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Assessment of the airway

The most common form of airway compromise is snoring, which results from loss of pharyngeal tone as a consequence of a reduced level of consciousness. This is an example of inspiratory stridor, which is characteristic of supraglottic obstruction. In contrast, airway obstruction below the larynx is usually more evident during the expiratory phase (wheezing). Upper airway obstruction may also be caused, or exacerbated, by excessive salivation, gastric contents, blood, or a foreign body in the pharynx or laryngeal opening. These may obstruct the airway directly or indirectly, by stimulating laryngeal spasm, and should always be considered, as should a history of maxillofacial or neck trauma.

Diagnosis Of Sleep Apnea

Modern diagnosis of sleep apnea has its roots in the landmark descriptions by Gastaut (2,3), Jung and Kuhlo (4), and others (5,6). Since these early descriptions of polygraphic recordings, the nocturnal, attended in-lab polysomnogram has become the standard for diagnosing OSA. In the early days of our understanding of the condition, the patient presented at advanced stages with severe symptoms, cardiovascular comorbidities, and a prominent history of loud snoring and witnessed apneic episodes. Over the years, a wider spectrum of disease severity has emerged and it is clear that many patients are minimally affected or not symptomatic at all. These patients are usually brought to attention because of their bed partner's descriptions of snoring and concerns about not breathing. This has increased the demands on in-lab polysomnography, still a limited resource, and prompted alternative strategies for diagnosing sleep apnea.

What Can Be Supported By The Evidence

As discussed previously, based on the current evidence, an attended Level III system with a minimum of airflow, oximetry, respiratory movement, and heart rate can be recommended under certain conditions. Strongly recommended is an additional sensor to measure body position. Also recommended is a sensor to measure snoring.

What Other Options May Be Considered

A high pretest probability (i.e., a high prevalence of OSA in the patient population), ideally to exceed 70 . There are a number of equations that use readily available data such as BMI, sex, history of snoring, neck circumference, and so on, or more complicated data such as X-rays of the upper airway with cephalometric measurements (68,71-76).

Health Outcomes And Continuous Positive Airway Pressure

Researchers have employed either an oral placebo or sham sub-therapeutic CPAP as control arms in RCTs examining the effects of CPAP. There is no perfect placebo for CPAP and each approach has limitations and obvious difficulties in blinding. Even a patient on sham CPAP may be made aware of persisting snoring or observed apneas by a bed partner. However, existing studies have clearly defined a role for CPAP in moderate-to-severe symptomatic OSA. The treatment of the asymptomatic patient with milder disease remains controversial (109). One study compared (humidified) CPAP to sham CPAP in mild OSA and showed improvement in

Technique of Auto Titration

As with manual attended PAP titrations with polysomnography, patient education, and mask fitting are essential for successful auto-titration. Patients must feel comfortable applying the mask interface and operating the APAP device if an unattended titration is planned. One study found a short 20-minute trial of APAP to be very useful in identifying patient problems including claustrophobia, mask leak or an inability to operate the device (21). The physician ordering the APAP titration designates the lower and upper pressure limits (for example, 4 and 20 cm H2O). The APAP device then titrates between these limits. Depending on the type of APAP device utilized, information on applied pressure, leak, snoring, flattening, and a

Obstructive Sleep Apnea

Based upon these data, it is prudent to screen patients with diagnostic poly-somnography at risk for or previously diagnosed with primary hypertension in the presence of other associated risk factors that increase the suspicion of OSA, including witnessed apneas, snoring, obesity, large neck circumference, and a small posterior airway space, with or without overt sleep complaints. If OSA is detected, even of mild severity, then treatment with PAP therapy is warranted. Accordingly, current

Upper Airway Resistance Syndrome See Also Chapter

Another controversial area is the utility of PAP therapy in patients with upper airway resistance syndrome (UARS). This disorder is generally considered to be present in patients with severe snoring accompanied by respiratory effort-related arousals during sleep and excessive daytime sleepiness (50). Typically, overt apneas and or hypopneas are absent, thus the patient fails to meet criteria for the diagnosis of OSA. Despite Medicare's failure to acknowledge this disease as noteworthy enough to warrant treatment, it is an important disease to acknowledge and in clinically symptomatic patients, may warrant treatment with either PAP, surgery, or more conservative approaches such as oral appliances, weight loss, or positional therapy.

Arterial Oxygen Saturation Measurement of Tissue Oxygenation

Low tissue oxygenation caused by any cardiorespiratory defect will result in an overproduction of erythropoietin and a consequent erythrocytosis. Pulse oximetry is the most convenient measure of arterial oxygen saturation. The oxygen saturation level should be 92 percent or greater any less has been taken to indicate a causal relationship with an absolute erythrocytosis.96 Nocturnal arterial desaturation with normal daytime values, however, were observed in 20 percent of patients who would otherwise have been classified as idiopathic erythrocytosis88 and symptoms that suggest the sleep-apnea syndrome such as daytime somnolence, excessive snoring, and waking unre-freshed should prompt sleep studies. A chest x-ray should be performed routinely to look for parenchymal lung abnormali

Laser Assisted Uvulopalatoplasty

Laser-assisted uvulopalatoplasty (LAUP) has been used as an office-based procedure to treat snoring and SDB. The rationale and indications for this procedure are the same as for UPPP. However, this surgery was developed as an alternative to performing UPPP in the operating room.

Supplemental Reading

Answer Three disorders are most often associated with EDS. Sleep apnea is characterized by pauses in respiration during sleep and usually excessive snoring. Patients with sleep apnea have EDS but often awake without feeling rested. Sleep apnea is managed by treating the nighttime episodes of apnea. Narcolepsy is characterized by episodic EDS. Patients with this pathology often exhibit periods of irresistible instantaneous REM sleep and may also progress to cataplexy, or sudden loss of tone in skeletal muscles (usually bilaterally). A final type of disorder that displays periods of EDS is idiopathic hypersomnia, in which patients usually have periods of EDS usually associated with non-REM sleep. W. M. most likely has narcolepsy, which could be more clearly defined by determining whether he has a specific human leukocyte antigen associated with the disorder (HLA-DR2). Management of narcolepsy is accomplished with psychomotor stimulants of the amphetamine type. Methylphenidate,...

