Upper-airway resistance syndrome

Size: px
Start display at page:

Download "Upper-airway resistance syndrome"

Transcription

1 Handbook of Clinical Neurology, Vol. 98 (3rd series) Sleep Disorders, Part 1 P. Montagna and S. Chokroverty, Editors # 2011 Elsevier B.V. All rights reserved Chapter 26 Upper-airway resistance syndrome CHRISTIAN GUILLEMINAULT* AND VIRGINIA DE LOS REYES Stanford University Sleep Medicine Program, Stanford, CA, USA INTRODUCTION Upper-airway resistance syndrome (UARS) was first recognized in children in 1982 (Guilleminault et al., 1982). The term UARS, however, was not used until adult cases were reported in 1993 (Guilleminault et al., 1993). The description of UARS brought the attention of clinicians to a group of patients that was left undiagnosed and untreated despite severe impairment. The authors indicated that they had to identify this clinical entity as many had been denied proper treatment based on subjects symptoms and polysomnographic (PSG) features that differ from those of obstructive sleep apnea syndrome (OSAS). However, controversies exist regarding UARS. Some have rejected it as a distinct clinical entity or even doubted its existence (Douglas, 2000). In the past few years, however, there has been greater acceptance of this entity, and review articles have been published on UARS in general (Exar and Collop, 1999) and in children (Guilleminault and Khramtsov, 2001). Since the first description of a polygraphic pattern called obstructive sleep apnea in the pickwickian syndrome in 1965 (Gastaut et al., 1965; Jung and Kuhlo, 1965), sleep medicine has undergone an evolution. UARS was introduced as part of the efforts to describe a generally unrecognized patient population that is nonobese and whose clinical features do not match those reported with OSAS. Unfortunately, many sleep-breathing abnormalities are still ignored due to the belief that sleepdisordered breathing is synonymous with OSAS and that patients must be overweight or clearly obese. Such limited views have already led to the underdiagnosis and undertreatment of OSAS in women, the forgotten gender (Guilleminault et al., 1995). With the use of new techniques, such as the esophageal catheter for esophageal pressure (P es ) measurement (Flemale et al., 1988) and nasal cannula/pressure transducer (Norman et al., 1997), it has become more convenient to identify subtle changes in breathing patterns during sleep. In the past few years, UARS has been linked to many somatic, psychiatric, or psychosomatic conditions, including parasomnias, attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD), fibromyalgia, as well as chronic insomnia. It has been shown that the consequences of the syndrome on the autonomic nervous system are different compared to those linked to OSAS. Some considered UARS as part of a spectrum that includes benign snoring, UARS, obstructive hypopnea, obstructive sleep apnea (OSA), and hypoventilation. However, despite the fact that some patients may present such progression, it is too simple to link all these entities together. The first issue is whether to believe that there is a benign chronic snoring. Our studies support that chronic snoring is not benign and is part of UARS. The American Academy of Pediatrics recognized such possibility when it recommended exploring chronic snoring in all children (American Academy of Pediatrics, 2002), but such a recommendation has never been made in adults. The second issue is whether to consider that UARS is systematically associated with chronic snoring, as even the initial description of the syndrome indicated that snoring was absent in about one-third of reported patients (Guilleminault et al., 1993). Finally, the progressive evolution from UARS is questionable. The only longitudinal study performed on about 100 UARS subjects seen again without treatment about 5 years later reported that fewer than 10% had such evolution (Guilleminault et al., 2006b). In these cases, it was associated with clear weight gain, leading to fatty infiltration of both neck and abdomen, with secondary restrictive chest bellows impairment; this was particularly obvious during rapid eye movement (REM) sleep and became worse by *Correspondence to: Christian Guilleminault, M.D., Biol.D., Stanford University Sleep Disorders Program, 401 Quarry Road, suite 3301, Stanford, CA, 94305, USA. Tel: , Fax: ,

2 402 C. GUILLEMINAULT AND V. DE LOS REYES physiologic development of the REM sleep-related muscle atonia that eliminates usage of respiratory accessory muscles. Our understanding of OSAS and its underlying lesions has improved in recent years, and the two syndromes can be understood as related to the presence of either normal or impaired capability to respond to specific upper-airway airflow challenges during sleep. EPIDEMIOLOGY There is no investigation of UARS in the general population. In children, it has been reported that 9 12% of children are chronic snorers (Guilleminault et al., 2005a). Chronic snoring without OSA in children has been shown to be associated with different health problems, mostly behavioral, such as hyperactivity, inattention, poor school performance, anxiety, or depressive effects. Unfortunately, most chronic snorers have not been studied with PSG. When studied, however, absence of apnea hypopnea and presence of increased respiratory effort, indicative of UARS, and documented by P es, were shown during sleep. In children, prevalence of OSAS has been calculated at between 4 and 5%, compared to the reports of chronic snoring, at 9 12% (Guilleminault et al., 2005a). CLINICAL SYMPTOMS Although some of the symptoms in UARS overlap with those in OSAS, studies have found some important differences (Guilleminault and Bassiri, 2005). Chronic insomnia tends to be much more common in patients with UARS than those with OSAS. Many UARS patients report maintenance insomnia characterized by frequent nocturnal awakenings and difficulty falling back to sleep, but sleep-onset insomnia is also present, and is thought to be caused by conditioning as a consequence of frequent sleep disruptions (Guilleminault et al., 2002a). Adult patients with UARS are also more likely to complain of fatigue rather than sleepiness. They may have difficulty getting up in the morning and may shift their sleep schedule, evolving toward a delayed sleep phase disorder. Other presentations include parasomnias with sleepwalking and sleep terrors (Guilleminault et al., 2006a), myalgia, depression, and anxiety. Gold and colleagues (2003) emphasized that UARS patients have complaints related more to functional somatic syndromes, such as headaches, sleep-onset insomnia, and irritable bowel syndrome. Not infrequently, UARS is misinterpreted as chronic fatigue syndrome, fibromyalgia, or psychiatric disorders such as ADD/ADHD (Lewin and Pinto, 2004) or depressive disorders. A clinical case report of UARS has also presented symptomatology mimicking nocturnal asthma (Guerrero et al., 2001). Symptoms related to chronic nasal allergies are often seen. The clinical interview reveals the presence of lightheadedness with abrupt positional changes, sometime more pronounced on awakenings, and subjects may have learned early to avoid jumping out of bed and having a two-step approach when getting up. History of fainting mostly during teenage years may also be elicited. Between one-fifth and one-fourth will report the presence of cold hands and/or cold feet and sometimes other mild signs associated with vagal hyperactivity such as orthostatic hypotension and cold extremities. The other reported health problems are related to the most common cause of UARS, i.e., small maxilla and/ or mandible manifested as impaction of wisdom teeth with need for removal between 15 and 25 years, history of orthodontic treatment often with teeth removal, usage of dental retainer or other dental device during childhood, or presence of bruxism. A history of chronic nasal allergies sometimes associated with chronic sinus infection or a history of repetitive upper-airway infection or earaches may occur during the first years of life. PHYSICAL EXAMINATION Clinical examination will show low blood pressure in about one-fourth of subjects, often associated with moderate worsening with orthostatic maneuvers (Guilleminault et al., 2001a, 2004). Indications of anatomic narrowing of the upper airway have to be evaluated: 1. evaluation of nose: asymmetrical external valve, collapse of internal valve at inspiration, narrow and long nose, enlargement of inferior nasal turbinates due to allergy, presence of deviated septum 2. evaluation of maxilla: high and narrow hard palate, presence of overlapping teeth, short intermolar distance 3. evaluation of mandible: retroposition indicated by important (>2.2 mm) overjet, presence of indentation on lateral sides of tongue, presence of scars related to lateral biting of cheek 4. evaluation of face: elongation of lower anterior third of face, steep mandibular plane, narrow and elongated chin. Soft tissues should also be evaluated with determination of tonsil size using standard scales and placement of the tongue in relation to the uvula, using the Mallampati scale (Mallampati et al., 1985). Cephalometric X-rays may confirm this information. Although the clinical evaluation allows one to suspect UARS and its potential relationship to anatomical factors impacting the upper airway, the diagnosis can only be confirmed by PSG.

