Cure Sleep Apnea Forever

Sleep Apnea

Have You Been Told Over And Over Again That You Snore A Lot, But You Choose To Ignore It? Have you been experiencing lack of sleep at night and find yourself waking up in the wee hours of the morning to find yourself gasping for air?

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The Sleep Apnea Exercise Program

Here Is a Tiny Sample of What Youll Get When You Register for the Sleep Apnea Exercises Program: 18 step-by-step videos that show you exactly how to do the sleep apnea exercises. A 52-page manual that includes a description of each exercise; illustrations to show you how to do each exercise; an explanation of what each exercise does for your body. The manual includes these sections: Causes of sleep apnea; Relationship between sleep apnea and snoring. Scientific studies backing up sleep apnea exercises. How to test your sleep apnea at home. Daily tasks to keep your sleep apnea at a low level. Names and website addresses of speech language pathologists in the U.S. and U.K. who specialize in sleep apnea, and have agreed to list their contact details in my manual. Names and contact details for obstructive sleep apnea support groups. MP3 (audio) recordings of the exercises that you can download and listen to on your iPod, iPhone, or MP3 device. (This is especially useful for the exercises that youll want to do in front of the mirror) Access to an online Members Area, where youll be able to download the manual, watch the videos, and get the bonuses!

The Sleep Apnea Exercise Program Summary


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Contents: 52 Pages EBook, 18 Videos
Author: Marc MacDonald
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Obstructive sleep apnoeas and gender

Obstructive sleep apnoeas, upper airway resistance syndrome and snoring are all at least twice as common in men as in women. The risk in women is five times greater after the menopause and twice as great while taking hormone replacement treatment, compared to before the menopause. Women tend to complain more of fatigue rather than excessive daytime sleepiness and of difficulty in initiating and maintaining sleep at night, and perhaps for these reasons are less likely to be diagnosed as having OSA until it is more advanced. The risk of road traffic accidents in men with OSA is greater than in women, probably because it causes more sleepiness. Survival is shorter in women than in men, even when adjusted for obesity. This may be partly because of delayed diagnosis or increased comorbidity, but women also appear to have greater endothelial dysfunction due to sleep apnoeas which may predispose to atheroma and cardiovascular complications 27 . Compliance with CPAP may also be less than in...

Mask continuous positive airway pressure CPAP and noninvasive ventilation NIV

In spontaneously breathing patients the application of low levels of mask CPAP (3-8 cm H2O) may improve respiratory rate, dyspnoea, and work of breathing in asthma, particularly if there is evidence of smoking related lung disease.20 54 55 There is a danger that CPAP may worsen lung hyperinflation. If patients are intolerant of the mask or do not derive benefit, CPAP should be withdrawn. In hypercapnic patients CPAP alone may not improve ventilation. Few studies have looked specifically at NIV in asthma. Low levels of CPAP and pressure support of 10-19 cm H2O in acute severe asthma improved gas exchange and prevented endotracheal intubation in all but two of 17 hypercapnic patients.56 However, the rate of intubation in patients with acute asthma, even in the presence of hypercapnia, is low at 3-8 .28 57 It is reasonable to give asthmatic patients a trial of NIV over 1-2 hours in an HDU or ICU if there are no contraindications (box 13.1).56 Deciding when to initiate NIV, when a trial...

Nasal continuous positive airway pressure CPAP and bilevel pressure support

The principle of CPAP is that it increases the pressure within the upper airway during both inspiration and expiration (Fig. 10.5). It acts as a pneumatic splint, counteracting the forces that tend to close the airway. It may also have effects on upper airway reflexes Fig. 10.6 Continuous positive airway pressure (CPAP) mask and pump. Fig. 10.6 Continuous positive airway pressure (CPAP) mask and pump. which activate the upper airway dilator muscles. Continuous positive airway pressure also increases the functional residual capacity slightly. This increases the oxygen stores and therefore reduces the degree of oxygen desaturation during an apnoea. It also reflexly increases the upper airway diameter, reduces the left ventricular preload and reduces any pulmonary oedema. A CPAP system comprises the following. Continuous positive airway pressure pump. This is a pump with a high flow capacity which delivers air at pressures which can be adjusted and then maintained almost constant during...

Sleep apnoeas

Central apnoeas are due to hypocapnia associated with a metabolic acidosis and an unstable respiratory pattern. Obstructive apnoeas are more common than in normal subjects and may be at least partly due to 'toxins' which alter central nervous system respiratory control. The association with obesity is less marked than in normal subjects, but the apnoeas appear to increase the risk of cardiovascular complications and may contribute to hypertension. They respond to nasal continuous positive airway pressure.

Sleep Apnea

Sleep apnea is a breathing disorder in which there are breathing interruptions during sleep. Apnea means want ofbreath in Greek. There are two types of sleep apnea central and obstructive. Central sleep apnea occurs when the brain fails to send the appropriate signals to the breathing muscles that cause you to breathe in and out. More common, however, is obstructive sleep apnea. This occurs when air cannot flow in or out of your nose or mouth. This can be linked to a growth or tumor in the neck or throat area such as a goiter (see Chapter 7) or a large thyroid nodule. In other people, apnea is the result of throat and tongue muscles relaxing during sleep, which can partially block airways. Obesity (see Chapter 16) can also lead to apnea, as an excess amount of tissue can narrow breathing airways. Signs that you may have sleep apnea are persistent loud snoring at night and daytime sleepiness. Frequent long pauses in breathing during sleep, followed by choking and gasping for breath,...

And Preoperative Evaluation

General guidelines for surgical intervention include significant symptoms of snoring and daytime somnolence documented failure in continuous positive airway pressure (CPAP) trials and documented failure of conservative measures, such as dental appliances, changes in sleeping position, and sleep hygiene in general. Apparent obstruction at the level of the soft palate must be determined by fiberoptic nasopharyngo-laryngoscopy, and M ller maneuver or sleep endoscopy. Adequate medical clearance and a thorough review with the patient of the procedure, its implications, and potential outcomes and complications are essential components of the preoperative workup.

And Objective Symptom Elimination

The treatment, like any other, may fail. Failure can be defined as a persistence of symptoms, which demands additional treatment. Failure also occurs when symptoms of snoring and daytime sleepiness are eliminated, but polysomnography scores still indicate persistent disease. Typically, patients who fail will show a pattern of elimination of apneas, with persistent hypopneas. Failure in achieving satisfactory results may in some cases convince the patient to accept CPAP therapy. When CPAP is not accepted by the patient, further evaluation and treatment are essential. The first step should be a thorough investigation in order to identify the site of failure. Sleep endoscopy evaluation may be a valuable test at this point. If the level of obstruction continues to be retropalatal, a transpalatal advancement pharyngoplasty can be considered 10 . If the persistence of obstruction is at the tongue base or hypopharyngeal level, genioglos-sus advancement alone or in combination with...

Indications and Patient Selection

Surgery for obstructive sleep apnea syndrome is indicated following failure, ineffectiveness, or noncompliance of more conservative treatments for obstructive sleep apnea syndrome. Patients should have an understanding of available reconstructive procedures and likely outcomes and that multiple surgical steps may be required. Surgical candidates should have undergone an appropriate sleep evaluation and objective testing to address associated sleep and medical problems. with a pattern of narrowing primarily in an anterior to posterior dimension. Although the procedure enlarges the lateral wall, those patients with marked lateral wall hypertrophy and collapse may not be ideal candidates for limited pharyngeal procedures of any type. Although obesity is not an absolute contraindication, morbidly obese patients with severe obstructive sleep apnea syndrome who have been recalcitrant to weight loss should be considered for possible bi-maxillary advancement, bariatric surgery, or...

