Transcript CRC 432 Subacute Care

CRC 432 Subacute Care
Module IV
Polysomnography (PSG)
&
Sleep-Disordered Breathing (SDB)
Normal Stages of Sleep
Two Major States of Sleep:
• NREM
• REM
Cycle back & forth every 60 to 90 minutes (4
to 5 cycles) during normal 8-hour sleep.
NREM
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1st stage of sleep
Restorative state
Three stages, each progressively deeper
Stage 1:
– Eye roll slowly
– Low amplitude waves
– 5% to 10% sleep in stage 1
NREM
• 2 to 10 minutes progresses to stage 2
• Stage 2:
– Sharp spike called “K-complexes” (sleep spindles)
– 405 to 50% sleep in stage 2
• Stage 3:
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Deepest stage of sleep
EEG demos “delta waves” (slow wave sleep)
Restorative sleep
Difficult to awaken person
Growth hormones released
NREM
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Body muscles exhibit tone
Core temp drops
Regulation of ventilation maintained
RR slow
VT decreases
PaCO2 increases
Occupies 75% of sleep (restorative sleep)
REM
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Brain active; dreaming
25% of total sleep period
Decreased skeletal muscle tone
Paralyzing effect
Paralysis causes episodes of hypoxemia &
hypercapnia
• Loss of sketal muscle tone affect pharyngeal
muscles
REM
• Increased upper airway resistance (pharyngeal
muscles relax)
• Upper airway lumen decreased
• Tongue & soft tissues relax, causing upper
airway obstruction
• Cardiac dysrhythmias common
• Active brain activity, dreaming, & paralysis
Sleep Architecture
• Pattern of various sleep stages a person
enters throughout the night.
• Each person has a distinct sleep architecture
Sleep Apnea
• Apnea - cessation of airflow from the mouth
and nose for at least 10 seconds during
sleep.
• Dyssomnia - a group of disorders
characterized by difficulty in going to sleep,
or staying asleep or excessive daytime
sleepiness.
Sleep Apnea
• Parasomnia - any of several disorders that
frequently interfere with sleep, occurring
especially among children, and including
sleepwalking, night terrors, and bed-wetting
(nocturnal enuresis).
Sleep Apnea
• Types of sleep apnea
– Obstructive (OSA)
– Central (CSA)
– Mixed (OSA & CSA)
Sleep Apnea
• Obstructive sleep apnea
– Most common form of sleep apnea
– Drive to breathe is intact
– Upper airway intermittently becomes obstructed during
sleep
– Respiratory muscles work harder & harder to move air
– Patient partially awakens
– Airways clears, & ventilation resumes
– Depending on severity, cycle may occur hundreds of
times/night
Sleep Apnea
• Central Sleep Apnea
– Central drive to breathe is intermittently absent
during sleep
– When efforts to breathe stop, respiratory muscles
fail to contract
– Airflow through the mouth and nose ceases
• Mixed Sleep Apnea
– Patient has both OSA & CSA
Sleep Apnea
• OSA Pathophysiology
– The muscles of the soft palate around the base of the
tongue and the uvula relax, obstructing the airway.
– Upper airway tissues relax to levels below waking
state.
– Upper Raw increases as airway becomes occluded.
– Inspiratory muscles contract more forcefully.
– Increased negative intrathoracic pressure to overcome
obstruction.
Sleep Apnea
• OSA Pathophysiology
– Wet paper soda straw analogy
• Straw collapses as air is drawn through more
forcefully
– Upper airway obstruction may cause
• Apnea
• Hypercarbia
• Hypoxemia
Sleep Apnea
• OSA Pathophysiology
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Patient enters a “lighter” stage of sleep
Muscle tone returns to upper airway
Hypoxemia & hypercapnia arouse patient
Breathing resumes
When patient returns to deeper stage sleep,
process repeats
– Hundreds of cycles of deeper-lighter stages
throughout the night
Sleep Apnea
• OSA Clinical Features
– Sleep-disordered breathing ranges from
• Benign snoring with no health consequences
- to • OSA with severe clinical consequences
Sleep Apnea
• OSA Clinical Features
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Snoring
Excessive daytime somnolence
Morning headaches
Sleep fragmentation
Memory loss
Confusional awakenings
Sleep Apnea
• OSA Clinical Features
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Personality changes
Impotence
Night sweats
Cardiac dysrhythmias
Pulmonary/systemic hypertension
CHF
Nocturnal enuresis
Sleep Apnea
• OSA Clinical Features
– Daytime hypersomnolence most common symptom
– Results from sleep fragmentation
– Daytime hypersomnolence leads to
• Impaired cognitive function
• Impaired psychomotor function
Sleep Apnea
• OSA Clinical Features
– General appearance of OSA patients
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Obesity
Short, thick neck
Large tongue
Daytime vital signs often normal at rest
50% are hypertensive while awake
Breathing pattern/auscultation normal while awake
Sleep Apnea
• OSA Clinical Features
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Almost all OSA patients snore
NOT all snorers have OSA
25% men & 15% women snore
Patients NOT aware of problem
Spouse generally is first alerted to problem
Heart rate changes & dysrhythmias common
during OSA episodes
Sleep Apnea
• OSA Clinical Features
– Bradycardia before apnea; tachycardia
immediately after
– PVCs most common dysrhythmias
– Asystole in 10% of patients; lasts few seconds
Sleep Apnea
• Long-Term Cardiopulmonary Changes
Occurring with Untreated OSA
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nocturnal dysrhythmias
diurinal hypertension
pulmonary hypertension
R or L ventricular failure
myocardial infarction (MI)
stroke
Sleep Apnea
• OSA in Children
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Snoring is hallmark symptom
Can occur at any age or gender
May be overweight or have failure to thrive
Children may be sleepy or hyperactive
Developmental delay
Poor school performance
Aggressive behavior/ social withdrawal
Sleep Apnea
• CSA Pathophysiology
– Cessation of airflow through nose & mouth 2nd
to lack of diaphragmatic & respiratory muscle
movement
• CSA Clinical Features
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Little daytime effect
Patient does not recognize problem
Insomnia most common complaint
Mild snoring
Sleep Apnea
• Upper Airway Resistance Syndrome (UARS)
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Symptoms similar to those with snoring & OSA
Severe UARS causes frequent sleep interruptions
Do NOT desaturate (NO hypoxia)
Positive response to CPAP use
UARS believed to be under-recognized
Sleep Apnea
• Observation of hospitalized patients
– Gross sleeping characteristics
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Snoring?
