Sleep Medicine Pearls

Cover......Page 1
Front Matter......Page 2
Sleep Medicine Pearls......Page 4
Copyright......Page 5
Dedication......Page 6
Preface......Page 7
Video Contents......Page 8
Electroencephalography Monitoring......Page 9
Recommended Electroencephalography Derivations......Page 10
ELECTROOCULOGRAPHY MONITORING OF SLEEP......Page 11
References......Page 13
EEG Derivations and Eye Movements......Page 15
References......Page 18
FUNDAMENTALS 2: Electroencephalography and Electrooculography Patterns of Interest for Staging Sleep......Page 19
EYE MOVEMENT ELECTROOCULOGRAPHY PATTERNS......Page 21
References......Page 23
Eye Movements, Alpha Rhythm and Sleep Spindles in a 20-Year-Old Man......Page 24
References......Page 26
OVERVIEW OF SLEEP STAGES......Page 27
STAGE W (WAKEFULNESS) RULES......Page 29
Start of Stage N2......Page 30
End of Stage N2: Effect of Major Body Movement......Page 32
STAGE N3......Page 34
References......Page 35
A 35-Year-Old Woman Who is Taking Fluoxetine and a Benzodiazepine......Page 36
References......Page 38
Scoring Stage N1 versus Stage Win Two Patients......Page 39
References......Page 41
Recognizing Stages N1 and N2......Page 42
References......Page 44
Recognizing Stage N3 in a NormalIndividual and a Patient withChronic Pain......Page 45
References......Page 48
FUNDAMENTALS 4: Scoring Stage R......Page 49
START OF STAGE R......Page 50
CONTINUATION OF STAGE R......Page 51
END OF STAGE R......Page 52
SCORING SLEEP WITH A MIXTURE OF K-COMPLEXES OR SLEEP SPINDLES AND RAPID EYE MOVEMENTS......Page 53
References......Page 55
An Arousal Interrupts Stage N2 and Stage R Sleep......Page 56
AROUSAL RULES......Page 59
MAJOR BODY MOVEMENTS......Page 60
References......Page 61
Scoring Stage R......Page 62
Reference......Page 63
Identifying Stage R in a Woman with Violent Behavior During Sleep......Page 64
References......Page 66
A Patient with a Major Body Movement During Sleep......Page 67
References......Page 68
TERMINOLOGY OF SLEEP STAGES......Page 69
ADDITIONAL WAVEFORMS OF WAKEFULNESS......Page 70
PEDIATRIC STAGE N1......Page 71
PEDIATRIC STAGE R......Page 72
References......Page 74
A 3-Year-Old Male Undergoes a Sleep Study......Page 75
References......Page 77
NORMAL SLEEP IN ADULTS......Page 78
TST and Sleep Efficiency......Page 79
Changes in Arousal Index with Age......Page 80
NORMAL SLEEP IN INFANTS AND CHILDREN......Page 81
References......Page 82
Sleep in a 20-Year-Old Man, a 2-Month-Old Infant, and a 6-Month-Old Child......Page 83
References......Page 84
Short REM Latency......Page 85
References......Page 88
MEDICATIONS AND SLEEP......Page 89
REM LATENCY......Page 90
MEDICATIONS AND NIGHTMARES......Page 91
References......Page 92
Medications and Sleep......Page 93
References......Page 94
FUNDAMENTALS 9: Polysomnography I......Page 95
PSG CHANNELS......Page 96
IMPEDANCE CHECKING, CALIBRATION, AND BIOCALIBRATIONS......Page 97
SAMPLING RATE AND DIGITAL RESOLUTION......Page 99
LOW-FREQUENCY AND HIGH-FREQUENCY FILTERS AND NOTCH FILTERS......Page 101
References......Page 102
A Patient with Artifact in Many Channels......Page 103
References......Page 105
DIAGNOSTIC PSG......Page 106
PSG TITRATION......Page 107
OCST (UNATTENDED LIMITED CHANNEL SLEEP TESTING)......Page 108
INDICATIONS FOR OCST and PATIENT SELECTION......Page 109
OCST DEVICES......Page 110
ACTIGRAPHY......Page 111
References......Page 112
Out-of-Center Sleep Testing versusPortable Monitoring......Page 114
References......Page 117
