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Home , Central sleep apnea

1/6/2015

Sleep Related Disorders

Elisabeth Brandauer, MD Department of , Innsbruck Medical University, Austria

Movement Disorders in Barcelona, Jan 30-31

Abnormalities of during sleep

Possible location of respiratory Possible consequences: disturbances : • Snoring • Central respiratory drive • Apneas, • Oropharyngeal muscles • • Respiratory muscles • • Ventilation

Definitions

Apnea : drop in the peak thermal sensor excursion by >90% of baseline, duration at least 10 sec.

– obstructive apnea – central apnea – mixed apnea

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Hypopnea: • The nasal pressure signal excursion drop by >30% of baseline, duration at least 10 sec. • There is a >3% oxygen desaturation from pre-event baseline or the event is associated with arousal

Oxygen desaturation index (ODI):  number of desaturation per hour of sleep

Apnea- index (AHI):  Number of apneas and hypopneas per hour of sleep

Classification

Obstructive Sleep Related Hypoventilation Disorders Disorders • , Adult • Obesity Hypoventilation Syndrome • Obstructive Sleep Apnea, Pediatric • Congenital Central Alveolar Hypoventilation Syndrome • Late-Onset Central Hypoventilation with Central Sleep Apnea Syndromes Hypothalamic Dysfunction • Central Sleep Apnea with Cheyne-Stokes • Idiopathic Central Alveolar Hypoventilation Breathing • Sleep Related Hypoventilation Due to a • Central Apnea Due to a Medical Disorder Medication or Substance without Cheyne-Stokes Breathing • Sleep Related Hypoventilation Due to a • Central Sleep Apnea Due to High Altitude Medical Disorder Periodic Breathing • Central Sleep Apnea Due to a Medication Sleep Related Hypoxemia or Substance Disorder • Primary Central Sleep Apnea • Sleep Related Hypoxemia • Primary Central Sleep Apnea of Infancy • Primary Central Sleep Apnea of Isolated Symptoms and Normal Prematurity Variants • Treatment-Emergent Central Sleep Apnea • Snoring • Catathrenia

Obstructive Sleep Apnea

• (A and B) or C satisfy the criteria

A. The presence of one or more of the following: The patient complains of sleepiness, nonrestorative sleep, fatigue, or insomnia symptoms The patient wakes with breath holding, gasping or choking. The bed partner or other observers reports habitual snoring, breathing interruptions, or both during the patients sleep. The patient has been diagnosed with hypertension, a mood disorder, cognitive dysfunction, coronary artery , , congestive , , or type 2 diabetes mellitus

B. (PSG) or OCST (out-of-center sleep testing) demonstrates: Five or more predominantly obstructive respiratory events (obstructive and mixed apneas, hypopneas, or respiratory effort related arousals (RERAs) per hour of sleep during PSG or per hour of monitoring in OCST C. PSG or OCST demonstrates:. The presence of one or more of the following: Fifteen or more predominantly obstructive respiratory events per hour of sleep during a PSG or per hour of monitoring International Classification of Sleep Disorders 3rd American Academy of Sleep Medicine, 2014

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Demographics:  9% of females and 24% of males between 30-60 years with criterion AHI>5/h; 2% of females and 4% of males using the criterion AHI>5/h plus exzessive daytime sleepiness (Young et al. 1993)  3-7% of adult males, 2-5% of adult females (Punjabi 2008)

Predisposing Factors:  Obesity  Male>female  Prevalence increases with age with a plateau reached app. at age 65  Alcohol consumption and sedating medication  menopause  Endocrine disorders (hypothyroidism, acromegaly)  Maxillomandibular malformation, adenotonsillar enlargement  First degree relatives of OSA patients are twice as likely to have OSA

International Classification of Sleep Disorders 3rd American Academy of Sleep Medicine, 2014

Pathophysiology:

 Reduced cross sectional area of the upper airway lumen due to excessive bulk of soft tissues or craniofacial anatomy  During inspiration negative pressure is generated in the lumen of the upper airway  Activity of pharyngeal dilating muscles becomes insufficient in OSA  Further reduction of activity in these muscles in REM sleep  Event termination may occur with or without arousal:  Some events resolve with augmentation of muscle tone from chemical and mechanical stimuli  Others resolve with arousals

International Classification of Sleep Disorders 3rd Graduation: American Academy of Sleep Medicine, 2014  Mild OSA: AHI > 5/h  Moderate OSA: AHI 15-30/h  Severe OSA: AHI > 30/h

Diagnostic steps

 Clinical history

 Scales (e.g. Epworth Sleepiness Scale)

 OCST (out of center sleep testing)

 Polysomnography

 Testing daytime symptoms  Neuropsychological testing systems  Multiple Sleep Latency Test

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OCST

Polysomnography

Complications

 Excessive daytime sleepiness, reduction in quality of life

 Risk of accidents sixfold higher (Teran-Santos et al. 1999)

 Cognitive impairment, depression

 Cardiovascular risks : systemic hypertension („non dipping“),, congestive heart failure, stroke, cardiac ,  Hints on elevated levels of circulating inflammatory mediators related to repetitive episodes of oxygen desaturation and increased sympathetic activity

