Sleep Pearls

Front 1

40 y/o with insomnia after death of his brother. ANSS without OSA or PLMD. Dx?

Back 1

Adjustment sleep disorder.

Front 2

Effect of benzos on sleep stages? Non-benzo hypnotics?

Back 2

Benzos increase stage II. Decrease REM, SWS. Non BZ agents do not decrease SWS or REM.

Front 3

Morning anxiety in patient using triazolam?

Back 3

Rebound anxiety can be seen with shorter acting agents.

Front 4

Nefazodone (Serzon) mechanism?

Back 4

Blocks 5HT2 and serotonin reuptake.

Front 5

Mirtazapine (Remeron) mechanism?

Back 5

Alpha-2 blocker (increases NE and serotonin), 5HT2, 5HT3 blocker.

Front 6

Hypnotic agent for mid-cycle awakenings?

Back 6

Sonata - shortest half-life.

Front 7

30 y/o woman with several year hx of sleep init/maintenance insomnia. Sleeps okay when traveling. Has normal ANSS. Why?

Back 7

Psychophysiological insomnia. If less than 6 monhs, this is adjustment sleep disorder. Normal ANSS cold also indicate sleep state misperception.

Front 8

Reverse first night effect?

Back 8

Good night sleep in the lab. Suggests psychophysiological insomnia or problem with home sleep environment.

Front 9

Cyclic activity in chin EMG suggests this dx.

Back 9

Bruxism

Front 10

Prevalence in kids and adults. Risk factors?

Back 10

20-88% in kids (before adult teeth come in). Approx 3% of adults over 60. Smokers may have more bruxism.

Front 11

Medications causing bruxism? Other possible causes?

Back 11

Levodopa, SSRIs. Stress, tooth malocclusion.

Front 12

Associated sx?

Back 12

Headache, TMJ pain,

Front 13

Bruxism most common in which stages?

Back 13

II, REM (tonic)

Front 14

Treatment for bruxism?

Back 14

Nothing proven in clinical trial. Mouthguard may help. Many meds tried: levodopa, benzos, muscle relaxants, relaxation therapy, biofeedback, hypnosis.

Front 15

Typical EMG pattern in bruxism?

Back 15

"Checkerboard" pattern.

Front 16

Percent of seizure occuring only during sleep?

Back 16

10-40%

Front 17

Order of seizure threshold from low to high in wakefulness, REM, NREM sleep?

Back 17

REM, wake, NREM. (Highest chance of a seziure in NREM sleep.)

Front 18

EEG pattern for seizures? Usual direction of initial deflection?

Back 18

Spike and wave. Negative (up).

Front 19

Correct way to amplify a nasal pressure signal on PSG?

Back 19

DC signal or AC with long time constant or very small low filter setting (<=0.01).

Front 20

Three factors influencing degree of O2 desat in OSA patients.

Back 20

Waking supine PaO2, amount of sleep spent in apnea, and ERV.

Front 21

Causes of a false negative sleep study?

Back 21

Abstinence from usual alcohol or sedative use. Mild OSA can show more night to night variability. Lack of REM or supine sleep.

Front 22

Minimum amount of sleep required for diagnostic portion of split night study.

Back 22

Two hours.

Front 23

Minimum AHI for split study.

Back 23

AHI > 20 with desats; > 40 if no associated findings.

Front 24

Shape of expiratory flow curve in a central apnea?

Back 24

Round.

Front 25

No change in body position with fluctuating level of recorded leak - probably source of leak?

Back 25

Mouth

Front 26

"Symptomatic" according to Medicare guidelines for CPAP treatment.

Back 26

EDS, HTN, ischemic heart dz, stroke, insomnia, mood disorder.

Front 27

Does sham nasal CPAP improve subjective daytime sleepiness?

Back 27

Yes. Placebo effect documented in 1999 Lancet article.

Front 28

Medicare definition of hypopnea.

Back 28

>=30% reduction in airflow with 4% desat. Does not include arousals without desats.

Front 29

Do split night studied over- or underestimate OSA severity.

Back 29

Usually underestimate. Don't record as much supine/REM sleep.

Front 30

Possibly useful types of positive airway pressure for patient who has trouble tolerating high pressures needed in specific position or sleep stage.