FUNDAMENTALS 11: Artifacts......Page 118
SNORING OR RESPIRATORY CHIN EMG ARTIFACT......Page 121
References......Page 123
Patients with Eye Movements of Interest......Page 124
Bibliography......Page 126
A Patient with Artifacts in the EEG and EOG Derivations......Page 127
References......Page 129
AIR FLOW......Page 130
ALTERNATIVE SENSORS FOR APNEA AND HYPOPNEA......Page 131
RESPIRATORY EFFORT......Page 133
ARTERIAL OXYGEN SATURATION......Page 134
OTHER RESPIRATORY SENSORS......Page 135
References......Page 136
Respiratory Monitoring Questions......Page 137
References......Page 140
HYPOPNEA......Page 141
Classification of Hypopneas......Page 142
RESPIRATORY EFFORT-RELATED AROUSAL (RERA)......Page 143
CHEYNE-STOKES BREATHING......Page 145
AHI AND RDI......Page 146
References......Page 147
Identifying Respiratory Events......Page 148
Bibliography......Page 151
Two Patients with PossibleCentral Apnea......Page 152
References......Page 155
Why is the Arterial OxygenDesaturation Severe?......Page 156
References......Page 158
Central Apnea Rule......Page 159
PERIODIC BREATHING RULE......Page 161
References......Page 162
Sickle Disease and an UnexplainedLow Arterial Oxygen Saturation......Page 164
Bibliography......Page 169
Central Apnea and ObstructiveHypoventilation in Children......Page 170
References......Page 172
SINUS RHYTHM DURING SLEEP......Page 173
ATRIOVENTRICULAR BLOCK......Page 174
TACHYCARDIA DURING SLEEP......Page 175
PACEMAKERS......Page 177
Bibliography......Page 179
A Patient with Slowing of Heart Rate During Sleep......Page 180
References......Page 182
Patients with a Sudden Increase in Heart Rate......Page 183
References......Page 185
CRITERIA FOR LEG MOVEMENTS AND PERIODIC LIMB MOVEMENTS IN SLEEP......Page 187
LEG MOVEMENTS ASSOCIATED WITH RESPIRATORY EVENTS ARE NOT SCORED......Page 188
PERIODIC LIMB MOVEMENTS IN SLEEP......Page 189
BRUXISM......Page 190
Rem Sleep Behavior Disorder......Page 192
References......Page 194
Identifying Movements During Sleep......Page 195
Bibliography......Page 198
A Child with Repeated Movements During Sleep......Page 199
References......Page 201
SUBJECTIVE MEASURES......Page 202
MSLT Protocol......Page 203
Interpretation of the MSLT......Page 204
Maintenance of Wakefulness Test......Page 205
MWT Normative Data......Page 206
References......Page 207
Two Patients withQuestionable MSLT Results......Page 209
Bibliography......Page 211
Evaluating an MSLT......Page 212
Bibliography......Page 216
Scoring an MSLT and an MWT......Page 217
References......Page 220
NORMAL SLEEP DURATION......Page 222
MSLT IN CHILDREN AND ADOLESCENTS......Page 223
References......Page 224
A Teenager with Sleep-Onset REM......Page 225
References......Page 227
Sleep in Children......Page 228
References......Page 229
EVALUATION OF PATIENTS......Page 230
LABORATORY TESTING IN OSA......Page 231
PREDICTION OF THE PRESENCE OF OSA......Page 232
DIAGNOSTIC TESTING FOR SUSPECTED SLEEP APNEA......Page 233
OUT-OF-CENTER SLEEP TESTING......Page 235
References......Page 236
BIBLIOGRAPHY......Page 239
A 30-Year-Old Woman with Unexplained Daytime Sleepiness......Page 240
REFERENCES......Page 247
References......Page 244
RISK FACTORS FOR OSA......Page 248
Primary (Simple) Snoring......Page 249
Overlap Syndrome......Page 250
References......Page 251
A 45-Year-Old Man with a Distinct Pattern of Desaturation......Page 252
Bibliography......Page 255
A Patient with Severe Obesity and Hypercapnia......Page 256
References......Page 259