Breathing pauses?
Cyanosis?
Note sleeping position
Note breathing pattern
oximetry
Sleep Apnea
• Observation of Hospitalized Patient
– Oximetry
• Gradual decrease on O2 SAT may indicate
nocturnal hypoventilation, NOT sleep apnea
• Pattern of sharp decline, followed by sharp
increase to baseline may indicate sleep apnea
Sleep Apnea
• Polysomnographic Studies
– Diagnostic Overnight PSG
– Diagnostic Daytime Multiple Sleep Latency
Test (MSLT)
– Two-Night PSG with CPAP Titration
– Split-Night PSG with CPAP Titration
Sleep Apnea
• Diagnostic Overnight PSG - General
monitoring and evaluation.
• Diagnostic Daytime Multiple Sleep
Latency Test (MSLT) - Used to diagnose
narcolepsy, and measure the degree of
daytime sleepiness. To ensure accurate
results, it is performed on the morning
following a Diagnostic Overnight PSG
Sleep Apnea
• Two-Night PSG with CPAP Titration - general
monitoring and diagnostic evaluation conducted
first night. If sleep apnea is discovered, patient
returns second night to determine the necessary
CPAP pressure required to alleviate apnea.
• Split-Night PSG with CPAP Titration conducted when moderate or severe sleep apnea
has been discovered, or strongly suspected during
the first part of the night’s study. The second half
of the night is used for CPAP titration.
Sleep Apnea
• Apnea: cessation of inspiratory gas flow
through both the nose and mouth for at least
10 seconds.
• Hypopnea: 30% or more decline in airflow
with a SaO2 decrease by at least 4%.
Sleep Apnea
• Apnea-Hypopnea Index (AHI)
• Mild: AHI 5 to 14, oxygen saturation ≥ 86%, and
minimal daytime disability.
• Moderate: AHI 15 to 30, oxygen saturation 80% to
85% ,and significant work or social dysfunction
due to drowsiness and loss of concentration.
• Severe: > 30, oxygen saturation ≤ 79%, and
incapacitation.
Sleep Apnea
• Respiratory Disturbance Index (RDI) number of apneas plus hypopneas per hour
of sleep, and quantifies SDB.
Sleep Apnea
• OSA Treatment
– CPAP acts as pneumatic splint, & maintains
upper airway patency during inspiration
– CPAP added in increments of 2.5 cm H2O until
apneas and snoring eliminated
– Uvulopalatopharyngoplasty (UPPP): eliminates
snoring, but OSA persists in 50% of cases
Sleep Apnea
• Periodic limb movement disorder (PLMD)
and restless legs syndrome (RLS) are
distinct disorders, but often occur
simultaneously.
• Both PLMD and RLS are also called
(nocturnal) myoclonus, which describes
frequent or involuntary muscle spasms.
Sleep Apnea
Periodic Limb Movement Disorder (PLMD)
• affects people only during sleep.
• characterized by behavior ranging from shallow,
continual movement of the ankle or toes, to wild and
strenuous kicking and flailing of the legs and arms.
• abdominal, oral, and nasal movement sometimes
• leg movement more typical than arm movement.
• typically occur for 0.5 to 10 seconds, in intervals
separated by five to 90 seconds.
Sleep Apnea
• PLMD
– repetitive, involuntary movement during the night
– movements usually occur in deep stage two sleep
– often causes arousal, poor sleep, which may lead to
sleep maintenance insomnia and/or excessive
daytime sleepiness
– considered a sleep disorder, because the movements
often disrupt sleep and lead to daytime sleepiness.