Back 30

BiPAP or Auto-CPAP

Front 31

Usual method of titrating BiPAP.

Back 31

Keep IPAP=EPAP and increase both until apneas resolve. Then increase IPAP until hypopnea and snoring resolves. Or, start at 6/4 and sequentially increase IPAP then EPAP to desired effect.

Front 32

BiPAP helpful for mouth leak?

Back 32

Yes. Not studied, but sometimes you can get away with less pressure.

Front 33

If there are persistent apnea, do you adjust IPAP or EPAP? And for persistent hypopneas?

Back 33

Increase EPAP for apneas, IPAP for hypopneas (and snore).

Front 34

Potential cause of hypoxia during REM immediately after adequate CPAP titration?

Back 34

Can have more REM d/t rebound, with hypoventilation during REM.

Front 35

How to treat hypoxia/hypercapnia in obese pts. with OSA? Is it permanent?

Back 35

Consider bilevel pressure or volume cycled mode. Ventilation usually improves after few weeks on CPAP.

Front 36

Patients that do best with UPPP?

Back 36

Those with upper airway narrowing limited to retropalatal area.

Front 37

Failed UPPP cases: most common site of failure?

Back 37

Retropalatal area.

Front 38

Less common but severe cause of failure post UPPP?

Back 38

Nasopharyngeal inlet stenosis.

Front 39

Post-op UPPP complications?

Back 39

Pain. Velopharyngeal incompetence (snarfing). Change in voice. Globus. Worsened OSA.

Front 40

Poor candidates for oral appliance?

Back 40

Pre-existing TMJ. Not in book but according to Dr. Rosen: very large neck.

Front 41

Two major types of oral appliance?

Back 41

Tongue retaining device and mandibular advancing device.

Front 42

Criteria for safety clearnace using MWT?

Back 42

None have been established.

Front 43

"Normal" MWT results?

Back 43

Stay awake more than 19 minutes on a 40 minute test or 11 minutes on a 20 minute test.

Front 44

Things that worsen simple snoring?

Back 44

Anything that narrows upper airway, increases nasal resistance, decreases upper airway muscle tone: sedatives, supine position, nasal congestion.

Front 45

Prevalence of habitual snoring over age 40?

Back 45

Some studies suggest 60% men 40% women.

Front 46

Intensity of snoring and stage of sleep?

Back 46

Loudest in SWS, quietest in REM.

Front 47

Do thermistors detect snoring?

Back 47

No. But nasal pressure xducer or pneumotachograph can.

Front 48

EMG chin pattern sometimes seen with snoring?

Back 48

Increase in chin EMG activity at inspiration.

Front 49

Stage of sleep with loudest snoring?

Back 49

Stage IV

Front 50

Can you have UARS without excess daytime somnolence?

Back 50

No

Front 51

Why would someone with Prader-Willi have prolonged elevation of transcutaneous CO2 and hypoxia without frank obstructive events?

Back 51

Markedly blunted hypoxic ventilatory response, especially in peripheral chemoreceptors. The hypercapneic response can be blunted, mainly in the obese.

Front 52

Chromosome usually affected in Prader Willi?

Back 52

15

Front 53

Are hypnotics safe in patients with COPD?

Back 53

Minimal effect on breathing if stable COPD (not overlap syndrome) with normal daytime CO2.

Front 54

Does nocturnal O2 cause CO2 retention?

Back 54

Should not as long as there is no sleep apnea present.

Front 55

DDx of nocturnal awakenings in patients with asthma?

Back 55

Diurnal reduction in airflow vs. OSA. FEV1 hits nadir at 4am. Treating OSA can also help control the asthma.

Front 56

Timing of arousal in Cheyne Stokes vs. idiopathic central apnea?

Back 56

C-S apnea - arousal usually at peak ventilatory effort. Idiopathic - usually at apnea termination.

Front 57

Tx of idiopathic central sleep apnea?

Back 57

Debatable. CPAP, oxygen, triazolam, inhaled CO2, acetazolamide all listed.

Front 58

Two top causes of Cheyne Stokes breathing?

Back 58

CHF and stroke

Front 59

Prevalence of C-S apneas in severe CHF?

Back 59

"As high as" 40-50%

Front 60

Difference in daytime pCO2 in CHF patients with or without Cheyne Stokes?

Back 60

Lower pCO2 in Cheyne Stokes patients.