3 UPPER-AIRWAY RESISTANCE SYNDROME 403 Polysomnography continuous respiratory effort, wherein the P es tracing shows a relatively stable and persistent negative peak inspiratory pressure, which is more than the baseline and nonobstructed breaths. This lasts longer than four breaths. The third form is P es reversal, wherein there is an abrupt drop in respiratory effort indicated by a less negative peak inspiratory pressure after a sequence of increased respiratory efforts independent of the EEG pattern seen. This indicates the end of an abnormal breathing sequence, independent of the EEG pattern. The disadvantage of P es measurement is the need to insert a small catheter from the patient s nostril down to the esophagus. Despite validations of good tolerability and a low complication rate in adults and children, P es measurement is not widely applied, due to patients fear of discomfort and sleep technologists hesitancy, except in centers where the technique has been well adapted, or in academic and research settings. We have applied a new algorithm using intercostal EMG signals to pick up the respiratory variations. The results are quite promising (Stoohs et al., 2004). Another technique using pulse wave signals was developed in Japan and patented in the USA for commercial development (Nanba et al., 2002). It is expected that, in the near future, new techniques will be available for measuring even more subtle changes in respiratory efforts without the need of a P es catheter placement. PSG reveals an apnea hypopnea index (AHI) < 5, oxygen saturation > 92%, and presence of respiratory effort-related arousals (RERAs) as well as other nonapnea/hypopnea respiratory events. Although inductive respiratory plethysmography (Loube et al., 1999), pneumotachograph, and most commonly nasal cannula/pressure transducer have been tried to measure subtle respiratory alterations (Ayap et al., 2000; Epstein et al., 2000; Virkula et al., 2002), measurement of P es remains the gold standard for detecting respiratory abnormalities. The use of a pediatric feeding catheter instead of an esophageal balloon has improved tolerance of the procedure in both adults (Epstein et al., 2000) and children (Serebrisky et al., 2002). The nasal cannula/pressure transducer is more sensitive than thermistors in picking up respiratory changes and has been used to detect RERAs. In addition to the nasal cannula/pressure transducer system, respiratory channels, mouth thermistor (mandatory to recognize mouth breathing with nasal obstruction), thoracic and abdominal piezoelectric bands or inductive respiratory plethysmography, neck microphone and P es are important to allow proper diagnosis. Calibration of different channels, particularly P es, before the beginning and at the end of monitoring, is mandatory. The other PSG channels all have to be present in these cases, particularly several electroencephalogram (EEG) leads that will allow monitoring not only C3 A2 and C4 A1 but also frontal and occipital derivations, that will help in the investigation of the presence of American Sleep Disorders Association (1992) arousals of 3 seconds or more duration as well as the calculation of cyclic alternating pattern (CAP) during non-rem (NREM) sleep. Analysis of PSG will not only recognize apnea and hypopnea as classically defined, but will also determine the presence of flow limitation based on the analysis of the nasal cannula curve. Flow limitation will appear as flattening of the normal bell-shaped curve of normal breath with a drop in the amplitude of the curve by 2 29% compared to the normal breaths immediately preceding (Figures ). The nasal cannula/ pressure transducer is more sensitive than thermistors in picking up respiratory changes and detecting RERAs. However, sensitivity comparable with P es measurement has not been demonstrated. Three abnormal forms of P es tracings have been described (Black et al., 2000; Guilleminault et al., 2001b). First, P es crescendo is a progressively increased negative peak inspiratory pressure in each breath which terminates with an alpha-wave EEG arousal or a burst of delta wave. This is not associated with a drop in oxygen saturation of 3%, as used for definition of hypopnea. The second form is a sustained POLYSOMNOGRAPHIC FINDINGS AND POWER SPECTRAL EEG ANALYSIS The typical PSG findings for UARS include AHI < 5, minimum oxygen saturation > 92%, an increase in alpha rhythm, and a relative increase in delta sleep, which persists in the latter cycles of sleep. Recent studies also confirm that UARS patients may have more alpha EEG frequency time (Guilleminault et al., 2001c; Poyares et al., 2002) and more RERAs (Poyares et al., 2002) during sleep than patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). Scoring of CAPs is another novel approach evaluating quality of sleep in UARS. A higher frequency of CAPs is noted in UARS compared to age- and gender-matched controls (Guilleminault et al., 2005a; Lopes and Guilleminault, 2005). The comparison of the sleep EEG of UARS, OSAHS, and normal control subjects, using power spectrum analysis, shows a higher amount of theta and alpha powers (i.e., 7 9 Hz bandwidth) during NREM sleep, and more delta powers during REM sleep compared with OSAHS and normal subjects (Guilleminault et al., 2001c). The new analytic approach design by Chervin et al. (2004) that quantifies the so-called respiratory cycle-related electroencephalographic changes breath by breath, and correlates delta, theta, and alpha EEG

4 404 C. GUILLEMINAULT AND V. DE LOS REYES Patient Name: Example, 1 Subject Code: X Study Date: 02/17/2006 (C3) - (A2) (C4) - (A1) (O1) - (A2) (Fp1) - (A2) Chin EMG (LOC) - (A2) (ROC) - (A1) [EKG-L - EKG-R] LAT RAT SaO2 Mic PULSE Min Nasal Oral Chest Abdomen 23:33:49 23:34:04 23:34:19 23:34:34 23:34:49 23:35:04 23:35:19 23:35:34 Fig Example of flow limitation in a patient with upper-airway resistance syndrome during slow-wave sleep. From top to bottom the following channels were recorded: channel 1 4 electroencephalogram (EEG) (C3/A2, C4/A1, O1/A1, Fp1/A2); channel 5: chin electromyogram (EMG), channels 6 and 7: left and right electro-oculogram (LOC and ROC), channel 8: electrocardiogram (EKG), channels 9 and 10: leg EMG, channel 11: pulse oximetry, channel 12: neck microphone, channel 13: nasal cannula/pressure transducer, channel 14: oral thermistor, channels 15 and 16 thoracic and abdominal movements. Bottom: time during the night. During this 120 seconds monitoring during slow-wave sleep, the presence of flow limitation can be seen without apnea, hypopnea, snoring, or oxygen saturation drop. The flow limitation is seen on the nasal cannula channel. Presence of cyclic alternating pattern can also be seen when looking at the EEG leads. powers with respiratory cycle variations, may allow the detection of more subtle sleep EEG changes related to abnormal respiratory efforts. PATHOPHYSIOLOGY Difference between OSAS and UARS The idea that OSAS involves the presence of a local neuropathy at the pharyngeal region was first proposed by Swedish investigators and is based on neurophysiologic, electron microscopic, and clinical investigations (Edstrom et al., 1992; Friberg et al., 1997, 1998a, b). The presence or absence of these neurogenic lesions is the basis for the existence of the two syndromes. Data obtained by Friberg et al. (1997, 1998a, b) provided evidence of local neurogenic lesions of the upper airway in OSAS and these lesions are associated with slowing of impulse conduction (MacKenzie et al., 1977). Their data are in accordance with those shown by Woodson et al. (1991), Series et al. (1996), Kimoff et al. (2001), and Guilleminault et al. (2002a). Friberg (1999) compared the findings observed in the vibration-induced white finger syndrome with those noted in clinical neurophysiologic and histologic tests in OSAS patients. The clinical and histologic findings secondary to long-term use of low-frequency hand-held vibrating tools include decreased sensitivity to vibration and temperature, hypertrophied muscle cells, and a demyelinating neuropathy in the peripheral nerves. There is marked loss of nerve fibers and myelin sheaths and relatively smaller axons without myelin. Similar findings have been reported with

5 Patient Name: Example, 1 Subject Code: X Study Date: 02/17/2006 UPPER-AIRWAY RESISTANCE SYNDROME 405 (C3) - (A2) (C4) - (A1) (O1) - (A2) (Fp1) - (A2) Chin EMG (LOC) - (A2) (ROC) - (A1) [EKG-L - EKG-R] LAT RAT SaO2 Mic PULSE Min Nasal Oral Chest Abdomen 03:02:19 03:02:29 03:02:39 03:02:49 03:02:59 03:03:09 Fig Example of flow limitation during stage 2 nonrapid eye movement sleep in a patient with upper-airway resistance syndrome. Montage is the same as for Figure Note the presence of flow limitation during 30 seconds of recording, well shown on the nasal cannula channel: the normal upper round shape of each breath has been replaced by a flattening of the curve, indicative of the flow limitation. clinical testing and with the Swedish group s histologic studies in the oropharyngeal region (Friberg, 1999). Heavy snoring produces low-frequency vibration, and these similarities support the hypothesis that a vibration trauma may be involved in the development of lesions (Nguyen et al., 2005). Furthermore, human receptors located in the upper airway respond to oscillations similar to snoring simply by increasing the EMG activity in the genioglossus and other respiratory muscles. Nguyen et al. (2005) used an endoscopic sensory testing technique (Aviv et al., 1993, 1999) in OSAS and an air pulse stimulator in control patients. Using such a technique, no difference in sensory thresholds was seen in patients and matched controls when air pulse was delivered on the lips, but clear differences were seen at the oropharyngeal and laryngeal levels, more particularly at the level of the aryepiglottic eminence, indicating that OSAS patients have lesions not only in the oral-pharyngeal but also laryngeal regions, with disturbance of an aryepiglottic reflex due to sensory lesions. The importance of the sensory lesions in the larynx correlates with the AHI (Nguyen et al., 2005). In OSAS the presence of local sensory lesions does not allow passage of information concerning airflow to induce motor response. An investigation performed by Affifi et al. (2003) also supports this conclusion. Simultaneous investigation of auditory evoked responses and respiratoryrelated evoked potentials were performed in OSAS and controls during wakefulness and sleep. An abnormal evoked response to inspiratory occlusion stimuli during NREM sleep was demonstrated in OSAS patients compared to matched normal controls. However, normal responses in the same OSAS subjects occurred with auditory stimulation. This study therefore supports the presence of a sleep-specific dampening of cortical processing of inspiratory effort-related information but presence of otherwise normal stimuli response. In summary, OSAS patients have local

