Sleep Medicine 101. Obesity and Sleep Apnea. Paul J. Windberg, MD Essentia Health

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1 Sleep Medicine 101 Paul J. Windberg, MD Essentia Health Obesity and Sleep Apnea Major risk factor, others include age, male gender, craniofacial abnormalities 60 to 90 % of OSA patients are obese (BMI >30) 2-4 % of US population have OSA (AH index >5) 1

2 Obesity and Sleep Apnea Up to 60 % of patients undergoing bariatric surgery have OSA Bariatric surgery ( and resultant weight loss) are effective treatment though issues are complex Fat distribution important, male vs. female Sleep Disorders Basic sleep physiology and function Sleep studies what?, how?, why? Sleep disorders: Sleep apnea Narcolepsy Insomnia Nocturnal Myoclonus Parasomnias (sleepwalking, night terrors, enuresis) Sleep Physiology Sleep once considered passive, EEG development proved it active and complex Two kinds of sleep: Non REM REM (rapid eye movement) Non REM - stage 1 (transitional) - stage 2 -slow wave (delta) 2

3 Sleep Physiology Stage 1 transition between waking and sleep (~30 sec 7 minutes) Reactivity to outside stimuli Short dreams People feel they are awake if asked Disconjugate rolling eye movements 3

4 Sleep Physiology Stage 2 About 50% of total sleep time Spindles/K complexes Delta Sleep (slow wave) EMG activity low Physiologically stable heart rate/respiration slow and regular Arousal difficult 10-20% of total sleep time REM Sleep EEG resembles stage 1/waking trace EMG lowest activity (paralysis) Rapid conjugate eye movements Dreaming usually reported REM Sleep Physiologic instability elevated and irregular heart rate, respiratory rate and blood pressure Erections in males About 20% of normal sleep time 4

5 Sleep Architecture Normally we cycle through all stages every minutes Most slow wave sleep is early in the night, most REM towards morning Age differences are prominent sleep in the elderly is fragmented / many stage changes / little slow wave sleep Optimum sleep may be at age sound sleep, easy onset/wakening, fully alert, circadian rhythms well entrained 5

6 Circadian Rhythm Our sun dictates a 24 hr. sleep/wake cycle our natural cycle is longer than this (~25 hr.) We synchronize these out of phase cycles by using clocks, meal times, sun positions, wake times Jet lag and rotating shifts cause significant sleep disruption Easier to delay sleep-wake cycle (stay up later) easier to adjust flying east to west 6

7 Sleep Needs Much variability average is 7.5 hours, cases of persons only needing 1-2 hours lifetime Persons have stayed awake up to 11 days they manifest microsleeps /poor function, but no ill effects What does sleep do? Delta sleep may aid musculoskeletal recovery REM aids psychologic recovery Why Do We Sleep? Restores body/brain deficits caused by waking activity no supporting evidence Energy conservation limit activity/energy expense (esp. warm blooded animals) Immobilization/protection from predators Sleep Studies Nocturnal polysomnogram monitors: EEG EOG (oculogram) EMG (chin and leg) Respiratory effort and airflow EKG Oximetry Videotape 7

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9 Who Needs A Sleep Study Loud snorers, witnessed apneas, marked daytime somnolence Sleepiness despite adequate sleep, abnormal REM behavior (*) RLS / PLMS / EDS Who Does Not Need A Sleep Study Insomnia Loud snorers who are not sleepy Most patients with COPD/CHF (periodic breathers) Chronic fatigue (non-sleepy) 9

10 Overnight Oximetry Normal study does not R/O OSA, UARS Abnormal study (mult. desats/ sawtooth ) nonspecific --? OSA,? CHF,? COPD Experienced clinicians have as good predictive power? reassurance test in borderline cases MSLT 5 naps (20 minutes) separated by 100 minutes awake EEG, EOG, EMG recorded Measure of somnolence sleep latency (normal about min., pathologic <5 min.) REM shortly after sleep? 10

11 Sleep Apnea (DOES) Most commonly obese men / history of loud snoring Complaint of EDS (excessive daytime somnolence), sleep attacks, (usually patient does not complain of difficulty during sleep) Hypertension, confusion, impotence, nocturia morning headaches seen Spouse describes apnea, snorting 11

12 OSA Clinical Manifestations EDS Morning HA RLS Choking (night and day) PND GERD (esp. nocturnal) Nocturia Depression Intellectual impairment Insomnia Obstructive Sleep Apnea Sleep study verifies frequent apneas (>10 sec) associated with respiratory effort Oxygen desaturation / arousals Poor sleep architecture, little REM or slow wave (delta) sleep Can see dangerous arrhythmias tachycardia (both atrial & ventricular) and severe bradycardia 12

