Hyoid Myotomy and Suspension

The genioglossus and geniohyoid muscles as well as the middle pharyngeal constrictors insert on the hyoid bone. Consequently, the position of the hyoid complex is important in maintaining the patency of the hypopharyngeal airway. Van de Graaff et al. (67) reported that anterior hyoid advancement improved the posterior airway space in a canine model. In 1984, Kaya (68) was the first to demonstrate this concept in human subjects. Thus, the rationale for hyoid myotomy and suspension is to...

Electroencephalographic Arousal and Microstructure

As with OSA, respiratory abnormality in UARS is closely linked to its clinical presentation in terms of excessive daytime sleepiness (EDS). Other atypical signs of OSA (such as disorders of initiating and maintaining sleep) may be more frequent in UARS. During inspiratory resistive loading, complex reflex mechanisms act to preserve upper airway patency (15) and metabolic demands. If this ultimate goal cannot be accomplished by respiratory compensation preserving sleep, only arousal from sleep...

Continuous Positive Airway Pressure Cost And Reimbursement Issues

In Australia, for the majority of those requiring it, the cost of CPAP is borne directly by the patient, or indirectly by the patient through his her coverage in a health insurance fund. Such funds, and wherein medical devices such as CPAP are covered under the specific scheme, reimburse approximately 30 to 50 of retail cost. Percentage reimbursement can be significantly better, even 100 , in smaller boutique health insurance schemes. Approximately 43 of Australians (2006 statistics) carry some...

Reimbursement Criteria And Issues

Financial constraints may limit the use of APAP devices for chronic treatment of OSA at least in some circumstances. In the United States durable medical equipment (DME) providers receive the same reimbursement for supplying an APAP device as a CPAP device despite the greater cost of APAP. One option is to pass the extra cost to the patient who often pays out of pocket for the difference. Some patients may choose to buy a unit directly from a national discount provider over the Internet....

Relation Between Sleep Apnea and Restless Legs Syndrome

RLS and OSA are two common sleep disorders but there is not much in the peer-reviewed literature to define or evaluate a possible relationship between the two. In a study by Lakshminarayanan et al. (93) a prevalence of clinically significant RLS with symptoms at least two to three days per week in 8.3 was reported in 60 sequentially polysomnographically studied patients with clinically significant sleep apnea (RDI > 10). This figure is, however, not dissimilar to the prevalence figure for...

Polymyositis and Dermatomyositis

Polymyositis and dermatomyositis (PM DM) are chronic inflammatory myositis characterized by proximal muscle weakness. Respiratory complications due to pharyngeal and respiratory weakness are common. Although SRBD has not been reported in these patients, alveolar hypoventilation is common (83). Patients with PM DM, symptoms of snoring, hypersomnolence, and respiratory complications should undergo polysomnography to rule out sleep apnea or hypoventilation. CPAP or BPAP should be implemented if...

Baseline Indicators Influencing Continuous Positive Airway Pressure Usage

Identification of claustrophobia prior to initiating CPAP using a 15-item Fear and Avoidance Scale predicted lower CPAP adherence at three months (95). Remedial measures to address such identified claustrophobia, logically, may improve adherence in those subjects. A patient's reporting initial problems after the first night of CPAP (using auto-titration) was the most powerful predictor of lower hours of CPAP on time at one-month follow-up (88). Recent life events and living alone were less...

Info

Passali D, Lauriello M, Anselmi M, et al. Treatment of hypertrophy of the inferior turbinate long-term results in 382 patients randomly assigned to therapy. Ann Otol Rhinol Laryngol 1999 108(6) 569-575. Ikematsu T. Study of snoring, fourth report therapy in Japanese . Jpn Otorhinolaryngol 1964 64 434-435. Powell NB, Riley RW, Guilleminault C, et al. A reversible uvulopalatal flap for snoring and obstructive sleep. Sleep 1996 19(17) 593-599. Kezirian EJ, Weaver EM, Yueh B, et al. Incidence of...

