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OVERVIEW OF SLEEP AND SLEEP APNEA
David Claman, MD
Professor of Medicine
Director, UCSF Sleep Disorders Center
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SLEEP HYPNOGRAM
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SLEEPY FIREFIGHTER?
• 45 year old firefighter complains of daytime sleepiness; “Doctor: I snore – could I have sleep apnea? I sleep alone so no one can tell me.”
• Reports “sleep hours 11 pm – 7 am”• Real schedule is 24 hr at work, then 48 hrs off
– At work sleep 2-4 hrs (no reports of apnea)
– 1st night after work: 10 pm – 8 am
– 2nd nightafter work: 1 am – 5:15 am (up early to drive to work!)
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CIRCADIAN RHYTHM DISORDERS
• Sunlight is main “Zeitgeber”; meals, exercise, & social activities can also shift sleep rhythms
• Internal Clock located in Suprachiasmatic nucleus (SCN) of hypothalamus
• Jet lag: light and social stimuli help shift internal biological clock 1-2 hrs / day
• Shift work: light and social stimuli are in conflict with work schedule; may lead to poor sleep quality, insomnia and chronic fatigue
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JET LAG
• Start trip sleep deprived• Dehydration on plane worsened by
caffeine and alcohol• Circadian rhythm “out of phase”• Flying West is easier
– delay sleep schedule by 1-2 hr/d
• Flying East is harder– advance sleep schedule by 0.5-1 hr/d
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JET LAG INTERVENTIONS• Avoid sleep deprivation before trip
– Consider daytime flight– Avoid important meetings the morning of arrival
• Adjust schedule before trip– 1-2 hours per day, for 1-2 days before trip
• Avoid alcohol and caffeine• Bright light
– In morning when flying east (to advance schedule)– In afternoon/evening when flying west (to delay)
• Hypnotic prn (zolpidem or melatonin)
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SHIFT WORK DISORDER
• Shift Work Disorder (SWD) is characterized by complaints of insomnia, excessive sleepiness and impaired performance that occur when work hours are scheduled during the usual sleep period
• 20% of workforce in industrialized countries are shift workers, & 40-80% of night workers report sleep difficulties
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SHIFT WORK DISORDER
• Most common schedule is to work Mon through Fri nights 11 pm – 7 am, but to sleep during those same hours on Sat / Sun
• Since sunlight is strongest stimulus of circadian rhythms, the body’s preferred sleep schedule stays oriented for the hours 11 pm – 7 am
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SHIFT WORK DISORDER
• Interventions: – Optimal approach is to stay awake at night on non-
working days and always sleep on the same schedule
– If patient continues to alternate their sleep schedule, try to maximize overlap between weekday and weekday schedules (if 7a-2p weekdays, then 3a-10a weekends)
– Avoiding sunlight on drive home at 7 am (using “glacier” sunglasses) may also be helpful
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DDx of Insomnia
• Psychiatric / psychological• Medical• Drugs (especially caffeine and alcohol)• Psychophysiological insomnia
– Somatized tension and anxiety causing insomnia
• Poor sleep hygiene– Maladaptive coping mechanisms are common
• Circadian rhythm issues
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SLEEP HYGIENE
• Keep regular bedtime and wake-up time
• Keep bedroom quiet, comfortable, & dark
• Relaxation technique for 10-30 min before bed
• Get regular exercise
• Don’t nap
• Don’t lie in bed feeling worried, anxious, or frustrated
• Don’t lie awake in bed for long periods of time
• Don’t use alcohol, caffeine, or nicotine
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DEFINITIONS: Apnea: complete cessation of airflow lasting 10
second or more Hypopnea: reduced airflow for 10 seconds or
more, associated with 4% oxygen desaturation (4% is classical definition)
Apnea-hypopnea index (AHI): average number of apneas & hypopneas per hour of sleep AHI < 5 is normal AHI 5-15 is mildly elevated AHI 15-30 is Moderate AHI > 30 Severe
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CLINICAL PREDICTORS OF OSA
Sleep Heart Health: Clinical predictors of AHI > 15: Male gender, older age, higher BMI, larger neck girth,
snoring & episodes of witnessed apnea
Young T et al. Arch Intern Med 2002 Apr 22;162(8):893-900
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Young T et al. Excess weight and sleep-disordered breathing. J Appl Physiol 2005;99(4):1592-9.
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Wisconsin OSA prevalence by gender and BMIYoung T. J Appl Physiol 2005;99(4):1592-9
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HYPERCAPNIA IN OSA
• French Multicenter Study; n=1141 from database• Excluded those with FEV1<80%• Overall prevalence of 11% with PaCO2 >45• BMI < 30 – prevalence 7.2%• BMI 30-40 – prevalence 9.8%• BMI > 40 – prevalence 23.6%
• Laaban J-P et al. Chest 2005;127:710-715
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OSA TREATMENT Weight loss (10% weight loss reduces AHI 25%) Avoid alcohol and sedatives Postural training (side sleeping since apnea worse on back) Nasal patency (treat allergies?) CPAP (also autoCPAP & Bi-level) Oral (dental) appliances ENT surgery:
Tonsillectomy in kids UPPP in adults 50% success; mandibular surgery 80-90% success
Nasal expiratory resistor (Provent) Nasal bandaid with microvalve – delivers approx 5 cm pressure
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CPAP – Site Non-specific
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LONGTERM USE OF CPAPBest compliance if AHI >30 & ESS >10
McArdle N et al. AJRCCM 1999;159:1108-1114
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PROFESSIONAL DRIVERS
• Hours of Service Rules– 10-11 hr driving limit; 14-15 hr on-duty limit– http://www.fmcsa.dot.gov/rules-regulations/topics/hos/index.htm
• Sleep Deprivation– Common in truck drivers; 35% up before 6 am
• Sleep Apnea – age and obesity major risks– Effect similar to being over legal alcohol limit in simulator
– Pack & Dinges: OSA prevalence• Mild 17%, Moderate 5.8%, Severe 4.7%• www.fmcsa.dot.gov/facts-research/research-technology/tech/Sleep-Apnea-Technical-Briefing.ht
m
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National Transportation Safety Board
• Sleep Apnea Alert October 2009
• Recommend “screening” but no regulations in place
• Federal Motor Carrier Safety Administration– Trucks, buses, trains
• US Coast Guard – ship pilots
• FAA – airline pilots
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DRIVER SAFETY• In California, if patient has caused an accident by
falling asleep at the wheel in the last 3 years, then Dept of Public Health must be notified
• If patient reports concerns about sleepiness while driving, chart should document: “Patient was advised not to drive if he / she is drowsy.”
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SLEEP HISTORY!!!
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REFERENCES• Behavioral and pharmacological therapies for late-life insomnia. CM
Morin et al. JAMA 1999;281:991-9• Cognitive Behavioral Therapy and Pharmacotherapy for Insomnia
Jacobs GD; Arch Intern Med 2004;164:1888-1896• Principles and Practice of Sleep Medicine. 4th Edition. Kryger, Roth,
& Dement. 2005• Jet lag and shift work sleep disorders: How to help reset the internal
clock. Kolla BP & Auger RR. Cleveland Clinic J of Med 2011;78(10):675-684
• Circadian Rhythm Sleep Disorders. Lu BS & Zee PC. CHEST 2006;130:1915-1923
• Marin JM et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea: an observational study. Lancet. 2005;365(9464):1046-53