Sleepinduced respiratory disturbances

Clinical features include night-time and daytime symptoms. Night-time symptoms are represented by loud snoring, apnoeic episodes ending with sonorous breathing resumption, nocturia, severe fatigue upon awakening, and sometimes headache. Daytime symptoms are dominated by excessive sleepiness which varies in intensity among patients. Other symptoms include irritability, negligence, loss of concentration, loss of libido, impotence, and sometimes depression. Symptoms are very much the same as in the obstructive sleep apnoea syndrome with loud snoring, fatigue on awakening, and excessive daytime sleepiness. However, snoring may be absent and special physical features such as high arched palate, malocclusion of the jaw type II, mandibular instability, or micrognathia may direct the diagnosis.

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. Volumetric analysis noted an initial inflammatory response, which resolved within 48 hours. A 26.3 volumetric reduction of tissue was documented on the 10th postoperative day (88). Based upon the positive studies in animal models, RF was attempted on human palates to treat snoring and SDB. Subsequent trials were then applied to the nasal turbinates and tongue base. TCRF treatment of the palate reduced subjective snoring scores by 77 and reduced EDS (89). Multiple studies have shown TCRF of the...

Central Ventilatory Control

Patients with IFL may mount an increased ventilatory response to meet the increased ventilatory demand. An exaggerated response to IFL, however, may result in ventilatory instability. Ventilatory instability can result in fluctuations in upper airway muscle activity, and subsequently result in upper airway obstruction, as well as sleep disruption. The physiologic mechanisms that preserve ventilation are another factor responsible for the spectrum of clinical expressions of IFL, with some manifesting only simple snoring and others developing full-blown OSA.

Cardiovascular Consequences

Severity of SDB is an important factor in predicting myocardial infarction in cardiac patients. A study by Hung et al. (36) showed that in male cardiac patients, 66 years old or younger, severe SDB was 25 times more likely to be associated with myocardial infarction compared to mild SDB. There is also evidence that snoring by itself increases the risk of ischemic heart disease in both men and women (37). Studies suggest that there is a direct relationship between cerebrovascular conditions and SDB in adults. There are reports of patients with a cerebrovascular accident having higher prevalence of SDB compared to age- and gender-matched controls without SDB (37). The Sleep Heart Health Study found an association between the severity of SDB and the risk of developing cerebrovascular disease and reported that even mild to moderate SDB increases this risk (34). In many patients the SDB persists even after the resolution of the stroke related symptoms, strengthening the argument that the...

Diagnostic Evaluations

To determine whether a sleep disorder exists and which factors are most important, the clinical history of the patient and desirable of partners or caregiv-ers is extremely important. Questions concerning the sleep complaint should include all the features the physician would obtain from any patient with a sleep complaint. Additionally, it needs to include disease specific questions on nocturnal akinesia, daytime drowsiness, or EDS in relation to drug intake and psychiatric symptoms. The use of a disease specific questionnaire, the Parkinson's disease sleep scale (PDSS), can be helpful for diagnostic evaluation as for assessment of follow-up.68 The bed partner needs to be asked for a careful description of the presence and frequency of movements during sleep as well as their timing, arousals and awakenings, snoring and episodes of apneas, and periods and durations of daytime sleepiness. The knowledge of the drug schedule is important If dopaminergic drugs are not...

Clinical Assessment And Management Of Sleepdisordered Breathing Presentation

As discussed earlier, EDS and snoring are the primary symptoms of SDB. The EDS manifests with high propensity to fall asleep throughout the day, sometimes inappropriately while talking to someone or even driving a car. In general, napping behavior can be intentional or inadvertent. Inadvertent napping, in particular, may be a clue that a patient has disrupted or insufficient sleep, possibly secondary to SDB. It is known that elderly patients tend to nap more frequently than younger adults, and that regular napping behavior is common in the elderly (68). Hence, it is imperative that clinicians discern whether these naps are planned or unintentional, as the latter may indicate the inability to maintain wakefulness, and thus may suggest the presence of SDB or other sleep disorder. Clinicians should also keep in mind that the EDS and the inadvertent napping may be caused by other medical conditions, such as PD, abnormal thyroid function, malignancies, depression, nocturia related to...

Respiratory Event Types

Tonsillar hypertrophy, and craniofacial abnormalities. Upper airway defense mechanisms translate into neuromuscular function whose net effect can be expressed as upper airway closing pressure (PCRIT). In fact, Schwartz et al. (12) have shown that in normal individuals PCRIT is markedly negative whereas in patients with predominantly apneas and hypopneas during sleep PCRIT is relatively more positive. More recently, Gold et al. (13) have demonstrated that patients with UARS (PCRIT -4.0 cm H2O) present with PCRIT levels, are intermediate between mild-to-moderate OSA (PCRIT -1.6 cm H2O) and normal controls (PCRIT -15.4 cm H2O). PCRIT in patients with UARS is significantly different from asymptomatic primary snorers (PS) shown to have an average PCRIT of -6.5 (14).

Clinical Features And Diagnosis

The presenting symptoms for patients with hypercapnic CSA may include symptoms of the underlying disease and features of sleep apnea. These symptoms include daytime sleepiness, snoring, and poor nocturnal sleep, as well as morning headache, peripheral edema, and dyspnea. Patients with nonhypercapnic central apnea can present with symptoms similar to obstructive sleep apnea including snoring and excessive daytime sleepiness. Alternatively, patients with CSA may present with insomnia and poor nocturnal sleep.

