Sleep Apnea: Epidemiology of Sleep Apnea 102
Introduction 102
Clinical Definitions of Obstructive Sleep Apnea 103
Prevalence 106
North America 109
Europe 109
Asia 110
South America 110
Australasia 111
Disease Progression 111
Risk Factors 112
Obesity 112
Age 114
Gender, Menopause, and Pregnancy 114
Craniofacial Features 115
Ethnicity 116
Alcohol and Cigarette Consumption 117
Familial/Genetic Factors 118
Summary of Keypoints 118
References 119
Chapter 6: Obstructive Sleep Apnea: Clinical Features and Adverse Consequences 125
Introduction 125
Risk Factors for OSA 127
Obesity 127
Age 128
Sex 128
Ethnicity 128
Bony Structures 129
Diseases Associated with Edematous States 129
Positive Family History 129
Hypothyroidism 130
Presence of Co-Morbid Conditions 130
Clinical Symptoms 130
Physical Signs 131
Adverse Consequences of OSA 133
Consequences Directly Linked to Symptoms 133
Cardiovascular and Metabolic Consequences 133
Hypertension 134
Coronary Artery Disease 135
Stroke 135
Arrhythmias 136
Diabetes and Metabolic Syndrome 136
Conclusion 137
Summary of Keypoints 137
Chapter 7: Assessments of Driving Risk in Sleep Apnea 139
Scope of the Problem 139
Factors in Driving Risk 141
The Interactive Responsibilities of a Driving Assessment 143
Potential for Liability Risk for Pulmonary Physicians 144
Societal Implications 146
Lessons from the Alcohol Literature 146
Principles in Assessment of Risk by the Pulmonary Physician 149
Summary of Keypoints 150
References 150
Chapter 8: Nasal Continuous Positive Airway Pressure (CPAP) Treatment 153
Mechanisms 153
Beneficial Effects 154
Excessive Daytime Sleepiness 154
Blood Pressure 154
Pulmonary Hypertension 155
Heart Failure 155
Cardiac Arrhythmias 155
Neurocognitive Function 156
Glucose Metabolism 156
Motor Vehicle Accidents 157
Adverse Effects 157
Setting Up CPAP 157
Titration 158
Auto Titration 158
Predictive Equations and Bedpartner Titration 159
CPAP Modifications 159
Adherence 160
Conclusion 160
Summary of Keypoints 161
References 161
Chapter 9: Obstructive Sleep Apnea: Oral Appliances 164
Introduction 164
Types of Appliances 165
Mechanism of Action 166
Efficacy and Effectiveness in the Treatment of OSA 167
Impact on Polysomnographic Outcomes 167
Impact on Health Outcomes 168
Long-Term Efficacy 169
Effectiveness Compared with Other Treatments 169
Patient Selection and Prediction of Treatment Outcome 171
Indications for Treatment 171
Oral Considerations 171
Indicators of Treatment Success 171
Techniques for Predicting Outcome 172
Contraindications 175
Appliance Titration Protocols 175
Adverse Effects 176
Treatment Adherence 177
Interdisciplinary Care Model 178
Future Research 178
Conclusion 179
Summary of Keypoints 179
References 180
Chapter 10: Obstructive Sleep Apnea: Surgery 184
Introduction 184
Clinical Evaluation 185
Background and Clinical Context of Surgical Therapy 185
Role of Surgical Therapy 186
Patient Evaluation 187
Snoring 188
Nasal Surgery 189
Anatomy and Physiology 189
Allergic Rhinitis and Sleep 190
Pathophysiology of Nasal Obstruction and Sleep Disturbance 192
Nasal Obstruction and Sleep-Disordered Breathing 193
Surgical Treatment of Nasal Obstruction 193
Nasal Surgery and Improved Effectiveness of Medical Therapy for OSA 194
Oropharyngeal Surgery 195
History 195
A Paradigm Shift 196
The Importance of Uvular Preservation 197
Palatal Anatomy and Examination 197
Surgical Techniques 199
Expansion Sphincter Pharyngoplasty 199
Transpalatal Advancement 200
Hypopharyngeal Surgery 201
Background 201
Anatomy 202
Hypopharyngeal Surgical Techniques 204
Maxillomandibular Advancement Surgery 205
Conclusion 206
Summary of Keypoints 206
References 207
Chapter 11: Sleep and Lung Disease 211
Introduction 211
Sleep and COPD 211
Hypoventilation 212
Measurement of Hypoventilation and Respiratory Dysfunction 213
Clinical Consequences of Sleep Hypoxemia in COPD 213
Diagnosis of Nocturnal Hypoxemia in COPD 214