EPIDEMIOLOGY......Page 260
Neurobehavioral Consequences......Page 261
PSG IN PEDIATRIC OSA......Page 262
Tonsillectomy and Adenoidectomy......Page 263
Rapid Maxillary Expansion and Distraction Osteogenesis......Page 264
PAP Treatment in Pediatric Patients......Page 265
References......Page 266
A 5-Year-Old Child with Behavior Problems......Page 267
Bibliography......Page 268
A Snoring Patient Goes to Surgery......Page 269
References......Page 271
A 50-Year-Old Man with Severe Hypertension......Page 272
References......Page 274
A Patient with Insomniaand Snoring......Page 275
References......Page 277
A Patient with Snoring and Recent Cerebrovascular Accident......Page 278
References......Page 280
An Patient with Obstructive Sleep Apnea Gets Sleepy While Driving......Page 281
Bibliography......Page 284
CHOOSING TREATMENT......Page 285
MEDICAL TREATMENT......Page 286
Weight Loss......Page 287
Medical Therapies to Improve Nasal Patency......Page 288
Modafinil, Armodafinil, and Stimulants......Page 289
References......Page 290
Patient with OSA and Weight Loss......Page 292
References......Page 295
Postural OSA......Page 296
References......Page 298
MODES OF PAP......Page 299
Flexible PAP......Page 301
Ramp......Page 302
INTERFACES......Page 303
References......Page 304
Unable to Tolerate Nasal CPAP Because of “Too Much Pressure”......Page 307
References......Page 311
MONITORING DURING POSITIVE PRESSURE TITRATION......Page 312
TITRATION PROTOCOL......Page 316
PAP AND SUPPLEMENTAL OXYGEN......Page 317
TECHNIQUE OF AUTO-TITRATION......Page 318
References......Page 319
Questions About PAP Titration......Page 321
Bibliography......Page 323
PAP Titration Questions......Page 324
Bibliography......Page 326
A 50-Year-Old Man with Problems During a CPAP Titration......Page 327
Bibliography......Page 329
FACTORS INFLUENCING ADHERENCE AND IMPORTANCE OF EARLY ADHERENCE......Page 330
HOW MUCH ADHERENCE IS ENOUGH?......Page 331
INTERVENTIONS FOR SIDE EFFECTS......Page 332
PAP ADHERENCE IN PEDIATRIC PATIENTS......Page 333
References......Page 334
A Patient with a High Residual AHI on PAP......Page 335
Bibliography......Page 338
Intervention for PAP Problems......Page 339
Bibliography......Page 342
Nasal Congestion and Oronasal Masks......Page 343
Bibliography......Page 346
Auto-Titration......Page 347
References......Page 350
A Man with OSA Still Sleepy on Nasal CPAP......Page 351
Bibliography......Page 354
A Retired Nurse with Nocturia and Snoring......Page 356
References......Page 357
A Patient with Claustrophobia......Page 359
Bibliography......Page 361
An Obese 12-Year-Old with Sleep Apnea and Enlarged Tonsils......Page 362
Bibliography......Page 364
Persistent OSA after TNA......Page 365
Bibliography......Page 367
CPAP Treatment in a Child......Page 368
Bibliography......Page 370
A 20-Year-Old Female with Daytime Sleepiness Since Childhood......Page 371
Bibliography......Page 373
EVALUATION FOR POSSIBLE SURGICAL TREATMENT......Page 374
PALATAL IMPLANTS......Page 375
UVULOPALATOPHARYNGOPLASTY......Page 376
GENIOGLOSSUS ADVANCEMENT OR HYOID ADVANCEMENT......Page 377
MAXILLOMANDIBULAR ADVANCEMENT......Page 378
SUCCESS RATES OF UPPER AIRWAY SURGERY......Page 379
REFERENCES......Page 380
Patient 62: A Man with Severe OSA and
Limited Treatment Options......Page 382
References......Page 384
Upper Airway Surgery in Two Patients......Page 385
Bibliography......Page 387
EVALUATION OF THE PATIENT......Page 388
EXCLUSIONS AND CONTRAINDICATIONS......Page 389