Obstructive Sleep Apnea Syndrome in Children Clinical Features

OSAS in children differs significantly from that in adults. Excessive daytime sleepiness (EDS) and snoring with apnea are essential diagnostic elements for OSAS in adults. EDS appears to be uncommon in children with equally severe OSAS. Some children are obese like adults, but most are not. Some have large tonsils and adenoids, while some with enormous adenoids or tonsils have only mild OSAS or are completely asymptomatic. In adults enlarged tonsils and adenoids are uncommon. OSAS in adults occurs predominantly in males and postmenopausal females. In children there isn't a significant difference between males and females. OSAS is more common in adults than in children, and the prevalence of OSAS in adults increases with age (Carroll and Loughlin 1995). Habitual snoring not associated with obstructive apnea, hypoxia, or hypoventilation is common in childhood, and occurs in 13 of preschool and school-aged children (Castronovo et al. 2003). OSAS is present in approximately 2 of 4- to...

Pathophysiology of OSAS

Sound of snoring originates in the collapsible part of the airway, where there is no rigid support, which implicates a primary role of the nasopharyngeal inlet, pharynx, and tongue. The key force that promotes the closure of the upper airway is the negative pressure applied during inspiration, which is determined by the inspiratory effort and the physiological dimensions of the upper airway. The primary force holding the airway is the activity of the dilator muscles that give tone and tension to the pharyngeal wall. Another cause of OSAS is nasal airway obstruction that contributes to nearly 40 of total airway resistance in healthy children. Causes of nasal airway obstruction are many, including enlarged adenoids as well as local inflammation. Goldbart, Krishna, Li, Serpero, and Gozal (2006) studied inflammatory mediators LTB4 (leukotriene B4) and cysteinyl leukotrienes (cys-LTs leukotriene C4 LTC4 leukotriene D4 LTD4 leukotriene E4 LTE4 ) in exhaled breath condensate and observed...

Parkinsons Disease and Other Neurodegenerative Disorders

Parkinson's disease (PD) is characterized by a progressive loss of dopaminergic neurons, resulting in bradykinesia and a resting tremor. This disorder is reported to have a higher prevalence of sleep apnea ranging from 20 to 43 of the patients (41,42). The high prevalence of sleep apnea in this population occurs despite their lower average BMI that makes oxygen desaturation less prominent. Hogl (43) found snoring to be associated with daytime sleepiness. Yet, several investigators did not demonstrate a relationship of daytime sleepiness to AHI and the impact on the cardiovascular system is unknown (41).

Asthma See Also Chapter

Nocturnal worsening of asthma is also apparently linked to snoring and sleep-disordered breathing. Chan et al. (18) evaluated nine patients with asthma and concurrent OSA, noting that all patients had frequent nocturnal exacerbations of their asthma. After initiating effective CPAP therapy, all patients demonstrated marked improvement in their asthma, with decreased symptoms, improved PEFR, reduced need for bronchodilator therapy, and resolution of their nocturnal worsening (Fig. 1). Guilleminault et al. (19) subsequently reported two separate populations of asthmatics, one group of middle-aged males with confirmed OSA, and a second group of younger males with recurrent snoring. Nocturnal worsening of asthma resolved in both groups after initiating CPAP therapy. Yigla et al. (20) studied 22 consecutive patients with severe, unstable asthma. Subsequent polysomno-graphy detected OSA in 21 (95.5 ) of these patients, although the patient group had a normal mean body mass index. These...

Immediate Questions

Does patient have risk factors for adverse events during sedation Risk factors include positive history for snoring or sleep apnea, reactive airways disease, or other chronic pulmonary disease congenital or acquired heart disease hypertension gastroesophageal reflux or vomiting and neurologic disease, such as muscle weakness or poorly controlled seizures.

Therapy for Obstructive Sleep Apnea Effects upon Cardiovascular Disease

Marin et al. (80) monitored 1465 snorers referred for polysomnography over a mean of 10 years. During the 10 years after their diagnoses, patients with untreated severe OSA (AHI > 30) had a nearly three-fold increase in risk for fatal cardiovascular events when compared to healthy controls and other patients with severe OSA who were treated with CPAP. These studies suggest that OSA has adverse effects upon blood pressure, cardiovascular status, and probably cardiovascular mortality. There is evidence that effective therapy with CPAP can improve blood pressure and cardiac function in adult OSA patients.

Obstructive sleep apnea syndrome

This sleep disorder occurs in 5 to 15 of adults. It is characterized by recurrent discontinuation of breathing during sleep for at least 10 seconds. Abnormal oxygen saturation and sleep patterns result in excessive daytime fatigue and drowsiness. Loud snoring is typical. Overweight, middle-aged men are particularly predisposed to sleep apnea. Weight loss can be helpful in obese patients.

Melatonin Role and Circadian Rhythms in Children with OSAS

Ulfberg, Micic, and Str0m (1998), in another study, showed that in comparison with normal controls, patients suffering from OSAS had significantly higher serum-melatonin levels in the afternoon. However, determination of afternoon serum-melatonin, as a diagnostic test for OSAS in patients with sleep-disordered breathing, showed a low sensitivity but high specificity. Determination of afternoon serum-melatonin alone or together with a scoring of daytime sleepiness does not identify OSAS patients in a heterogeneous population of patients complaining of heavy snoring and EDS (Ulfberg et al. 1998). OSAS in children differs significantly from that in adults. EDS and snoring with apnea are essential diagnostic elements for OSAS in adults, EDS appears to be uncommon in children with equally severe OSAS. Children with OSAS, during the day, can present hyperactivity, decreased intellectual performance and learning problems. We studied circadian rhythms of melatonin in children with severe...