Peripheral Neuropathy

Peripheral neuropathy is ascribed when peripheral nerves are damaged. This condition is associated with impaired motor, sensory, and or autonomic nerve dysfunction, and may be either inherited such as in Charcot-Marie-Tooth (CMT) disease or acquired. Acquired neuropathies are commonly caused by leprosy (most common world-wide), other diseases (diabetes mellitus, autoimmune disorders, toxins such as alcohol or heavy metals) or nutritional deficiencies (B12 or thiamine). The prevalence of OSA in...

References

Polygraphic study of the episodic diurnal and nocturnal (hypnic and respiratory) manifestations of the Pickwickian syndrome. Brain Res 1966 2 167. 2. Martin RJ, Pennock BE, Orr WC, et al. Respiratory mechanics and timing during sleep in occlusive sleep apnea. J Appl Physiol 1980 48(3) 432-437. 3. Sanders MH, Moore SE. Inspiratory and expiratory partitioning of airway resistance during sleep in patients with sleep apnea. Am Rev Respir Dis 1983 127(5) 554-558. 4....

Sleep Disordered Breathing in Special Populations

SDB may occur more often in special populations (82-86). Any condition or syndrome associated with craniofacial anomalies may be associated with SDB. Pierre Robin (Fig. 2), Apert's and Crouzon's are among these syndromes. Approximately FIGURE 2 (See color insert.) Infant with Pierre Robin syndrome micrognathia, specifically mandibular hypoplasia, as depicted is characteristic of this disorder. FIGURE 2 (See color insert.) Infant with Pierre Robin syndrome micrognathia, specifically mandibular...

Diagnostic Criteria

The diagnostic criteria used for adults with OSA cannot be used reliably in children (5,49,62,63). The diagnosis of SDB is based on the history, physical findings, and supportive data. Laboratory testing should be, ideally, tailored to the clinical question. For example, if there are concerns about excessive daytime sleepiness, a multiple sleep latency test (MSLT) may be indicated (64). The MSLT is ideally performed in subjects who are at least eight years old. The polysomnogram in a child uses...

Upper Airway During Wakefulness

Individuals with normal upper airway anatomy do not suffer from obstructive apneas or hypopneas even though they experience reductions in muscle tone and airway caliber during sleep. What anatomic factors predispose an individual to sleep apnea Why are the upper airway structures enlarged in patients with OSA This section will first highlight the differences between normal and apneic upper airways and then discuss the factors that confer influence these differences. The overwhelming majority of...

The Physical Examination For Adult Sleep Apnea

A sleep physical examination is directed at modifying the probability of sleep-disordered breathing based on the history, looking for evidence of associated or complicating disease, and excluding other potential causes for neurologic or cardiovascular symptoms. A broader examination incorporating many of the other organ systems should be employed when considering other sleep disorders that may be caused by or confounded by other diagnoses. TABLE 2 Medications as Clues to Predisposing Factors...

Oral Appliances See Also Chapter

The evidence assessing the role of oral appliances in the treatment of OSA continues to grow in both quantity and quality with several randomized placebo-controlled and cross-over trials having been completed (151). The efficacy of oral appliances in successfully treating mild-to-moderate OSA (defined as less than or equal to 10 apneas or hypopnea per hour of sleep) is approximately 50 (151). The oral appliances can be broadly divided into two types devices that reposition the mandible 0 cm HjO...

The Faces of Sleepiness

FIGURE 1 Venn diagram for introspective, physiological, and manifest sleepiness. physiological sleepiness can be thought of as the underlying biologic drive to sleep indexed by the amount of time it takes to fall asleep, given the opportunity. Finally, manifest sleepiness reflects an individual's inability to volitionally remain awake. This state can be indexed by behavioral signs of sleepiness or sleep onset (eye closure, head bobbing, snoring) or by performance deficit on a wide variety of...

Continuous Positive Airway Pressure And Cardiovascular Outcomes

The present evidence for a significant protective or ameliorating effect of CPAP against adverse cardiovascular outcomes in OSA is mixed, especially in the management of mild OSA. In a large observational cohort study, there was an increased risk of stroke and death, which persisted after allowing for other risk factors including hypertension however, CPAP use did not appear to provide protection against adverse outcomes in this study (112). In contrast, in case-control studies, there is some...