Preoperative Evaluation

Polysomnography is appropriate in patients with sleep-disordered breathing, including mild to moderate or severe obstructive sleep apnea syndrome undergoing airway reconstruction. Since successful clinical outcomes of surgery cannot be guaranteed, maximal attempts at more conservative treatments are appropriate. Additionally, the sleep study provides information on the severity of disease and the nadir of oxygen desaturation and helps to identify those who warrant postoperative care and observation. Individuals at higher general surgical risk also include those with severe obesity, severe sleepiness, difficult intubation, or severe pharyngeal tissue redundancy. Individuals with preexisting speech or swallowing disorder should be identified and warned that pharyngeal surgery may worsen symptoms or problems with dysphagia, muco-ciliary function, mouth dryness, and aspiration.

Results and Complications

Published data on transpalatal advancement pharyngoplasty includes case series and studies of airway mechanics 4-6 . Early experience observed significant reductions in the apnea-hypopnea index (AHI) and the apnea index. A 67 successful response rate with a respiratory disturbance index (RDI) of less than 20 events per hour was observed in patients who only underwent transpalatal advancement. The RDI in the responder group decreased from 52.8 to 12.3 events per hour. Seven of 11 patients (64 ) had the RDI reduced to less than 20 events per hour. This group was skewed by several individuals with massive redundant nasopharyngeal lymphoid tissue that when removed likely contributed to such marked improvement. Subsequent studies on subjects without lym-

Indications Contraindications

The extent of surgical treatment of sleep apnea is determined by patient motivation, the severity of symptoms, the severity of disease as determined by polysomnography, and the site of obstruction as well as the medical and psychological fitness of the patient. General recommendations for the surgical treatment of sleep apnea are as follows 9, 10 Oxyhemoglobin desaturation of less than 90 AHI of more than 5 and less than 14, with excessive daytime sleepiness Upper airway resistance syndrome, preferably with objective improvement of neurocognitive dysfunction using medical therapy (continuous positive airway pressure, CPAP) Significant cardiac arrhythmias associated with obstruction

Preoperative Workup

Up to 40 of patients seeking surgery for sleep apnea have a history of cardiovascular disease 12 . Preoperative assessment therefore should include an electrocardiogram, chest X-ray, complete blood count, and a thorough general medical evaluation to assess the risks of cardiopulmonary complications and the need for medical referral. Stress testing and pulmonary function testing should be considered for those patients with significant histories. Preoperative flexible laryngoscopy is useful to assess the ease of intubation for surgery and also to rule out an occult lesion as the source of airway obstruction. The addition of M ller's maneuver assists in determination of areas of collapse. Upper-airway imaging, including lateral cephalometric radiographs, fluorosco-py, CT, and MRI, is usually unnecessary, but may aid in identification of the site of collapse.

Postoperative Care

It is important to recognize that surgical intervention of OSA may result in a temporary exacerbation of airway obstruction. The tongue suspension procedure, in particular, involves manipulation of the floor of the mouth and the base of the tongue, which often results in temporary edema with the potential for respiratory embarrassment therefore, the authors advocate overnight hospitalization with pulse oximetry monitoring for all patients undergoing tongue suspension. Admission to an intensive care setting should be considered when severe comorbidity is present. Patients with severe OSA should continue CPAP in the perioperative period. Narcotic pain medications are used judiciously, recognizing that the use of these medications may worsen the severity of OSA. Patients are treated with broad-spectrum antibiotics perioperative steroids ameliorate discomfort and edema from tongue and floor-of-mouth manipulation. Patients are suitable for discharge once pain has been controlled and...

Indications and Contraindications

In the case of mild obstructive sleep apnea (OSA) with a suspected retrolingual collapse, hyoid suspension is an alternative to radiofrequency therapy of the tongue base. We primarily choose the radiofrequency procedure owing to the lower invasiveness and postoperative morbidity, and offer hyoid suspension secondarily, after failed radiofrequency surgery. But for mild OSA and diagnosed retrolaryngeal stenosis, we often choose the hyoid suspension in combination with radiofrequency therapy of the tongue base. In the case of moderate OSA, the cure rate of radio-frequency therapy decreases. For this situation, hyoid suspension is superior to radiofrequency therapy. Therefore, we consider moderate OSA (apnea-hypopnea index, AHI, from 20 to 40) as a primary indication for the hyoid suspension procedure. If the obstruction site is suspected to lie solely in the retrolingual segment, an isolated hyoid suspension presents itself as an option.

Evaluation of Polysomnography

Surgical techniques for OSA aim to correct airway obstruction in two main sites retropalatal and or ret-rolingual. Success rates of UPPP alone in all patients are significantly lower than those of tracheotomy or CPAP. Early modifications of UPPP with aggressive tissue resection were suggested to achieve better results, but these were associated with increased complication rates instead of success 53 . Electrosur-gery, laser-assisted uvulopalatoplasty, radiofrequency and use of chemical agents were suggested for palate operations, as consequences of advanced technology 5, 21, 28, 39 . Instead of providing better results than UPPP, most of them tried to attain the success of UPPP, and have been recommended for snoring and mild OSAS only. It appears that multilevel and staged surgery provides the best surgical results in patients with OSA 40 . aggressively, it may occasionally result in an abscess of the tongue base, which can drain spontaneously or with surgery, without permanent...

Lower Pharyngeal Airway Surgery

Genioglossus advancement and hyoid myotomy with suspension are used for patients with OSAHS as a first-line treatment or after failure of a velopha-ryngeal procedure 4, 8, 32 . Use of these procedures as a primary therapy was shown to be successful 8 . Tongue-base resection with hyoid suspension is another technique for patients with moderate to severe apnea who are not compliant with and or tolerant of CPAP treatment 6 .

Indications for Genioplasty

Genioplasty is indicated for the treatment of patients suffering from OSAS with a respiratory disturbance index above 15 per hour of sleep and oxyhemoglobin desaturation to less than 87 that failed CPAP or are unwilling to use CPAP on a long-term basis. Documentation of hypopharyngeal airway obstruction contributing to OSAS based on the physical examination (including fiberoptic laryngoscopy) and or imaging (typically cephalometry) is needed. The operation may be performed as a same-stage operation with palatopharyngeal surgery or a second stage for failures of palatopharyngeal surgery. In addition, the operation

Training Upper Airway Sleep

Locations Upper Airway Mass

Continuous narrowing of upper airway. UARS upper-airway resistance syndrome, OSA obstructive sleep apnea. (Modified after 15 ) In adults, I always offer a conservative treatment as first-line treatment, in other words CPAP or oral Fig. 29.3. Indications for different surgeries depending on the severity of obstructive sleep apnea. UARS upper-airway resistance syndrome, OSA obstructive sleep apnea, RFQ radiofrequency surgery, UPPP uvulopalatopharyngo-plasty, MMA maxilloman-dibular advancement, DOG distraction osteogenesis, combined RFT RFT on soft palate, tonsils and base of tongue nCPAP nasally applied continuous positive airway pressure Fig. 29.4. Algorithm for treatment decisions in adult sleep-disordered breathing. UARS upper-airway resistance syndrome, OSA obstructive sleep apnea, AHI apnea-hy-popnea index, BMI body mass index (kg m2), CPAP continuous positive airway pressure Fig. 29.4. Algorithm for treatment decisions in adult sleep-disordered breathing. UARS...

How to Examine a Child with Suspected OSA

A 12-year-old boy with sleep apnea. a Severe ob- like edge of the soft palate. d Throat after uvulopalatopharyn- structive sleep apnea due to mandibular hypoplasia. Primary goplasty (UPPP). Good passage to the nasopharynx. No snor- Fig. 43.1. A 12-year-old boy with sleep apnea. a Severe ob- like edge of the soft palate. d Throat after uvulopalatopharyn- structive sleep apnea due to mandibular hypoplasia. Primary goplasty (UPPP). Good passage to the nasopharynx. No snor- However, if the history suggests severe disease or you do not find large tonsils or an occluding adenoid pad, partial polysomnography is necessary to verify the condition. In some cases, the sleep study is therapeutic as you can calm the parents that the child's breathing is normal despite some snoring. In all cases where preoperative polysomnography has demonstrated apneas hypopneas and or oxygen desaturation, a control postoperative polysomnography should be performed. Registration of apnea hypopnea either...