Concluding Note and Future Directions

As with anything else, there are those who insist on only the most high-tech approaches. This is no longer appropriate. I have always said probably 90 of victims can be identified by asking two questions (i) Do you snore loudly or does the bed partner, if there is one, complain and (ii) Are you unusually tired when you are awake throughout the daytime with no apparent cause If the answers to both the foregoing questions are yes, OSA is highly likely. Keep in mind that individuals often do not seem to be aware of their fatigue, and among other individuals there is often a misapprehension that the tiredness is caused by depression, anemia, or some other esoteric problem. Any time there is loud snoring, check it out. As I have indicated, checking it out could not be easier. In fact, an educated bed partner can easily assess the implications of the snoring.

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 sleeping animal is vulnerable to be attacked by a predator, why would it make breathing noises when its guard is down Indeed animals in the wild do not seem to snore only domestic animals snore. Not all snoring is due to OSA. It may be due to other forms of obstruction such as nasal allergies or a cold (41,42). The prevalence of SDB in children was studied by Rosen et al. (43), who performed a cross-sectional study of school-aged children in a Cleveland cohort. The cohort consisted of 829...

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 earliest studies showed that witnessed apneic episodes combined with loud snoring predicted an apnea-hypopnea index (AHI) > 10 with a sensitivity of 78 and specificity of 67 (1l). Crocker et al. (12) used an alternative approach and developed a statistical model using clinical data to predict disturbance of sleep-disordered breathing in 114 consecutive patients. Witnessed apneic episodes, hypertension, body mass index (BMI), and age provided a sensitivity of 92 but a specificity of only 51 for an...

Classification Of Methods For Diagnosis Of Sleepdisordered Breathing

Sleep Apnea Rera Events

FIGURE 6 A respiratory effort-related arousal (RERA) with a crescendo increase in esophageal pressure (Pes) is depicted in the first half of the epoch. There is a decrease in nasal but not oral airflow, so the abnormal respiratory event does not meet criteria for a hypopnea. Snoring is observed, and the RERA culminates in an arousal, noted by an increase in chin and leg electromyogram tone and an increase in the electroencephalogram signal frequency. The RERA occurs in non-rapid eye movement stage 1 sleep, and the arterial oxygen desaturates to 90 . Following the RERA, there is a resumption of snoring and a crescendo increase in esophageal pressure, and the decrease in both the nasal and oral airflow is more compatible with a hypopnea. The epoch is two minutes in duration. Abbreviations C3A2 and C4A1, left and right electroencephalogram electrodes placed centrally and referenced to the right (A2) and left (A1) ear, respectively O1A2 and O2A1, left and right electroencephalogram...

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

The case involved a board-certified otolaryngologist who scheduled a nonurgent tonsillectomy for his 49-year-old male patient. The patient asked whether the procedure would help his snoring. Examining the patient further, the physician diagnosed mild sleep apnea and recommended surgical treatment. The patient testified at trial that he heard the doctor say that the doctor would trim his uvula, but the physician's notes indicated surgery discussed, risks, and complications, schedule tonsillectomy, septoplasty, UVPP (uvulopharyngoplasty) (51). In fact, the defendant physician performed the UPPP procedure. At no time did the physician advise his patient as to any nonsurgical alternatives to remedy his snoring. The patient suffered various neurological disorders following the surgery and brought a malpractice action against the physician. Plaintiff based his claim on the physician's failure to inform his patient of noninvasive alternatives and failure to inform him of the diagnosis of OSA...

Regulatory Screening for Obstructive Sleep Apnea in Safety Sensitive Positions

Federal regulations require that only physically fit persons are eligible to operate a commercial motor vehicle in interstate commerce (108). Persons are considered physically fit if they obtain medical certification from a physician certifying that the applicant does not have an established medical history or clinical diagnosis of, among other ailments, a respiratory dysfunction or other condition which is likely to cause loss of consciousness or any other loss of ability to control a commercial motor vehicle safely (109). The current Medical Examination Form, updated in 2000, makes specific inquiry whether the applicant suffers from sleep disorders, pauses in breathing while asleep, daytime sleepiness, (or) loud snoring (110). Individuals with suspected or untreated sleep apnea (symptoms of snoring and hyper-somnolence) should be considered medically unqualified to operate a commercial vehicle until the diagnosis has been dispelled or the condition has been treated successfully. In...

Reimbursement Criteria

Sergei Eisenstein Montage

FIGURE S A two-minute epoch during Stage 2 sleep with frequent episodes of obstructive apnea and oxygen desaturation. Incidental periodic limb movements are also noted in leg electromyogram channel. Abbreviations ABD, abdominal plethysmogram C4-A1, right central-left reference EEG CZ-OZ, midline central-occipital EEG ECG, electrocardiogram EEG, electroencephalogram EMG, electro-myogram FZ-CZ, midline frontal-central EEG HR, heart rate LOC and ROC, left and right outer canthi (eye movements), respectively Nasal P, nasal pressure via transducer RC, rib cage plethysmogram Sono, sonogram (snoring intensity) SpO2, oxygen saturation Sum, plethysmogram summed signal. FIGURE 4 Another two-minute epoch during non-rapid eye movement stage 2 sleep now with 1O cm H2O of continuous positive airway pressure applied. Note the exaggerated periodic breathing with central apnea pattern now predominating. Abbreviations ABD, abdominal plethysmogram C4-A1, right central-left reference EEG CZ-OZ, midline...

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 number of injections required to achieve adequate reduction in snoring was 1.2 injections per patient. Exclusion criteria for this modality include comorbid diseases that interfere with wound healing (uncontrolled diabetes, uncontrolled hypothyroidism, and periodontal disease), marked tonsillar hypertrophy, previous surgical procedures for snoring, and significant OSA. Complete cessation or a significant reduction in snoring was reported by 92 of patients or bed partners. However, the rate of snoring...