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14 OSA -? How Dangerous Good correlation with systemic hypertension and hyperglycemia Poor correlation with pulmonary hypertension in the absence of daytime abnormal ABGs Some increase in risk of MI, CVA and sudden death, studies still not clear if only in severe cases,? Efficacy of treatment Obstructive Sleep Apnea Medical Treatment Weight loss Avoidance of sedatives (Position change) Nasal CPAP Dental appliances Nasal CPAP Continuous positive low pressure generated by a blower, applied via nasal mask Pressure can be increased by increasing resistance distal to the mask Acts to splint the airway Effectively abolishes OSA, may also CSA 14

15 Obstructive Sleep Apnea Surgical Treatment Tracheostomy UPPP (uvulopalatopharyngoplasty) Mandibular surgery Tonsillectomy / nasal repair 15

16 Mandibular repositioning appliance. This mandibular repositioning oral appliance is manufactured in a laboratory from dental impressions. 16

17 Mandibular repositioning appliance. This mandibular repositioning oral appliance is manufactured in a laboratory from dental impressions. Tongue retaining device (four views). When inserted into the suction cavity of this oral appliance, the tongue is held forward to maintain airway patency. Obesity Hypoventilation Syndrome ( Pickwickian ) Extreme obesity, alveolar hypoventilation during wakefulness ( CO 2, O 2 ) Typically also severe OSA, hypersomnolence Often cor pulmonale, high mortality Rx with CPAP/? BIPAP, O 2, weight loss (? surgical) occasionally need tracheostomy 17

18 Narcolepsy (DOES) Incidence 4/10,000/some familial predisposition Major symptom excessive sleepiness, starts in teens and twenties Patients often nap with short-term benefit Narcolepsy Abnormal manifestations of REM sleep Cataplexy Sleep paralysis Sleep hallucinations MSLT Sleep latency <5 min. Sleep-onset REM 18

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20 Narcolepsy Treatment with REM suppressants to control auxiliary symptoms Stimulants (Ritalin,Modafinil) to control hypersomnolence Naps are helpful Disease is lifelong Insomnia (DIMS) Perception of insufficient sleep common Transient / situational Psychiatric ( depression, anxiety ) Psychophysiologic: Learned poor sleep behavior Disruption of sleep-wake rhythm Fear of insomnia Insomnia Drugs and Alcohol Depressants decrease delta and REM sleep Stimulants disturb sleep/wake cycle crash on withdrawal Alcohol fragments sleep (like aging) alcoholic s sleep may remain disturbed for life 20

21 Sleep Hygiene Sleep as much as needed to feel refreshed and healthy during the following day, but not more. Curtailing the time in bed seems to solidify sleep; excessively long times in bed seem related to fragmented and shallow sleep. A regular arousal time in the morning strengthens circadian cycling and, finally, leads to regular times of sleep onset. A steady daily amount of exercise probably deepens sleep; occasional exercise does not necessarily improve sleep the following night. Sleep Hygiene (cont.) Occasional loud noises (e.g., aircraft flyovers) disturb sleep even in people who are not awakened by noises and cannot remember them in the morning. Soundattenuated bedrooms may help those who must sleep close to noise. Although excessively warm rooms disturb sleep, there is no evidence that an excessively cold room solidifies sleep. Sleeping with someone disturbs sleep Sleep Hygiene (cont.) Hunger may disturb sleep; a light snack may help sleep. An occasional sleeping pill may be of some benefit, but their chronic use is ineffective in most insomniacs. Caffeine in the evening disturbs sleep, even in those who feel it does not. 21

22 Sleep Hygiene (cont.) Alcohol helps tense people fall asleep more easily, but the ensuing sleep is then fragmented. People who feel angry and frustrated because they cannot sleep should not try harder and harder to fall asleep but should turn on the light and do something different. The chronic use of tobacco disturbs sleep. Nocturnal Myoclonus Usually associated with RLS Stereotyped leg twitches / repeat every seconds in cycles Patients complain both of frequent awakenings and excessive daytime sleepiness Usually are not aware of the twitching Nocturnal Myoclonus Diagnosis through sleep study showing the twitches on EMG and associated arousals (poor sleep architecture) R/O drug withdrawal, obstructive apnea, narcolepsy, uremia Treatment with clonazepam (benzo-diazepine), antiparkinsonian, opiates can be effective 22

23 Parasomnias Events that occur during or are exacerbated by sleep Sleepwalking (somnambulism), night terrors, enuresis Most common in children /? incomplete arousal from delta sleep Occur early in night Patients are often confused, hard to arouse Events rarely remembered Parasomnias Sleepwalking patients often are semipurposeful, but higher cortical functions are poor speech garbled, poor coordination Occasional episodes are normal in children, especially if wakened from delta sleep R/O epilepsy, drug effects (lithium/hypnotics) Don t waken, make environment safe 23

24 Parasomnias Night terrors marked anxiety/screams but hard to arouse (delta sleep) No memory / no dream described Common in children 4-10, usually clears by adolescence Different from nightmare occurs in REM/patients easily aroused, memory of event persists Why refer to a full service, accredited Sleep Center? Cheerleading Complexity of sleep disorders Coordination with psychiatry/behavioral specialists, ENT surgeons, respiratory therapists, bariatric surgeons, dentists When not to do a sleep study, and what then? 24