David Claman, MD
Professor of Medicine
Director, UCSF Sleep Disorders Center

• 45 year old firefighter complains of daytime sleepiness; “Doctor: I snore – could I have sleep apnea? I sleep alone so no one can tell me.”
• Reports “sleep hours 11 pm – 7 am”
• Real schedule is 24 hr at work, then 48 hrs off
– At work sleep 2-4 hrs (no reports of apnea)
– 1 st night after work: 10 pm – 8 am
– 2 nd nightafter work: 1 am – 5:15 am (up early to drive to work!)

• Sunlight is main “Zeitgeber”; meals, exercise, & social activities can also shift sleep rhythms
• Internal Clock located in Suprachiasmatic nucleus
(SCN) of hypothalamus
• Jet lag: light and social stimuli help shift internal biological clock 1-2 hrs / day
• Shift work: light and social stimuli are in conflict with work schedule; may lead to poor sleep quality, insomnia and chronic fatigue

• Start trip sleep deprived
• Dehydration on plane worsened by caffeine and alcohol
• Circadian rhythm “out of phase”
• Flying West is easier
– delay sleep schedule by 1-2 hr/d
• Flying East is harder
– advance sleep schedule by 0.5-1 hr/d

• Avoid sleep deprivation before trip
– Consider daytime flight
– Avoid important meetings the morning of arrival
• Adjust schedule before trip
– 1-2 hours per day, for 1-2 days before trip
• Avoid alcohol and caffeine
• Bright light
– In morning when flying east (to advance schedule)
– In afternoon/evening when flying west (to delay)
• Hypnotic prn (zolpidem or melatonin)

• Shift Work Disorder (SWD) is characterized by complaints of insomnia, excessive sleepiness and impaired performance that occur when work hours are scheduled during the usual sleep period
• 20% of workforce in industrialized countries are shift workers, & 40-80% of night workers report sleep difficulties

• Most common schedule is to work Mon through Fri nights 11 pm – 7 am, but to sleep during those same hours on Sat / Sun
• Since sunlight is strongest stimulus of circadian rhythms, the body’s preferred sleep schedule stays oriented for the hours
11 pm – 7 am

• Interventions:
– Optimal approach is to stay awake at night on nonworking days and always sleep on the same schedule
– If patient continues to alternate their sleep schedule, try to maximize overlap between weekday and weekday schedules (if 7a-2p weekdays, then 3a-10a weekends)
– Avoiding sunlight on drive home at 7 am (using “glacier” sunglasses) may also be helpful

• Psychiatric / psychological
•
Medical
• Drugs (especially caffeine and alcohol)
•
Psychophysiological insomnia
– Somatized tension and anxiety causing insomnia
•
Poor sleep hygiene
–
Maladaptive coping mechanisms are common
•
Circadian rhythm issues

• Keep regular bedtime and wake-up time
• Keep bedroom quiet, comfortable, & dark
• Relaxation technique for 10-30 min before bed
• Get regular exercise
• Don’t nap
• Don’t lie in bed feeling worried, anxious, or frustrated
• Don’t lie awake in bed for long periods of time
• Don’t use alcohol, caffeine, or nicotine


Apnea: complete cessation of airflow lasting 10 second or more

Hypopnea: reduced airflow for 10 seconds or more, associated with 4% oxygen desaturation
(4% is classical definition)
 Apnea-hypopnea index (AHI): average number of apneas & hypopneas per hour of sleep

AHI < 5 is normal

AHI 5-15 is mildly elevated

AHI 15-30 is Moderate

AHI > 30 Severe



Sleep Heart Health: Clinical predictors of AHI > 15:
Male gender, older age, higher BMI, larger neck girth, snoring & episodes of witnessed apnea

Young T et al. Arch Intern Med 2002 Apr 22;162(8):893-900

Young T et al. Excess weight and sleep-disordered breathing. J Appl
Physiol 2005;99(4):1592-9.

Wisconsin OSA prevalence by gender and BMI
Young T. J Appl Physiol 2005;99(4):1592-9

• French Multicenter Study; n=1141 from database
• Excluded those with FEV1<80%
• Overall prevalence of 11% with PaCO2 >45
• BMI < 30 – prevalence 7.2%
• BMI 30-40 – prevalence 9.8%
• BMI > 40 – prevalence 23.6%
• Laaban J-P et al. Chest 2005;127:710-715

 Weight loss (10% weight loss reduces AHI 25%)

Avoid alcohol and sedatives

Postural training (side sleeping since apnea worse on back)
 Nasal patency (treat allergies?)
 CPAP (also autoCPAP & Bi-level)
 Oral (dental) appliances
 ENT surgery:

Tonsillectomy in kids
 UPPP in adults 50% success; mandibular surgery 80-90% success
 Nasal expiratory resistor (Provent)
 Nasal bandaid with microvalve – delivers approx 5 cm pressure

Best compliance if AHI >30 & ESS >10
McArdle N et al. AJRCCM 1999;159:1108-1114

• Hours of Service Rules
– 10-11 hr driving limit; 14-15 hr on-duty limit
– http://www.fmcsa.dot.gov/rules-regulations/topics/hos/index.htm
• Sleep Deprivation
– Common in truck drivers; 35% up before 6 am
• Sleep Apnea – age and obesity major risks
– Effect similar to being over legal alcohol limit in simulator
– Pack & Dinges: OSA prevalence
• Mild 17%, Moderate 5.8%, Severe 4.7%
• www.fmcsa.dot.gov/facts-research/research-technology/tech/Sleep-Apnea-Technical-Briefing.htm

• Sleep Apnea Alert October 2009
• Recommend “screening” but no regulations in place
• Federal Motor Carrier Safety Administration
– Trucks, buses, trains
• US Coast Guard – ship pilots
• FAA – airline pilots

• In California, if patient has caused an accident by falling asleep at the wheel in the last 3 years, then
Dept of Public Health must be notified
• If patient reports concerns about sleepiness while driving, chart should document: “Patient was advised not to drive if he / she is drowsy.”

• Behavioral and pharmacological therapies for late-life insomnia. CM
Morin et al. JAMA 1999;281:991-9
• Cognitive Behavioral Therapy and Pharmacotherapy for Insomnia
Jacobs GD; Arch Intern Med 2004;164:1888-1896
• Principles and Practice of Sleep Medicine. 4th Edition. Kryger, Roth,
& Dement. 2005
• Jet lag and shift work sleep disorders: How to help reset the internal clock. Kolla BP & Auger RR. Cleveland Clinic J of Med
2011;78(10):675-684
• Circadian Rhythm Sleep Disorders. Lu BS & Zee PC. CHEST
2006;130:1915-1923
• Marin JM et al. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea: an observational study. Lancet.
2005;365(9464):1046-53