6 406 C. GUILLEMINAULT AND V. DE LOS REYES Patient Name: Example, 1 Subject Code: X Study Date: 02/17/2006 (C3) - (A2) (C4) - (A1) (O1) - (A2) (Fp1) - (A2) Chin EMG (LOC) - (A2) (ROC) - (A1) [EKG-L - EKG-R] LAT RAT SaO2 Mic PULSE Min Nasal Oral Chest Abdomen 01:50:19 01:50:29 01:50:39 01:50:49 01:50:59 01:51:09 Fig Example of flow limitation during stage 2 nonrapid eye movement sleep in a patient with upper-airway resistance syndrome. Montage is the same as for Figure 26.1 and duration of recording is 60 seconds. Note the presence of flow limitation on the nasal cannula channel and the associated snoring on the microphone channel. neurogenic lesions in the pharynx and upper larynx that interfere with normal control of upper-airway patency and lead to slow modulations of airway patency. Apneas and hypopneas occur due to the abnormal balance between intrathoracic effort and upper-airway muscle contractions created by local sensory pathway impairment. UARS patients do not present these local sensory destructions, or at least not in a sufficient amount to impair reflexes adjusting the upper-airway patency continuously during sleep. The studies supporting the absence of local neurogenic lesions in UARS are more limited: one study compared the responses between age- and gender-matched OSAS and UARS patients and normal controls, involving 20 subjects per group (Guilleminault et al., 2002a). The results showed similar two-point discrimination responses between UARS and controls while OSAS had abnormal responses. This study matched the results obtained by Dematteis et al. (2005) in patients with low AHI scores (5 10 events/hour). The pathophysiological difference between OSAS and UARS is conceptualized as follows. The blunting or elimination of sensory input from the upper airway in OSA does not allow an appropriate adjustment of upper-airway muscle tone to many challenges and this leads to a too narrow upper airway at onset of inspiration, causing airway collapse. In UARS, however, the absence of neurogenic lesions in the upper airways and the persistence of sensory input lead to a faster arousal and changes despite the presence of a narrow airway related to anatomical changes at a point with variable location, from the external valve of the nose to the base of the tongue (Guilleminault et al., 1993; Bao and Guilleminault, 2004). The presence or absence of an important decrease in the size of the airway in relation to the importance of the local neurogenic lesions will lead to variable changes in blood gases and the need to call upon other stimuli to reopen a collapsing airway. Drops in oxygen saturation (SaO 2 ) and arousal responses related to these blood gases changes will have a direct impact on the

7 autonomic nervous system. UARS and OSAS will lead to different autonomic nervous system stimulations. Investigation of UARS patients with low blood pressure (Guilleminault et al., 2001a; Guilleminault et al., 2004) and studies of heart rate variability using fast Fourier transformation (Guilleminault et al., 2005c) have shown that UARS subjects present an active vagal tone compared to sympathetic tone during sleep. In contrast, hyperactivity of the sympathetic tone has been well shown in OSAS patients. This sympathetic hyperactivity, initially during sleep but quickly seen during wakefulness, has been well demonstrated in OSAS using different techniques, but the most demonstrative is the continuous recording of muscle nerve sympathetic activity in the leg. This technique shows an abnormal resetting of sympathetic tone, with hyperactivity as the first sign in the development of lesions of the vascular endothelium and of hypertension. In UARS, the inhibition of sympathetic tone during sleep is related to the abnormal inspiratory effort associated with increased airway resistance. The liberation of the vagal tone left alone as the autonomic regulator during sleep is responsible for the observation of mild orthostatism and vagal dominance during sleep and sometimes during wakefulness. The absence of a clear SaO 2 drop in UARS also eliminates one of the important stimuli of the sympathetic tone activity during sleep, as seen in OSAS. In summary, UARS patients have upper-airway reflexes intact during wakefulness and sleep, while they are impaired in OSAS. Furthermore, in OSAS, the presence of repetitive SaO 2 drops excite sympathetic tone during sleep, leading to progressive sympathetic tone resetting and hyperactivity, a response not present in UARS. TREATMENT In the original description of UARS by Guilleminault et al. (1993), patients were treated successfully with nasal continuous positive airway pressure (CPAP). Since then, other therapeutic alternatives have been used. CPAP is still widely tried as the first-line therapy. It is often used as a therapeutic trial to demonstrate improvement of symptoms (Guilleminault et al., 2002b). Studies have demonstrated that adding cognitive behavioral therapy to CPAP treatment is beneficial for patients with chronic insomnia or psychosomatic symptoms secondary to UARS (Guilleminault et al., 2002b; Krakow et al., 2004). On the other hand, in a randomized study conducted on postmenopausal women with UARS and chronic insomnia, radiofrequency reduction of nasal turbinates, or turbinectomy, UPPER-AIRWAY RESISTANCE SYNDROME 407 or a trial of CPAP showed better relief in daytime fatigue than behavioral treatment alone at 6 months (Guilleminault et al., 2002b). Oral appliances can also achieve satisfactory outcomes in UARS (Yoshida, 2002). Septoplasty and radiofrequency reduction of enlarged inferior nasal turbinates can be successful in treating UARS. Anatomical abnormalities also often involve soft tissues in the soft palate and the maxilla and mandible skeletal structures. If the primary cause of the abnormal breathing, such as crowded airway and narrowed jaws, is not corrected, patients will be left with the complaint of worsening functional symptoms, which potentially may lead to the development of local polyneuropathy. The classic surgical procedures have often been considered too aggressive for treatment of UARS. Treatment must address the cause of the syndrome and avoid progression of untreated anomalies. Uvuloflap (Powell et al., 1996) and distraction osteogenesis (Guilleminault and Li, 2004) have been helpful in the management of UARS. Orthodontic approaches, such as rapid maxillary distraction, which are conveniently performed in children and teenagers, are not directly applicable in adults. This is due to complete ossification of the maxilla and mandible. In adults, midline incisions of the maxilla and mandible are necessary prior to the placement of internal jaw distractors. Distraction osteogenesis applied to sleep-disordered breathing patients showed promising clinical improvement (Pirelli et al., 2004). This combined surgical and orthodontic treatment is much less invasive than the traditional jaw advancement surgery. However, patients are required to wear braces for an extended time after jaw expansion for orthodontic purposes. In summary, the treatment of UARS may be more demanding than OSAS, as patients usually tolerate nasal CPAP less and become quickly noncompliant. Treatment of the underlying causes of the upperairway anatomical problems is the usual approach that may consist of aggressive treatment of nasal allergies, usage of palatal soft-tissue surgery, orthognatic surgery, or the use of dental devices. REFERENCES Affifi L, Guilleminault C, Colrain I (2003). Sleep and respiratory stimulus specific dampening of cortical responsiveness in OSAS Respir. Physiol Neurobiol 136: American Academy of Pediatrics (2002). Clinical practice guideline: diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 109: American Sleep Disorders Association Atlas Task Force (1992). EEG arousals: scoring rules and examples. A preliminary report from the Sleep Disorders Atlas Task

