Sleep Disorders Part II - Hypersomnia Amr A. Jamal, MBBS Family Medicine Senior Resident Department of Family and Community Medicine King Abdulaziz Medical.

Sleep DisordersPart II - Hypersomnia

Amr A. Jamal, MBBSFamily Medicine Senior ResidentDepartment of Family and Community Medicine King Abdulaziz Medical City Riyadh, Saudi Arabia

Differential DiagnosisHypersomniaIntrinsic Causes

Narcolepsy

Recurrent Hypersomnia Syndrome

Menstrual-related Hypersomnia

Idiopathic Hypersomnia

Post-traumatic Hypersomnia

Sleep apnea syndromes

PLMS

Extrinsic Causes

Circadian Rhythm Disorders

Medical Disorders

Psychiatric Disorders

Medication Related

Obstructive Sleep Apnea

Key points

The most common respiratory condition Prevalence:

2% of middle aged men 1% of middle aged women

Cardinal symptoms: Snoring excessive daytime sleepiness Witnessed apneas

Major risk factor for RTA Risk factor for HTN It is Treatable

Knowledge and attitude of primary health care physicians towards OSA in Riyadh

40% felt that sleep disorders are common medical problems based on their practice

Recognition of consequences of OSA motor vehicle accidents (63%) ischemic heart disease (40%) hypertension (50%) pulmonary hypertension (13%)

What is it?

Apneas may be • “central”, in which there is cessation of

inspiratory effort• “obstructive”, in which inspiratory efforts

continue but are ineffective because of upper airway obstruction.

What is it?

obstruction occurs at the pharyngeal level due to the dilator muscles relaxing

Obeseity micro- or retrognathia

pharyngeal obstruction leads to: Asphyxia drop in arterial oxygen saturations rise in PaCO2 levels intrathoracic pressure swings as inappropriate

What is it?

arousal sufficient to increase the pharyngeal tone and re-opens the airway sudden inflow of air rise in oxygen saturations

This cycle then often repeats almost immediately leading to fragmented and unrefreshing sleep difficulty concentrating at work or while driving

What is it?

repetitive narrowing and closure of the pharynx during sleep

sleep fragmentation and repeated oxygen desaturationsExcessive somnolence Impaired alertness Poor cognition.

Who gets it?

More in menSnoresOverweightGenetic acquired

Prevalence

2-3% of Children4-7 % of Middle Aged Adults10-15% > 65 years

The prevalence is likely to rise as obesity rates continue to increase.

Risk factors

Being a middle aged man

overweight

snoring

collar size >43 cm

craniofacial abnormalities

minor risk factors

Large tonsils

Hypothyroidism

Neuromuscular disease

neuron disease

Rare causes

Mucopolysaccharidoses

Acromegaly

Cushing's syndrome

Marfan's syndrome

Down's syndrome.

Snoring

Snoring is common and may be a serious medical problem.

The family doctor and his team should be aware of the condition, using simple screening test such as ESS, improves the patient care, and finding of suspected cases.

How is my sleep?Epworth Sleepiness Scale

Never High Chance1. Sitting and Reading

0 1 2 32. Watching T.V.

0 1 2 33. Sitting, inactive in a public place (e.g. Theatre or a Meeting)

0 1 2 34. As a passenger in a car for an hour without a break

0 1 2 35. Lying down to rest in the afternoon when circumstances permit

0 1 2 36. Sitting and talking to someone

0 1 2 37. Sitting quietly after a lunch without alcohol

0 1 2 38. In a car, while stopped for a few minutes in the traffic

0 1 2 3

A total score of 10 or more

suggests that you may need

further evaluation by a physician to

determine the cause of your

excessive daytime

sleepiness and whether you have

an underlying sleep disorder

Hypoxic Periodic Breathing

http://www.sleepeducation.com

How should I diagnose it?

Excessive sleepiness, measured by the Epworth Sleepiness Score (>9 is abnormal, >15 is severely abnormal)

Loud snoring, witnessed apnoeas, and choking noises

Feeling unrefreshed on waking Poor concentration Mood swings, personality changes, or

depression Nocturia. Less common symptoms are: Nocturnal sweating Reduced libido Oesophageal reflux.

Examination

Neck circumference Oropharynx Teeth Nasal patency Respiratory function Blood pressure Evidence of endocrine

abnormalities Evidence of neuromuscular

disorders Evidence of heart failure

Investigations

Routine haematology and biochemistry

Thyroid function tests Cholesterol, fasting

triglycerides, glucose, and folate

Arterial or capillary blood gas

Sleep studies

Overnight oximetry

Overnight oximetry

Respiratory polysomnography

Limited sleep studies assess some or all of: Snoring Body movements Heart rate Oro-nasal flow Chest and abdominal movements Leg movements.

Full polysomnography

in addition to the above:EEGelectro-oculogram EMG

Proforma for assessing patients who snore

SleepinessDoes the patient feel sleepy?

Major symptomsDoes the patient have one or more of:Witnessed

apneas ?Choking during

sleep ?Obesity

Minor symptomsDoes the patient have two or more of:

Hearing the end of their own

snore ?Having to sleep

sitting up ?Nocturia ?

may need to

be referred

Medical History

Have possible respiratory failureawake hypoxia (SaO2

<94%), ankle oedema

professional driver whose job is at risk.

How should I treat it?

Not all patients with OSA need treatmentDetermine treatment upon:

significant daytime symptoms that warrant intervention

patient's occupation Patient’s desire severity of their condition determined by a

sleep study

A.

B.

C.

D.

E.

A 40 year old man presents with snoring of new onset. Which one of the following statements is correct?

Excessive alcohol intake is not relevant

A neck circumference of >17 inches carries a low risk of obstructive sleep apnoea

Testing thyroid function would not be useful

You should consider carrying out an Epworth Sleepiness Score

You should refer the patient to a sleep specialist for a full polysomnography

A.

B.

C.

D.

E.

Which one of the following statements about obstructive sleep apnoea is correct?

Tracheostomy is not beneficial

Vivid disturbing dreams are a prominent feature of this disorder

The problem is caused by absent or reduced ventilatory drive due to an abnormality in the brainstem

Rare causes of obstructive sleep apnoea include acromegaly

It is a rare disorder that usually affects women

A.

B.

C.

D.

E.

Which one of the following statements is correct about investigating patients with obstructive sleep apnea?

Referral to an ENT surgeon is essential

An arterial blood gas often shows daytime hypercapnia

Overnight oximetry is all that is required to diagnose obstructive sleep apnoea

A fasting glucose level and cholesterol level may be helpful

Full lung function tests are always needed

QUESTIONS?

A.

B.

C.

D.

E.

Which one of the following statements about mandibular advancement splints is correct?

They are safe if the patient has poorly controlled epilepsy

They are useful for treating snoring

They are available only from sleep clinics

They are effective at controlling severe obstructive sleep apnoea