Front 61

Difference in hypercapneic ventilatory drive in CHF patients with or without Cheyne Stokes breathing (CSB)?

Back 61

Higher drive in CSB patients.

Front 62

Difference in LV filling pressure in CHF patients with or without Cheyne Stokes?

Back 62

Higher LV filling pressure in CSB.

Front 63

Effect of higher filling pressures on ventilation?

Back 63

Can stimulate lung receptors, lead to increased ventilation.

Front 64

Why does CPAP help CSB? Three reasons (in theory).

Back 64

Improve LV function, increase O2 stores (less desat), and slightly increase pCO2.

Front 65

How does adaptive servo ventilation work?

Back 65

During hypoventilation, the IPAP/EPAP difference widens. Narrows during increased ventilation. Usually maintains minimum of EPAP 5. Can have back up rate.

Front 66

Usual PSG finding in congenital central hypoventilation?

Back 66

Reduced tidalvolume and respiratory rate. Central apneas not common.

Front 67

Why would ventilation be worse in NREM sleep for CCHS patients?

Back 67

Metabolic control of ventilation occurs during NREM; durin REM, there is less related to hypoxic/hypercapenic input.

Front 68

Two disease associationg seen with CCHS?

Back 68

Hirschsprung dz and neuroblastomas.

Front 69

Are peripheral chemo-receptors functional in CCHS?

Back 69

Yes. (AK - One study showed passive pedaling of legs during sleep reduced pCO2 in these patients.)

Front 70

Are leg movements associated with apnea termination counted towards the PLMI?

Back 70

No.

Front 71

If there is a periodic movement in the left leg >5 seconds after onset of a periodic movement in the right leg, are the events counted as one or two?

Back 71

Two. More than 5 secs apart and they're separate events.

Front 72

Difference between a leg movement and a periodic leg movement?

Back 72

PLM has to be part of 4 repetitive movements, not associated with apnea termination or after an arousal.

Front 73

Criteria for counting a leg movement?

Back 73

Lasts 0.5 to 5 secs and is at least 25% amplitude seen in the biocal. These criteria can vary.

Front 74

ICSD categorization of PLMs into mild, mod, severe?

Back 74

5-24 mild; 25-49 moderate; > 50 severe. PLMA index > 25 is severe. Not based on any data.

Front 75

Frequency of augmentation when RLS treated with carbidopa? If PLMS tx'd with crabidopa?

Back 75

Up to 80% in RLS and 30% in PLMS.

Front 76

First step if you see augmentation with Mirapex?

Back 76

Treat earlier in the evening.

Front 77

Side effects seen in Mirapex?

Back 77

Nausea, hypotension, somnolence, headache, and rare lower extremity edema.

Front 78

If you get nausea or augmentation with mirapex, what advice do you give?

Back 78

Try splitting dose - half at 6p half at 8p.

Front 79

Requip side effects?

Back 79

Nausea, somnolence, postural hypotension.

Front 80

Mechanism of clearnace in requip? In Mirapex?

Back 80

Requip = hepatic; mirapex = renal.

Front 81

% of narcolepsy patients with cataplexy

Back 81

70%

Front 82

Concordance in twins?

Back 82

25-30%

Front 83

% of narcolepsy cases starting over age 50?

Back 83

5%

Front 84

Percent of narcoleptics with the tetrad (cataplexy, hypnagogic hallucination, sleep paralysis, sleep attacks)?

Back 84

10-15%

Front 85

Is cataplectic weakness ever asymmetric?

Back 85

No.

Front 86

Abnormally low REM latency? Percent of narcoleptics wit this PSG finding?

Back 86

Less than 20 mins. 40-50%.

Front 87

Probablility of a positive MSLT (two REM naps and mean sleep latency < 5 mins) in a narcoleptic?

Back 87

70-80%

Front 88

Generic name of Dexedrine? Dexosyn? Ritalin?

Back 88

Dextroamphetamine. Methamphetamine. Methylphenidate.

Front 89

Major toxicity of pemoline?

Back 89

Liver

Front 90

Nonpharmacologiscal methods to treat narcolepsy?

Back 90

Sleep hygiene, scheduled naps, adequate sleep time.

Front 91

Most common side effect of Provigil? How to avoid it?