Continuous Positive Airway Pressure and Adherence to Therapy

Nasal CPAP is the therapy of choice for OSA. While CPAP therapy is effective for resolving upper airway obstruction, adherence to therapy is overall poor, from 46 to 89 depending on the definition of adherence (85-87). Results of studies to determine the role of gender in predicting adherence to CPAP are conflicting, with men more likely to be adherent to therapy in some (88,89), while women are more likely in others (90). Measures to improve adherence, including warm air, humidification, and...

Chronic Obstructive Pulmonary Disease See Also Chapter 20

COPD affects approximately 14 million adult Americans. COPD patients often report multiple problems with sleep, including insomnia and frequent awakenings. Sleep studies of COPD patients have revealed decreased total sleep time, frequent arousals and awakenings, and reduced amounts of slow-wave and rapid eye movement (REM) sleep. Impaired sleep quality likely results from a combination of factors, including chronic shortness of breath, nocturnal cough, and sleep-associated hypoxemia. In 1962,...

Behavioral Therapies

All patients with OSA should be given advice concerning the avoidance of activities or agents that may worsen their disease. These include alcohol and sedative hypnotics (benzodiazepines, narcotics, zolpidem, zopiclone, baclofen) (see also Chapter 17), as well as smoking, anabolic steroids, and sleep deprivation. Alcohol is a gamma aminobutyric acid agonist that acts as a respiratory depressant and increases upper airway resistance it has a greater effect on upper airway dilator muscle activity...

On Adult Presentations

Sleep apnea is a very prevalent disorder in important populations. Epidemiological studies estimate the prevalence to be 2 to 4 in the general population (3,30,31), while other, more selected population studies achieved a prevalence range of 7 to 16 (2,32). Prevalence estimates (and therefore pretest probability) increase in clinical populations due to an enrichment of medical problems. Rates encountered in the primary care or hospital settings are particularly high primary care (high risk 37.5...

Laboratory Diagnosis Of Sleep Apnea

Obstructive Sleep Apnea Event

Attended laboratory-based polysomnography has been and remains a de facto gold standard for diagnosis of sleep-disordered breathing, even though the utility of a single overnight recording for diagnosis or exclusion of significant sleep has never been clearly addressed in the literature. It is clear that there is considerable night-to-night variability in AHI particularly, when the AHI is low (29-32). Standard overnight polysomnography involves (i) recordings of sleep-related...

Continuous Positive Airway Pressure Reimbursement In The United States

For any therapeutic plan to be viable for the patient, it must be accessible and reimbursable. The coverage criterion throughout the world varies but, generally, more socialized governmentally directed care is difficult to access, but is more favorably reimbursed. The opposite is true in the United States where accessibility to care is typically easy, but coverage criteria are usually more cumbersome. Throughout the world, a physician must not only decide the appropriate treatment but also...

Pharmacologic Therapy Of Obstructive Sleep Apnea Drugs that Increase Respiratory Drive See Also Chapter

Patients with OSA have compromised upper airway anatomy making the airway more vulnerable to collapse (76-80). During wakefulness, reflex mechanisms lead to increased upper airway dilator muscle activity keeping the collapsible part of the upper airway open (79,81). However, with sleep onset, these reflex mechanisms are lost resulting in a fall in upper airway dilator muscle activity, and upper airway collapse in those anatomically susceptible (82). A variety of respiratory stimulants have been...

Relation Between Sleep Apnea and Parasomnias

Parasomnias can emerge in close association with OSA. The following associations have been noted between the two conditions (30). 1. OSA is becoming an increasingly recognized precipitant of sleepwalking (107,108). Guilleminault et al. (107) described 84 children (5 with sleep terrors and 79 with both sleep terrors and sleepwalking). Fifty-one (61 ) of 84 children with parasomnia had a diagnosis of an additional sleep disorder 49 with SDB and two with RLS. Forty-three of 49 children with SDB...