Upper Pharyngeal Airway Surgery

Redundant Tonsillar Pillar

General algorithm in the management of the sleep-related breathing disorder (SRDB) patient. nCPAP nasal continuous positive airway pressure Fig 48.3. General algorithm in the management of the sleep-related breathing disorder (SRDB) patient. nCPAP nasal continuous positive airway pressure Fig. 48.4. Postoperative velopharyngeal pictures a After ryngoplasty with significant narrowing of the posterior pillar. uvulopalatopharyngoplasty and tonsillectomy. b After radio- d After uvulopalatopharyngoplasty with nasopharyngeal ste-frequency tissue-volume reduction. c After uvulopalatopha- nosis

And Perioperative Management

- Uvulopalatopharyngoplasty for the lower pharyngeal level (Table 48.1). Patients with moderate to severe apnea are usually treated with CPAP therapy and undergo invasive surgical procedures if they have poor compliance and or are intolerant to CPAP treatment. Using a multilevel surgical approach for these patients results in higher success rate. Whether this multilevel approach should be based on radiological evaluation, such as dynamic MRI, or proposed with a why not philosophy is not yet resolved in the literature. Tonsillectomy or tonsil size reduction must be performed in the case of tonsil hypertrophy. UARS upper-airway resistance syndrome, OSAHS obstructive sleep apnea-hypopnea syndrome Tonsillectomy or tonsil size reduction must be performed in the case of tonsil hypertrophy. UARS upper-airway resistance syndrome, OSAHS obstructive sleep apnea-hypopnea syndrome

For Sleep Related Breathing Disorders

SD standard deviation, AHI apnea-hypopnea-index, O2 oxygen saturation, ESS Epworth sleepiness scale SD standard deviation, AHI apnea-hypopnea-index, O2 oxygen saturation, ESS Epworth sleepiness scale Fig. 39.5. With the hyoid suspension the apnea-hypop-nea-index could be reduced with statistical significance from 40.8 to 25.8, whereas in the group without hyoid suspension the reduction from 27.8 to 22.9 showed no statistical significance. HS hyoid suspension, AHI apnea-hypopnea-index NSS no statistical significance Fig. 39.5. With the hyoid suspension the apnea-hypop-nea-index could be reduced with statistical significance from 40.8 to 25.8, whereas in the group without hyoid suspension the reduction from 27.8 to 22.9 showed no statistical significance. HS hyoid suspension, AHI apnea-hypopnea-index NSS no statistical significance

Children Under 2 Years

Pierre Robin syndrome and Down syndrome and other genetic syndromes often exhibit breathing problems early in life. In those cases, CPAP may be a good solution until the child has grown enough. A temporary tracheostomy may be life-saving, especially if organic heart disease coexists.


Cephalometry is the most commonly performed imaging study for this purpose. It offers both bone and soft-tissue measurements, and is used for surgical planning and predicting outcome. Its main drawback is lack of normative data, especially for soft-tissue measurements. Findings that correlate with the diagnosis of sleep apnea are low hyoid bone position, long and thick soft palate, diminished size of the posterior airway space, increased distance from the tip of the tongue to the base of the vallecula, and facial skeletal abnormalities (such as micrognathia) 4, 11 .


Polysomnography (sleep study) is essential for the diagnosis of sleep apnea. It serves to confirm the presence of sleep apnea and exclude other causes of excessive daytime somnolence such as narcolepsy, insufficient amount of sleep, and periodic limb movement disorder. Moreover, polysomnography determines the severity of the sleep apnea since the information obtained from the medical history and physical examination in any particular patient is a poor indicator of the level of the disease severity 10 . In addition, polysomnography allows for continuous positive airway pressure (CPAP) titration and initiation of CPAP therapy.


Cause decreased and disturbed sleep with suppression of REM sleep. Antipsychotic drugs with sedative effects can cause decreased sleep latency, increased total sleep time, and improved sleep continuity. Firstgeneration antihistamines (H1 antagonists) might produce daytime sleepiness and worsen OSA symptoms. This effect can be avoided by replacing them with second-generation antihistamines. Some anti-depressant drugs have sedative effects. Sedative and hypnotic drugs can worsen sleep apnea, as does alcohol consumption. -adrenergic blockers may cause daytime sleepiness owing to fragmentation of sleep, while a-adrenergic agonists, such as methyldopa and clonidine, may cause sedation. All stimulants, such as caffeine, theophylline, amphetamine, and cocaine, increase wakefulness and withdrawal of these agents may produce severe hypersomnia in chronic use. Alcohol consumption can increase snoring and worsen sleep apnea. It is also a major cause of sleep disruption. Always consider alcohol...

Results Outcomes

Previously, surgical interventions were limited to volumetric reduction of the soft palate, and creation of scar tissue. The improvement following a reduction procedure results from a decrease in the volume of tissue as well as an increase in the stiffness of the palate secondary to scar formation. This new method of stiffening the soft palate with implants appears to be effective in the reduction of snoring intensity and daytime sleepiness. It remains premature to conclude that these implants will be effective in the treatment of sleep apnea.

Associated Medical Findings

The physical examination in a patient with a suspected sleep disorder focuses on several features. To assess for physical abnormalities associated with obstructive sleep apnea, particular attention is directed toward examination of height, weight, and blood pressure. Abnormalities of the upper airway, including enlarged tonsils, tongue, or low palate, can indicate possible airway obstruction. A reddened uvula and palate may be associated with loud snoring. Retrognathia and a small pharyngeal opening may also be seen in patients with sleep apnea.

Evaluation Guidelines

Routine EEG may be indicated when a diagnosis of sleep-related seizures is suspected. Likewise, electromyography may provide valuable information if peripheral neuropathy is suspected associated with RLS, or if neuromuscular disorders are thought to be predisposing to sleep apnea. The standard test of sleep is overnight PSG. PSG is an overnight recording of sleep, monitoring EEG, eye movements, chin muscle tone, muscle activity of the limbs, electrocardiogram, respiratory effort, nasal airflow, and oxygen saturation. During polysomnography, a patient is closely monitored by a technician Focal abnormalities, brain stem abnormality in central sleep apnea who is present throughout the night. Videotaping abnormal sleep behaviors is possible. PSG testing provides objective data concerning sleep latency, sleep efficiency, sleep staging, severity and type of sleep apnea, periodic limb movements, and parasomnias. PSG is of more limited usefulness in the evaluation of...

Respiratory Management

CPAP can improve oxygenation in diffuse lung disease by recruiting and stabilising collapsed alveolar units. It is a standard treatment in severe pneumocystis pneumonia and a few case reports describe its successful use in severe CAP25 However, a recent randomised controlled trial of CPAP in patients at high risk of developing acute respiratory distress syndrome (ARDS) was negative.26 In the study 123 consecutive adult patients with marked impairment of gas exchange (Pao2 FIo2

Clinical Features

Sion is likely higher than reported in the literature 16, 39, 86, 95, 462 . Adenomatoid hyperplasia typically presents as a painless mass located on the hard and soft palate in up to 95 of cases 39 . Rarely, adenomatoid hyperplasia is located on the retromolar trigone 86, 116 . While it can present at any age it is more common in the fourth decade with a slight male predominance. The typical clinical concern is that of a benign salivary gland tumor 462 . We have occasionally noted these lesions in uvulo-palatopharyngoplasty specimens suggesting their role in some cases of obstructive sleep apnea.

Evaluation Guidelines Table211

Electroencephalography may show epileptiform activity in the temporolimbic areas, which may be associated with syncope or other paroxysmal autonomic phenomena. Sleep polysomnograms in patients with multiple system atrophy may allow the physician to make a diagnosis of sleep apnea.