Treatment of Nocturnal Hypoxemia 214
Medications 215
Noninvasive Positive Pressure Ventilation 216
COPD and Obstructive Sleep Apnea: The Overlap Syndrome 216
Sleep and Asthma 216
Sleep Disturbances in Nocturnal Asthma 217
Diagnosis 217
Sleep and Restrictive Lung Disorders 217
Chest Wall Disorders 218
Pathophysiology of Hypoxemia 218
Diagnosis 219
Therapy 219
Interstitial Lung Disease 219
Diagnosis 219
Treatment 220
Sleep and Obesity: Hypoventilation Disorders 220
Pathogenesis 220
Clinical Features 221
Diagnosis 221
Therapy 221
Weight Loss 222
Summary of Keypoints 222
References 223
Chapter 12: Central Sleep Apnea 226
Determinants of Central Apnea During NREM Sleep 226
Hypocapnia 226
Short-Term Potentiation 227
Duration of Hyperpnea 227
Role of Upper Airway Reflexes 227
Mechanisms Perpetuating Breathing Instability 228
Pathophysiologic Classification of Central Sleep Apnea 228
Central Sleep Apnea Secondary to Hypoventilation 229
Central Apnea Secondary to Hyperventilation 230
Central Apnea Risk Factors 230
Sleep State 230
Age and Gender 231
Medical Conditions 231
Clinical Features and Diagnosis 232
Management 233
Positive Pressure Therapy 233
Pharmacological Therapy 234
Supplemental O 2 and CO 2 235
Approach in Selected Clinical Syndromes 235
Summary 235
Summary of Keypoints 236
References 236
Chapter 13: Insomnia: Etiology, Clinical Manifestations, and Morbidity 240
Introduction 240
DSM – IV 243
ICSD – II 243
Prevalence and Risk Factors of Insomnia 245
Pathophysiology of Insomnia 246
Clinical Assessment 248
Sleep History 248
Medical History 249
Psychiatric History 249
Family History 249
Medication History 249
Functional Outcomes Associated with Insomnia 251
Conclusion 251
Summary of Keypoints 252
References 252
Chapter 14: Management of Insomnia 256
Introduction 256
Control of Breathing During Sleep 258
Pulmonary Disorders and Sleep 260
Bronchospastic Airway Disorders 260
Interstitial Lung Diseases and Sleep 260
Kyphoscoliosis, Restrictive Thoracic Cage Disorders, and Sleep 262
High Altitude Sickness and Insomnia 264
Carbonic Anhydrase Inhibitors: Acetazolamide 265
Benzodiazepines 265
Non-benzodiazepine Benzodiazepine Receptor Agonists 266
Oral Steroids 267
Other Medication Used to Treat Insomnia at High Altitude 267
Medications Used to Treat Insomnia 267
Efficacy of Hypnotics 268
Safety of Medications Commonly Used in Insomnia 272
Sedating Antidepressants 275
Cognitive-Behavioral Therapy of Insomnia 276
Other Medications 276
Summary of Keypoints 277
References 278
Chapter 15: Circadian Disorders 284
Circadian Biology 284
Circadian Rhythm Sleep Disorders 286
Delayed Sleep Phase Disorder 286
Diagnosis of Delayed Sleep Phase Disorder 287
Treatment of Delayed Sleep Phase Disorder 287
Advanced Sleep Phase Disorder 289
Diagnosis of Advanced Sleep Phase Disorder 289
Treatment of Advanced Sleep Phase Disorder 290
Free-Running Type 290
Diagnosis of Free-Running Type 290
Treatment of Free-Running Type 291
Irregular Sleep–Wake Rhythm 291
Diagnosis of Irregular Sleep–Wake Rhythm 291
Treatment of Irregular Sleep–Wake Rhythm 292
Shift Work Disorder 292
Diagnosis of Shift Work Disorder 293
Treatment of Shift Work Disorder 293
Jet Lag 295
Diagnosis of Jet Lag 295
Treatment of Jet Lag 295
Summary 296
Summary of Keypoints 297
References 297
Chapter 16: Narcolepsy and Idiopathic Hypersomnia 304
Introduction 304
Clinical Features 305
Narcolepsy 305
Idiopathic Hypersomnia 307
Epidemiology 308
Narcolepsy 308
Idiopathic Hypersomnia 308
Pathophysiology 309
Narcolepsy 309
Idiopathic Hypersomnia 310
Diagnosis 310
Narcolepsy 310
Idiopathic Hypersomnia 312
Differential Diagnosis 313
Head Trauma and Excessive Sleepiness 314
Treatment 314
Nonpharmacologic Management 315
Pharmacologic Management of Symptoms Common to Both Narcolepsy and Idiopathic Hypersomnia 315
Pharmacologic Management of Symptoms Specific to Narcolepsy 316
Cataplexy 316