Surgical Proceduresphase Ii Maxillomandibular Advancement Osteotomy

MMO, also referred to as bimaxillary surgery, is considered phase II of the Powell-Riley two-phase surgical protocol. The rationale for MMO is to ameliorate refractory hypopharyngeal obstruction by advancing the mandible and maxilla forward. Treatment of SDB by skeletal surgery was first described by Kuo et al. (72) and Bear and Priest (73). Subjective improvements in SDB were reported, but there was no postoperative PSG to support these claims. Subsequently, our group objectively documented an...

Signs and Symptoms of Hypoventilation

The presence of clinical symptoms and or physiologic markers of hypoventilation are useful in identifying clinical severity as it relates to therapeutic decision-making with regard to initiation of nocturnal NIPPV. In the course of a typical progressive disease, two successive steps occur more or less rapidly (i) nocturnal hypoventilation reversible during wake associated with none or a few clinical symptoms and (ii) nocturnal and daylight hypoventilation associated with clinical symptoms,...

Titration Techniques

The current standard of care dictates CPAP therapy be commenced and titrated under direct supervision by a trained technician. Direct supervision allows for immediate assessment of various sleep-related disturbances, direct determination of the optimal CPAP pressure, and identification of significant sleep-related comorbidities, including but not limited to nocturnal seizures, cardiac arrhythmias, para-somnia activity, and nocturnal myoclonus. Furthermore, direct supervision allows for...

Injection Snoreplasty

Palatal injection sclerotherapy (injection snoreplasty) was introduced as an inexpensive, minimally invasive office procedure that treats palatal flutter snoring. Essentially, a sclerotherapy agent is injected into the submucosal layer of the soft palate to promote fibrosis and scarring (106). Several different sclerotherapy agents have been employed to stiffen the soft palate. The two most commonly used agents are 3 sodium tetradecyl sulfate (sotradecol) and 50 ethanol (107). The average...

Upper Airway Surgery See Also Chapter

There are several surgical options for sleep apnea patients including UPPP (tonsil-lectomy and removal of the uvula, distal margin of soft palate, and any excessive tissue), uvulopalatopharyngo-glossoplasty (UPPGP combines UPPP with limited resection of the tongue), transpalatal advancement pharnyngoplasty (TPAP resection of the posterior hard palate with advancement of the soft palate to enlarge the retropalatal airway), sliding genioplasty or genioglossus advancement (advancing the tongue...

Duty to Warn and Report Impaired Driving

Because hypersomnolence generally follows untreated OSA, a physician may have additional legal and ethical duties to the public to inform the patient of the risks of fatigued driving caused by the failure or refusal to treat the disease. In appropriate cases, the physician may be required by law to report the patient's condition to applicable state motor vehicle agencies. Although no case found expressly discusses a physician's duty to third parties in the context of an OSA patient, under the...

Evidence of Efficacy of Auto Titrating Positive Airway Pressure

One important use of APAP devices is selection of a fixed CPAP pressure as an alternative to traditional manual (attended) PAP titration (1,2,10-19). Information stored in the device memory can be analyzed and a pressure can be chosen for fixed CPAP treatment. A common method is to choose the 90th or 95th percentile pressure (pressure exceeded only 10 or 5 of the time, respectively) as the prescription pressure. This assumes periods of high leak have been eliminated from the analysis. There is...

Duchenne Muscular Dystrophy

Duchenne muscular dystrophy (DMD) is a degenerative disease of voluntary muscles that leads to generalized weakness and muscle wasting. It affects one in 3300 live male births. A less severe variant is known as Becker muscular dystrophy. Weakness of ventilatory muscles eventually develops in DMD patients, leading to eventual death typically in the third decade. Respiratory insufficiency during sleep is the earliest sign of respiratory compromise in this patient population. REM-related...

Clinical Practice Issues Indications and Contraindications

According to the updated AASM practice parameters published in 2006, oral appliances are indicated in patients with mild-to-moderate OSA who prefer this form of treatment over CPAP, or who do not respond to or are unable to tolerate CPAP (20). The AASM also recommends that patients with severe OSA be considered for CPAP in preference to oral appliances whenever possible, given its greater efficacy. A major clinical limitation of oral appliance therapy, stemming from the need for titration...

