Sleep disorders – overview and pitfalls

Dr. Aditya Jindal

Interventional Pulmonologist & Intensivist, sleep specialist
Jindal Clinics
SCO 21, Sec 20D, Chandigarh
DM Pulmonary and Critical Care Medicine (PGI Chandigarh),
FCCP
 Sleep disorders
1. Sleep related breathing disorders
2. Sleep related movement disorders
3. Insomnias
4. Parasomnias
5. Hypersomnias
6. Circadium rhythm sleep-wake disorders
Sleep related breathing disorder
• Central sleep apnea due to drug or substance
• Primary sleep apnea of infancy
• Obstructive sleep apnea
• Sleep-related nonobstructive alveolar
hypoventilation, idiopathic
• Primary central sleep apnea
• Central sleep apnea due to Cheyne Stokes
breathing pattern
• Central sleep apnea due to medical condition
not Cheyne Stokes
Spectrum of sleep disorder breathing

• Obesity-hypoventilation syndrome
• Severe obstructive sleep apnea
• Moderate obstructive sleep apnea
• Mild obstructive sleep apnea
• Upper airways resistance syndrome
• Chronic, heavy snoring
• Intermittent snoring
• Quiet breathing
 What is OSA?

OSA is a syndrome characterized by frequent

episodes of upper airway obstruction during
sleep, associated with recurrent arousals,
oxygen desaturation, and daytime symptoms
 Pathophysiology of OSA

Interplay between three important factors

• Anatomic Structural narrowing of
airway
• Neurologic Inadequate upper airway
dilator muscle function
• Mechanical Altered upper airway
collapsibility
Veasey, CCNA 2003
Risk of Untreated OSA
 Primary Secondary Clinical
events events consequences
• Vibration of soft palate • Snoring
Sleep onset • Pulmonary arterial • Pulmonary hypertension
vasoconstriction • Right heart failure
• Systemic arterial • Systemic hypertension
Upper airway vasoconstriction
narrowing
• Vagal bradycardia • Cardiac arrhythmias
• Cardiac ischemia and • Sudden unexplained
irritiability cardiac death
Obstructive apnea
• Cerebral vascular • Morning headache
dilatation
ipO2,hpCO2,ipH • Hypothalamic-pituitary- • Reduced libido
testicular dysfunction • Impotence
• Stimulation of • Polycythemia
Arousal from sleep erythropoeisis
• Cerebral impairment • Excessive daytime
and/or damage sleepiness
Airflow resumption
• Sleep fragmentation • Intellectual deterioration
• Loss of deep sleep • Behavioural disorders
Return to sleep • Excessive motor activity • Nocturnal “epilepsy”
 Sleep studies

Overnight
polysomnography is the
‘gold standard’ for diagnosis
of OSA

• Count number of respiratory events and

divide by hours of sleep to generate AHI
EEG

EOG Sleep staging

EMG

Flow sensor Oronasal Flow

Microphone Snoring

ECG Rate, rhythm

Thoracic Respiratory
Abdominal effort

Position Body position

EMG Leg movement

Oximeter SaO2
Diagnosis
Types of PSG
 EEG
Potentials generated by the
cerebral cortex
10-20 electrode placement
 Sleep staging
• Rechtschaffen and Kales (R and K) 1967
stage W,N1-4 & R

• AASM 2007stage W,N1-3 & R

Hypnogram in normal adult
 Hypnogram in OSA pt
W Sta g e

N1

N2

N3

2 1 :0 3 :5 3 2 3 :0 0 0 0 :0 0 0 1 :0 0 0 2 :0 0 0 3 :0 0 0 4 :0 0 0 5 :0 0 0 6 :0 0
 Awake

Alpha rhythm-trains of sinusoidal 8-13 activity over occipital region ; attenuating

with eye opening
Eye blinks- conjugate vertical eye movementsat a frequency of .5-2hz
REM may be seen with initial deflection lasting < 500msec
Submental EMG - relatively high tone
 NREM 1

slow eye movements: conjugate, regular , sinusoidal eye movement with

initial deflection >500 msec
vertex sharp waves
low amplitude 4-7 Hz/ mixed frequency activity
NREM 2
 Sleep Spindles

• Sleep Spindle – 11-16 Hz

• .5 second spindles - 6-7
cycles
• Central - vertex region
• >.5 second in duration
 K Complexes

• Sharp, slow waves, with a negative then positive

deflection
• No amplitude criteria
• >.5 second in duration
• Central in origin
 NREM 3

•>20% Delta Activity ( .5-2 Hz with amplitude >75 uV)is

seen over frontal region
•no eye movements
•EOG leads will only pick up the EEG activity
•about thirty to forty five minutes after sleep onset
•far more difficult to awaken
 Stage R

•Brain suddenly becomes much more active.

