inv sleep 2012
DESCRIPTION
25/3/2012Ix of sleep disorders by dr.Jaidaa MekkyTRANSCRIPT
![Page 1: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/1.jpg)
![Page 2: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/2.jpg)
Investigations of sleep disorders
BY
Dr.Jaidaa MekkyLecturer of NeuropsychiatrySleep Medicine Consultant
Member of the American Academy of NeurologyMember of the American Academy of Sleep
Medicine
Faculty of MedicineAlexandria University
![Page 3: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/3.jpg)
Background
• One-half to one-third of life asleep
• Sleep medicine relatively new field
• Sleep is a co-morbidity in a long list of diseases
• It was mentioned in the holy Quran 9 times, describing the sleep fnctions and stages
: فذلك ،� وجعا %ب يسب المزمنة األمراض فى النوم كان إذا قال أبقراط إن وقالالموت عالمات .من
![Page 4: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/4.jpg)
Milestones
• 1837 – Dickens – describes overweight/hypersomnolent boy in the Posthumous Papers of the Pickwick Club (term “pickwickian” used by Osler)
• 1875 – Caton – EEG in dogs• 1928 – Berger – Human EEG alpha waves• 1937 – Loomis – EEG Sleep stages
described
![Page 5: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/5.jpg)
Milestones• 1953 – Aserinsky & Kleitman – REM sleep
• 1970s – Polysomnography
• 1972 – Guilleminault – coins term OSA
• 1990 – International Classification of Sleep Disorders
![Page 6: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/6.jpg)
Sleep Physiology
• What is Sleep?– “a reversible behavioral state of perceptual
disengagement from and unresponsiveness to the environment”
• 75% in Non-REM sleep
• 25% REM sleep – muscle atonia, autonomic activation
![Page 7: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/7.jpg)
Sleep Architecture: NREM & REM Sleep
Pace-Schott EF, Hobson JA. Nat Rev Neurosci. 2002.
![Page 8: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/8.jpg)
Biological rhythms (periodic physiological fluctuations)
Types of rhythms
1. Ultradian (Basic Rest-Activity Cycle)2. Circadian (sleep-wake cycle)3. Infradian (menstrual cycle)4. Circannual (annual breeding cycles)
![Page 9: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/9.jpg)
![Page 10: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/10.jpg)
A major input to the relay and reticular nuclei of the thalamus (yellow pathway) originates from cholinergic (ACh) cell groups in the upper pons, the pedunculopontine (PPT) and laterodorsal tegmental nuclei (LDT). These inputs facilitate thalamocortical transmission. A second pathway (red) activates the cerebral cortex to facilitate the processing of inputs from the thalamus. This arises from neurons in the monoaminergic cell groups, including the tuberomammillary nucleus (TMN) containing histamine (His), the A10 cell group containing dopamine (DA), the dorsal and median raphe nuclei containing serotonin (5-HT), and the locus coeruleus (LC) containing noradrenaline (NA). This pathway also receives contributions from peptidergic neurons in the lateral hypothalamus (LHA) containing orexin (ORX) or melanin-concentrating hormone (MCH), and from basal forebrain (BF) neurons that contain γ-aminobutyric acid (GABA) or ACh. Note that all of these ascending pathways traverse the region at the junction of the brainstem and forebrain where von Economo noted that lesions caused profound sleepiness.
![Page 11: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/11.jpg)
![Page 12: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/12.jpg)
Sleep architecture over the lifespan
![Page 13: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/13.jpg)
![Page 14: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/14.jpg)
The main sleep c/o:
• Insomnia
• EDS
• Parasomnia
• Symptoms of SDB(snoring)
![Page 15: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/15.jpg)
![Page 16: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/16.jpg)
![Page 17: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/17.jpg)
![Page 18: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/18.jpg)
![Page 19: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/19.jpg)
ApproachSleep history( SLEEP LOG)( from the patient & bed partner)Medications ( hypnotic dependant sleep
disorder)Medical history( COPD, Hypothyroidism,
end organ failure)Neurological ( Parkinson,s disease,
dementia)Psychiatric ( depression, anexiety)Social history( marital ,social &
occupational functioning)
![Page 20: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/20.jpg)
Sleep Diary
![Page 21: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/21.jpg)
![Page 22: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/22.jpg)
Sleep Log
![Page 23: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/23.jpg)
Epworth sleepiness scaleSituation Chance of dozing
Sitting and reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Watching TV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sitting, inactive in a public place (e.g. a theatre or a meeting) . . . . . . .As a passenger in a car for an hour without a break . . . . . . . . . . . . . . .Lying down to rest in the afternoon when circumstances permit . . . . .Sitting and talking to someone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sitting quietly after a lunch without alcohol . . . . . . . . . . . . . . . . . . . . . In a car, while stopped for a few minutes in the traffic
Total . . . . . . . . . . . . . . . . . . . . . . . .