8 408 C. GUILLEMINAULT AND V. DE LOS REYES Force of the American Sleep Disorders Association. Sleep 15: Aviv JE, Martin JH, Keen MS et al. (1993). Air-pulse quantification of supra-glottic and pharyngeal sensation: a new technique. Ann Otol Rhinol Laryngol 102: Aviv JE, Martin JH, Keen MS et al. (1999). Laryngopharyngeal sensory discrimination testing and the laryngeal adductor reflex. Ann Otol Rhinol Laryngol 108: Ayap I, Norman RG, Krieger AC et al. (2000). Non-invasive detection of respiratory effort-related arousals (RERAs) by a nasal cannula/pressure transducer system. Sleep 23: Bao G, Guilleminault C (2004). The upper airway resistance syndrome one decade later. Curr Opin Pulm Med 10: Black J, Guilleminault C, Colrain I et al. (2000). Upper airway resistance syndrome: central EEG power and changes in breathing effort. Am J Respir Crit Care Med 162: Chervin RD, Burns JW, Subotic NS et al. (2004). Correlates of respiratory cycle-related EEG changes in children with sleep-disordered breathing. Sleep 27: Dematteis M, Lévy P, Pépin J-L (2005). A simple procedure for measuring pharyngeal sensation: a contribution to sleep apnoea diagnosis. Thorax 60: Douglas NJ (2000). Upper airway resistance syndrome is not a distinct syndrome. Am J Respir Crit Care Med 161: Edstrom L, Larsson H, Larsson L (1992). Neurogenic efforts on the palatopharyngeal muscle in patients with obstructive sleep apnea: a muscle biopsy study. J Neurol Neurosurg Psych 55: Epstein MD, Chicoine SA, Hanumara RC (2000). Detection of upper airway resistance syndrome using a nasal cannula/pressure transducer. Chest 117: Exar EN, Collop NA (1999). The upper airway resistance syndrome. Chest 115: Flemale A, Gillard C, Dierckx JP (1988). Comparison of central venous, oesophageal and mouth occlusion pressure with water-filled catheters for estimating pleural pressure changes in healthy adults. Eur Respir J 1: Friberg D (1999). Heavy snorer s disease: a progressive local neuropathy. Acta Otolaryngol 119: Friberg D, Gazelius B, Holfelt T et al. (1997). Abnormal afferent nerve endings in the soft palatal mucosa of sleep apneics and habitual snorers. Regul Pept 71: Friberg D, Ansved T, Borg K et al. (1998a). Histological indications of a progressive snorer s disease in an upperairway muscle. Am J Resp Crit Care Med 157: Friberg D, Gazelius B, Linblad LE et al. (1998b). Habitual snorers and sleep apneics have abnormal vascular reaction of the soft palatal mucosa or afferent nerve stimulation. Laryngoscope 108: Gastaut H, Tassinari CA, Duron B (1965). Polygraphic study of diurnal and nocturnal (hypnic and respiratory) episodic manifestations of Pickwick syndrome. Rev Neurol (Paris) 112: Gold AR, Dipalo F, Gold MS et al. (2003). The symptoms and signs of upper airway resistance syndrome: a link to the functional somatic syndromes. Chest 123: Guerrero M, Lepler L, Kristo D (2001). The upper airway resistance syndrome masquerading as nocturnal asthma and successfully treated with an oral appliance. Sleep Breath 5: Guilleminault C, Bassiri A (2005). Clinical features and evaluation of obstructive sleep apnea hypopnea syndrome and the upper airway resistance syndrome. In: MH Kryger, TH Roth, WC Dement (Eds.), Principles and Practice of Sleep Medicine. 4th edn. WB Saunders, Philadelphia, pp Guilleminault C, Khramtsov A (2001). Upper airway resistance syndrome in children: a clinical review. Semin Pediatr Neurol 8: Guilleminault C, Li KK (2004). Maxillomandibular expansion for the treatment of sleep-disordered breathing: preliminary result. Laryngoscope 114: Guilleminault C, Winkle R, Korobkin R et al. (1982). Children and nocturnal snoring: evaluation of the effects of sleep related respiratory resistive load and daytime functioning. Eur I Pediatr 139: Guilleminault C, Stoohs R, Clerk A et al. (1993). A cause of daytime sleepiness: the upper airway resistance syndrome. Chest 104: Guilleminault C, Stoohs R, Kim YD et al. (1995). Upper airway sleep disordered breathing in women. Ann Intern Med 122: Guilleminault C, Faul JL, Stoohs R (2001a). Sleepdisordered breathing and hypotension. Am J Respir Crit Care Med 164: Guilleminault C, Poyares D, Palombini L et al. (2001b). Variability of respiratory effort in relationship with sleep stages in normal controls and upper airway resistance syndrome patients. Sleep Med 2: Guilleminault C, Kim YD, Chowdhuri S et al. (2001c). Sleep and daytime sleepiness in upper airway resistance syndrome compared to obstructive sleep apnea syndrome. Eur Respir J 17: Guilleminault C, Li K, Chen NH et al. (2002a). Two-point palatal discrimination in patients with upper airway resistance syndrome, obstructive sleep apnea syndrome, and normal control subjects. Chest 122: Guilleminault C, Palombini L, Poyares D et al. (2002b). Chronic insomnia, post-menopausal women, and SDB. Part 2: Comparison of non-drug treatment trials in normal breathing and UARS post-menopausal women complaining of insomnia. J Psychosomat Res 53: Guilleminault C, Khramtsov A, Stoohs RA et al. (2004). Abnormal blood pressure in pre-pubertal children with sleep-disordered breathing. Pediatr Res 55: Guilleminault C, Lee JH, Chan A (2005a). Pediatric obstructive sleep apnea syndrome. Arch Pediatr Adolesc Med 159: Guilleminault C, Poyares D, Rosa A et al. (2005c). Heart rate variability, sympathetic and vagal balance, and EEG

9 arousal in upper airway resistance and mild OSA. Sleep Med 6: Guilleminault C, Kirisoglu C, Rosa A da et al. (2006a). Sleepwalking, a disorder of NREM sleep instability. Sleep Med 7: Guilleminault C, Kirisoglu C, Poyares A et al. (2006b). Upper airway resistance syndrome: an outcome study on a retrospective cohort. J Psychiatr Res 40 (3): Jung R, Kuhlo W (1965). Neurophysiological studies of abnormal night sleep and the pickwickian syndrome. Prog Brain Res 18: Kimoff JR, Sforza E, Champagne V et al. (2001). Upper airway sensation in snoring and obstructive sleep apnea. Am J Respir Crit Care Med 164: Krakow B, Melendrez D, Lee SA et al. (2004). Refractory insomnia and sleep-disordered breathing: a pilot study. Sleep Breath 8: Lewin DS, Pinto MD (2004). Sleep disorders and ADHD: shared and common phenotypes. Sleep 27: Lopes MC, Guilleminault C (2005). Cyclic alternating pattern in adults with upper airway resistance syndrome. Sleep 28 (S1): A184. Loube DI, Andrada T, Howard RS (1999). Accuracy of respiratory inductive plethysmography for the diagnosis of upper airway resistance syndrome. Chest 115: MacKenzie RA, Skuse NF, Lethelean AF (1977). A microelectrode study of peripheral neuropathy in man. Part 2. Response to conditioning stimuli. J Neurosci 34: Mallampati SR, Gatt SP, Gugino LD et al. (1985). A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 32: Nanba S, Ohsaki R, Shiomi T (2002). Apparatus and method for electronically predicting pleural pressure from pulse wave signals. United States Patent Application US2002/ A1. UPPER-AIRWAY RESISTANCE SYNDROME 409 Nguyen ATD, Jobin V, Payne R et al. (2005). Laryngeal and velo-pharyngeal sensory impairment in obstructive sleep apnea. Sleep 28: Norman RG, Ahmed MM, Walslebel JA et al. (1997). Detection of respiratory events during NPSG: nasal cannula/ pressure sensor versus thermistor. Sleep 20: Pirelli P, Saponara M, Guilleminault C (2004). Rapid maxillary expansion in children with obstructive sleep apnea syndrome. Sleep 27: Powell N, Riley R, Guilleminault C et al. (1996). A reversible uvulopalatal flap for snoring and sleep apnea syndrome. Sleep 19: Poyares D, Guilleminault C, Rosa A et al. (2002). Arousal, EEG spectral power and pulse transit time in UARS and mild OSAS subjects. Clin Neurophysiol 113: Serebrisky D, Cordero R, Mandeli J et al. (2002). Assessment of inspiratory flow limitation in children with sleep-disordered breathing by a nasal cannula pressure transducer system. Pediatric Pulmonol 33: Series F, Simoneau JA, St.Pierre S et al. (1996). Characteristics of the genioglossus and musculus uvulae in sleep apnea hypopnea syndrome and in snorers. Am J Resp Crit Care Med 153: Stoohs RA, Blum HC, Knaak L et al. (2004). Non-invasive estimation of esophageal pressure based on intercostals EMG monitoring. IEEE IMB Virkkula P, Silvola J, Maasilta P et al. (2002). Esophageal pressure monitoring in detection of sleep-disordered breathing. Laryngoscope 112: Woodson BT, Garancia J, Toohill RJ (1991). Histopathologic changes in snoring and obstructive sleep apnea syndrome. Laryngoscope 101: Yoshida K (2002). Oral device therapy for the upper airway resistance syndrome patient. J Prosthet Dent 87:

Underwriting Sleep Apnea

Underwriting Sleep Apnea Underwriting Sleep Apnea Joel Weiner, MD, FLMI April 29, 2014 WAHLU The Northwestern Mutual Life Insurance Company Milwaukee, WI A Brief Survey Before We Get Started The Weiner Sleepiness Scale How likely

More information

Snoring and Obstructive Sleep Apnea (updated 09/06)

Snoring and Obstructive Sleep Apnea (updated 09/06) Snoring and Obstructive Sleep Apnea (updated 09/06) 1. Define: apnea, hypopnea, RDI, obstructive sleep apnea, central sleep apnea and upper airway resistance syndrome. BG 2. What are the criteria for mild,

More information

Department of Pulmonology, Critical Care and Sleep Medicine, Bolan Medical College, Pakistan

Department of Pulmonology, Critical Care and Sleep Medicine, Bolan Medical College, Pakistan Cronicon OPEN ACCESS PULMONOLOGY AND RESPIRATORY MEDICINE Review Article Sleep Apnea Sanaullah Tareen Department of Pulmonology, Critical Care and Sleep Medicine, Bolan Medical College, Pakistan *Corresponding

More information

ROLE OF ORAL APPLIANCES TO TREAT OBSTRUCTIVE SLEEP APNEA

ROLE OF ORAL APPLIANCES TO TREAT OBSTRUCTIVE SLEEP APNEA 1 ROLE OF ORAL APPLIANCES TO TREAT OBSTRUCTIVE SLEEP APNEA There are three documented ways to treat obstructive sleep apnea: 1. CPAP device 2. Oral Appliances 3. Surgical correction of nasal and oral obstructions

More information

Sleep Apnea from an Anatomical, Anthropologic and Developmental Perspective.