Sleep Apnea
• PLMD
– The causes of PLMD are unknown
– people with a variety of medical problems,
including Parkinson's disease and
narcolepsy, may have frequent periodic
limb movements in sleep
– PLMD may be induced by medications,
e.g., antidepressants
Sleep Apnea
• PLMD (Treatment)
– Parkinson's disease drugs, anticonvulsant
medications, benzodiazepines, and narcotics
– anti-Parkinson's medications first line of defense
– medical treatment of PLMD significantly reduces
or eliminates the symptoms
– no cure for PLMD
– medical treatment must be continued to provide
relief
Sleep Apnea
• PLMD (Treatment)
– Usual treatment is a combination of levodopa
and carbidopa (Sinemet)
Sleep Apnea
• PLMD
– incidence increases with age
– occurs in 5% of people ages 30 to
50; 44% of people over age of 65
– 12.2% of patients suffer from
insomnia; 3.5% patients exhibit
excessive daytime sleepiness may
experience PLMD.
Sleep Apnea
• RLS
– described as early as the 16th century, but was
not studied until the 1940s
– irresistible urge to move the legs while at rest
– person experiences vague, uncomfortable
feeling while at rest
– only relieved by moving the legs
Sleep Apnea
• RLS
– symptoms may be present all day long, making it
difficult for an individual to sit motionless
– may be present only in late evening.
– late evening symptoms can lead to sleep onset
insomnia, which tends to compound the effects of
RLS
– pregnancy, uremia, and post-surgery conditions have
also been known to increase incidence of RLS.
Sleep Apnea
• RLS
– strong urge to move legs
– need to move often accompanied by uncomfortable
sensations : "creeping," "itching," "pulling," "creepycrawly," "tugging," or "gnawing."
– symptoms start or become worse at rest
– the longer at rest, the greater the chance symptoms
will occur
– symptoms get better leg movement
– relief complete or partial, but generally starts soon after
starting activity
– relief persists as long as motor activity continues
Sleep Apnea
• RLS
– symptoms are worse in evening, especially
when person lies down
– activities bothersome at night are not
bothersome during the day
Sleep Apnea
• RLS (Treatment)
– dopaminergic agents, used to treat Parkinson's
disease, have been shown to reduce RLS
symptoms and PLMD, and are considered initial
treatment of choice
– benzodiazepines (clonazepam and diazepam)
prescribed for patients who have mild or intermittent
symptoms
– help patients obtain a more restful sleep
– do not fully alleviate RLS symptoms and can cause
daytime sleepiness
– because these depressants also may induce or
Sleep Apnea
• RLS (Treatment)
– no particular drug is effective for everyone with
RLS
– lifelong condition for which there is no cure
– diagnosis of RLS does not indicate the onset of
another neurological disease
Sleep Apnea
• RLS
– incidence increases with age.
– Affects 5% of population
– Approximately 80% of people with
RLS have PLMD, though most people
with PLMD do not experience RLS
Sleep Apnea
• Multiple Sleep Latency Testing (MSLT)
– Measures degree of sleep tendency or sleepiness
– Conducted during day following PSG
– 5 naps for < 30 min, start every 2 hours during day,
e.g., 8 AM, 10 AM, 12 PM, 2 PM ,4 PM
– Averages number of minute to fall asleep (sleep onset
latency)
– Determines if REM stage occurs during any naps
– Same leads as PSG
– Patient MUST remain awake between naps
– Diagnoses narcolepsy
Sleep Apnea
• MSLT
– Normal to fall asleep within 15 minutes during
daytime nap
– Falling asleep within 8 minutes & entering REM
indicate narcolepsy
Sleep Apnea
• Narcolepsy
– Permanent and overwhelming feeling of
sleepiness and fatigue (90%)
– Frequently unrecognized for many years
– Could be delay of 10 years between onset and
diagnosis
Sleep Apnea
• Narcolepsy
– Symptoms
• Dream-like hallucinations
• Feeling weak or paralyzed for a few seconds
• Sleep paralysis (25%)
• Cataplexy (75%)
• Hypnagogic hallucinations (30%)
Sleep Apnea
• Sleep paralysis (25%)
– Abnormal episode of REM sleep atonia
– Unable to move for few minutes
– Often upon falling asleep or awakening
• Cataplexy (75%)
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Sudden muscle weakness triggered by emotions
Knees buckle
Laughing, elation, surprise, or anger
Patient may fall and become completely
paralyzed a few minutes
Sleep Apnea
• Hypnagogic hallucinations (30%)
– Dream-like auditory or visual hallucinations
– Occur when dozing off, falling asleep, or awakening
Sleep Apnea
• Narcolepsy Treatment
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7 to 8 hours sleep
Regularly scheduled daytime naps
Avoid heavy meals and alcohol before sleeping
modafinil (Provigil), stimulant
methylphenidate (Ritalin) or other amphetamines
tricyclic antidepressants: protriptyline (Vivactil)
or imipramine (Tofranil)
Sleep Apnea
• Narcolepsy Treatment
– Antidepressants suppress REM sleep and
eliminate symptoms of cataplexy, hypnagogic
hallucinations, and sleep paralysis