Idiopathic hypersomnia

The diagnosis of idiopathic hypersomnia is mainly based on clinical features and the absence of associated symptoms such as cataplexy, snoring at night, or depression. Polysomnography is necessary to exclude other sleep disorders, especially the upper airway resistance syndrome. Nocturnal sleep recording shows a sleep of normal quality with few awakenings and a normal proportion of the different sleep stages. Sleep apnoeas and periodic movements in sleep are absent. The multiple sleep latency test is not very demonstrative in showing a mean sleep latency of 8 to 10 min. On the other hand, continuous polysomnography with the subject free to switch on and off the light at his or her own convenience shows most prolonged night sleep followed by one or two naps of long duration. Sleep-onset REM periods are not a feature of the condition.

Relation Between Sleep Apnea and Parasomnias

OSA-induced arousals from REM sleep may mimic RBD (pseudo-RBD), with immediate post-arousal dream-related, complex or violent behaviors. Since OSA is a very common sleep disorder and OSA is most severe during REM sleep, this form of parasomnia may be more prevalent than currently believed. Iranzo and Santamaria (112) reported 16 patients presenting with dream-enacting behaviors and unpleasant dreams, in whom VPSG excluded RBD and was diagnostic of severe OSA, also demonstrating that the reported abnormal behaviors occurred only during apnea-induced arousals. Further, CPAP therapy eliminated the abnormal behaviors, unpleasant dreams as well as the snoring and daytime

Laboratory Diagnosis Of Sleep Apnea

Obstructive Sleep Apnea Event

Patients a diagnosis of sleep apnea may be established on more simple recordings. This has led to a number of recording devices ranging from simple oximetry, snoring sound, respiratory effort, and airflow to full portable attended PSG devices. The EdenTrace II Recording System (Nellcor Puritan Bennett Ltd., Kanata, Ontario, Canada) is a portable monitor that measures nasal and oral air flow via thermistry, chest wall impedance, snoring intensity, oxygen saturation via finger pulse oximetry, heart rate, and body position. Movement is detected by electrical comparison of the signals from the ECG and the pulse oximetry, and discrepancies between these channels are indicated as motion on the saturation channel. Several studies have been performed comparing either the ambulatory device only in the laboratory with simultaneously recorded polysomnography, or both home and The Stardust Sleep Recorder (Respironics, Murrysville, Pennsylvania, U.S.) detects nasal airflow and snoring (pressure...

On Adult Presentations

In regards to the presentation of sleep apnea, studies show a strong relationship between age and sleep apnea (see also Chapter 16) (15,30,42,43). Duran (2) found that sleep apnea prevalence increased with age with an OR of 2.2 for each 10-year increase. The Sleep Heart Health Study noted that prevalence rose steadily with age up to 60 years at which point a plateau in prevalence occurs around 20 (15). It has also been shown that the severity of sleep apnea (42) and the effect of body mass index (BMI) seem to decrease with age (15,43) and that the magnitude of associations for sleep apnea, snoring, and breathing pauses also decreases with age (15). Snoring is extremely common in sleep apnea patients and its absence should make OSA less likely (13). In one study only 6 of patients with OSA did not report snoring. Keep in mind however, that many patients have misperceptions about their snoring and tend to underestimate it (57). Some studies have shown that a report of loud habitual...

Hypersomnolence excessive daytime sleepiness EDS in PD

The diagnosis of excessive daytime sleepiness is begins with patient and caregiver interview. The interview should include sleep habits, presence of nocturnal sleep disruption (snoring, respiratory pauses, movements in sleep), and a complete drug history. The ESS provides a useful tool that is practical in an office setting for evaluating the presence and severity of EDS. When combined with the Inappropriate Sleep Composite index, it serves to identify those PD patients at risk for falling asleep at the wheel. Although anecdotal reports of PD patients involved in driving mishaps have appeared (Frucht et al., 1999, 2000 Hauser et al.,

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 evidence of cardiovascular benefit from nasal CPAP therapy in severe sleep apnea. Long-term CPAP therapy seemed to provide a protective benefit against death from established cardiovascular disease though there was no difference in the development of new cases of hypertension, cardiac disorder or stroke between CPAP-treated and untreated groups (113). In a large Spanish study patients with untreated severe OSA had a higher incidence of both fatal and nonfatal cardiovascular events than untreated...

The Faces of 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 psychomotor and cognitive tasks. Although introspective, physiological, and manifest sleepiness levels may stem from a common source, tests assessing sleepiness in these different realms cannot be used interchangeably. Furthermore, attempts to use these measures interchangeably miss the importance of the differences between them.

Upper Airway During Wakefulness

Chronic trauma or repetitive exposure to negative pressures during snoring or apnea also appears to be important factors leading to enlargement of upper airway soft tissue structures. The repetitive apneic events are thought to result in two consequences edema and muscular dysfunction. The soft palate is especially at risk for the development of edema due to caudal tugging during apneic events. MRI has demonstrated this edema (39) and CPAP is thought to reduce it (43). Quantitative magnetic resonance mapping has demonstrated increased edema and or fat in the genioglossus muscles of apneics compared to controls (110). Uvulas of OSA patients histologically have shown increased edema (70). Tobacco abuse may also play a role in provoking inflammatory edema and therefore compromise upper airway diameter (111,112). Thus, there is emerging evidence that edema may be important in the pathogenesis of upper airway soft tissue enlargement in apneics. Experiments measuring two-point...

Polymyositis and Dermatomyositis

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 needed.

Impact And Nature Of Fatigue In Pd

Hogl et al.80 evaluated daytime sleepiness in control subjects and in patients with PD. They found that, while daytime sleepiness was more common in PD patients compared with control subjects, in both groups, sleepiness was associated with heavy snoring, suggesting that daytime sleepiness reflects the presence of a sleep disorders. Other studies81 have supported these findings, but not all. Fabbrini et al.82 found no differences in daytime sleepiness in PD patients as compared with healthy control subjects, but they did find that sleepiness was associated with PD drug treatments, suggesting that sleepiness is a side effect of treatment rather than caused by the disease itself.