Sleep Apnea from an Anatomical, Anthropologic and Developmental Perspective. Sleep Apnea from an Anatomical, Anthropologic and Developmental Perspective. Brian Palmer, DDS Kansas City, Missouri ADSM June 4 2004 www.brianpalmerdds.com A1 Warning Some pictures in this presentation

More information

Diseases and Health Conditions that can Lead to Daytime Sleepiness

Diseases and Health Conditions that can Lead to Daytime Sleepiness October 21, 2014 Diseases and Health Conditions that can Lead to Daytime Sleepiness Indira Gurubhagavatula, MD, MPH Associate Professor Director, Occupational Sleep Medicine University of Pennsylvania,

More information

Sleep Difficulties. Insomnia. By Thomas Freedom, MD and Johan Samanta, MD

Sleep Difficulties. Insomnia. By Thomas Freedom, MD and Johan Samanta, MD Sleep Difficulties By Thomas Freedom, MD and Johan Samanta, MD For most people, night is a time of rest and renewal; however, for many people with Parkinson s disease nighttime is a struggle to get the

More information

HEALTH EVIDENCE REVIEW COMMISSION (HERC) COVERAGE GUIDANCE: DIAGNOSIS OF SLEEP APNEA IN ADULTS DATE: 5/9/2013 HERC COVERAGE GUIDANCE

HEALTH EVIDENCE REVIEW COMMISSION (HERC) COVERAGE GUIDANCE: DIAGNOSIS OF SLEEP APNEA IN ADULTS DATE: 5/9/2013 HERC COVERAGE GUIDANCE HEALTH EVIDENCE REVIEW COMMISSION (HERC) COVERAGE GUIDANCE: DIAGNOSIS OF SLEEP APNEA IN ADULTS DATE: 5/9/2013 HERC COVERAGE GUIDANCE The following diagnostic tests for Obstructive Sleep Apnea (OSA) should

More information

Changes in the Evaluation and Treatment of Sleep Apnea

Changes in the Evaluation and Treatment of Sleep Apnea Changes in the Evaluation and Treatment of Sleep Apnea Joseph DellaValla, MD FACP Medical Director Center for Sleep Medicine At Androscoggin Valley Hospital Sleep Related Breathing Problems Obstructive

More information

Obstructive Sleep Apnoea

Obstructive Sleep Apnoea for health professionals Obstructive Sleep Apnoea Obstructive Sleep Apnoea Definition Sleep apnoea is a disorder in which breathing is repeatedly interrupted during sleep. The word apnoea literally means

More information

Arlington Dental Associates Ira Stier DDS PC 876 Dutchess Tpk 2 Lafayette Ct. Poughkeepsie, NY 12603 Fishkill, NY 12524 845-454-7023 845-896-4977

Arlington Dental Associates Ira Stier DDS PC 876 Dutchess Tpk 2 Lafayette Ct. Poughkeepsie, NY 12603 Fishkill, NY 12524 845-454-7023 845-896-4977 Home Sleep Test Liability Form Study Equipment Due: @ I, accept responsibility for the sleep monitoring device while it is in rny possession. I understand that if I fail to return the device or I return

More information

Obstructive Sleep Apnoea

Obstructive Sleep Apnoea Obstructive Sleep Apnoea What is obstructive sleep apnoea? People who suffer from Obstructive Sleep Apnoea (OSA) reduce or stop their breathing for short periods while sleeping. This can happen many times

More information

Raising Sleep Apnea Awareness:

Raising Sleep Apnea Awareness: Raising Sleep Apnea Awareness: Among People with Diabetes in North Carolina, 2012 People with diabetes have more sleep problems than people without diabetes in the same age, sex, and race/ethnicity group.

More information

DIAGNOSING SLEEP APNEA. Christie Goldsby Florida State University PHY 3109 04/09/14

DIAGNOSING SLEEP APNEA. Christie Goldsby Florida State University PHY 3109 04/09/14 DIAGNOSING SLEEP APNEA Christie Goldsby Florida State University PHY 3109 04/09/14 Outline of Talk Background information -what is sleep apnea? Diagnosing sleep apnea -polysomnography -respiratory airflow

More information

About Sleep Apnea ABOUT SLEEP APNEA

About Sleep Apnea ABOUT SLEEP APNEA ABOUT SLEEP APNEA About Sleep Apnea What is Sleep Apnea? Sleep Apnea (from Greek, meaning "without breath") is one of the most common sleep disorders in which breathing stops and then restarts again recurrently

More information

SLEEP. Sleep Sleep disorders Lifestyle SCIENCE FAIR JUNE 11, 2010. Polysomnography (PSG) Polygraphy (PG) Neurophysiological parameters in PSG

SLEEP. Sleep Sleep disorders Lifestyle SCIENCE FAIR JUNE 11, 2010. Polysomnography (PSG) Polygraphy (PG) Neurophysiological parameters in PSG Sleep Sleep disorders Lifestyle SLEEP SCIENCE FAIR JUNE 11, 2010 Dirk Pevernagie and Ronald M. Aarts 1 2 Polysomnography (PSG) Method:Simultaneous recording of neurophysiological signals (EEG, EOG, EMG)

More information

Summary of AASM Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea - Updated July 2012

Summary of AASM Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea - Updated July 2012 Summary of AASM Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea - Updated July 2012 SUMMARY: Sleep technologists are team members who work

More information

Obstructive Sleep Apnea Case Study

Obstructive Sleep Apnea Case Study Obstructive Sleep Apnea Case Study Shirin Shafazand, MD, MS Neomi Shah, MD for the Sleep Education for Pulmonary Fellows and Practitioners, SRN ATS Committee August 2014 Part 1: Case Presentation Mr. Simon

More information

Children Who Snore Do they have Sleep Apnea? Iman Sami, M.D. Division of Pulmonary and Sleep Medicine, Children s National

Children Who Snore Do they have Sleep Apnea? Iman Sami, M.D. Division of Pulmonary and Sleep Medicine, Children s National Children Who Snore Do they have Sleep Apnea? Iman Sami, M.D. Division of Pulmonary and Sleep Medicine, Children s National June 3, 2015 No disclosures relevant to this talk No disclosures relevant to this

More information

PROVIDER POLICIES & PROCEDURES

PROVIDER POLICIES & PROCEDURES PROVIDER POLICIES & PROCEDURES CONTINUOUS POSITIVE AIRWAY PRESSURE The primary purpose of this document is to assist providers enrolled in the Connecticut Medical Assistance Program (CMAP Providers) with

More information

Treatment for Snoring and Obstructive Sleep Apnea. Ri 林 鴻 錡 /AsP 譚 慶 鼎

Treatment for Snoring and Obstructive Sleep Apnea. Ri 林 鴻 錡 /AsP 譚 慶 鼎 Treatment for Snoring and Obstructive Sleep Apnea Ri 林 鴻 錡 /AsP 譚 慶 鼎 Nonsurgical treatment Weight loss Avoidance of alcohol,sedatives,tobacco Positional devices Oral or nasal appliances Nasal continuous

More information

CRANIOFACIAL ABNORMALITIES

CRANIOFACIAL ABNORMALITIES CRANIOFACIAL ABNORMALITIES It is well documented that mouth-breathing children grow longer faces. A paper by Tourne entitled The long face syndrome and impairment of the nasopharyngeal airway, recognised

More information

Snoring. As you breathe, air passes in and out of your lungs through your mouth, nose, and throat.

Snoring. As you breathe, air passes in and out of your lungs through your mouth, nose, and throat. Snoring Introduction Snoring is the harsh sound that is made when the flow of air through your mouth and nose is blocked while you are sleeping. Snoring can be an annoyance for your partner or other people

More information

Polysomnography in Patients with Obstructive Sleep Apnea. OHTAC Recommendation. Polysomnography in Patients with Obstructive Sleep Apnea

Polysomnography in Patients with Obstructive Sleep Apnea. OHTAC Recommendation. Polysomnography in Patients with Obstructive Sleep Apnea OHTAC Recommendation Polysomnography in Patients with Obstructive Sleep Apnea June 16, 2006 1 The Ontario Health Technology Advisory Committee (OHTAC) met on June 16, 2006 and reviewed a health technology

More information

MODULE. POSITIVE AIRWAY PRESSURE (PAP) Titrations

MODULE. POSITIVE AIRWAY PRESSURE (PAP) Titrations MODULE POSITIVE AIRWAY PRESSURE (PAP) Titrations POSITIVE AIRWAY PRESSURE (PAP) TITRATIONS OBJECTIVES At the end of this module the student must be able to: Identify the standards of practice for administering

More information

Maharashtra University of Health Sciences, Nashik. Syllabus. Fellowship Course in Sleep Medicine

Maharashtra University of Health Sciences, Nashik. Syllabus. Fellowship Course in Sleep Medicine Maharashtra University of Health Sciences, Nashik Syllabus Fellowship Course in Sleep Medicine Appendix A a) Title of the Fellowship Course: Fellowship Course in Sleep Medicine b) Duration of Course: 1

More information

What is sleep apnea? 2/2/2010

What is sleep apnea? 2/2/2010 Outline Nocturia and Sleep Apnea R. Keith Huffaker, MD Introduction Background & Incidence Definitions Differential Diagnosis of Nocturia Risk Factors of OSA Mechanism of OSA-Nocturnal Polyuria Diagnosis

More information

Diagnosis and Treatment

Diagnosis and Treatment Sleep Apnea: Diagnosis and Treatment Sleep Apnea Sleep Apnea is Common Dangerous Easily recognized Treatable Types of Sleep Disordered Breathing Apnea Cessation of airflow > 10 seconds Hypopnea Decreased

More information

Acknowledgements. Dental Management of Obstructive Sleep Apnea in a Maxillofacial Prosthodontic Practice. Transfer of Information

Acknowledgements. Dental Management of Obstructive Sleep Apnea in a Maxillofacial Prosthodontic Practice. Transfer of Information Dental Management of Obstructive Sleep Apnea in a Maxillofacial Prosthodontic Practice Alvin G. Wee, BDS, MS, MPH Associate Professor and Director Division of Oral Facial Prosthetics / Dental Oncology

More information

Rapid Resolution of Intense Suicidal Ideation after Treatment of Severe. From the Department of Psychiatry and Psychology (L.E.K.