High frequency oscillatory ventilation HFOV

HFOV differs from HFV in a number of important aspects. Tidal volume (1-3 ml kg) is generated by the excursion of an oscillator within a ventilator circuit similar to that used for CPAP and is varied by altering the frequency, I E ratio, and oscillator amplitude. The use of an oscillator to generate Vt results in active expiration. Mean airway pressure is adjusted by altering the fresh gas flow (bias flow) into the circuit or the expiratory pressure valve. Oxygenation is controlled by altering mean airway pressure or FiO2.

Rapid shallow breathing

A common finding in patients who fail to wean is the early development of rapid shallow breathing when the ventilator is disconnected.5 This represents the coordinated response of the patient to the ventilatory load applied. The attractive features of this assessment are that it tests the whole ventilatory system and requires that the patient be disconnected from the ventilator, thus indicating whether or not the patient can breathe in a controlled environment. Rapid shallow breathing (frequency divided by tidal volume, f Vt) is best assessed with the patient breathing with continuous positive airway pressure (CPAP) at the level of PEEP used during mechanical ventilation. Rapid shallow breathing has a sensitivity of 0.97 with a specificity of 0.64.8 Weaning parameters with a low specificity result in some patients, who are able to breathe independently, being prevented from weaning. By encouraging all patients to be disconnected from the ventilator this may in part be avoided.

Assisted modes of ventilatory support

One disadvantage of pressure support occurs during sleep when prolonged apnoeic periods, potentiated by lowering Paco2 below normal, may result in repeated ventilator alarms. It is our preference to ensure adequate ventilatory support and allow restorative sleep at night using a controlled mode and then progressively reduce the degree of pressure support during the day. An alternative is to use timed bi-level pressure support42 which ensures adequate ventilation during sleep and, if adjusted appropriately, comfortable pressure support by day. As this method does not involve triggered breathing (it can be conceptualised as cPAP with a timed higher pressure period superimposed), inadvertent triggering during suctioning or coughing is avoided another mechanism for patients becoming distressed. With bi-level pressure support (BiPAP) there is the potential for increasing hyperinflation if inappropriate timing results in expiratory effort during the high pressure period.

Chromosomal Anomalies

In addition to the typical phenotypic features of the syndrome, associated congenital cardiac and gastrointestinal abnormalities may be present. A third to a half of patients with Down's syndrome have congenital cardiac defects, of which one third are endocardial cushion defects, and the remainder are ventricular septal defects. Tetralogy of Fallot and atrial septal defects also occur, and there is an increased incidence of moyamoya disease. More than half of patients have bilateral hearing loss, of which many cases are attributable to anomalies of the inner and middle ear. Malformations of the gastrointestinal tract, including intestinal atresia and imperforate anus, occur in about 5 to 7 percent of patients, and there is a reported increased incidence of Hirschsprung's disease. Although abnormalities of T-lymphocyte function have been reported, no specific relationship of these to the infection rate has been established. Other associated abnormalities include gastroesophageal...

Mechanical ventilation

Low level CPAP may be beneficial in spontaneously breathing, mechanically ventilated patients, especially if expiratory muscle activity is contributing to dynamic airways collapse. However, in mechanically ventilated paralysed patients extrinsic PEEP was of no benefit at low levels and was detrimental at high levels because the fall in gas trapping was outweighed by the rise in functional residual capacity (FRC).22 However, in this study large Vt were used (up to 18 ml kg) furthermore PEEPi and arterial blood gases were not measured. Changes in FRC and gas trapping may guide the level of PEEP. Applied extrinsic PEEP should not exceed PEEPi.

Initiation and termination of apnoeas

The pharyngeal airway tends to become smaller during expiration and if this is prolonged, as in for instance a central sleep apnoea, or if there is an instability of respiratory control, it tends to close 5 . Once the airway is closed, surface forces may hold the mucosae of the airway walls together and increase the force required to open the airway. During each apnoea the section of the airway that is closed spreads progressively proximally. Table 10.1 Maintenance and termination of an obstructive sleep apnoea. Table 10.1 Maintenance and termination of an obstructive sleep apnoea.

Physiological factors

Males have a higher apnoeic threshold than women. This predisposes to central sleep apnoeas during NREM sleep-stage transitions. The hyperventilation related to arousal at the end of sleep apnoeas lowers the Pco2 and if this falls below the apnoeic threshold it will lead to a central sleep apnoea. The upper airway tends to occlude during the prolonged expiration of a central sleep apnoea, particularly if the Pco2 is low.

Wakefulness promoting drugs

Mandibular Tonsillectomy CPAP Nasal advancement ventilation Fig. 10.4 Treatment of obstructive sleep apnoeas (OSA). CPAP, continuous positive airway pressure REM, rapid eye movement. physiological effects of OSA such as transient hypertension during apnoeas, and its effect on preventing long-term complications such as strokes or myocardial infarction is unknown. It should, however, be considered if excessive daytime sleepiness persists despite optimization of treatment, particularly nasal CPAP. Treatment with modafinil has not been shown to reduce compliance with nasal CPAP.

Treatment of the patient

These are similar in principle to those for OSA, but upper airway surgery is usually more effective because the site of snoring is often more localized than the site of obstruction in OSA. Mandibular advancement devices may be useful, but nasal CPAP is less frequently required than in OSA and wakefulness promoting drugs are not indicated. 2 Palatal surgery. Resection of part of the palate together with a uvulectomy has been practised for many years (uvulopalatopharyngoplasty, UVPPP, UPPP) and is often combined with a tonsillectomy 48 . UPPP may lead to nasopharyngeal stenosis, nasal regurgitation of fluids due to palatal incompetence (velopharyngeal insufficiency), voice change and loss of taste.

Treatment of respiratory effects

Treatment with diuretics, nitrates and opiates reduces sympathetic activity and leads to vasodilatation. Nevertheless intubation and ventilation may still be required, although the intubation rate can be reduced by around 30 by the application of continuous positive airway pressure. This reduces ventilationperfusion mismatching, offsets intrinsic PEEP, reduces the work of breathing, and reduces the left ventricular afterload and preload. Continuous positive airway pressure is safe if the left ventricular end-diastolic pressure is greater than 12 cmH2O, but if it is less than this it may cause hypotension and possibly myocardial infarction. Bilevel pressure support ventilation may be better tolerated with a lower expiratory pressure, but is more likely to reduce the arterial Pco2. Continuous positive airway pressure (CPAP) treatment. 1 Central sleep apnoeas. A level of at least 10 cmH2O is required to have a significant effect on preload. CPAP is in effect a left ventricular assist...

Diffuse Autonomic Failure Pandysautonomia Central Preganglionic Disorders

Multiple system atrophy (MSA, Shy-Drager syndrome) is a degenerative disorder of the CNS that affects the extrapyramidal, cerebellar, and autonomic neurons (see Chaptei.34,). Autonomic dysfunction in patients with MSA is due to the loss of preganglionic neurons in the brain stem and spinal cord. Patients with MSA typically present with diffuse autonomic failure and parkinsonian, cerebellar, or pyramidal deficits in different combinations. y Autonomic features include orthostatic intolerance, erectile dysfunction in males, bowel hypomotility, urinary incontinence due to denervation of the external urinary sphincter, and respiratory disturbances (sleep apnea and laryngeal stridor). There is usually a poor response to levodopa. Pathologically, cell loss and gliosis in striatonigral, olivopontocerebellar, and autonomic neurons are evident, and intracytoplasmic oligodendroglial and neuronal inclusions are frequently present.