Fragmented Nocturnal Sleep 317
Conclusion 317
Summary of Keypoints 317
References 318
Chapter 17: Parasomnias 322
Introduction 322
NREM Parasomnias or Disorders of Arousal 322
Confusional Arousal 322
Definition 322
Clinical Symptomatology 323
Etiology 323
Pathophysiology 323
Epidemiology 323
Diagnostic Workup 323
Treatment 324
Sleepwalking or Somnambulism 324
Definition 324
Clinical Symptomatology 324
Etiology 325
Pathophysiology 325
Epidemiology 326
Diagnostic Workup 326
Treatment 326
Sleep Terror or Pavor Nocturnus 327
Definition 327
Clinical Symptomatology 327
Etiology 328
Pathophysiology 328
Epidemiology 328
Diagnostic Workup 328
Treatment 328
REM Parasomnias 329
REM Sleep Behavior Disorder 329
Definition 329
Clinical Symptomatology 329
Etiology 330
Pathophysiology 330
Epidemiology 330
Diagnostic Workup 330
Treatment 330
Parasomnia Overlap Syndrome/Status Dissociates 332
Isolated Recurrent Sleep Paralysis 333
Definition 333
Clinical Symptomatology 333
Etiology 333
Pathophysiology 333
Epidemiology 333
Diagnostic Workup 334
Treatment 334
Nightmares 334
Definition 334
Clinical Symptomatology 334
Etiology 335
Pathophysiology 335
Epidemiology 335
Diagnostic Workup 335
Treatment 335
Other Parasomnias 336
Sleep-Related Dissociative Disorder 336
Treatment 337
Sleep Enuresis 337
Definition 337
Clinical Symptomatology 337
Etiology 338
Pathophysiology 338
Epidemiology 338
Diagnostic Workup 338
Treatment 339
Sleep-Related Eating Disorder 341
Definition 341
Etiology 341
Pathophysiology 341
Clinical Symptomatology 341
Epidemiology 342
Diagnostic Workup 342
Treatment 342
Exploding Head Syndrome 343
Treatment 343
Catathrenia 343
Treatment 343
Sleep-Related Hallucinations 344
Treatment 344
Future Directions 345
Conclusion 345
Summary of Keypoints 345
References 346
Chapter 18: Movement Disorders 356
Introduction 356
Restless Legs Syndrome 357
Demographics 357
Diagnosis 357
Associated Features 358
Differential Diagnosis 359
Primary vs. Secondary Factors 359
Management 360
Periodic Limb Movement Disorder 362
Demographics 362
Diagnosis 362
Associated Features 363
Differential Diagnosis 363
Management 363
Sleep-Related Leg Cramps 364
Diagnosis 364
Demographics 364
Differential Diagnosis 365
Associated Features 365
Treatment 365
Sleep-Related Bruxism 367
Demographics 367
Diagnosis 367
Differential Diagnosis 367
Associated Features 368
Management 368
Sleep-Related Rhythmic Movement Disorder 369
Demographics 369
Diagnosis 369
Associated Features 370
Differential Diagnosis 370
Treatment 371
Conclusion 371
Summary of Keypoints 371
References 372
Chapter 19: Perioperative Care of Patients with Obstructive Sleep Apnea Syndrome 377
Introduction 377
Preoperative Risk Assessment and OSA Screening Protocols 378
Factors Contributing to Increased Risk of Complications in Surgical Patients 378
Morbid Obesity and OSA 379
Preoperative Evaluation 379
Preoperative Screening for Suspected OSA 379
The Berlin Questionnaire 380
The American Society of Anesthesiologists’ Checklist 380
The STOP Questionnaire 380
The STOP-Bang Model 381
Sleep Apnea Clinical Score 381
Preoperative Evaluation of Known OSA 383
Preoperative OSA Optimization 384
Intraoperative OSA Management 384
Choice of Anesthetics/Anesthetic Technique 384
Increased Risk of Difficulty with Tracheal Intubation 385
Postoperative OSA Management 386
Postoperative Pain Control 386
Postoperative Monitoring 387
Oximetry 387
Capnography 388
Management Algorithms 388
PACU 388
Intervention Protocols 392
General Surgery 392
Intervention Protocols in Orthopedic Surgery 392
Intervention Protocols in Gastric Bypass Surgery Patients 393
Conclusion 394
Summary of Keypoints 394
References 395
Chapter 20: Sleep and Critical Illness 400
Introduction 400
Why Care? 401
Measurement of Sleep During Critical Illness 402
Nature and Extent of Sleep Disturbances 403
Causes and Cures 404
Conclusion 407
Summary of Keypoints 407
References 408
Index 411