Rapid Resolution of Intense Suicidal Ideation after Treatment of Severe. From the Department of Psychiatry and Psychology (L.E.K. Category [Case Report] Rapid Resolution of Intense Suicidal Ideation after Treatment of Severe Obstructive Sleep Apnea Lois E. Krahn, MD Bernard W. Miller, RPSGT Larry R. Bergstrom, MD From the Department

More information

Sleep Apnea. ACP Oct 26, 2014. Bashir Chaudhary, MD Sleep Institute of Augusta, Augusta GA

Sleep Apnea. ACP Oct 26, 2014. Bashir Chaudhary, MD Sleep Institute of Augusta, Augusta GA Sleep Apnea ACP Oct 26, 2014 Bashir Chaudhary, MD Sleep Institute of Augusta, Augusta GA Emeritus Professor of Medicine and Assistant Dean of Clinical Affairs, CAHS Medical College of Georgia, Georgia

More information

Sleep Apnea: Treatment

Sleep Apnea: Treatment Sleep Apnea: Treatment I. Policy University Health Alliance (UHA) will reimburse for positive airway pressure devices for the treatment of obstructive sleep apnea (OSA) when it is determined to be medically

More information

Treatment of Obstructive Sleep Apnea (OSA)

Treatment of Obstructive Sleep Apnea (OSA) MP9239 Covered Service: Prior Authorization Required: Additional Information: Yes when meets criteria below Yes as shown below None Prevea360 Health Plan Medical Policy: 1.0 A continuous positive airway

More information

SLEEP DISTURBANCE AND PSYCHIATRIC DISORDERS

SLEEP DISTURBANCE AND PSYCHIATRIC DISORDERS E-Resource December, 2013 SLEEP DISTURBANCE AND PSYCHIATRIC DISORDERS Between 10-18% of adults in the general population and up to 50% of adults in the primary care setting have difficulty sleeping. Sleep

More information

Reviews in Clinical Medicine

Reviews in Clinical Medicine Mashhad University of Medical Sciences (MUMS) Reviews in Clinical Medicine Clinical Research Development Center Ghaem Hospital The effect of nasal surgery on apnea-hypopnea index Navid Nourizadeh (MD)

More information

CPAP titration: PSG technologist or at Home

CPAP titration: PSG technologist or at Home CPAP titration: PSG technologist or at Home Carolyn D Ambrosio, MD, MS Associate Professor of Medicine Director, The Center for Sleep Medicine Tufts Medical Center Conflict of Interest No financial interest

More information

Obstructive Sleep Apnea and Sleep Disorders in All Age Groups Treatment

Obstructive Sleep Apnea and Sleep Disorders in All Age Groups Treatment Obstructive Sleep Apnea and Sleep Disorders in All Age Groups Treatment W. McD. Anderson, M.D. Medical Director, Tampa General Hospital Sleep Center Professor of Medicine, USF College of Medicine Program

More information

SLEEP APNEA AND SLEEP Diagnostic aspects. Carin Sahlin

SLEEP APNEA AND SLEEP Diagnostic aspects. Carin Sahlin SLEEP APNEA AND SLEEP Diagnostic aspects Carin Sahlin Department of Public Health and Clinical Medicine, Respiratory Medicine and Allergy, Umeå University, Sweden 2009 Umeå University Medical Dissertations

More information

Chapter 17 Medical Policy

Chapter 17 Medical Policy RAD-1 LCD for Respiratory Assist Devices (L11482) Contractor Information Contractor Name Contractor Number 00635 Contractor Type LCD Information LCD Database ID Number L11482 AdminaStar Federal, Inc. DMERC

More information

A Healthy Life RETT SYNDROME AND SLEEP. Exercise. Sleep. Diet 1. WHY SLEEP? 4. ARE SLEEP PROBLEMS A COMMON PARENT COMPLAINT?

A Healthy Life RETT SYNDROME AND SLEEP. Exercise. Sleep. Diet 1. WHY SLEEP? 4. ARE SLEEP PROBLEMS A COMMON PARENT COMPLAINT? Diet Sleep Exercise RETT SYNDROME AND SLEEP DR. DANIEL GLAZE, MEDICAL DIRECTOR THE BLUE BIRD CIRCLE RETT CENTER A good night s sleep promotes learning, improved mood, general good health, and a better

More information

Obstructive Sleep Apnea: Test and you will diagnose But what does that mean? A PCP s attempt to understand

Obstructive Sleep Apnea: Test and you will diagnose But what does that mean? A PCP s attempt to understand Obstructive Sleep Apnea: Test and you will diagnose But what does that mean? A PCP s attempt to understand John Koeppe, MD General Internal Medicine Grand Rounds March 18 th, 2014 Disclosures No financial

More information

What is Obstructive Sleep Apnoea?

What is Obstructive Sleep Apnoea? Patient Information Leaflet: Obstructive Sleep Apnoea Greenlane Respiratory Services, Auckland City Hospital & Greenlane Clinical Centre Auckland District Health Board What is Obstructive Sleep Apnoea?

More information

Obstructive sleep apnea and type 2 diabetes Obstructive Sleep Apnea (OSA) may contribute to or exacerbate type 2 diabetes for some of your patients.

Obstructive sleep apnea and type 2 diabetes Obstructive Sleep Apnea (OSA) may contribute to or exacerbate type 2 diabetes for some of your patients. Obstructive sleep apnea and type 2 diabetes Obstructive Sleep Apnea (OSA) may contribute to or exacerbate type 2 diabetes for some of your patients. Prevalence of OSA and diabetes Prevalence of OSA Five

More information

Treating Sleep Apnea A Review of the Research for Adults

Treating Sleep Apnea A Review of the Research for Adults Treating Sleep Apnea A Review of the Research for Adults Is This Information Right for Me? Yes, if: A doctor said you have mild, moderate, or severe obstructive sleep apnea, or OSA. People with OSA may

More information

Summary and Conclusions

Summary and Conclusions Summary and Conclusions Summary and Conclusions Conclusions Cardiovascular complications, diabetes mellitus and death q Obstructive sleep apnoea syndrome covaries with cardiovascular disease, including

More information

Each of us has our own

Each of us has our own Orthodontic Strategies for Sleep Apnea A team of orthodontists has developed a strategy to effectively implement treatment of obstructive sleep apnea into a practice and improve patients lives BY TERRY

More information

THE PANTHERA ANTI-SNORING DEVICE PATIENT INSTRUCTIONS FOR USE

THE PANTHERA ANTI-SNORING DEVICE PATIENT INSTRUCTIONS FOR USE THE PANTHERA ANTI-SNORING DEVICE PATIENT INSTRUCTIONS FOR USE Contents Definitions...3 Before sleeping...4 General information...5 Description of Your Anti-Snoring Device...5 Material Used...6 Indications

More information

Proceedings of the International MultiConference of Engineers and Computer Scientists 2009 Vol I IMECS 2009, March 18-20, 2009, Hong Kong

Proceedings of the International MultiConference of Engineers and Computer Scientists 2009 Vol I IMECS 2009, March 18-20, 2009, Hong Kong Pairwise Classifier Approach to Automated Diagnosis of Disorder Degree of Obstructive Sleep Apnea Syndrome: Combining of AIRS and One versus One (OVO-AIRS) K. Polat, S. Güneş, and Ş. Yosunkaya Abstract

More information

Sleep Medicine. Maintenance of Certification Examination Blueprint. Purpose of the exam

Sleep Medicine. Maintenance of Certification Examination Blueprint. Purpose of the exam Sleep Medicine Maintenance of Certification Examination Blueprint Purpose of the exam The exam is designed to evaluate the knowledge, diagnostic reasoning, and clinical judgment skills expected of the

More information

Diagnosis of Sleep Apnea

Diagnosis of Sleep Apnea Diagnosis of Sleep Apnea John E. Stevenson, MD, FACP ABSTRACT Rapidly accumulating evidence shows that sleep apnea is a major factor influencing personal health and public safety. Diagnosis and treatment

More information

Medical Information to Support the Decisions of TUECs INTRINSIC SLEEP DISORDERS

Medical Information to Support the Decisions of TUECs INTRINSIC SLEEP DISORDERS Introduction Excessive daytime sleepiness (EDS) is a common complaint. Causes of EDS are numerous and include: o Intrinsic sleep disorders (e.g. narcolepsy, obstructive sleep apnoea/hypopnea syndrome (OSAHS)

More information

Fiberoptic bronchoscopy (FOB) is a procedure that pulmonologists

Fiberoptic bronchoscopy (FOB) is a procedure that pulmonologists Original Article Diagnosing Obstructive Sleep Apnea by Performing Fiberoptic Bronchoscopy and PEEP Titration of Mask Continuous Positive Airway Pressure Saenghirunvattana S, MD Sawang Saenghirunvattana,