Straight Back Syndrome

Pectus Excavatum Haller Index

Dr. John C. Wain, at Massachusetts General Hospital, managed a patient with straight back syndrome and pronounced pectus excavatum deformity, by performing a thorough correction of the pectus problem with osteotomies in both the manubrium and gladiolus. The correction was held in place by an Adkins strut. This successfully opened the trachea, which had been compressed to one-third of its normal cross-sectional area. Mori and colleagues corrected an asymptomatic but severe midtracheal stenosis caused by abnormal ossification behind the top of the manubrium, but in a patient with a vertebral column typical of straight back syndrome.47 Andrews and colleagues described a narrowed anteroposterior thoracic dimension due to severe pectus excavatum and kyphoscoliosis, which produced obstructive sleep apnea in a 5-year-old, due to compression of the distal trachea and left main bronchus.48 This problem was corrected by pectus repair and aortic suspension. A...

Treatment Algorithm of Acromegaly

SMS analogs can be used as primary treatment, in patients without prior surgery or irradiation, in selected newly diagnosed cases.24 This concept has gained popularity in recent years and is based on the idea that acromegalic patients, with little prospect of complete surgical resection of their pituitary adenoma, could benefit from medical treatment.25 Factors favouring the primary use of SMS analogs include low cure rates achieved after surgical resection for pituitary macroadenomas, especially in the presence of cavernous sinus invasion, wide variability in surgical experience, prevalence of perioperative side effects, unacceptable anesthetic risk for some patients, cardiovascular or pulmonary complications and refusal of surgery.26-29 Ac-romegalic complications, including insulin resistance, hypertriglyceridemia, hypertension, sleep apnea syndrome or cardiac indices, improve with primary treatment and may be beneficial on hemodynamic outcome of surgery.24 Shrinkage of tumor before...

Autonomic Neuropathy of Multiple System Atrophy Shy Drager Syndrome

Often in the male, the first symptom is impotence and loss of libido, with disturbance in micturition being common in both sexes. The characteristic orthostatic hypotension may be seen either as so-called drop attacks or as a gradual loss of consciousness over about a minute that is often associated with a neckache that radiates to the occiput and shoulders. Generally, there is at least partial loss of thermoregulatory sweating. Respiratory disturbance occurs as involuntary gasping, cluster breathing, and laryngeal stridor that may lead to obstructive sleep apnea and even death, or to central sleep apnea.

Jean K Matheson Randip Singh and Andreja Packard

The classification of sleep disorders is based both on clinical and neurophysiological criteria and is undergoing constant refinement. Sleep disorders can be caused by either a primary disorder of a mechanism controlling sleep or inadequate function of an end organ, such as the upper airways and lungs. Understanding the physiology and pattern of normal sleep is an important foundation for interpreting the clinical symptoms, signs, and neurophysiological abnormalities observed in patients with sleep disorders. The term polysomnography refers to the simultaneous recording of multiple sleep parameters, including a limited electroencephalogram, respiratory parameters, chest excursion, limb movements, and the electrocardiogram. Polysomnography is important for assessing a variety of sleep disturbances, including disorders such as sleep-related breathing disorders (including obstructive sleep apnea), rapid eye movement behavior disorder, and periodic movements of sleep. The multiple sleep...

Autonomic Dysfunction Secondary to Focal Central Nervous System Disease

Other brain stem disorders associated with autonomic dysfunction include tumors, syringobulbia, Arnold-Chiari malformation type 1, multiple sclerosis, and poliomyelitis. Brain stem tumors may present with intractable vomiting, orthostatic hypotension, or paroxysmal hypertension. Syringobulbia may produce Horner's syndrome, orthostatic hypotension, cardiovagal dysfunction, lability of arterial pressure, and central hypoventilation. y Syncope, sleep apnea, and cardiorespiratory arrest have been reported in association with the Arnold-Chiari malformation type 1. Less common manifestation of brain stem dysfunction include hypertension due to involvement of the medullary reticular formation in poliomyelitis (see Chapter . ) autonomic hyperactivity, most likely due to disinhibition of preganglionic sympathetic and parasympathetic neurons in tetanus (see Chapterii39 ) and fulminant neurogenic pulmonary edema due to demyelination of the area surrounding the NTS in patients with multiple...

Consequences of Sleep Deprivation

Sleep loss can be voluntary or produced by a variety of environmental factors, or medical, psychiatric, and sleep disorders which disrupt sleep, including chronic pain, depression, sleep apnea, and RLS. High-frequency sleep fragmentation due to repeated arousals from sleep produces nonrestorative sleep and results in similar neurobehavioral consequences and performance deficits as voluntary SD (8). Sleep fragmentation and SD both result in daytime sleepiness, decreased psychomotor performance, and comparable physiological changes (9). In combination, voluntary sleep restriction and sleep fragmentation due to underlying medical or sleep disorders, both individually common occurrences, are likely to have synergistic and therefore even greater negative impact. further exacerbated by coexisting disorders like sleep apnea, the treatment of which with positive airway pressure therapy has been shown to reduce the risk of traffic accidents (32). Respiratory testing in healthy adults has shown...

Abnormal Findings and Clinical Uses of Polysomnography

It is important in confirming the existence of insomnia and characterizing its nature by determining, for example, whether it is associated with nocturnal myoclonus or periodic leg movements. Some patients complain of insomnia but, in fact, have a normal amount of sleep. Patients with complaints of excessive daytime somnolence may have sleep apnea, which can be diagnosed by polysomnography. Apnea is defined in this context as the cessation of air flow at the mouth and nostrils for at least 10 seconds, whereas hypopnea refers to a reduction in respiratory air flow to one third of its basal value, with an associated reduction of abdominal and thoracic respiratory movements and a decline in oxygen saturation. The number of respiratory irregularities per hour of sleep can be calculated by dividing the number of apneic and hypopneic episodes by the total sleep time in minutes and multiplying the result by 60. A value of 5 or less is regarded as within the normal range. y Polysomnography...

Sleep Disorders Classification

Sleep-related breathing disorders include central sleep apnea syndromes (including primary in adults or children as well as those related to Cheyne Stokes, high-altitude, medical conditions, or drugs), obstructive sleep apnea syndromes, sleep-related hypoventilation hypoxemic syndromes (related to alveolar hypoventilation or a medical condition), and other sleep-related breathing disorders. Hypersomnias of central origin include narcolepsy, recurrent hypersomnia (as in Kleine-Levin syndrome or as related to menses), idiopathic hypersomnia (with or without a long sleep time), behaviorally induced insufficient sleep syndrome, or hypersomnia due to a medical condition, drug, or nonorganic or physiological (organic) factors.

Canadian Psychological Association

The governance of the CPAconsists of an appointed honorary president plus an 11-person board of directors (including the president, president elect, and past president) assisted by an executive director and head office staff. (Administrative offices are located in Ottawa.) Two directors, one representing the Canadian Society for Brain, Behaviour, and Cognitive Science and the other the Council of Canadian Departments of Psychology, have designated seats, while other directors and the president are elected. The Council of Provincial Associations of Psychologists (CPAP), the Canadian Council of Professional Psychology Programs, and the Association of State and Provincial Psychology Boards enjoy observer status at board meetings. Various functions are assigned to committees of the board, with a director serving as chair. Included among the 15 extant committees are By-Laws, Rules and Procedures Convention Education and Training Ethics Fellows and Awards International Relations Membership...