Diagnosis Of Obstructive Sleep Apnea

In adults, the patient complains of daytime sleepiness, unrefreshing sleep, fatigue, insomnia, awaking with breath holding, gasping, or choking, or there is a bed partner that notes loud snoring or breathing pauses during sleep. If the patient is not symptomatic, for example the patient has only snoring during sleep, then a PSG showing > 15 obstructive apneas, obstructive hypopneas, and or RERAs per hour of sleep can be confirmatory. If the patient is symptomatic, for example the patient has daytime sleepiness, OSA is confirmed by a PSG showing > 5 obstructive apneas, obstructive hypopneas, and or RERAs per hour of sleep. A child may not be able to give a history and the parent or other caregiver may note snoring, labored or obstructed breathing, or both during the child's sleep. There are a number of witnessed sleep events that may indicate OSA, which include paradoxical inward rib cage motion during inspiration, movement arousals, sweating, or neck hyperextension. In addition,...

Hypercapnic Central Sleep Apnea

Patients with this condition have blunted chemoreflex responsiveness, either due to weakness of the respiratory muscles or due to impaired pulmonary mechanics rather than diminished central chemoreflex responsiveness. The clinical picture contains features of the underlying medical condition as well as symptoms of obstructive sleep apnea. Thus, it is common for patients to present with underlying ventilatory insufficiency (e.g., morning headache, cor pulmonale, peripheral edema, polycythemia, and abnormal pulmonary function tests) and features of obstructive sleep apnea (e.g., poor nocturnal sleep, snoring, and daytime sleepiness).

The Examination Of The Pediatric Patient

Sleep complaints or disorders occur in 1 to 28 of the pediatric population (121-123) (More information on the examination of the pediatric patient can be found in Chapter 15.). The incidence of OSA in children can range from 1 to 10 , while snoring can occur in 3 to 12 (123-126). These studies often emphasize the idea that the presentation of sleep disorders in children is different from those in adults. While this literature is interesting, for the purposes of this chapter, the basic elements of the history and physical have limitations in regard to common measures and approaches from which to make firm evidence-based conclusions.

Sleep Measured by Subjective Reports

There was an effect of age on TST in that older mothers had less TST at the end of pregnancy than younger mothers. Like the data derived from other studies, late pregnancy was associated with increased nighttime awakenings and restless sleep (Hedman et al. 2002). As mentioned, the questionnaires used in research studies can vary. A study by Izci, Martin, Dundas, Liston, Calder, and Douglas (2005) examined whether snoring and sleepiness were linked in pregnancy. They used a scale to determine refreshment upon awakening as well as the ESS. They did confirm that sleepiness is increased in the third trimester, however, sleepiness in pregnancy is not primarily a result of snoring or breathing problems (Izci et al. 2005). The take home message from this overview of using the questionnaire method to acquire sleep data during pregnancy is that the results ultimately depend on how the question(s) is asked.

Device Characteristics

Many brands and models of APAP devices are currently approved for treatment. The devices differ in the respiratory variables that are monitored and in the algorithms used to adjust the delivered pressure. The devices typically monitor one or more of the following airflow (or motor speed), airflow profile (flattening), snoring (airway vibration), or airway impedance (forced oscillation technique). The algorithms used to adjust pressure are proprietary but determine if the delivered pressure should be increased or decreased. Depending on the type of respiratory event that is detected the delivered pressure is increased by a certain amount. Typically, pressure changes occur slowly over several minutes to prevent pressure-induced arousals. If no respiratory events are detected within a certain time window the delivered pressure is slowly decreased. Thus, the lowest effective pressure is delivered. In some of the devices machine adjustment is available for various mask types and for the...

Clinical features

Lymphoma Lesions The Tongue

Patients with NHL of the lip, buccal mucosa, gingiva, floor of mouth, tongue or palate usually present with ulcer, swelling, discoloration, pain, paraesthe-sia, anaesthesia, or loose teeth. Those with NHL of the Waldeyer ring (tonsils) or oropharynx usually present with a sensation of fullness of the throat, sore throat, dysphagia, or snoring. The high-grade tumours often show rapid growth. Systemic symptoms such as fever and night sweat are uncommon 201 . Clinical examination reveals solitary or multiple lesions, in the form of an exo-phytic mass, ulcer or localized swelling. Some cases may mimic inflammatory

Airway obstruction

Airway obstruction presents a major hazard in the comatose patient. The most common cause is the tongue, which slips backwards into the pharynx, blocking the airway. Characteristically, this produces noisy breathing or snoring. Laryngeal edema or tracheal obstruction is associated with inspiratory stridor. Although complete obstruction is silent, respiratory movements continue, often becoming more marked and labored, and characterized by a paradoxical 'seesaw' respiratory pattern in which the chest wall and suprasternal fossa are drawn inwards on inspiration.


The clinical evaluation for a patient being evaluated for presumed OSA represents an essential first step in the diagnosis of this common sleep disorder. The primary care physician or sleep specialist needs to inquire about the key symptoms of sleep apnea, such as EDS, snoring, and witnessed sleep-disordered breathing symptoms other important symptoms or practices that affect the patient's sleep such as insomnia, sleep hygiene, and the patient's Sleep-Wake schedule also need to be assessed. Symptoms of other sleep disorders, such as those associated with narcolepsy, restless legs syndrome, PLMD, and parasomnias should be ruled out as


A 3-year-old boy with a history of snoring and chronic congestion is rushed to the emergency department in the middle of the night after he reportedly stopped breathing at home. He has a cold, but no fever, and was asleep at the time of the episode. Now he is awake, but sleepy. His color is good, but he is congested and mouth breathing.


