Clinical evaluation of patients
with sleep disordered breathing
By
Ahmad Younis
Professor of Thoracic Medicine
Mansoura Faculty of Medicine
Sleep disordered breathing
• Abnormal breathing pattern: apnea
hypopnea ,RERA, hypo-ventilation
• It lead to:
1-daytime symptoms and signs
2-organ system dysfunction.
It is difficult to take a history of
a sleep disorder than to inquire
about a complaint that occurs
during wake-fullness
The patient often has a little or no
awareness of the problem and it is
important to obtain the bed
partner view of the events during
sleep and during wake-fullness
The aims are:
1- establish whether or not
there is a sleep disorder.
2- Assess the relative contribution of
psychological ,medical and social
factors to the complaint.
Sleep complaints:
1-Excessive sleepiness
Sleep disordered breathing
Narcolepsy
Idiopathic hypersomnia
Psychatric disorders
2-Insomnia
3-Circadian rhythm disorders
4- Parasomnia
Sleep disordered breathing
• Symptoms: habitual loud snoring ,EDS
,nocturnal choking ,witnessed apnea,
morning headaches ,un-refreshed sleep.
• Risk factors: BMI ,waist and neck
circumference ,hypothyroidism ,CHF.
COPD. stroke.
• Consequences: motor vehicle or work
accidents related to EDS. type 2 DM,
HTN,IHD, CVA .
• Events during sleep :wake during sleep,
why(
pain
,anxiety
,nightmares
,choking, heartburn ,nocturia, nocturnal
wheeze ) ,how long is it before sleep is
re-entered. Awareness of any mental or
physical activities , sleep paralysis.
• Events during awakening: is sleep
refreshing ,frontal headache ,level of
alertness
,accident
related
to
somnolence,
naps
if
refreshing
,hallucination ,cataplexy, unpleasant
sensation in legs relieved by movement
Sleepiness can be defined as a high
physiologic drive toward sleep
• Excessive daytime sleepiness, defined as
sleepiness that interferes with daytime
activities, productivity, or enjoyment, is
usually abnormal and may reflect insufficient
sleep, disrupted sleep, or a primary sleep
disorder .
• Sleepiness following sleep restriction or
extended wakefulness does not always require
detailed assessment when the underlying
cause is identifiable and self-limited.
• Sleepiness that interferes with everyday
activities or occurs at inappropriate times is
almost always abnormal, particularly if the
somnolence is chronic, recurrent, or severe
• Berlin Questionnaire
test for OSA )
(Screening
1-High risk was defined as persistent
symptoms (>3 times/wk) in two or
more questions about their snoring.
2-High risk was defined as persistent
(>3 times/wk) wake-time sleepiness,
drowsy driving, or both.
3-High risk was defined as a history of
high blood pressure or a body mass
index more than 30 kg/m2.
To be considered at high risk for sleep apnea,
a patient had to qualify for at least two
symptom categories.
Somnolent individuals may complain of
fatigue, tiredness, lack of energy, inattention,
impaired concentration, or emotional lability.
Severely somnolent individuals often appear
visibly sleepy and in extreme cases stuporous
or encephalopathic.
Visible signs of sleepiness on examination may
include
drooping of the eyelids, pupillary miosis, nodding
of the head, or intermittent loss of postural
tone.
• True hypersomnia (sleep for abnormal long
duration each 24 h cycle) must be
differentiated
from
hypersomnolence
(sensation of sleepiness).
The history alone often allows accurate
assessment of whether a patient's sleepiness
is likely to be the result of sleep derivation
which include insufficient sleep and disrupted
sleep (e.g., secondary to obstructive sleep
apnea, percentages of sleep stages) or a
central nervous system disorder such as
narcolepsy.
• Patients with excessive sleepiness commonly
exhibit identifiable symptoms that help
identify specific underlying causes. Such
symptoms include snoring or observed apnea
during nighttime sleep, restlessness or jerking
of the legs, hypnagogic or hypnopompic
hallucinations, sleep paralysis, automatic
behavior, cataplexy, and other constitutional
symptoms
• Epworth sleepiness scale:
The chance to doze off or fall asleep in the
following situation:
1-sitting and reading
2- watching TV
3- sitting inactive in public place
4-as a passenger in a car for an hour without a
break
5-lying down to rest in the afternoon when
circumstances permit
6-sitting and talking to someone
7- sitting quietly after a lunch without alcohol.