Cushings Syndrome Cushings Disease

The hypersecretion of GH produces various forms of disfigurement and other physical changes (, Tab.leii.SSzl.I). Central sleep apnea has been reported in one third of acromegalic patients with sleep apnea. W Importantly, the presence of sleep apnea increases the risk for hypertension, myocardial infarction, and stroke, as well as accident susceptibility due to daytime sleepiness. '110 Mononeuropathies, especially compression neuropathies such as carpal tunnel syndrome (CTS), may be noted. CTS occurs in 50 percent of patients and is noted in 75 percent when EMG testing is performed. y Objective weakness, in a myopathic pattern, is observed in about 40 percent of acromegalic patients.y The weakness typically has an insidious onset and is a late manifestation, correlating best with the duration of acromegaly. y Polyneuropathies, nerve root and spinal cord compression, headaches, and visual changes have also been described. y

Desaturation index DI

In oxygen saturation due to, for instance, alterations in body position and ventilation-perfusion matching. Small desaturations often follow hyperventilation during wakefulness at night, leading to a return to a normal oxygen saturation during sleep. This does not represent an abnormal sleep apnoea or sleep desaturation. Visual inspection of the pattern of the oximetry tracing during sleep is often of more value than using unvalidated indices, such as the desaturation index. In obstructive sleep apnoeas each desaturation is slower than the resaturation, but the pattern is more symmetrical in central sleep apnoeas and Cheyne-Stokes respiration, which often also have a more uniform frequency and minimum desaturations during the night. In chronic obstructive pulmonary disease the desaturations are more prolonged and occur particularly in REM sleep.

Neurological Examination

Central sleep apnea is the loss of respiratory airflow associated with a loss of respiratory muscle effort. It is thought to arise from alterations in the functioning of chemoreceptors monitoring hypoxic and hypercapnic influences on respiration. Patients should be examined for waking respiratory difficulties and cardiac functioning, in particular for congestive heart failure. Neuromuscular diseases likewise may predispose to episodes of sleep apnea, as can autonomic nervous system instability. Patients should be assessed for evidence of orthostatic hypotension and examined for those disorders with autonomic nervous system involvement, including multiple system atrophy, Guillain-Barre(c) syndrome, and diabetes. Neurovascular System. A general cardiac and vascular examination reveals signs of cardiac failure and blood pressure, specifically signs of pulmonary hypertension that is frequently associated with obstructive sleep apnea.

Mandibular advancement or positioning devices

The indications for mandibular advancement devices are mild to moderate obstructive sleep apnoeas which are unresponsive to first-line treatments and in which surgery or CPAP either have failed or are con-traindicated. The devices are most beneficial in the following situations. 4 In subjects who cannot tolerate alternative treatments such as CPAP. These devices rarely completely abolish snoring, but may significantly improve mild to moderate obstructive sleep apnoeas. A reduction of the apnoea-hypopnoea index to less than 10 per hour is usually taken as a successful outcome. A reduction of around 50 of the number of sleep apnoeas is achievable in around 50 of those with sleep apnoeas. Improvements in daytime sleepiness, memory and ability to learn have been demonstrated with mandibular advancement devices. Localization techniques, such as sleep nasendoscopy, have been used as a predictor of response to this type of treatment, but there is little evidence regarding their value.

Demyelinating Disorders

Obstructive sleep apnea Even though the patient has been adequately preoxygenated, some method of supplemental oxygen delivery is still necessary. This may be accomplished either by placing a suction catheter near the carina with a 10 L min oxygen flow, or by using a continuous positive airway pressure (CPAP) circuit with 10 cm H 2 O pressure. A CPAP circuit does not provide ventilation, so it does not interfere with observation for spontaneous respirations. Even with one of these methods employed, some patients with cardiorespiratory dysfunction may not tolerate the approximately 10 minutes of apnea necessary to raise the PaCO 2 to 60 mm Hg without becoming hypoxemic and hypotensive. In this circumstance, a confirmatory test may be necessary.

Carinal Resection and Reconstruction

Position, increasing FiO2, and varying the ventilatory patterns. Unlike many thoracotomies, it is not as easy to administer ventilation to the deflated lung. While the airway is intact, deflating the endobronchial cuff, blocking the mouth and nose, and delivering longer and larger tidal volumes can help. Alternatively, placing another endotracheal tube high in the trachea (ie, two endotracheal tubes, of small diameter) can allow differential ventilation, or at least constant positive airway pressure (CPAP). Another approach is to place an LMA after the endobronchial tube, and if it seals sufficiently, CPAP can then be administered. Finally, a jet catheter can be placed in the trachea. Indeed, a technique using two jet catheters has been described.31 The jet catheter has the advantage of not requiring a seal, but may not be effective if there is substantial distal obstruction. In extreme circumstances, blood flow to the pulmonary artery can be restricted, lessening shunt. Once the...

Growth Hormone Hypersecretion Museuloskeletal Increas

Ng hat, glove, or shoe sizes prognathism prominent supraorbital ridges coarsening of facial features (e.g, large bulbous nose, thick lips, separated teeth) Endocrine Hyperhidrosis, fatigue, exercise intolerance, hoarseness, sleep apnea (peripheral and central) MEN-I, Multiple endocrine neoplasia, type I Data from Kissel IT Endocrine myopathies, In Update on Neuromuscular Disease course 423 of the AAN annual meeting, Washington, D.C., May, 1994, pp 34-35 Maugans TA, Coates ML Diagnosis and treatment of acromegaly Am Fam Phys 1995 52 207-213 Molitch ME Clinical manifestations of acromegaly. Endocrinol Metab Clin North Am 1992 21 597-614 and Grunstein RR, Ho KY, Sullivan CE Sleep apnea in acromegaly Ann Intern Med 1991 115 527-532. The prevention of many of the sequelae of disorders associated with acromegaly (e.g., hypertension, cardiovascular disease, stroke, sleep apnea, diabetes, arthropathy) requires early identification and treatment. The management of acromegaly includes the...

Cheyne Stokes respiration CSR periodic breathing

Cheyne-Stokes respiration is closely related to central sleep apnoeas. It is characterized by a regular waxing and waning of tidal volume with little change in respiratory frequency during the phases when breathing is taking place. Between these cycles there may be a short or prolonged apnoea, which if it exceeds 10 s is classified as a central sleep apnoea using conventional criteria. Occasionally, however, the waxing and waning of tidal volume occurs without any cessation of breathing (Cheyne-Stokes variant).

Inflammatory reaction

Hypoxia also increases the synthesis of plasma vascular endothelial growth factor (VEGF). This is a glycoprotein and angiogenic cytokine, which also modifies vascular tone. It is increased in OSA, both during the day and at night, but its levels fall if nocturnal hypoxia is relieved by CPAP.

Haematological changes

OSA may also induce a hypercoagulable state due primarily to an increase in fibrinogen levels 11 . Fibrinogen is an acute phase protein which promotes thrombus formation and also leads to platelet aggregation and smooth muscle proliferation. The increased fibrinogen level is mainly due to oxygen desaturations. It peaks in the mornings, is independent of obesity, but can be slightly reduced by CPAP treatment.

Excessive Daytime Somnolence

EDS indicates the occurrence of abnormal sleepiness during the normal waking hours. y EDS may be associated with inadequate nocturnal sleep and can arise secondary to insomnia. EDS can also occur independently of insomnia. y Primary sleep disorders, such as sleep apnea and PLMD, may disrupt nocturnal sleep, leading to sleep deprivation and EDS. Often, patients with these disorders have frequent arousals punctuating the night but are unaware of these events. During the day, they report a susceptibility to falling asleep. When the condition is mild, inadvertent napping may occur only during sedentary activities during the normal nadirs in daytime alertness in the afternoon or evening. As EDS becomes more severe, patients may report nodding off during active periods, such as driving a car or when conversing. Narcolepsy is characterized by a propensity to sleep during the day. Sometimes, these periods may present as microsleeps in which there is a sudden but momentary lapse of...

Neuromuscular conditions

Adenotonsillectomy usually gives partial relief of the apnoeas. Nasal CPAP may be required. In this condition there is herniation of the brainstem and cerebellum through the foramen magnum leading to lower cranial nerve palsies. These include damage to the 9th and 10th cranial nerves, causing vocal cord adduction, abnormal control of the pharyngeal muscles and changes in respiratory drive. Nasal CPAP may be required. The brainstem compression also reduces the ventilat-ory response to oxygen and carbon dioxide, causing central sleep apnoeas, and these may improve with posterior fossa decompression. In this disorder, obesity, hypogonadism and mental retardation are combined with hypotonia and hypo-thalamic abnormalities. Excessive daytime sleepiness is seen in around 70 of subjects. The sleepiness may be partly due to an intrinsic hypersomnia related to hypothalamic abnormalities, but obstructive sleep apnoeas are frequent and often contribute. They may lead to respiratory and right...