Reimbursement Criteria

The delivery of appropriate treatment for any condition may at times become problematic if coverage criteria are not met or are not well-documented for the individual patient. This is especially true in the world of SDB for Medicare patients with respect to PAP therapy. There are separate criteria specifically for BPAP or in Center for Medicare and Medicaid (CMS) vernacular, respiratory assist devices. The coverage criteria are divided into four categories but two of these related to patients...

Epilepsy See Also Chapter

Epilepsy is the chronic condition of recurrent unprovoked seizures, and can be caused by multiple etiologies that result in dysfunction of cortical neurons. SRBDs are common in individuals with epilepsy. Polysomnographic investigations by Malow (27) showed that nearly one-third of patients with medically refractory epilepsy had a respiratory disturbance index of greater than five. Although the exact cause of this increased prevalence of OSA in this population is unknown, we have speculated that...

Restrictive Lung Disease

Restrictive lung disease is another category of pulmonary disorders that may require nocturnal PAP therapy. Lung restriction is most commonly seen in obesity, kypho-scoliosis, neuromuscular disease, interstitial lung disease, and pregnancy. PAP therapy should be used unequivocally in these patients if they have coexisting OSA. However, in the absence of OSA, PAP therapy must be considered on a case-by-case manner, depending upon the disease process being considered. Obese patients without OSA...

Magnetic Resonance Imaging

MRI may be the best current mode of imaging for assessment of the upper airway and surrounding soft tissue and craniofacial structures (Figs. 1-4) (13-25). Advantages of MRI include that it (i) achieves high resolution images of the upper airway and soft tissue (ii) provides precise and accurate measurements of the upper airway and surrounding tissue (iii) obtains multiplanar images in the axial, sagittal, and coronal planes (iv) permits volumetric data analysis including three-dimensional...

Employers Liability for Employees Negligence

The application of traditional vicarious liability rules renders employers vicariously liable for the acts of their employees when performed in the scope of their employment (93). Thus, when Norman Munnal killed a woman when he fell asleep at the wheel of a tractor-trailer while driving for his trucking company employer, it was W.L. Logan Trucking Company that faced liability for its driver's acts (94). The trucking company invoked Ohio's version of the sudden blackout doctrine to defend...

Side Effects And Limitations

Side effects from CPAP therapy tend to be minor though can often be a significant barrier between long-term adherence (113) and tend to be related either due to problems with the interface or due to positive pressure. Common complaints include nasal congestion, rhinorrhea, skin abrasion, difficulty with exhalation, chest discomfort, dry mouth, claustrophobia, conjunctivitis due to air leak, and or aerophagia (114). Reports document up to 10 of all CPAP users complaining of some degree of...

Regulatory Screening for Obstructive Sleep Apnea in Safety Sensitive Positions

Because sleep apnea is a relatively common medical condition which, if untreated, contributes to daytime sleepiness and impaired job performance (2), public policy suggests that certain industries directly affecting public safety screen employees in safety-sensitive positions for sleep apnea or other fatigue-enhancing sleep disorders. Thus, each of the air, rail, ferry, distance trucking, and nuclear power industries have or propose regulatory fitness for duty programs addressing OSA. The...

Physicians Duty to Obtain Patients Informed Consent for Obstructive Sleep Apnea Surgery

Physicians have a general duty to provide their patients with sufficient information concerning their diagnosis, the nature and reason for the proposed treatment, the risks or dangers involved, the prospects for success and alternatives methods of treatment and the risks and benefits of such treatment (49). An unpublished decision of the Tennessee Court of Appeals discusses a physician's duty to inform a sleep apnea patient of CPAP treatment before performing uvulopalatopharyngo-plasty (UPPP)...

Myotonic Dystrophy

Myotonic dystrophy (MD) is a common type of muscular dystrophy and is a genetic disorder inherited with an autosomal dominant pattern. Myotonia, muscle weakness, and dystrophic changes in tissue are characteristic features of this disorder. Although this disorder is characterized by the muscle features, it is also associated with cognitive components, facial dysmorphic features, and sleep disturbance. Fatigue, tiredness, and excessive daytime sleepiness are very common in patients with MD....