8- in a car while stopped for few minutes in
traffic
Stanford sleepiness scale:
Describe the
alertness
patients
current
state
of
It is limited in usefullness due to lack of
reference values
It is more sensitive to sleep deprivation
than ESS
Visual analog scale:
Most simple
Designate degree
of alertness
sleepiness on a 10-cm scale.
–
Severity of daytime sleepiness
• Mild : infrequent, at times of day
when sleep should be expected (24pm or late in the evening or at
rest or in passive environment)
• Severe: frequent, at any time of
the day ,occur despite stimulating
circumstances
(while
talking
,eating ,walking (
Cyclical sleepiness
• Weekly: catch up their sleep debt at
week end due to intermittent sleep
deprivation.
• Monthly: premenstrual sleepiness
• Elimination
of
sleepiness
when
sufficient sleep is allowed as in holidays
suggest that sleep deprivation rather
than a primary sleep disorder is the
cause.
Snoring and Other Obstructive
Symptoms during Sleep
• Loud snoring is a cardinal symptom of OSA and
upper airway resistance syndrome and may be
accompanied by mouth breathing, unusual
body positions, or visible restlessness during
sleep.
• Respiratory pauses are sometimes witnessed
by bed partners or family members, sometimes
terminating with a snort or gasp when
breathing resumes. Such symptoms are most
informative when present;
• conversely, the absence of observed apnea
and even snoring does not rule out the
possibility of an obstructive SRBD.
Nocturnal choking
•
•
•
•
SAHS
GERD
Vocal cord adduction
Panic attacks
Hypnagogic or Hypnopompic
Hallucinations
• Hypnagogic (at sleep onset) and hypnopompic
(at waking) hallucinations are brief, dreamlike
episodes that last seconds to minutes.
Hallucinations are often vivid and distressing
despite their brevity.
• Although these hallucinatory episodes are
often reported by patients with narcolepsy,
they have also been reported in association
with a variety of psychiatric conditions, and as
a medication side effect.
Cataplexy
• Cataplexy is characterized by paroxysmal episodes of
bilateral muscle weakness or paralysis, triggered by
laughing or emotion. The phenomenon reflects muscle
atonia, which is normally restricted to REM sleep but, in
this condition, is inappropriately expressed during
wakefulness.
• The duration of cataplexy is usually ranging from
seconds to minutes, but successive attacks precipitated
by extreme emotional stimuli (status cataplecticus) may
rarely last as long as 1 hour.
• Mild attacks may consist only of a brief sensation of
weakness without externally visible manifestations.
• Severe episodes may be characterized by complete
paralysis, sparing only respiration, eye movements, and
sphincters.
Sleep Paralysis
• Sleep paralysis is a condition in which muscle
atonia, normally restricted to REM sleep,
instead occurs at the interface between sleep
and wakefulness. Sleep paralysis may be total
or partial and may coincide with hypnagogic
hallucinations.
• Although episodes typically last for only a few
minutes, they may be extremely frightening to
affected patients and accompanied by
sensations of suffocation.
Other Constitutional Symptoms and Signs
Associated with Specific Causes of
Sleepiness
• Lethargy, weight gain, and unsteady gait may
accompany somnolence in patients with
hypothyroidism, who are at increased risk for
OSA.
• Morning
headache
or
other
neurologic
complaints
are
nonspecific
symptoms
sometimes
associated
with
sleepiness
secondary to structural pathology within the
central nervous system.
• Hypersomnia can occur in individuals with
depression, in whom associated symptoms of
anhedonia, fatigue, or intermittent mania may
be apparent
Social history
• Shift work
• Cross
time
zones
through travel
• Bedroom environment
• Pet animal
frequently
Family history
•
•
•
•
•
Snoring
OSAS
Narcolepsy
RLS
Bed partner have a sleep problem
which disturb the patient
• Signs:
1-BP
2-Neck circumference
3-Central cyanosis
4-Upper airway examination
5-Chest and heart examination
6-Neurological examination
7- Endocrinal examination
Modified Mallampati classification
Categorize the severity of posterior
pharyngeal narrowing
It is a weak predector of OSAS
• Chronic tonsillar enlargement
• Sleep diary:
• The time when you go bed for the night
• Your estimate of approximately when you go
to Sleep
• Note each time that you wake up during the
night
• If you must leave your bed, note the time and
duration
• Medicines and doses taken.