More information

Name of Policy: Management of Obstructive Sleep Apnea Syndrome

Name of Policy: Management of Obstructive Sleep Apnea Syndrome Name of Policy: Management of Obstructive Sleep Apnea Syndrome Policy #: 065 Latest Review Date: December 2015 Category: Surgery/Medical/DME Policy Grade: D Background/Definitions: As a general rule, benefits

More information

SLEEP STUDIES AND THERAPY MANAGEMENT

SLEEP STUDIES AND THERAPY MANAGEMENT SLEEP STUDIES AND THERAPY MANAGEMENT Effective November 1 st, 2012 Policy NHP has partnered with SMS (Sleep Management Solutions) and their parent company, CareCentrix (CCX) to provide sleep study and

More information

Comparing the Performance and Efficacy of the 3B/BMC RESmart. Auto-CPAP with the ResMed S9 AutoSet

Comparing the Performance and Efficacy of the 3B/BMC RESmart. Auto-CPAP with the ResMed S9 AutoSet 3B MEDICAL, INC., 21301 US HIGHWAY 27, LAKE WALES, FL. 33859 Comparing the Performance and Efficacy of the 3B/BMC RESmart Auto-CPAP with the ResMed S9 AutoSet Zhi Zhuang, PhD, Research and Development,

More information

Sleep and Home Sleep Studies November 2013

Sleep and Home Sleep Studies November 2013 TITLE: Sleep and Home Sleep Studies SOURCE: Grand Rounds Presentation, The University of Texas Medical Branch in Galveston, Department of Otolaryngology DATE: November 26, 2013 RESIDENT PHYSICIAN: Robert

More information

Does Depression affect compliance with CPAP therapy in patients with Obstructive Sleep Apnea? Ramesh Metta, MBBS M Jeffery Mador, MD

Does Depression affect compliance with CPAP therapy in patients with Obstructive Sleep Apnea? Ramesh Metta, MBBS M Jeffery Mador, MD Does Depression affect compliance with CPAP therapy in patients with Obstructive Sleep Apnea? Ramesh Metta, MBBS M Jeffery Mador, MD Background Obstructive Sleep Apnea(OSA) Obstructive sleep apnea (OSA)

More information

Sleep Disorders , The Patient Education Institute, Inc. [www.x-plain.com] nr Last reviewed: 03/06/2011 1

Sleep Disorders , The Patient Education Institute, Inc. [www.x-plain.com] nr Last reviewed: 03/06/2011 1 Sleep Disorders Introduction Sleep disorders are very common conditions that can be overcome. It is important to understand what affects sleep and the importance of sleep. This reference summary will help

More information

General Information about Sleep Studies and What to Expect

General Information about Sleep Studies and What to Expect General Information about Sleep Studies and What to Expect Why do I need a sleep study? Your doctor has ordered a sleep study because your doctor is concerned you may have a sleep disorder that is impacting

More information

Corporate Medical Policy

Corporate Medical Policy Corporate Medical Policy Polysomnography for Non Respiratory Sleep Disorders File Name: Origination: Last CAP Review: Next CAP Review: Last Review: polysomnography_for_non_respiratory_sleep_disorders 10/2015

More information

EXPECTATIONS OF PHYSICIANS INTENDING TO PRACTISE SLEEP MEDICINE CHANGING SCOPE OF PRACTICE PROCESS BACKGROUND

EXPECTATIONS OF PHYSICIANS INTENDING TO PRACTISE SLEEP MEDICINE CHANGING SCOPE OF PRACTICE PROCESS BACKGROUND EXPECTATIONS OF PHYSICIANS INTENDING TO PRACTISE SLEEP MEDICINE CHANGING SCOPE OF PRACTICE PROCESS BACKGROUND The College is gradually moving toward a system of performance measurement by focusing on a

More information

Headache and Sleep Disorders 屏 東 基 督 教 醫 院 沈 秀 祝

Headache and Sleep Disorders 屏 東 基 督 教 醫 院 沈 秀 祝 Headache and Sleep Disorders 屏 東 基 督 教 醫 院 沈 秀 祝 Sleep Sleeping later Sleep deprivation Excessive Sleep Sleep Migraine Physiology of sleep Headache Clinical, Anatomical, and Physiologic Relationship Between

More information

DIAGNOSIS AND MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA. Venigalla Naga Venu Madhav 1 *

DIAGNOSIS AND MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA. Venigalla Naga Venu Madhav 1 * DIAGNOSIS AND MANAGEMENT OF OBSTRUCTIVE SLEEP APNEA 1 * 1. Dr. M.D.S. Reader, Department of Prosthodontics, Bharati Vidyapeeth Dental College and Hospital, Pune. Abstract Collapsibility of the upper airway

More information

Understanding Sleep Apnea

Understanding Sleep Apnea Understanding Sleep Apnea www.sleepmangementsolutions.com What is Obstructive Sleep Apnea (OSA)? OSA afflicts 20 million adult men and women in the U.S. People who have OSA stop breathing repeatedly during

More information

CLINICAL NEUROPHYSIOLOGY

CLINICAL NEUROPHYSIOLOGY CLINICAL NEUROPHYSIOLOGY Barry S. Oken, MD, Carter D. Wray MD Objectives: 1. Know the role of EMG/NCS in evaluating nerve and muscle function 2. Recognize common EEG findings and their significance 3.

More information

Sleep Apnea Dr. Douglas Tapper

Sleep Apnea Dr. Douglas Tapper Sleep Apnea Dr. Douglas Tapper Dr. Hendler: Hello and welcome to KP Healthcast. I m your host today, Dr. Peter Hendler, and our guest is Dr. Douglas Tapper who is the chief of Pulmonary Medicine at Kaiser

More information

SNORING. Snoring. What Causes Snoring?

SNORING. Snoring. What Causes Snoring? SNORING Snoring Forty-five percent of normal adults snore at least occasionally, and 25 percent are habitual snorers. Problem snoring is more frequent in males and overweight persons, and it usually grows

More information

Surgical Treatment of Sleep Apnea Surgical Information

Surgical Treatment of Sleep Apnea Surgical Information Surgical Treatment of Sleep Apnea Surgical Information Obstructive Sleep Apnea General Information Obstructive sleep apnea (OSA) is a disorder of breathing during sleep characterized by decreased or absence

More information

elf-awareness Toolkit

elf-awareness Toolkit S Snoring & Sleep Apnea elf-awareness Toolkit Snoring: Your Dentist Can Test So You Can Rest 2009 Snoring Isn t Sexy, LLC S Snoring & Sleep Apnea elf-awareness Toolkit Snoring: Your Dentist Can Test So

More information

You re saving teeth but are you saving lives? An Introduction & Overview of Dental Sleep Medicine Dr. Gy Yatros Diplomates, ABDSM

You re saving teeth but are you saving lives? An Introduction & Overview of Dental Sleep Medicine Dr. Gy Yatros Diplomates, ABDSM You re saving teeth but are you saving lives? An Introduction & Overview of Dental Sleep Medicine Dr. Gy Yatros Diplomates, ABDSM Des Moines, IA May 2, 2015 2 WHO WE ARE Dental Sleep Solutions was founded

More information

Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea

Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea Positive Airway Pressure and Oral Devices for the Treatment of Obstructive Sleep Apnea Policy Number: Original Effective Date: MM.01.009 11/01/2009 Line(s) of Business: Current Effective Date: HMO; PPO;

More information

THE LUNGS IN MARFAN SYNDROME

THE LUNGS IN MARFAN SYNDROME THE LUNGS IN MARFAN SYNDROME Many people with Marfan syndrome and some related disorders experience pulmonary complications, or problems with their lungs. If you have Marfan syndrome, it is important for

More information

Respiratory Inductance Plethysmography An Introduction

Respiratory Inductance Plethysmography An Introduction Respiratory Inductance Plethysmography An Introduction Gandis G. Mazeika, MD Rick Swanson, RPSGT, CRTT Committed to Excellence Pro-Tech Services, Inc. 4338 Harbour Pointe Blvd. S.W. Mukilteo, WA 98275

More information

Scoring (manual, automated, automated with manual review)

Scoring (manual, automated, automated with manual review) A. Source and Extractor Author, Year Reference test PMID RefID Index test 1 Key Question(s) Index test 2 Extractor B. Study description Sampling population A Recruitment Multicenter? Enrollment method

More information

Integration of the new miniaturized pneumotachograph for SOMNOscreen plus (Item no.: SEN513)

Integration of the new miniaturized pneumotachograph for SOMNOscreen plus (Item no.: SEN513) Software-News DOMINO 2.7.0 July 2015 The latest DOMINO version 2.7.0 comes with a handful of new features, allowing a high quality, user-friendly collection and analysis of the ambulatory PG and PSG recordings

More information

Sleep-Wake Patterns in Brain Injury Patients in an Acute Inpatient Rehabilitation Hospital Setting

Sleep-Wake Patterns in Brain Injury Patients in an Acute Inpatient Rehabilitation Hospital Setting Sleep-Wake Patterns in Brain Injury Patients in an Acute Inpatient Rehabilitation Hospital Setting David T. Burke, MD * Mrugeshkumar K. Shah, MD * Jeffrey C. Schneider, MD * Brian Ahangar, MD Samir-Al-Aladai,