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Therapy

 Weight reduction, prevention of alcohol and medication

 Prevention of back position

 therapy

 Mandibular advancement devices

 Surgery (UVPP, surgery of tongue, tonsillectomy, hypoglossal nerve stimulation)

Positive airway pressure therapy

 CPAP (continous positve airway pressure)  APAP (automatically adjusting positive airway pressure)

Effect of CPAP therapy

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Central Sleep Apnea Syndromes

 Central Sleep Apnea with Cheyne-Stokes Breathing  Central Apnea Due to a Medical Disorder without Cheyne-Stokes Breathing  Central Sleep Apnea Due to High Altitude Periodic Breathing  Central Sleep Apnea Due to a Medication or Substance  Primary Central Sleep Apnea  Primary Central Sleep Apnea of Infancy  Primary Central Sleep Apnea of Prematurity  Treatment-Emergent Central Sleep Apnea

International Classification of Sleep Disorders 3rd American Academy of Sleep Medicine, 2014

Common features

– AHI > 5/h – Number of central apneas/hypopneas > 50%

Abb: central apneas, Polysomnography

Central Sleep Apnea Syndromes

Central Sleep Apnea with Cheyne- Stokes breathing

– Presence of atrial fibrillation/flutter, congestive heart failure or a neurological disorder

– Therapy: adaptive Servo-ventilation

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Central Sleep Apnea Syndromes

Due to medication or substances: Treatment Emergent Central  e.g Sleep Apnea  Central apneas due to CPAP treatment

Primary Central Sleep Apnea  rare  Arterial pCO2 drops below the hypocapnic apnea treshold  Frequent arousals from sleep predispose to central apneas

Sleep Related Hypoventilation Disorders

 Obesity Hypoventilation Syndrome  Congenital Central Alveolar Hypoventilation Syndrome  Late-Onset Central Hypoventilation with Hypothalamic Dysfunction  Idiopathic Central Alveolar Hypoventilation  Sleep Related Hypoventilation Due to a Medication or Substance  Sleep Related Hypoventilation Due to a Medical Disorder

Common features:  Insufficient sleep related ventilation, resulting in abnormally elevated PaCO2  Oxygen desaturation may be present, not necessarily  Scoring Hypoventilation: rise of pCO2 > 55mmHg for> 10min or rise of pCO2 during sleep> 10mmHg and pCO2>50mmHg for>10min

International Classification of Sleep Disorders 3rd American Academy of Sleep Medicine, 2014

Sleep Related Hypoventilation Disorders

Obesity Hypoventilation Syndrome

 Presence of hypoventilation during wakefulness (PaCO2>45mmHg)

 Obesity (BMI>30kg/m 2)

 Hypoventilation is not primarily due to other disease

 OSA is often present (80-90%)

 Symptoms like in OSA, hypersomnolence is common

 Therapy: CPAP, adaptive Servoventilation

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Sleep Related Hypoventilation Disorders

Congenital Central Alveolar Hypoventilation (Ondine ´s curse)

 Sleep related hypoventilation

 Mutation of gene PHOX2B

 Some central apneas may occur, but the predominant pattern is reduced flow/tidal volume

 Some patients may present phenotypically later in life

Sleep Related Hypoventilation Disorders

Sleep Related Hypoventilation due to a Medical Disorder

 Lung parenchymal or airway disease, pulmonary vascular pathology, chest wall disorder, neurologic disorder, muscle weakness

 Usually most severe in REM sleep

Sleep Apnea in Movement Disorders

 Parkinson ´s Disease

  Occurence of OSA, central sleep apnea, irregular and apneustic breathing, Cheyne Stokes breathing pattern, stridor

 Due to damaged brainstem structures controlling respiration

 OSA occurs more frequently than central sleep apnea

Caig and Iranzo, 2012

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Sleep Apnea in Parkinsons disease

• Controversial results on prevalence of SDB in PD

n Manifest or subclinical sleep breathing disorders in 50% of PD patients, but

sleep structure not normalized with nCPAP treatment (Schäfer 2001)

• Moderate or severe obstructive sleep apnea syndromes in 20% (Arnulf 2002) • 43 % sleep apnea syndrome, mostly mild or moderate with little oxygen desaturations (Diederich 2005) • Significant correlation of heavy snoring and ESS in PD and controls • (Högl et al 2003, Braga Neto 2006)

• Sleep apnea in PD less frequent than in sick in hospital controls (Arnulf 2009)

Sleep Apnea in Parkinsons disease

• Pathophysiology: Upper airway obstruction present in 24-65% of PD patients, thought to be related to hypokinesia and rigidity involving the upper airway (Sabate 1996, Shill 2002)

• PD patients might be protected from OSA due to lower body weight and muscle atonia during REM sleep

• Review of da Silva-Junior 2014: neither obstructive nor central disordered breathing events were more frequent in PD patients

Sleep Apnea in Parkinsons disease

• Excessive daytime sleepiness does not correlate with AHI in PD patients (da Silva-Junior 2014, review)

• SDB in PD does not seem to be a disease related process, more an aging related conditon (da Silva-Junior 2014, review)

• CPAP treatment should be done when necessary, and it is effective (Neikrug 2014)

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