Lateral cephalometry is a simple and well-standardized technique involving radiographs of the head and neck with focus on bony and soft tissue structures. Several cephalometric studies have been performed in OSA patients and have provided important insights (54-64). Most of these studies have investigated the airway with the subject in the upright position, although comparisons between upright and supine postures have been made (54,55). An upright lateral cephalograph is obtained while the subject is seated with gaze parallel to the floor and teeth together. Investigators have used radiopaque material to enhance the outline of the oropharyngeal structures (56). The cephalometric images are used to study measurements of many set points, planes or distances within the head and neck region. The cepha-lometric technique has highlighted important differences between sleep apneics and normal subjects, sleep apneics and snorers, and obese and nonobese subjects. OSA patients have been shown...

Disorders Of Sleep

When breathing ceases, the resultant hypercapnia and hypoxia eventually stimulate respiration. Patients may present with daytime sleepiness, nocturnal insomnia and early morning headache. Snoring and restless movements are characteristic. In severe cases of sleep apnoea, hypertension may develop with right heart failure secondary to pulmonary arterial hypertension. Polycythaemia and left heart failure may ensue.

The First Night

On the first night of treatment, it is important to ensure that the CPAP level that is identified as most therapeutically effective is sufficient not only to prevent apnea and oxyhaemoglobin desaturation (Fig. 3) but also to prevent respiratory-related arousals in all sleep stages and postures of sleep. Thus, simple apnea prevention is not the sole endpoint of CPAP titration. It is important to ensure that the airflow-CPAP pressure measurement is competent so as to avoid residual partial airway obstruction (7). An abnormal or technically challenged tracing (e.g., amplifier saturation, clipped signals) presents an opportunity for failure in detection of flow limitation and snoring. It is important to treat residual flow limitation as it may indicate upper airway obstruction, potentially causing arousal (22). Studies have emphasized the importance of proper airflow measurement in CPAP titration using pressure-based airflow transducers rather than thermistors or other more indirect...


The gold standard for the titration of PAP is attended polysomnography with full-electroencephalogram (EEG) monitoring to detect the presence and stage of sleep (12). Respiratory monitoring allows classification of apneas (obstructive, mixed, and central) and detection of hypopnea or drop in arterial oxygen saturation. Snoring and evidence of airflow limitation or leak can also be detected with the proper monitoring equipment. Body position is identified by technologist documentation or by position sensors. Manual PAP titration is labor intensive and usually a single technologist can titrate only two patients at a time. Patients in some geographical areas may have limited or delayed access to a sleep laboratory offering polysomnography. In addition, the gold standard PAP titration method may result in suboptimal titrations due to a number of problems including poor sleep, lack of supine REM sleep, high mask leak, or uncorrected mouth leak. Patient characteristics such as weight gain...


Obstructive sleep-disordered breathing is relatively uncommon in otherwise healthy young women of reproductive age. However, biochemical and physical changes associated with pregnancy have opposing effects on the risk for OSA, which alter the risk of OSA in an individual. A study published in 2005 showed that symptoms consistent with OSA (snoring, excessive daytime sleepiness) occur in 10 of pregnant women, and increase during the course of the pregnancy, particularly in women with higher baseline BMI and greater increases in neck circumference (68).

Sleep apnoea

Apnoea is defined as the complete cessation of respiratory airflow for 10 or more seconds. (35> Apnoea can occur during any sleep stage, but is particularly likely to occur during the period of rapid eye movement sleep. It is important to remember that normal people have apnoeic episodes during sleep. When apnoeic events are frequent and prolonged, they lead to chronically disrupted sleep and excessive daytime somnolence. This defines the condition known as sleep apnoea. When severe, sleep apnoea can be complicated by hypoxia, arrhythmias, and heart failure. Sleep apnoea can be central, obstructive, or a mixture of the two. Central sleep apnoea is caused by an abnormal central drive to the respiratory muscles. Congestive heart failure is the most common cause, followed by neurological disorders involving the brainstem and respiratory centres. Obstructive sleep apnoea is more common it is estimated that 4 per cent of middle-aged men are affected. Obesity is a major risk factor, but...


Not only are the diagnostic criteria different in children than adults but also the treatment options. SDB in adults has four treatments options which may be combined. The most common treatment is continuous positive airway pressure (CPAP) to help splint open the upper airway (see also Chapter 6). When CPAP is used correctly snoring should be absent during sleep. There are several sophisticated surgical options with a wide range of success (see also Chapter 11). In adults, oral appliances, which help reposition the mandible, have improved breathing during sleep in selected patients (see also Chapter 12). As a conservative measure, adults with SDB are advised to sleep off their backs, lose weight, and avoid alcohol before sleeping (see also Chapter 13).


Ancoli-Israel et al. in a large study on randomly selected community-dwelling elderly between the age of 65 and 95 years reported that 24 had an AI > 5 with an average AI of 13. In addition, 81 of the study participants had an AHI > 5, with an average AHI of 38. Using more stringent criteria, the prevalence rates reported were 62 for an AHI > 10, 44 for an AHI > 20, and 24 for an AHI > 40 (4). The higher rates of SDB found in this study might be the result of objective sleep recordings rather than subjective measurements (such as self-reported snoring with observed apneas), which were used in many previous studies (11).


Because EDS and snoring are common in the older population as well as being the two main clinical features of SDB, it is extremely important that clinicians do not directly assume that if an older adult has complains of snoring or EDS, that these complaints must be due to SDB, nor should they assume that snoring or EDS are normal signs of aging. A complete evaluation is always warranted.