TITRATION OR ADJUSTMENT OF ORAL APPLIANCES......Page 390
SIDE EFFECTS AND COMPLICATIONS......Page 391
FOLLOW-UP......Page 392
REFERENCES......Page 393
A 40-Year-Old Man with Sleep Apnea Unable to Accept CPAP Treatment......Page 394
Bibliography......Page 396
A45-Year-Old Woman Experiencing Daytime Sleepiness After UPPP......Page 397
Bibliography......Page 399
OBSTRUCTIVE VENTILATORY DYSFUNCTION......Page 400
NOCTURNAL DESATURATION IN COPD (NONAPNEIC)......Page 402
TIME OF NIGHT AND CIRCADIAN VARIATION IN LUNG FUNCTION......Page 404
BIBLIOGRAPHY......Page 405
35-Year-Old Woman with Asthma and Poor Sleep at Night......Page 406
Bibliography......Page 408
A 55-Year-Old Man with Chronic Obstructive Pulmonary Disease and Snoring......Page 409
References......Page 413
A 55-Year-Old Man with COPD and Nocturnal Desaturation......Page 414
Bibliography......Page 417
A Patient with Snoring and Heart Failure......Page 418
Bibliography......Page 421
CENTRAL SLEEP APNEA SYNDROMES......Page 422
CSA with Cheyne-Stokes Breathing (CSA-CSB)......Page 424
Treatment-Emergent Central Sleep Apnea......Page 426
Primary Central Sleep Apnea of Infancy......Page 427
SLEEP-RELATED HYPOVENTILATION DISORDERS......Page 428
Sleep-Related Hypoventilation Due to Medication or Substance......Page 429
BIBLIOGRAPHY......Page 430
A Man with Unexplained Central Sleep Apnea......Page 431
Bibliography......Page 434
BPAP-ST AND BPAP-T......Page 435
ADAPTIVE SERVOVENTILATION......Page 438
VOLUME-ASSURED PRESSURE SUPPORT......Page 440
USE OF AVAPS VERSUS ASV VERSUS BPAP-ST......Page 441
NPPV TITRATION AND TREATMENT......Page 442
REIMBURSEMENT FOR NPPV DEVICES......Page 443
BIBLIOGRAPHY......Page 445
Three Patients with Central Apneas on CPAP......Page 446
Bibliography......Page 451
Treatment-Emergent Central Sleep Apnea......Page 452
Bibliography......Page 455
A Patient with CHF and Central Apnea......Page 457
Bibliography......Page 462
A Patient with Sleep Apnea on Pain Medications......Page 463
Bibliography......Page 466
A Newborn with Cyanosis and a Young Child with Hypoventilation......Page 467
References......Page 470
A Young Woman with Headaches and Central Apnea and a Man with Breathing Pauses After Stroke......Page 471
Bibliography......Page 473
Bilevel Positive Airway Pressure(BPAP) and Adaptive Servoventilation (ASV)......Page 474
Bibliography......Page 476
Patients with a Neuromuscular Disorder......Page 477
Bibliography......Page 482
The Essential RLS Diagnostic Criteria (Box F31-1 and F31-2)2,4,5......Page 483
Causes of RLS......Page 485
PSG Findings in Patients with RLS......Page 486
Clinical Significance of the PLMSI and the PLMS Arousal Index......Page 487
Prevalence and Manifestations of PLMD......Page 488
REFERENCES......Page 489
Patients with Leg Kicks on a Sleep Study......Page 491
References......Page 493
A 58-Year-Old Man with Sleep Apnea and Leg Jerks on CPAP......Page 495
Bibliography......Page 497
NONPHARMACOLOGIC TREATMENTS......Page 498
DOPAMINERGIC MEDICATIONS......Page 499
Dopaminergic Side Effects......Page 500
Augmentation......Page 501
ANTICONVULSANT MEDICATIONS (ALPHA-2-DELTA LIGANDS)......Page 502
RLS TREATMENT ALGORITHM......Page 503
REFERENCES......Page 505
Problems with Dopamine Agonist Treatment for RLS......Page 507
Bibliography......Page 509
Patients on Dopamine Agonists with Worsening RLS......Page 511
Bibliography......Page 514
A Patient with RLS and Pain and a Patient with Ropinirole-Induced Nausea......Page 515