Classification Of Methods For Diagnosis Of Sleepdisordered Breathing

The AASM, formerly known as the American Sleep Disorders Association, in 1994 (16,17) classified diagnostic sleep equipment into four levels (Table 1). Attended PSG has already been described and is Level I. Unattended PSG is Level II. Measurement of a minimum of four channels, which must include oximetry, one channel each of respiratory effort or movement and airflow or two channels of respiratory effort or movement, and heart rate is Level III. A single or two-channel system typically...

Techniques And Modes Of Imaging The Upper Airway

Anatomic Radiology Oral Cavity

A wide array of options exists to image the upper airway. In the past, the upper airway was examined by measuring pressure at different levels to obtain data pertaining to airway compliance and collapsibility (1-4). Investigators have also examined electromyographic activity of various upper airway muscles such as genioglossus, levator palatini, alae nasi, tensor palatini, geniohyoid, sternohyoid, palatoglossus, and the pharyngeal constrictors (1,5-11). These studies have FIGURE 2 Retropalatal...

Clinical Prediction Models

Well-established sleep apnea is characterized by loud snoring, witnessed apneic episodes, disturbed nocturnal sleep, daytime sleepiness, and impaired cognition and is typically associated with obesity and (in men) a large neck size. Given this profile, it is not surprising that clinical prediction models would arise in an effort to diagnose OSA in larger populations. Virtually all of these studies have been done in sleep clinic populations rather than in the general population. One of the...

Relation Between Sleep Apnea and Periodic Limb Movement During Sleep

Chervin (104) studied 1124 patients with suspected or confirmed SDB. Surprisingly, increased leg movements were associated with decreased objective sleepiness (but explained less than 1 of the variance) and showed no association with subjective sleepiness or sleep propensity. These results are in accordance with those of Mendelson (102). It must, however, be realized that in both these studies, movements secondary to an arousal at the end of a respiratory event, could be misinterpreted as a...

Relation Between Sleep Apnea and Insomnia

Insomnia and OSA are the two most common sleep disorders and yet peer-review publications based on state-of-the-art, evidence based literature are lacking in describing the interaction and implications emerging from the inter-relationship between the two. This has been well addressed in an editorial by Krakow (33). Insomnia is generally considered an infrequent presenting night-time complaint in patients with OSA. Yet review of limited literature shows a higher percentage than generally...

Sedative Hypnotics

Benzodiazepines are commonly prescribed orally to treat anxiety disorders, mood disorders, and insomnia. In addition, they are used parenterally as premedications before procedures such as endoscopy or minor surgery. The most prescribed agents include alprazolam (Xanax , Niravam ), clonazepam (Klonopin ), diazepam (Valium ), lorazepam (Ativan ), midazolam (Versed ), and temazepam (Restoril ) (29). Benzodiazepines exert respiratory-depressant effects centrally in addition to decreasing upper...

Anesthetics Opioids and Barbiturates

Recommendations for safe perioperative care in the OSA patient include the use of CPAP preoperatively, consideration of intubation over fiberoptic bronchoscope during surgery, and the use of CPAP and regional anesthesia postoperatively rather than the continuous administration of opiates (26). Nasal CPAP can eliminate the postoperative risk of hypoxemia, which would then allow the use of adequate parenteral or oral analgesics. Analgesia has been achieved safely with intravenous morphine sulfate...

Continuous Positive Airway Pressure Mode of Action

The concept of CPAP in managing respiratory failure is relatively old (11). However, the original experiments using CPAP in sleep apnea followed from the notion that closure of the oropharynx in OSA results from an imbalance of the forces (12) that normally keep the upper airway open. In the first description of CPAP use for treatment of OSA in 1981 (2), it was suggested that nasal CPAP acts as a pneumatic splint to prevent collapse of the pharyngeal airway, by elevating the pressure in the...

