Movers and Shakers
Which antidepressant has dopamine promoting activity, so does not aggravate RLS?
Bupropion
What drug is specifically approved for non-24 sleep-wake disorder?
20mg once daily tasimelteon (hetlioz) taken at same time each night before bedtime. Agonist of Mt2 > Mt1. Mt2 influences circadian rhythms while Mt1 induces sleepiness. Studied and used in blind individuals.
What is the finding shown in this 30s epoch of N2 sleep? The patient has daytime sleepiness and depression. He is taking fluoxetine and clonazepam.
Prozac eyes, but really any SSRI can cause a pattern of rapid eye movements mixed with slow eye movements during NREM sleep making staging difficult. In one study 36% of patients had this. Finding may persist after cessation of ssri. Thought to be due to a potentiation of serotonergic neurons found in the pontine raphe nuclei, those neurons normally inhibit brainstem "omnipause neurons", which, in turn, inhibit saccadic eye movements. Thus, the result is a disinhibited release of saccades.
What circadian rhythm sleep-wake disorders require at least a 14d sleep diary?
Non-24 hour, shift work sleep disorder.
What is this finding beloved by Dr. X?
Expiratory snore - can be seen in patients with lower obstructive airways disease. For more on this mechanism, see Abdul Sankari Annals ATS 2015.
In what stages of sleep are PLMS least likely to be found?
What two drugs are recommended for patients with ONLY sleep maintenance insomnia?
Suvorexant (belsomra) orexin receptor antagonist and doxepin (silenor) tricyclic that has potent antihistaminergic properties.
-AASM insomnia guidelines 2017.
What PSG finding is found in patients with schizophrenia?
Reduced slow wave (N3) sleep.
What are the 3 Ps in Spielman’s model of insomnia?
Predisposing factors (family hx, growing up in unstable environ)
Precipitating factors (deployment, lack of housing, family death, job)
Perpetuating factors (excessive time in bed, worry).
How do you tell which is the correct way to look at a ptaf (pressure transducer airflow) signal?
Go to picture....
Look for the expiratory pause and know that expiration should be a downward deflection coming before that.
PLMS (> 5/hr) are associated with which diseases?
Found in 80% of RLS, 70% of RBD, and 45-60% narcolepsy.
What two drugs are used to treat RBD?
Clonazepam and melatonin
What artifact is seen here?
Electrode pop artifact – note the artifact is seen in M2 and appears to occur with respiration suggesting that it is “popping” off each breath. How to fix: re-apply lead, re-apply conducting gel to improve conductance, replace lead.
What are the components of CBTI?
Cognitive therapy (identify, challenge and replace dysfunction beliefs)
Behavioral therapy (sleep restriction, stimulus control, sleep hygiene, relaxation).
VAPS – what is it good for?
Intelligent vs average, Va vs Vt, proprietary resmed vs Respironics, they target a ventilation parameter and adjust pressure support to reach it, comes with a back up rate, alarms, daytime night time modes, other bells and whistles.
Indicated for chronic respiratory failure leading to hypoventilation, like in neuromuscular disease, OHS, restrictive lung diseases, and COPD. Theoretical benefits: can adjust ps and maintain volumes in setting of altered patient effort, altered compliance, altered lung mechanics based on patient’s body position or sleep stage, less pressure adjustment visits, almost a set it and forget it with the VAPS-AE modes. Review in Curr opin pulm med 2019 by Tim Morganthaler (Mayo) showing that VAPS fails to demonstrate a significant difference in gas exchange, sleep, or quality of life improvement compared to BPAP. Possible reduction in COPD exacerbations. Long term studies needed.
True or false: The prevailing dopaminergic theory in RLS physiology is a CNS deficiency in dopamine.
False. Hyperdopa state, increased tyrosine hydroxylase levels, increase in CSF metabolites of dopamine leading to a downregulation of dopa receptors. Pair this with a normal circadian profile of dopamine acitivity which is high in the day low in the evening…and this leads to a bad mixture of normal low dopa levels with an abnormal downregulation of dopa receptors which leads to a “dopamine deficiency” during the evening leading to RLS symptoms.
-Khan. J neurol. 2017.
What two drugs may increase REM sleep?
Nefazodone and Bupropion
Where are arousals found in OSA vs CSA with CSR?
OSA = end of respiratory event.
CSR = peak of respiratory effort (peak of the hyperpneic phase) in between central events.
What are 2 objective measures/markers of circadian rhythm and when do they occur?
DLMO 2h before sleep onset.
CBTmin occurs 2-3h before awakening.
Mallampati vs modified mallampati vs friedman – whaaaats the deal!?!?!
1985 Mallampati – head neutral, open mouth fully stick out tongue maximally. 1, 2, 3 – tonsillar pillars, uvula, soft palate. Correlate this view to airway view on DL.
1987 – Samsoon and young – sometimes you can only see hard palate, add grade 4.
1999 - Friedman said just open your mouth, don’t stick out tongue, also called it MMP and said that increase in this number “correlated with increasing AHI" r=0.34. Subsequently Friedman changed the name to Friedman tongue position, but the confusion was there. Now MMP is used to describe both techniques in sleep literature.
Overall both FTP and MMP are poor independent predictors of OSA in systematic reviews/meta-analyses, but good when used in conjunction. Interrater reliability of FTP among ENT mds is 0.36, while mmp among anesthesiologists is 0.31.
-Ilene Rosen JCSM Feb 2020.
What is augmentation and why does it happen?
It is a complication of long term dopaminergic therapy for RLS leading to increase in symptom severity with increasing dosages of drug, earlier onset of symptoms, increased intensity, and spread to arms and trunk. Mechanism: dopa activity consistently supplemented with medicine, dopa receptors become further downregulated and desensitized, the “dopamine deficiency” at night due to circadian variation is heightened. Dopamine requirements increase.
What is the only FDA drug approved for middle of the night awakenings?
Intermezzo – Zolpidem tartrate, sublingual.
How would you fix this artifact?
ECG artifact. Right answer is to link M1+M2 (bridging) or averaging. Other options, reposition ECG electrodes or reference electrodes (M1, M2).
What are some pregnancy effects on sleep?
1st trimester = increased sleepiness and TST, decrease N3, decrease REM.
2nd trimester = normal sleep in second.
3rd trimester = disturbed sleep from urination, backache. Progesterone increases which is a respiratory stimulant in 3rd and this lowers the pCO2. Edema in nasal passages and pharynx + diaphragm pushed upwards = snoring in 30% of all pregnant women.
Name one gene associated with RLS.
BTBD9, MEIS1, MAP2K5/LBXCOR, PTPRD