•REM-conjugate, irregular, sharply peaked eye movements with initial

deflection< 500 msec

•Low chin EMG activity
•Sawtooth waves- low amplitide sharply contoured or triangular (2-
6hz); over central head regions
EOG and EMG Placements

• E1
• M1
• M2
• E2
• CHIN EMG
Corneoretinal potential
EMG placement
Leg EMG
Position sensor
Thoraco-abdominal movements
Flow tracing
 EKG
Exhale Airway obstructs Airway opens

Airflow
Effort gradually increases
Inhale

Thoracic
effort
Paradoxing
Abd.
effort
Paradoxing Ends

SAO2
Blood oxygen levels reduce
to < 3% of basline value

Obstructive Apnea A complete blockage of the airway despite efforts

to breath. Notice the effort gradually increasing ending in airway
opening.
 ECG
ECG

Airflow
Airflow

Thor.
Thor.
Effort
Effort

Abd.
Abd.
Effort
Effort

SAO
SAO2 2

Central Apnea
 EKG

Airflow

Thoracic Effort

Abdominal Effort

SAO2

Mixed Apnea
 Exhale Airflow reduction

Inhale

> effort with paradox Paradox ends

SAO2 desaturation

Hypopnea This is an 18 second hypopneic event. The airflow

signal is reduced by approximately 50% during this event.
 Scoring SDB

Severity Mild Moderate Severe

AHI 5-15 15-30 >30

RDI 15-20 20-40 >40

OSA Treatment: CPAP
 5 Questions to Monitor CPAP
• Snoring despite CPAP?
• Weight change since CPAP started?
• When was equipment last checked?
• Still symptomatic?
• Problems?
 CPAP Compliance
-Widely variable rates 50-70% overall

– -Probably need >4 hrs. nightly for

response

– -Compliance determined early on

 CPAP Compliance
• Man or Machine?
– Man
• -Monitoring- Compliance feedback
• -Education/Reassurance/Reevaluation
• -Partner involvement

– Machine
• -Humidification- Warm Vs. Cold
• -Mask- Nasal Pillows, Full Face, Other
• -Blower- Bi-level, Auto-titration

• Berry RB. Sleep Med (1): 175; 2000

 Practice points: Auto-Adjusting CPAP
• Auto-CPAP offers no benefit over fixed CPAP in terms of
efficacy on the AHI
• It has not been established that unattended auto-CPAP
titration is safe without a previous diagnostic PSG
• Some, but not all, studies indicate auto-CPAP results in a
lower cumulative CPAP level. However, the importance of the
amount of applied pressure on CPAP adherence is not
consistently demonstrated
• Auto-CPAP has variable effects on adherence
 OSA Treatment: Surgery

• Laser-assisted uvulopalatoplasty (LAUP)

– AASM: not advised for OSA

• Uvulopalatopharyngoplasty (UPPP)
– 40% patients achieve AHI < 5

• Somnoplasty or Radiofrequency volumetric tissue

reduction (RFVTR)
– Role has yet to be fully defined

• Maxillofacial surgery
– Infrequently performed, but can be very effective
Radiofrequency Ablation
-Programmable levels of
radiofrequency energy delivered
by a proprietary disposable
device into upper airway
structures causing tissue necrosis
and fibrosis

-Less painful; ambulatory

procedure

-Unlikely to be singularly effective

for most OSA

-May be effective in combination

procedures

-Minimal peer-reviewed data

Oral Appliances
Tongue advancing
device
Sleep related disorders in other specialities
VPC, tachycardia in OSA pt
After CPAP
 CSR
• If there is at least 3 consecutive cycles of cyclical crescendo
and decrescendo change in breathing amplitude
• + atleast one of the below :
1. 5 or more central apnea / hypopnea per hr of sleep.
2. The cyclic cresendo and decresendo change in breathing
amplitude has a duration of atleast 10 consecutive mins.

CSR has variable cycle length that is most commonly in the

range of 60 seconds.
Nocturia
Erectile
dysfunction
• Psychiatry
– ADHD
– Depression
– Bipolar disorders
– Alcoholism
– PTSD
• Gastro
– GERD
• Dental
– Bruxism
 Pitfalls
1. Artifacts
2. Misdiagnosis
3. Superadded apnoea
4. Inadequate relief
POPPING ARTIFACT
MOISTURE ARTIFACT
Equipment malfunction
Oximetry probe malfunction
ECG artifact
Eye movement artifact
Complex sleep apnea
Kapur et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep
apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep
Med. 2017
 Take home message
1. Have a high index of suspicion

2. In hospital/ clinic study (both diagnostic & titration) is

recommended

3. Use home sleep testing only if parameters are met

4. Be aware of sleep related non-respiratory disorders

5. Be ready to tackle problems!