Bibliography......Page 517
Patients with RLS and Treatment Challenges......Page 518
Bibliography......Page 521
A Child with Difficulty Staying Asleep and Leg Kicks......Page 522
References......Page 524
NARCOLEPSY......Page 525
HLA Typing, Genetics, and CSF Hypocretin......Page 527
Narcolepsy Type I......Page 528
Daytime Sleepiness......Page 529
Narcolepsy Due to MedicalCondition (NDMC type 1 and type 2)......Page 530
IDIOPATHIC HYPERSOMNIA......Page 531
Subtype: IH with Long Sleep Time......Page 532
REFERENCES......Page 533
A 20-Year-Old Woman with Emotion-Induced Weakness......Page 534
Bibliography......Page 536
A 45-Year-Old Male with Severe Sleepiness......Page 537
Bibliography......Page 540
A Patient with Frequent Cataplexy and Sleep Paralysis......Page 541
Bibliography......Page 544
A Patient with Sleep Apnea and Possible Narcolepsy......Page 545
Bibliography......Page 547
A Child with Sleepiness and ``Syncope´´......Page 548
References......Page 550
Modafinil and Narcolepsy......Page 551
References......Page 552
A 25-Year-Old Woman with Narcolepsy Who Is Still Sleepy on Medication......Page 554
Bibliography......Page 558
Patients with Daytime Sleepiness and Cataplexy......Page 559
Bibliography......Page 562
A Patient with Extreme Difficulty Getting Out of Bed in the Morning......Page 563
Bibliography......Page 565
KLEINE-LEVIN SYNDROME (KLS)......Page 566
INSUFFICIENT SLEEP SYNDROME (ISS)......Page 567
Parkinson Disease (PD)......Page 568
REFERENCES......Page 569
A 35-Year-Old Man Requesting Stimulant Medication......Page 571
Bibliography......Page 573
Insufficient Sleep......Page 575
Bibliography......Page 577
A Patient with Prader-Willi Syndrome and Daytime Sleepiness......Page 578
Bibliography......Page 580
Sleepiness After Head Trauma......Page 582
Bibliography......Page 585
A Patient with Possible Narcolepsy and Weakness in the Hands......Page 586
Bibliography......Page 588
NREM PARASOMNIA......Page 589
Common Characteristics of NREM Parasomnia......Page 590
PSG in NREM Parasomnia......Page 591
RBD-Causes and Associations......Page 592
PSG in RBD......Page 593
Parasomnia Overlap Disorder......Page 594
Diagnosis of Nightmare Disorder......Page 595
BIBLIOGRAPHY......Page 596
A 20-Year-Old Student with Severe "Nightmares"......Page 598
Bibliography......Page 601
Violent Behavior During Sleep......Page 602
Bibliography......Page 604
Patients with Violent Dreams......Page 605
Bibliography......Page 607
A Woman Who Eats During the Night and Does Not Remember......Page 608
Bibliography......Page 610
A Woman Who Moans at Night anda Woman Who Experiences Jerks When Falling Asleep......Page 611
Bibliography......Page 613
MONITORING WITH ELECTROENCEPHALOGRAPHY (EEG)......Page 615
BIPOLAR MONITORING AND STANDARD MONTAGES......Page 616
INTERICTAL AND ICTAL ACTIVITY......Page 617
PHASE REVERSAL......Page 618
ICTAL ACTIVITY......Page 619
CLASSIFICATION OF SEIZURES AND TERMINOLOGY......Page 621
BIBLIOGRAPHY......Page 622
Rhythmic Electroencephalography Pattern During Polysomnography......Page 623
Bibliography......Page 625
A 55-Year-Old Man with Unusual Movements During Sleep......Page 626
Bibliography......Page 631
Abnormal Behavior During Sleep......Page 632
Bibliography......Page 635
A Child with Mouth Movements During Sleep and a Teenager with Jerks in the Morning After Awakening......Page 636
Bibliography......Page 638
Patients with Parkinsonism and Sleep Problems......Page 639
Bibliography......Page 643