• Note the time that you wake up in the morning
• Note whether or not you needed an alarm
clock to awaken you.
• Note every nap that taken during the day,
when you went to Sleep, and when you
awakened
• Make a note of how you felt during times of
the day. Note if you felt groggy, drowsy, or
tired and what time .
• Sleep hygien:
your personal collection of habits that
determine the quality of your sleep.
• Rules:
1-Wait until you are sleepy before going to bed
If you’re not sleepy at your regular bedtime, do something
relaxing; read a book, listen to music, or do some other
activity that relaxes, not stimulates you. This will relax your
body and distract your mind to remove your worries about
sleep.
2-Pre-sleep rituals help to initiate relaxation each night before
bed
A warm bath, light snack, or a few minutes of reading or
listening to music can initiate good sleep. Avoid eating heavy
meals near bedtime.
3-If you're not asleep in 20 minutes, get out of bed
, leave your bedroom and find something else that will relax
you enough to help make you sleepy.
4-Try
to
keep
a
regular
sleep/wake
schedule
Wake up at the same time each day, even on weekends and
holidays.
5-Keep
a
regular
daily
schedule
Maintaining a regular schedules for meals, medications, and
other activities helps keep your body’s clock running smoothly.
Rules:
6-Sleep
a
full
night
on
a
regular
basis
Get enough sleep every day so that you feel wellrested.
7-If
possible,
avoid
naps
If you have to take a nap, try to keep it to less than
one hour and avoid taking a nap after 3 pm.
8-Do not read, eat, watch TV, talk on the phone, or play
board games in bed
9-Avoid caffeine after lunch
10-Avoid alcohol of any type within six hours of your
bedtime
11-Do not smoke or ingest nicotine within two hours of
your bedtime
12-Exercise regularly but avoid strenuous exercise
within
six
hours
of
your
bedtime
Regular exercise is good, but do it earlier in the day
13-Avoid sleeping pills, or use them cautiously.
14-Try to clear your mind of things that make you
worry
Rules:
16-Maintain a quiet, dark and cool
bedroom environment
17-Every person has his or her own
personal preference as to the ideal
sleep environment. Extremes should
be avoided. If you need noise, use
white noise or soft music. If you need
light, use off-light such as a night
light in the bathroom or down the
hall.
Temperature
is
highly
subjective….be comfortable.
Idiopathic Hypersomnia with
Long Sleep Time
• Idiopathic hypersomnia with long sleep time is
characterized by pervasive daytime sleepiness
despite longer-than-average nighttime sleep.
Prolonged nighttime sleep of 10 or more hours
with few or no awakenings still leave affected
patients un-refreshed or confused (sleep
drunkenness) on waking in the morning
• Daytime naps of these patients tend to be
longer and less refreshing than those of the
patients with narcolepsy.
Idiopathic Hypersomnia
Long Sleep Time
without
Although the severe, pervasive daytime
somnolence and un-refreshing naps
seen in this condition are identical to
those seen in idiopathic hypersomnia
with long sleep time, the nighttime
sleep period is <10 hours.
Behaviorally Induced
Insufficient Sleep Syndrome
• Excessive daytime sleepiness often results
solely from habitually insufficient nighttime
sleep.
• Review of a sleep diary or sleep history of the
affected patients usually reveals a chronically
shortened nighttime sleep period that is either
less than the patient's pre-morbid baseline or
less than normal for age.
• Symptoms remit with lengthening of the
nighttime sleep period ,for example, on
weekends .
Hypersomnia due to Medical
Condition
• Neurologic conditions may include stroke,
brain tumor, encephalitis, head trauma, and
Parkinson disease.
• Genetic conditions sometimes associated with
sleepiness most notably include Prader-Willi
syndrome and myotonic dystrophy.
• Endocrine and toxic metabolic causes include
hypothyroidism,
hypo-adrenalism,
hepatic
encephalopathy, and renal failure.
• Drug-induced and psychiatric causes