Case 5 SLOs

Define hypersomnolence.
Hypersomnolence is excessive sleepiness. People with hypersomnolence, as opposed to fatigue, often fall asleep unintentionally.
Once hypersomnolence has been confirmed, the first cause to be ruled out should be inadequate sleep time (chronic insufficient sleep).
Most people require at least 7 hours of sleep per night and often closer to 8, men generally requiring less than women.
Explain what the Epworth sleepiness scale is and why it is used.
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Describe the Mallampati scoring system for airway classification, and explain to the relevance to sleep apnea.

Class I (easy)visualization of the soft palate, fauces, uvula, and both anterior and posterior pillars
Class IIvisualization of the soft palate, fauces, and uvula
Class IIIvisualization of the soft palate and the base of the uvula
Class IV (difficult)the soft palate is not visible at all
Higher score will indicate a more difficult intubation and increased incidence of sleep apnea

Explain the role of the bed-partner in the diagnosis of sleep-related pathology.

The partner may have a better idea of the sleeping habits and snoring patterns, additionally the partner could be contributing
to his sleeping problems
Define what is meant by the term snoring, and discuss the relationship of this condition with obstructive sleep apnea.
Snoring may indicate a blockage in the airway, and can be a sign of obstructive sleep apnea. Snoring is sound generated by
the vibration of the pharyngeal soft tissues.
Types of Sleep Apnea
A. Obstructive Sleep Apnea
1. Cessation of air flow despite respiratory effort
2. Obstruction in low pharynx
1. Between base of Tongue and Larynx

b.

Obesity is a major risk factor for OSA. The increased fat deposition around the neck and parapharyngeal spaces
is postulated to narrow
B. Central Sleep Apnea
a. Cessation of respiratory effort
b. Effects diaphragmatic or intercostal effort
C.
Mixed Obstructive Sleep Apnea and Central Sleep Apnea

Describe the polysomnogram test. Explain the purposes of these tests, what measurements are involved, and what do these
measurements reflect? In addressing this question you should have discussed EEG, ECG, EMG, EOG, chest/abdominal
excursion, nasal flow, O2sat.
Polysomnography (PSG), a type of sleep study, is a multi-parametric test used in the study of sleep and as a diagnostic tool in
sleep medicine. The PSG monitors many body functions including brain (EEG), eye movements (EOG), muscle activity or
skeletal muscle activation (EMG) and heart rhythm (ECG) during sleep. After the identification of the sleep disorder sleep
apnea in the 1970s, the breathing functions respiratory airflow and respiratory effort indicators were added along with
peripheral pulse oximetry.
Polysomnographic recordings of (A) obstructive sleep apnea and (B) periodic limb movement of sleep. Note the snoring and
reduction in air flow in the presence of continued respiratory effort, associated with the subsequent oxygen desaturation
(upper panel). Periodic limb movements occur with a relatively constant intermovement interval and are associated with
changes in the EEG and heart rate acceleration (lower panel). RAT, right anterior tibialis; LAT, left anterior tibialis

Describe the clinical indicators of obstructive sleep apnea according to Harrisons, 18th edition, Table 265-1.

Differentiate between the terms apnea and hypopnea. Also define the apnea-hypopnea index.
OSAHS is defined as the coexistence of unexplained excessive daytime sleepiness with at least five obstructed breathing
events (apnea or hypopnea) per hour of sleep. This event threshold may have to be increased in the elderly. Apneas are

defined in adults as breathing pauses lasting 10 s and hypopneas as events 10 s in which there is continued breathing but
ventilation is reduced by at least 50% from the previous baseline during sleep.
The AHI is the number of apneas or hypopneas recorded during the study per hour of sleep. It is generally expressed as the
number of events per hour. Based on the AHI, the severity of OSA is classified as follows:

None/Minimal: AHI < 5 per hour

Mild: AHI 5, but < 15 per hour
Moderate: AHI 15, but < 30 per hour
Severe: AHI 30 per hour
Sometimes the Respiratory Disturbance Index (RDI) is used. This can be confusing because the RDI includes not only apneas and
hypopneas, but may also include other, more subtle, breathing irregularities. This means a person's RDI can be higher than his or her
AHI.
Provide an overview of the effect of sleep on the respiratory control system. Specifically, what happens to respiratory tonic and
phasic motor outflow to the respiratory muscles, and chemosensory response to changes in arterial CO2 and hypoxia.

During sleep, the metabolic rate falls (hence, decreased CO 2 production), but this is offset by a proportionately greater fall in
minute ventilation with the result that the PaCO 2 increases slightly. The fall in ventilation is due to increased upper airway
resistance and decreased chemosensitivity as well as the loss of the wakefulness stimulus to breathe. The result is that the
PaCO 2 rises and the PaO 2 falls slightly.

Because of the normal position on the flat portion of the O 2Hb dissociation curve, there is little change in the SaO 2 as a
result of the fall in PO 2 associated with sleep. If the baseline awake PaO 2 is lower, the fall in SaO 2 will be greater for the
same drop in PaO 2. In patients with lung disease and a lower awake PO 2, even a normal sleep-related drop in PO 2will be
associated with a larger decrease in the SaO 2.
Chemosensitivity. In humans, the slope of the hypercapnic and hypoxic ventilatory responses are markedly reduced during
sleep. In both cases, the slope is reduced by approximately one-third during non-REM sleep, and even further reduced during
REM sleep, but fortunately the responses are never abolished completely.
The change in ventilation with sleep is due to a fall in V T with minimal change in the RR. During the transition from wake to
stage N1 and early stage N2, the ventilation can be slightly irregular. However, in stable stage N2 and stage N3, the V T and
RR are nearly constant. During rapid eye movement (REM) sleep, ventilation is irregular with periods of decreased V T
associated with bursts of eye movements. The FRC decreases from wake to sleep. In some individuals, there may be a further
decrease from nonrapid eye movement (NREM) to REM sleep.

Define the criteria for a diagnosis of obstructive sleep apnea by polysomnogram. Use the Clinical Guideline - American
Academy of Sleep Medicine as a reference (pg 267): http://www.aasmnet.org/Resources/clinicalguidelines/OSA_Adults.pdf
A substantial amount of data is generated by a sleep study, but the most crucial is the apnea-hypopnea index, or AHI. An
apnea is a complete cessation of breathing for 10 seconds or longer. A hypopnea is a constricted breath (more than one-fourth,
less than three-fourths) that lasts 10 seconds or longer. The index number is the number of apneas and hypopneas the sleeper
experiences each hour.

Differentiate between a full-night polysomnogram and a split-night study.

Full-night polysomnogram-General monitoring of sleep and a variety of body functions during sleep, including breathing
patterns along with oxygen levels in the blood, heart rhythms, and limb movements

In a split-night study, the first part consists of standard polysomnography (PSG) for the diagnosis of obstructive sleep apnea
syndrome while the second part is used to establish a suitable level of continuous positive airway pressure.