Parkinsonism Plus Syndromes

Clinical Features and Associated Disorders. MSA encompasses three neurodegenerative syndromes, which in the past were considered clinically distinct striatonigral degeneration (SND), olivopontocerebellar atrophy (OPCA), and Shy-Drager syndrome (SDS). All these conditions share similarities with one another and with PD. The hallmark features of MSA are parkinsonism that is poorly responsive to levodopa therapy and varying degrees of autonomic, cerebellar, and pyramidal dysfunction. SDS is diagnosed clinically when dysautonomia far outweighs the other signs, SND is designated when anterocollis and pyramidal dysfunction are prominent, and OPCA is used to characterize the patient with prominent cerebellar features of ataxia, limb dyssynergia, and kinetic tremor. For all MSA patients, autonomic insufficiencies include orthostatic hypotension, postprandial hypotension, anhidrosis with thermoregulatory disturbances, poor lacrimation and salivation, constipation, and impotence. Disturbances...

Aetiology of periodic limb movements

The relationship of PLMS to obstructive sleep apnoeas is complex. The diagnosis of PLMS may be difficult in the presence of obstructive sleep apnoeas because arousal from the apnoeas often causes a limb movement indistinguishable from a PLM. The sleep fragmentation due to obstructive sleep apnoeas may also induce PLMS. Treatment of sleep apnoeas with, for instance, nasal continuous positive airway pressure may clarify the situation by abolishing the limb movements, but equally it may lead to more consolidated sleep and increase the number of PLMS.

Respiration during REM sleep

Increase in upper airway resistance Weakness of the upper airway dilator muscles combines with the intense loss of muscle tone in REM sleep to predispose to upper airway obstruction. The risk of this is greater if the chest wall muscles are selectively spared and remain able to generate a sufficiently negative intra-airway pressure. Conversely, if the chest wall muscles, particularly the diaphragm, are involved then obstructive sleep apnoeas are less likely. The upper airway diameter is reduced through a reflex mechanism related to the loss of lung volume in REM sleep. The obstruction may occur at any level from the base of the tongue to the larynx, in which case stridor-like noises are often heard at night. If, however, the chest wall muscles are too weak to generate rapid airflow rates there may be little noise despite the upper airway obstruction (Table 11.3). The high threshold for arousal during REM sleep prolongs the obstructive sleep apnoea and, together with the small oxygen...

Pulmonary artery pressure

Arousal from sleep, for instance by a sleep apnoea, does not itself alter the pulmonary artery pressure, but hypoxia during each apnoea causes pulmonary vasoconstriction with the result that the pulmonary artery pressure rises towards the end of the apnoea and immediately afterwards 10 . This causes systolic right ventricular afterload which reduces the stroke volume. This reduction in stroke volume contrasts with the situation towards the start of the apnoea when the right ventricular output is reduced because of the bradycardia although the stroke volume is normal.

Assessment Clinical Findings

The diagnosis of congenital tracheal stenosis and other obstructive anomalies is based on a high degree of suspicion in infants and children with respiratory distress. Inspiratory and or expiratory stridor may be present, accompanied by retraction. Recurrent or persistent cough and exercise intolerance occur. There may be a history of respiratory difficulties of lesser intensity since birth, or shortly after birth, or of repeated and stubborn respiratory infections. Strangely, dyspnea may be episodic. Cyanosis and apneic episodes may occur. In some cases, difficulty in intubation had led to the diagnosis. Late manifestations of congenital stenosis may represent the child's respiratory demands outpacing the ventilation permitted by the stenotic airway. Only then may a clinical history be retrospectively traced to a much earlier time. Other obstructive lesions are manifest in similar ways.

Sleep study

The complexity of the sleep study varies according to the suspected diagnosis. If obstructive sleep apnoea is most likely, an oximetry study may be sufficient on its own, or combined with measurement of airflow and abdominal and rib cage movement. In most other situations polysomnography is needed to give information about sleep architecture, arousals, sleep-onset REM, and the cause of arousals from sleep, such as periodic limb movements in sleep, central sleep apnoeas or gastro-oesophageal reflux. Serial sleep studies may be required to monitor progress with treatment.


The diagnosis of narcolepsy is established on the basis of the narcoleptic tetrad (overwhelming sleepiness, cata-plexy, hypnagogic hallucinations, sleep paralysis), combined with characteristic findings on the nocturnal poly-somnogram and the multiple sleep latency test (MSLT). The nocturnal polysomnogram is a procedure in which the activity of multiple bodily functions, such as the electroencephalogram (EEG), eye movements, chin and leg electro-myogram (EMG), airflow, thoracic and abdominal respiratory effort, electrocardiogram, and oxygen saturation, are recorded simultaneously on a strip of moving graph paper or a computer system. The test helps exclude disorders such as obstructive sleep apnea and periodic limb movement disorder which may also impair daytime alertness and mimic narcolepsy. On the morning following the nocturnal poly-somnogram, the patient undergoes the MSLT, during which four 20-minute nap opportunities are provided at two hourly intervals in a darkened, quiet...

Craniofacial causes

Tongue and soft palate, which is often cleft. There may also be other malformations of the upper respiratory tract. Obstructive sleep apnoeas are often severe neonatally, but improve as the mandible grows. They can be overcome initially with a nasopharyngeal tube rather than a tracheostomy. Sleep apnoeas may present later in life, at which time an adenotonsillectomy may be at least partially effective. Nasal CPAP is an alternative. Treacher-Collins syndrome. Mandibular hypoplasia is associated with other abnormalities such as conduction deafness. Obstructive sleep apnoeas are common and usually respond to mandibular advancement surgery or nasal CPAP. Craniosynostes. The three commonest syndromes are Apert's, Crouzon's and Pfeiffer's syndromes in which different cranial sutures become prematurely fused. They lead to failure of growth of the maxilla with posterior displacement of the tongue. They are often associated with cleft palate and mental retardation. Obstructive sleep apnoeas...

Subjective Objective

Myopathy can be a feature of hypothyroidism and manifests with proximal muscle weakness. Regardless of the cause of the hypothyroidism, weakness is observed in about one third of these patients.y Increased muscle size and firmness, which is most obvious in the limb musculature, as well as slowed muscle contraction are important features to identify. Exertional pain, stiffness, and cramps may be noted, and myoedema may be observed. Myoedema, a mounding of the muscle in response to direct percussion, is painless and electrically silent, and occurs in one third of hypothyroid patients. y Difficulty relaxing the hand grip and exacerbation by cold weather may suggest myotonia. However, unlike myotonia, hypothyroid myopathy involves a slowness of muscle relaxation and contraction, and resolves with correction of the hypothyroid state. y Although sleep apnea is usually of the obstructive type, other possibilities include a central abnormality, chest muscle weakness, and blunted responses to...


OSA may occur following any type of stroke 20 , but particularly with those involving the posterior inferior cerebellar artery, leading to pharyngeal and palatal dysfunction. Obstructive sleep apnoeas after a stroke correlate with early neurological deterioration and increased disability at 6 months, possibly because the lability of the blood pressure during each apnoea increases the extent of the cerebral damage. Treatment with nasal CPAP is poorly tolerated with only around 50 using it acutely and 10 at 3 months. Nasal CPAP could also have harmful effects, such as reducing the Pco2, which leads to cerebral vasoconstriction.