Score:
0-10 Normal range10-12 Borderline
12-24 pathological
![Page 24: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/24.jpg)
Examination
• Body habitus( obesity, poor hygiene)• Neck( circumference ,thyroid etc.)• Craniofascial abnormalities
(retrognathia, craniosynsitosis)• Otolaryngeal examination( nasal
mucosa, tongue ,uvula)• Pulmonary & cardiac examination• Neurological & Psychiatric assessment
![Page 25: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/25.jpg)
![Page 26: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/26.jpg)
Mallampati classification
![Page 27: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/27.jpg)
InvestigationsLaboratory Tests:
Thyroid functionSerum ferritin, hemoglobinHLA typing(HLA DQB1*0602 )Toxocological screeningLiver & kidney function
![Page 28: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/28.jpg)
Investigations( cont.)Neurologic Assessment:Videomonitored EEGImaging Studies: CT& / MRI
![Page 29: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/29.jpg)
Assessment of the upper airway
• Fluoroscopy
• Nasopharyngoscopy
• Cephalometry
• CT, Volumetric reconstruction
• MRI
![Page 30: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/30.jpg)
![Page 31: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/31.jpg)
![Page 32: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/32.jpg)
![Page 33: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/33.jpg)
Investigations( cont.)
Sleep TestsSleep Tests•Overnight PolysomnographyOvernight Polysomnography
) )VideomonitoredVideomonitored((•MSLTMSLT•MWTMWT•ActigraphyActigraphy•OSLER testOSLER test
![Page 34: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/34.jpg)
Polysomnography
Polysomnography is a simultaneous recording of multiple physiologic parameters related to sleep and wakefulness
– EEG – EOG – EMG
![Page 35: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/35.jpg)
![Page 36: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/36.jpg)
![Page 37: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/37.jpg)
![Page 38: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/38.jpg)
![Page 39: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/39.jpg)
![Page 40: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/40.jpg)
![Page 41: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/41.jpg)
Aapplication
![Page 42: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/42.jpg)
Parameters monitored: 1-Four (EEG) channels2-Two (EOG) channels 3-One (EMG) channel4-Airflow( nasal and
oral) for the detection of apnea
5-Sound recordings to measure snoring
![Page 43: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/43.jpg)
6-ECG 7-Pulse oximetry 8-Respiratory effort
(Thoracic and abdominal belts)
9- Tibialis anterior EMG10-Detector of the body
position 11-Esophageal
manometry
![Page 44: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/44.jpg)
![Page 45: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/45.jpg)
![Page 46: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/46.jpg)
Videomonitored PSG
![Page 47: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/47.jpg)
Neurologic monitoring Techniques
• Extended EEG ( 12-36) channel
• Repeated studies ,video monitored
DD:
• Nocturnal seizures
• Parasomnias
• REM behavioral disorders
![Page 48: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/48.jpg)
![Page 49: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/49.jpg)
Hypnogram
Standard Hypnogram
![Page 50: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/50.jpg)
PositionLeft
Right
Supine Prone
Upright
PLMS
With Arousal
W/O Arousal
Respiratory EventsMixed Apnea
Obstructive Apnea
Central Apnea
Hypopnea
Staging
Stage 4Stage 3Stage 2Stage 1
REMAwake
Movement Time
06 ã05 ã04 ã03 ã02 ã01 ã12 ã11 Õ
![Page 51: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/51.jpg)
![Page 52: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/52.jpg)
The main data presented in PSG are:
• 1) Total sleep time, wake time, total recording time;• 2) Sleep efficiency (total sleep time/total recording time);• 3) Latency for sleep onset, latency for REM sleep and other sleep
stages.• 4) Duration (in minutes) and proportion of total-sleep-time sleep
stages (5) Frequency of apneas and hypopneas per hour of sleep • 6) Saturation values and events of oxyhemoglobin desaturation • 7) Total number and index of periodic lower limb movements per hour
of sleep.• 8) Total number and index of micro-arousals per hour of sleep and
their relationship with breathing events or lower limb movements;• 9)Esophageal ph anormalities• 10)Penile tumecence
![Page 53: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/53.jpg)
Portable PSG
![Page 54: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/54.jpg)
MSLT -MWT
• 4-6 naps with 2h interval• Parameters monitored:• EEG(4channel)• EOG• Chin EMG• ECG• Respiratory flow (if needed)• Microphone (if needed)
![Page 55: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/55.jpg)
GERD
![Page 56: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/56.jpg)
Actigraphy
![Page 57: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/57.jpg)
![Page 58: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/58.jpg)
Actigraphy
• Cost efficient
• Records motor movements
• Aallows estimates for several days, avoiding the sampling error of NPSG
• It gives an idea about TST,SL, Nocturnal arousals
• It is superior to sleep log
![Page 59: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/59.jpg)
Uses:
• Used in assessment of Insomnia
• Useful in children and old age
• Circadian rhythm disorders
• Epidemiologic sleep studies
Limitations:
• It is not standardized yet for diagnosing PLMS,SDB or RBD.
![Page 60: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/60.jpg)
Osler testThe Oxford Sleep Resistance Test
![Page 61: Inv sleep 2012](https://reader035.vdocuments.mx/reader035/viewer/2022062312/5541e0465503465b0c8b45ab/html5/thumbnails/61.jpg)
Sleep tight