Back 91

Headache. Can start at 100mg for a few days before increasing dose.

Front 92

Important warning for women taking Provigil?

Back 92

Reduced efficacy of birth control meds.

Front 93

Alternative therapy to stimulants in narcoleptics?

Back 93

Selegiline - alerting and anticataplectic properties. Irreversible MAO type B inhibitor. Has non-selective MAO inhibition abotve 20mg dose. Need low tyramine diet.

Front 94

Does negative HLA DQB1*602 rule out narcolepsy? How many narcoleptics are negative?

Back 94

No. 1-5%.

Front 95

Approach to persistent sleepiness in OSA?

Back 95

Check compliance, rule out concurrent sleep disorders. MSLT with CPAP can show narcolepsy in right clinical scenario.

Front 96

Other haplotypes associated with narcolepsy?

Back 96

HLA-DR2. HLA-DR15 (negative in 40% of African Americans).

Front 97

Familial cases of idiopathic hypersomnia associated with which HLA?

Back 97

HLA-Cw2

Front 98

Associated symptoms in familial IH?

Back 98

Autonomic dysfunction - hypotension, Raynaud's, syncope.

Front 99

Hypersomnia after head injury?

Back 99

Posttraumatic hypersomnia develops 6-18 months after accident.

Front 100

Clue to depression on PSG?

Back 100

REM latency less than 60 mins.

Front 101

Things to rule out prior to making diagnosis of IH?

Back 101

Depression, hydrocephalus, meds/abuse, insufficient sleep, UARS or OSA, PLMS.

Front 102

MSLT findings in IH?

Back 102

Latency < 10 mins, less than two REM naps.

Front 103

Stage of sleep associated with bruxism?

Back 103

Stage II

Front 104

Does sleepwalking require a psych eval?

Back 104

No. Usually not associated with psychopathology. Book says "at least" 50% of adults who sleepwalk don't have psychpathology. Sounds like a lot of psychopathology to me.

Front 105

When does sleepwalking occur?

Back 105

Classically in SWS (first third of night), especially in kids. Can occur in stage II, so it may be seen in 2nd half of night.

Front 106

Sleepwalking triggers?

Back 106

Sleep deprivation, fevers, meds (lithium, phenothiazenes [compazine, thorazine], tricyclics).

Front 107

Reasons to get sleep study in suspected parasomnia?

Back 107

Injury, medico-legal issues, high frequency of events, daytime somnolence.

Front 108

Prevalence of bruxism over age 60? In kids?

Back 108

About 3%. 20-88% of kids.

Front 109

Usual rate of bruxism?

Back 109

About 1 per second.

Front 110

Appropriate paper speed for examining rhytmic EEG activity?

Back 110

30mm/sec (10 second epoch)

Front 111

Probablility of seizure in REM, NREM, wake.

Back 111

NREM > Wake > REM

Front 112

Mimics of spike and wave?

Back 112

Bursts of theta or delta (no spikes); electrode popping (usually slower frequency than spike and wave).

Front 113

Difference between interictal spike and wave activity versus ictal (or seizure) activity?

Back 113

Interictal is isolated. Ictal occurs in bursts.

Front 114

Percentage of seizure occuring primarily or only in sleep?

Back 114

10-40%

Front 115

Insomnia at home, but relatively normal sleep in the lab or when away from home?

Back 115

Psychophysiological insomnia.

Front 116

Psychophysiological insomnia of less than 6 months?

Back 116

Adjustment sleep disorder

Front 117

Three GABA-benzo receptor subtypes, BZ1, 2, and 3. Which is responsible for hypnotic effect?

Back 117

BZ-1.
BZ-2 and -3 induce muscle relaxant, anti-seizure and anxiolytic effects.

Front 118

Presentation of delayed sleep phase syndrome?

Back 118

Sleep onset insomnia.

Front 119

Two antidepressants that increase REM sleep?

Back 119

Bupropion and nefazodone.

Front 120

Mechanism of mirtazapine?

Back 120

Blocks 5HT-2, 5HT-3, histamine type 1, alpha-2 receptors.

Front 121

Kleine-Levin syndrome?

Back 121

Recurrent hypersomnia. At leas 1-2 times per year, 3-21 day episode of voracious appetite, hypersexuality, disinhibition. Can just be hypersomnolence.