Chronic hypertension is associated with obstructive sleep apnoeas even when confounding factors such as obesity, alcohol intake, diabetes mellitus and inactivity are taken into account. It is mainly due to sustained increased sympathetic activity during the day as a result of intermittent hypoxia at night. The blood pressure usually rises by around 3-5 mmHg. Hypertension has been thought to be associated even with mild obstructive sleep apnoeas but is probably only significant when the desaturation index is greater than around 20 per hour. Hypertension is most closely associated with OSA between the ages of 30 and 50, possibly because of a greater sympathetic reaction to hypoxia in this age range, and may be drug resistant, although it is reversible with CPAP treatment. systemic vasoconstriction that OSA lead to. It improves slightly with CPAP treatment 21 .

Life expectancy

The life expectancy of women with OSA is shorter than that of men. The cause of this is uncertain, but it may be because of a delay in presentation, a gender-specific susceptibility to endothelial dysfunction in response to repeated episodes of hypoxia, the presence of more comorbidity or poorer compliance with CPAP (see below).


This is rarely effective in OSA, although it may improve the sensation of nasal obstruction and occasionally enables a lower CPAP level to be effective. This is rarely indicated in OSA, whether by a conventional surgical, laser or radio frequency technique. It is only effective in around 15 of those with significant OSA, and is hardly ever of value if OSA is severe. Palatal surgery may cause mouth leaks if CPAP is subsequently used with a nasal mask and an oronasal mask may be needed. CPAP off CPAP on Fig. 10.5 Continuous positive airway pressure (CPAP) principle. The right-hand figure shows positive pressure generated by the CPAP pump being conducted to the upper airway and expanding it at pharyngeal level. The left-hand figure indicates spontaneous breathing without CPAP with negative pressure in the upper airway drawing the pharyngeal walls together. CPAP off CPAP on Fig. 10.5 Continuous positive airway pressure (CPAP) principle. The right-hand figure shows positive pressure...

Ventilatory support

The nasal masks used for ventilatory support are similar to those used for nasal CPAP (Fig. 11.3), but oronasal masks are occasionally required. If neither can be tolerated a mouthpiece or nasal seals are alternatives. The mask connects to either a pressure or volume preset ventilator. The former is more frequently used, and in neuromuscular and skeletal disorders it is common for the peak inspiratory pressure to be 20-25 cmH2O with a positive end expiratory pressure of 2-4 cmH2O to prevent alveolar closure. The inspiratory time is 0.8-1.0 s with an expiratory time of around 2 s. A sensitive trigger and short response time are preferable in view of the rapid respiratory rate adopted by these patients.

Sleep Disorders

Sleep-related breathing disorders are the most common diagnoses made in sleep centers. Based on a random sample of 602 employed people between 30 and 60 years of age, Young et al. (1993) estimated that 4 of men and 2 of women meet diagnostic criteria for sleep apnea syndrome. Obesity, large neck circumference, and hypertension are associated with sleep apnea. Most patients are loud snorers and are sleepy during the day, although these complaints often come from family members rather than the patients themselves. The polysomnogram provides objective evidence of sleep apnea. Airflow, chest and abdominal movement, and oxygen saturation are monitored continuously during the night. Sleep stages are identified by recording the electroencephalogram, eye movements, and chin muscle tone. Initially, breathing was assessed by counting the number of episodes of complete cessation of airflow lasting more than 10 seconds. More recently, decreases of airflow and arousals related to diminished...

Respiratory effects

In arterial Pco2 of 2-3 mmHg at sleep onset does not occur. The Pco2 during sleep is therefore close to the apnoeic threshold and if ventilation increases slightly, for instance with an arousal at the end of an apnoea, the arterial Pco2 may fall below the apnoeic threshold and lead to a central sleep apnoea. The reduced oxygen stores in the lungs as a result of the reduced lung volume accentuate the oscillations in Po2, which further destabilize respiration 9 . Obstructive sleep apnoeas and cardiac failure are related particularly to obesity in males and age in females. Their cause is uncertain, but mixed apnoeas commonly develop when the airway closes during a primarily central apnoea. In addition, a low arterial Pco2 is associated with narrowing of the glottis and possibly of the rest of the upper airway as well, and the reduction in lung volumes due to pulmonary oedema causes a reflex reduction in pharyngeal diameter. Upper airway oedema also narrows its lumen and contributes to...

Overview Of Sleep

Some disorders are exacerbated by or occur only during certain sleep stages. Sleepwalking, for example, occurs with arousal from slow-wave sleep. Epileptic seizures tend to be facilitated by NREM sleep but inhibited by REM sleep. Obstructive sleep apnea (OSA) is typically worse in REM sleep because of REM atonia and alteration of respiratory chemosensitivity.

Sleep and obesity

A genetic failure to produce leptin can lead to obesity of early onset, but in obesity there is usually an increased leptin level due to leptin resistance. Leptin is also increased in obstructive sleep apnoeas due to increased sympathetic activity, but is reduced in narcolepsy, where there is also a loss of the physiological nocturnal increase in leptin secretion. Obstructive sleep apnoeas Obstructive sleep apnoeas are caused by obesity and may also contribute to it through inducing the metabolic syndrome with insulin resistance, diabetes mellitus, an increase in lipids and hypertension. The serum leptin is raised due to increased sympathetic activity both during the day and at night, but falls once effective CPAP treatment is started. Sleep disorders may affect the bed partner, family, friends, carers and even neighbours in addition to the patient. The partner may become concerned because of the implications of the sleep disorder, especially when the patient stops breathing, as in...


The absolute contraindication for T therapy is the suspected or documented presence of prostate cancer or breast cancer 212 . Although there is no evidence that T or any other androgen initiates prostate cancer, it is generally accepted that T therapy may accelerate an already existing prostate cancer. Relative contraindications and cautions include severe congestive heart failure for concern of fluid retention, and polycythemia, severe sleep apnea, severe lower urinary tract symptoms, gynecomastia, and male infertility 157 .

Accident prevention

2 Treat any underlying sleep disorder. Effective treatment of obstructive sleep apnoeas with nasal continuous positive airway pressure (CPAP) treatment reduces the risk of road traffic accidents 21 . The DVLA are responsible for identifying drivers with sleep disorders who are likely to be a source of danger while driving. 'Likely' in this sense is interpreted as 'more than a bare possibility'. The DVLA do not require notification of EDS due to poor sleep hygiene, sleep deprivation, shift work or sedative medication. The patient has a legal duty to report narcolepsy, irrespective of the extent of any perceived difficulty with driving. Approximately 2500 patients with obstructive sleep apnoeas and 300 with narcolepsy are identified each year in the UK. This is probably considerably fewer than the total number that are diagnosed with these conditions. Medical disorders which affect the ability to drive may require a report from the doctor caring for the patient before a licence is...


There has been considerable variation in the use of this term, but it usually implies a reduction in airflow or respiratory movements by over 50 for 10 s or more from the baseline, associated with either oxygen desaturation or evidence of an arousal. It therefore requires more complex monitoring than is needed to identify a sleep apnoea.

Osahs Proteomics

Obstructive sleep apnoeas (OSA) are due to transient closure of the upper airway during sleep. Air is prevented from entering the lungs and this interrupts the continuous gas exchange in the alveoli (Fig. 3.7). Obstructive sleep apnoeas are common and form a continuous spectrum ranging from normality with a few obstructions to a life-threatening state which may present with respiratory, cardiovascular or sleep-related complications. The term obstructive sleep apnoea syndrome (OSAS) refers to the combination of symptoms and the presence of apnoeas 1 . An identical clinical picture may result from hypopnoeas (obstructive sleep apnoea hypopnoea syndrome, OSAHS). There is, however, only a moderate correlation between the objective findings of apnoeas and hypopnoeas during sleep and the severity of symptoms. The latter are also determined by physiological changes during sleep which are not identified accurately by simply counting the apnoeas or hypopnoeas, as well as other factors such as...