FUNDAMENTALS 37: Evaluation of Insomnia......Page 644
MAJOR COMPONENTS OF CHRONIC INSOMNIA DISORDER......Page 645
INSOMNIA EVALUATION......Page 646
QUESTIONNAIRES, SLEEP LOGS, AND ACTIGRAPHY......Page 647
SLEEP LOGS......Page 648
ACTIGRAPHY......Page 649
CO-MORBID INSOMNIA......Page 651
REFERENCES......Page 652
A 30-Year-Old Woman Having Difficulty Falling and Staying Asleep......Page 653
Bibliography......Page 654
A Patient with Insomnia and an Irregular Sleep Pattern......Page 655
Bibliography......Page 657
A Woman with Sleepless Nights......Page 658
Bibliography......Page 659
Cognitive Therapy......Page 660
Behavioral Treatment of Insomnia in Children......Page 662
REFERENCES......Page 663
Patient 113: Behavioral Insomnia of Childhood......Page 665
Bibliography......Page 668
Patient with Unfavorable Sleep Habits......Page 669
Bibliography......Page 671
GABA-BZ-CHLORIDE IONOPHORE COMPLEX......Page 672
BZRA Effects on Sleep......Page 673
Side Effects of BZRAs......Page 675
General Considerations......Page 676
Choice of BZRA Hypnotic Medication......Page 677
SEDATING ANTIDEPRESSANTS AND ANTIPSYCHOTICS......Page 678
PHARMACOTHERAPY FOR PATIENTS WITH DEPENDENCE ISSUES......Page 679
PHARMACOTHERAPY OF INSOMNIA: OVERALL STRATEGY......Page 680
REFERENCES......Page 681
Sleep-Maintenance Insomnia WhileTaking a Hypnotic......Page 682
Bibliography......Page 684
Patient 116: Middle-of-the-Night Awakening and a Patient with Drug Dependence and Insomia......Page 685
Bibliography......Page 687
FUNDAMENTALS 40: Circadian Rhythm Sleep-Wake Disorders......Page 689
MARKERS OF CIRCADIAN PHASE......Page 690
Phase-Response Curve for Light......Page 691
Phase Shifting by Exogenous Melatonin......Page 692
Circadian Rhythm Sleep-Wake Disorders (CRSWD)......Page 693
Sleep Logs and Actigraphy......Page 695
REFERENCES......Page 696
Patient 117: A 20-Year-Old with Difficulty Falling Asleep......Page 698
Bibliography......Page 702
A 60-Year-Old Man with Early-Morning Awakening......Page 703
Bibliography......Page 705
A Patient with Periods of Insomnia and Daytime Sleepiness......Page 706

Bibliography......Page 708
An Older Woman with an Irregular Sleep Schedule......Page 709

Bibliography......Page 712
A Patient with Night Shift Work......Page 713

Bibliography......Page 716
Patients with Jet Lag......Page 717
Bibliography......Page 720
Major Depressive Disorder......Page 721
Bipolar 1 Disorder......Page 722
Bipolar 2 Disorder......Page 723
Effects of Antidepressants on Sleep......Page 724
Posttraumatic Stress Disorder......Page 725
REFERENCES......Page 727
Patients with Fatigue and Abnormal Sleep......Page 728
Bibliography......Page 731
A 45-Year-Old Man with Persistent Insomnia While on Treatment for Depression......Page 732
Bibliography......Page 734
A 30-Year-Old Woman Who Has Difficulty Getting Out of Bed......Page 735
Bibliography......Page 737
Patients with Terrifying Awakenings......Page 738
Bibliography......Page 739
A 50-Year-Old Combat Veteran with Upsetting Dreams......Page 741
Bibliography......Page 743
Normal Ranges for Sleep Architecture......Page 744
Typical Values for Sleep Parameters in Normal Children......Page 745
Medicare Guidelines for Reimbursement for Respiratory Assist Device......Page 747
Glossary......Page 749
A......Page 758
C......Page 759
E......Page 761
H......Page 762
I......Page 763
M......Page 764
O......Page 765
P......Page 767
R......Page 768
S......Page 769
Z......Page 771
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......Page 772