Myasthenia Gravis and Lambert Eaton Syndrome

MG is the most common disorder of neuromuscular transmission that is usually due to acquired immunological dysfunction, but can rarely be caused by a genetic abnormality. There are approximately 36,000 cases in the United States. Patients complain of generalized skeletal muscle weakness that fluctuates throughout the day and is worse with sustained activity. Lambert-Eaton syndrome (LES) is another, yet rare disorder of neuromuscular transmission. Sleep apnea has been reported in approximately...

Uvulopalatopharyngoplasty Uvulopalatal Flap

Uppp Before And After

Ikematsu (57) is credited with developing the uvulopalatopharyngoplasty (UPPP) for the treatment of habitual snoring. This technique was later adapted to treat SDB and snoring by Fujita et al. (29) in 1981. Since this time, multiple variations have TABLE 6 Fujita Classification of Obstructive Regions Type I Palate (normal base of tongue) Type II Palate and base of tongue Type III Base of tongue (normal palate) been developed to treat the obstructing tissues of the soft palate, lateral...

Effect of Treatment of Sleep Apnea on Depression

The belief that depression is an actual phenomenon seen increasingly in patients with sleep apnea is well documented by numerous studies showing significant improvement in depression, daytime sleepiness, and quality of life following treatment of sleep apnea with CPAP (58-63). Schwartz et al. (62) demonstrated this effect in patients with RDI > 15 and in patients with and without antidepressant pharmacotherapy. Hilleret et al. (64) reported an interesting case of a 50-year-old man with no...

Reasonable Care and the Sudden Blackout Doctrine

The driver of a car has the general duty to exercise ordinary and reasonable due care in controlling his vehicle so as to avoid colliding with other persons and property (16). Under general negligence principles, a driver's breach of that duty in a manner that proximately causes damages to person or property will be held liable to the injured party (5). However, the law has long recognized that damages caused by a driver's sudden and unforeseen onset of sleep while driving does not constitute...

Sleeprelated Breathing Disorders Clinical Features

Although SRBD in children have many important similarities to the adult versions of these diseases, there are also marked differences in presentation, diagnosis, and management (Table 1). While awake breathing is typically silent, and the most obvious of nocturnal SRBD is snoring. Snoring indicates turbulent airflow and is not normal in children (21,35-39). The American Academy of Pediatrics (AAP) has recommended all children should be screened for snoring as part of well child care (40). If a...

Concluding Note and Future Directions

Stanford Sleep Research Center, Palo Alto, California, U.S.A. Obstructive sleep apnea (OSA) and other sleep-related breathing disorders are arguably the number one health problem in the United States if not the entire world. Given the high prevalence, it is amazing that this problem was completely unknown to the general public as well as health professionals as recently as 1965 and mostly unknown until the late 1970s. In addition to the actual obstructive sleep disorder itself, there are strong...

RERA Frequency

In addition to defining the event type (apnea, hypopnea, RERA), the frequency of these events occurring during sleep that defines the diagnosis has to be established. Based on data published in 1992, it was observed that patients with UARS who were subsequently treated with continuous positive airway pressure (CPAP) improved significantly in terms of daytime sleepiness when the RERA index (RERAs hour of sleep) dropped below 10 (1). Therefore, the number of abnormal respiratory events (RERAs)...

Contemporary Treatment Alternatives For Pharyngeal Reconstruction Temperature Controlled Radiofrequency of the Palate

Radiofrequency ablation RF of tissue has many applications in the medical and surgical fields. It has been used to treat benign prostatic hypertrophy and Wolfe-Parkinson-White syndrome 86,87 . Powell and Riley adapted this modality to treat redundant tissue of the upper airway in patients with SDB. The initial investigation trial was performed in a porcine model. Histologic assessments revealed a well-circumscribed lesion with normally healing tissue without damage to peripheral nerves....

Pictorial Sleepiness Scale

Maldonado et al. 11 sought to develop a nonverbal sleepiness scale that could be used to test young children or poorly educated adults. Subject groups were asked to rank in order seven cartoon faces designed to depict different sleepiness levels. Results were used to transform rankings into linear measures that eliminated two faces. A new subject group ranked the remaining five cartoons and a scale was constructed. The scale correlated significantly with KSS and SSS when tested in groups of...