Oral Appliances

Considering the low adherence rates with CPAP and health insurance guidelines in patients with UARS (2,61,62) treatment with oral appliances is an important treatment alternative to surgical intervention. In this context an update of practice parameters for the treatment of snoring with oral appliances was published in 2006 (70). This American Academy of Sleep Medicine (AASM) practice recommendation defines the oral appliance treatment objective by separating patients with PS from patients with UARS and OSA. However, unlike for patients with OSA it does not

Social factors

Doctors may unwittingly reinforce social mores. Advice to move to separate bedrooms because of snoring, failure to ask about sex life, and willingness to leave vaginal pessaries in situ may be seen by patients as prohibiting sex. The doctor should not create guilt because sex has been abandoned or because it continues. Many patients find it easier to justify genital sex and seek treatment to restore potency when all they need is permission for mutual masturbation and intimacy.

Sleep apnea

Obstructive sleep apnea is typically associated with an increased body mass index and was not considered a major issue in PD. However, the occurrence of sleep apnea in PD is more frequent than previously suspected. In one study, 31 of PD patients assessed with polysomnography were shown to have a significant apnea (Ferini-Strambi et al., 1992), and in another, 20 had moderate to severe sleep apnea (Arnulf et al., 2002) despite a normal body mass index. Snoring, one of the symptoms of sleep apnea, has been shown to predict the occurrence of daytime sleepiness (Hogl et al., 2003 Braga-Neto et al., 2004). Polysomnographic studies in PD demonstrate a greater frequency of sleep apnea than normal controls, with obstructive events being most common (Maria et al., 2003).


AD-HKD is associated with deficits in various cognitive skills planning, sustaining attention, maintaining performance, identifying and adjusting to errors, judging the passage of time, and inhibiting inappropriate responses (see Table .2). Their sleep is poor for example, they tend to have sleep-related breathing disorders, periodic limb movements, and habitual snoring 37) Frequently, these children feel demoralized and incompetent. Compared with their normally developing peers, children with AD-HKD get lower marks, fail more grades at school, are more poorly organized, and more often have a diagnosis of a mental retardation. (3,39>

Pompes Disease

Pompe's disease is a glycogen storage disease due to acid maltase deficiency. It is an autosomal recessive disorder with a clinical course of progressive and severe muscle weakness. There is also involvement of respiratory muscles. Muscle replacement by fibro-fatty tissue was noted in the tongue and diaphragm in one autopsy case of a patient who developed severe OSA and respiratory failure (92). Nocturnal hypoventilation and REM-related hypopneas were noted (92). Patients with clinical symptoms of snoring, hypersomnolence, and respiratory problems should undergo polysomnography to rule out sleep apnea or hypoventilation. CPAP or bilevel pressure support should be used if needed.

Titration Techniques

When determining a titration algorithm, it is essential to understand that elimination of apneas, hypopneas, and oxygen desaturations is the first objective, but not the endpoint of the titration. Rather, the endpoint of the titration should be elimination of snoring and respiratory-related arousals in all positions and all stages of sleep (50,93). Persistent inspiratory airflow limitation is evidenced by a flattened airflow pressure tracing and can best be demonstrated with titrations that are performed with nasal pressure-flow transducers, as opposed to thermistors or other indirect measures of airflow (94). Although esophageal pressure monitoring is the most accurate means of assessing increased respiratory effort due to flow limitation, this modality is often poorly tolerated which may in turn limit its routine use in CPAP titration studies. When inspiratory airflow limitation is associated with spontaneous arousals, it is likely due to UARS and a further increase in airway...

Diagnostic Criteria

FIGURE 1 Polysomnogram of a 10-year-old girl depicting several obstructive apneas and hypop-neas during a 60-second epoch of rapid eye movement (REM) sleep, accompanied by esophageal pressure crescendos, intermittent snoring (as detected by the Chin EMG and Mic), and oxygen desaturations. Note the rapid respiration rate consistent with that of a child. Abbreviations C3-A2, C4-A1, O1-A2, Fp1-A2, electroencephalogram electrodes placed centrally (C3, C4), occipitally (O1), and fronto-parietally (Fp1), and referenced to the right (A2) or left (A1) ear Chin EMG, elec-tromyogram recorded from chin muscles LOC, left eye electro-oculogram ROC, right eye electro-oculogram EKG, electrocardiogram LAT and RAT, electromyogram recorded from the left and right anterior tibialis muscles, respectively SaO2, pulse oximetry Mic, microphone to detect snoring Nasal, nasal pressure measured by pressure transducer Oral, oral airflow measured by thermistor Chest and Abdomen, impedance bands to measure...


Obstructive events result from the completely or partially obstructed upper airway during sleep may lead to cessation (apnea) (Fig. 1) or reduction (hypopnea) (Fig. 2) of airflow. Partial obstruction can also lead to snoring without a reduction in airflow. Partial or complete cessation of respiratory effort leads to central apneas (Fig. 3) or hypopneas. Mixed events start with a central component and end with an obstructive component. Mixed apneas (Fig. 4) and hypopneas are considered to be obstructive in behavior. FIGURE 2 An obstructive hypopnea associated with snoring and ending in an arousal. The airflow is reduced but not absent and is associated with continued respiratory effort with a paradox of the abdominal and thoracic movement (respiratory excursions are out of phase) and an arterial oxygen desaturation to 82 . The hypopnea is occurring in rapid eye movement (REM) sleep (REMs seen at the beginning and end of the epoch). The hypopnea ends with a snore associated with a brief...

Natural Ways To Stop Snoring

Natural Ways To Stop Snoring

Is Snoring Ruining Your Life? Find A Cure For It Today! It's loud, it's disturbing and it's embarrassing during a sleep over. Snoring effects everyone around you and if you are one of the millions of people around the world who suffer from snoring, then you know how negatively it can affect your relationships. People who don't snore don't understand how bad it really is to snore. Going to bed every night knowing that as soon as you coast off into sleep you'll be emitting an annoying and loud sound that'll disturb everyone around you.

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