More information

Tara Leigh Taylor, MD, FCCP Intensivist, Wyoming Medical Center

Tara Leigh Taylor, MD, FCCP Intensivist, Wyoming Medical Center Tara Leigh Taylor, MD, FCCP Intensivist, Wyoming Medical Center Objectives Define the magnitude of the problem Define diagnostic criteria of insomnia Understand the risk factors and consequences of insomnia

More information

Sleep Apnea Monitoring (SAM)

Sleep Apnea Monitoring (SAM) Sleep Apnea Monitoring (SAM) With the Sleep Apnea Monitoring (SAM) function, REPLY TM 200*, KORA TM 100* and KORA TM 250 * pacemakers provide the physician with automatic screening of pacemaker patients

More information

News on sleep apnea for the commercial trucking industry. Support system leads to CPAP success

News on sleep apnea for the commercial trucking industry. Support system leads to CPAP success PPD Protecting Professional Drivers SM Driver edition Summer 2011 Volume 4, Issue 3 News on sleep apnea for the commercial trucking industry Visit PPD s new driver blog for OSA support Support system leads

More information

Contractor Information. LCD Information

Contractor Information. LCD Information LCD for Continuous Positive Airway Pressure System (CPAP) (L11528) Contractor Name Tricenturion Contractor Number 77011 Contractor Type DMERC Contractor Information LCD ID Number L11528 LCD Title LCD Information

More information

New Mouthpiece Provides Relief for Truckers with Obstructive Sleep Apnea

New Mouthpiece Provides Relief for Truckers with Obstructive Sleep Apnea For Immediate Release For More Information Contact: Dave Kushin Zebra Communications 805-955-0009 Fax: 805-955-0003 email: dave.kushin@zebracom.net www.zebracom.net New Mouthpiece Provides Relief for Truckers

More information

Obstructive Sleep Apnea (Not so) Sweet Dreams

Obstructive Sleep Apnea (Not so) Sweet Dreams Obstructive Sleep Apnea (Not so) Sweet Dreams Sleep, riches, and health, to be truly enjoyed, must be interrupted. -- Jean-Paul Richter Presented by: Brad Heltemes, M.D. VP & Chief Medical Director ING

More information

SLEEP AND PARKINSON S DISEASE

SLEEP AND PARKINSON S DISEASE A Practical Guide on SLEEP AND PARKINSON S DISEASE MICHAELJFOX.ORG Introduction Many people with Parkinson s disease (PD) have trouble falling asleep or staying asleep at night. Some sleep problems are

More information

Respiratory Medicine. Understanding Sleep Apnoea

Respiratory Medicine. Understanding Sleep Apnoea Respiratory Medicine Understanding Sleep Apnoea The Respiratory Medicine Service provides inpatient and outpatient care on acute and chronic respiratory diseases. Apart from treating conditions, we also

More information

The Importance of Restful Sleep 4. Normal Breathing During Sleep 5. The Impact of Snoring on Sleep 6. Causes of Snoring 7

The Importance of Restful Sleep 4. Normal Breathing During Sleep 5. The Impact of Snoring on Sleep 6. Causes of Snoring 7 Contributing Authors THEODORE M. BERMAN, M.D. is a board certified medical specialist in sleep disorders medicine and pulmcnary medicine. Dr. Berman is a partner of the Minn sota Sleep Institute and practices

More information

Understanding sleep apnea

Understanding sleep apnea Understanding sleep apnea What is Obstructive Sleep Apnea (OSA)? OSA is a common, yet often undiagnosed sleep disorder. It afflicts 20 million adult men and women in the U.S. People who have OSA stop breathing

More information

Obstructive Sleep Apnea

Obstructive Sleep Apnea STANDARDS & GUIDELINES Obstructive Sleep Apnea The Role of Dentists in the Treatment of Snoring and Obstructive Sleep Apnea with Oral Appliances TABLE OF CONTENTS Standards and guidelines inform practitioners

More information

Pulmonary Diseases. Lung Disease: Pathophysiology, Medical and Exercise Programming. Overview of Pathophysiology

Pulmonary Diseases. Lung Disease: Pathophysiology, Medical and Exercise Programming. Overview of Pathophysiology Lung Disease: Pathophysiology, Medical and Exercise Programming Overview of Pathophysiology Ventilatory Impairments Increased airway resistance Reduced compliance Increased work of breathing Ventilatory

More information

Snoring is caused by vibration of the uvula and

Snoring is caused by vibration of the uvula and Acoustic rhinometry findings in patients with mild sleep apnea STEVEN M. HOUSER, MD, FAAOA, BULENT MAMIKOGLU, MD, BENJAMIN F. AQUINO, MS, MD, RIZWAN MOINUDDIN, BA, and JACQUELYNNE P. COREY, MD, FACS, FAAOA,

More information

Respiratory Concerns in Children with Down Syndrome

Respiratory Concerns in Children with Down Syndrome Respiratory Concerns in Children with Down Syndrome Paul E. Moore, M.D. Associate Professor of Pediatrics and Pharmacology Director, Pediatric Allergy, Immunology, and Pulmonary Medicine Vanderbilt University

More information

OUTCOMES OF CPAP TREATMENT IN A SLEEP LABORATORY SPECIALIZED IN NEUROPSYCHIATRY

OUTCOMES OF CPAP TREATMENT IN A SLEEP LABORATORY SPECIALIZED IN NEUROPSYCHIATRY JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2004, 55, Suppl 3, 15 22 www.jpp.krakow.pl J. ANTCZAK 1,2, P. GEISLER 2, R. POPP 2 OUTCOMES OF CPAP TREATMENT IN A SLEEP LABORATORY SPECIALIZED IN NEUROPSYCHIATRY

More information

Paul Wylie, MD 1, Sukhdev Grover, MD 2 1 Arkansas Center for Sleep Medicine, Little Rock AR; 2 Sleep Center of Greater Pittsburgh, Pittsburgh, PA

Paul Wylie, MD 1, Sukhdev Grover, MD 2 1 Arkansas Center for Sleep Medicine, Little Rock AR; 2 Sleep Center of Greater Pittsburgh, Pittsburgh, PA Automatic Bi-level Positive Airway Pressure Delivery with Flow-Directed Pressure Modulation and Expiratory Pressure Relief an In-laboratory Comparison with Conventional Bi-level Positive Airway Pressure

More information

What Can I Do about Atrial Fibrillation (AF)?

What Can I Do about Atrial Fibrillation (AF)? Additional Device Information 9529 Reveal XT Insertable Cardiac Monitor The Reveal XT Insertable Cardiac Monitor is an implantable patientactivated and automatically activated monitoring system that records

More information

Perioperative Management of Patients with Obstructive Sleep Apnea. Kalpesh Ganatra,MD Diplomate, American Board of Sleep Medicine

Perioperative Management of Patients with Obstructive Sleep Apnea. Kalpesh Ganatra,MD Diplomate, American Board of Sleep Medicine Perioperative Management of Patients with Obstructive Sleep Apnea Kalpesh Ganatra,MD Diplomate, American Board of Sleep Medicine Disclosures. This activity is supported by an education grant from Trivalley

More information

Understanding Hypoventilation and Its Treatment by Susan Agrawal

Understanding Hypoventilation and Its Treatment by Susan Agrawal www.complexchild.com Understanding Hypoventilation and Its Treatment by Susan Agrawal Most of us have a general understanding of what the term hyperventilation means, since hyperventilation, also called

More information

Sleep Position Trainer. The best treatment for Positional OSAS

Sleep Position Trainer. The best treatment for Positional OSAS Sleep Position Trainer The best treatment for Positional OSAS Innovation distinguishes between a leader and a follower. - Steve Jobs Positional Therapy for (P)OSAS Positional Obstructive Sleep Apnea Syndrome

More information

CPAP TREATMENT Patient information September 2007

CPAP TREATMENT Patient information September 2007 LUNG FUNCTION UNIT CASTLE HILL HOSPITAL MEDICAL DIVISION CPAP TREATMENT Patient information September 2007 Working in Partnership to Provide a Quality Healthcare Service INTRODUCTION This leaflet has been

More information

Don t just dream of higher-quality sleep. How health care should be

Don t just dream of higher-quality sleep. How health care should be Don t just dream of higher-quality sleep. How health care should be Many of our patients with sleep disorders don t realize there s another way of life, a better way, until they are treated. Robert Israel,

More information

Multifocal Motor Neuropathy. Jonathan Katz, MD Richard Lewis, MD

Multifocal Motor Neuropathy. Jonathan Katz, MD Richard Lewis, MD Multifocal Motor Neuropathy Jonathan Katz, MD Richard Lewis, MD What is Multifocal Motor Neuropathy? Multifocal Motor Neuropathy (MMN) is a rare condition in which multiple motor nerves are attacked by

More information

The Upper Airway Resistance Syndrome and the Single Girl

The Upper Airway Resistance Syndrome and the Single Girl The Upper Airway Resistance Syndrome and the Single Girl Madge began her workday differently from the hundreds of others that had gone before. Avoiding the coffee room (the gathering place ), she took

More information