Sleep Medicine Pearls

1. Introduction - p. 1 2. Patient 1. EEG Derivations and Eye Movements - p. 5 3. Fundamentals 2. Electroencephalography and Electrooculography Patterns of Interest for Staging Sleep - p. 9 4. Introduction - p. 9 5. Patient 2. Alpha Rhythm and Sleep Spindles in a 20-Year-Old Man - p. 13 6. Fundamentals 3. Sleep Staging in Adults I - p. 15 7. Introduction - p. 17 8. Patient 3. A 35-Year-Old Woman Who is Taking Fluoxetine and a Benzodiazepine - p. 25 9. Patient 4. Scoring Stage N1 versus Stage W in Two Patients - p. 27 10. Patient 5. Recognizing Stages N1 and N2 - p. 30 11. Patient 6. Recognizing Stage N3 in a Normal Individual and a Patient with Chronic Pain - p. 32 12. Fundamentals 4. Scoring Stage R - p. 35 13. Introduction - p. 37 14. Patient 7. An Arousal Interrupts Stage N2 and Stage R Sleep - p. 42 15. Fundamentals 5. Arousals and Major Body Movements - p. 45 16. Introduction - p. 45 17. Patient 8. Scoring Stage R - p. 46 18. Patient 9. Identifying Stage R in a Woman with Violent Behavior During Sleep - p. 49 19. Patient 10. A Patient with a Major Body Movement During Sleep - p. 51 20. Fundamentals 6. Sleep Staging in Infants and Children - p. 54 21. Introduction - p. 54 22. Patient 11. A 3-Year-Old Male Undergoes a Sleep Study - p. 60 23. Fundamentals 7. Sleep Architecture Terminology and Normal Patterns - p. 63 24. Introduction - p. 64 25. Patient 12. Sleep in a 20-Year-Old Man, a 2-Month-Old Infant, and a 6-Month-Old Child - p. 68 26. Patient 13. Short REM Latency - p. 69 27. Fundamentals 8. Effects of Sleep Disorders and Medications on Sleep Architecture - p. 73 28. Introduction - p. 74 29. Patient 14. Medications and Sleep - p. 77 30. Fundamentals 9. Polysomnography I - p. 79 31. Introduction - p. 80 32. Patients 15. A Patient with Artifact in Many Channels - p. 87 33. Fundamentals 10. Indications for Polysomnography, Portable Monitoring, and Actigraphy - p. 90 34. Introduction - p. 90 35. Patient 16. Out-of-Center Sleep Testing versus Portable Monitoring - p. 98 36. Fundamentals 11. Artifacts - p. 101 37. Introduction - p. 102 38. Patient 17. Patients with Eye Movements of Interest - p. 107 39. Patient 18. A Patient with Artifacts in the EEG and EOG Derivations - p. 110 40. Fundamentals 12. Monitoring Respiration - p. 113 41. Introduction - p. 114 42. Patient 19. Respiratory Monitoring Questions - p. 120 43. Fundamentals 13. Respiratory Event Definitions in Adults - p. 123 44. Introduction - p. 123 45. Patient 20. Identifying Respiratory Events - p. 130 46. Patient 21. Two Patients with Possible Central Apnea - p. 133 47. Patient 22. Why is the Arterial Oxygen Desaturation Severe? - p. 136 48. Fundamentals 14. Respiratory Events in Children - p. 139 49. Introduction - p. 140 50. Patient 23. Sickle Disease and an Unexplained Low Arterial Oxygen Saturation - p. 143 51. Patient 24. Central Apnea and Obstructive Hypoventilation in Children - p. 148 52. Fundamentals 15. Electrocardiography Monitoring During Sleep Studies - p. 151 53. Introduction - p. 151 54. Patient 25. A Patient with Slowing of Heart Rate During Sleep - p. 158 55. Patient 26. Patients with a Sudden Increase in Heart Rate - p. 161 56. Fundamentals 16. Monitoring Limb and Other Movements During Sleep - p. 165 57. Introduction - p. 165 58. Patient 27. Identifying Movements During Sleep - p. 173 59. Patient 28. A Child with Repeated Movements During Sleep - p. 176 60. Fundamentals 17. Subjective and Objective Measures of Sleepiness - p. 180 61. Introduction - p. 181 62. Patient 29. Two Patients with Questionable MSLT Results - p. 187 63. Patient 30. Evaluating an MSLT - p. 189 64. Patient 31. Scoring an MSLT and an MWT - p. 194 65. Fundamentals 18. Sleepiness and Sleep Complaints in Children - p. 199 66. Introduction - p. 200 67. Patient 32. A Teenager with Sleep-Onset REM - p. 202 68. Patient 33. Sleep in Children - p. 205 69. Fundamentals 19. Diagnosis of Obstructive Sleep Apnea Syndromes in Adults - p. 207 70. Introduction - p. 207 71. Patient 34. A Patient with a Negative Out-of-Center Sleep Test - p. 215 72. Patient 35. A 30-Year-Old Woman with Unexplained Daytime Sleepiness - p. 217 73. Patient 36. Women with Loud Snoring - p. 222 74. Fundamentals 20. Obstructive Sleep Apnea in Adults: Epidemiology and Variants - p. 224 75. Introduction - p. 224 76. Patient 37. A 45-Year-Old Man with a Distinct Pattern of Desaturation - p. 229 77. Patient 38. A Patient with Severe Obesity and Hypercapnia - p. 232 78. Fundamentals 21. Pediatric Obstructive Sleep Apnea - p. 237 79. Introduction - p. 238 80. Patient 39. A 5-Year-Old Child with Behavior Problems - p. 244 81. Patient 40. A Snoring Patient Goes to Surgery - p. 246 82. Patient 41. A 50-Year-Old Man with Severe Hypertension - p. 248 83. Patient 42. A Patient with Insomnia and Snoring - p. 251 84. Patient 43. A Patient with Snoring and Recent Cerebrovascular Accident - p. 253 85. Patient 44. An Patient with Obstructive Sleep Apnea Gets Sleepy While Driving - p. 256 86. Fundamentals 22. Obstructive Sleep Apnea: Treatment Overview and Medical Treatments - p. 259 87. Introduction - p. 260 88. Patient 45. Patient with OSA and Weight Loss - p. 266 89. Patient 46. Postural OSA - p. 269 90. Fundamentals 23. PAP Modes and Treatment - p. 271 91. Introduction - p. 272 92. Patient 47. Unable to Tolerate Nasal CPAP Because of “Too Much Pressure” - p. 279 93. Fundamentals 24. PAP Titration and Auto-Titration - p. 282 94. Introduction - p. 282 95. Patient 48. Questions About PAP Titration - p. 292 96. Patient 49. PAP Titration Questions - p. 295 97. Patient 50. A 50-Year-Old Man with Problems During a CPAP Titration - p. 298 98. Fundamentals 25. PAP Adherence - p. 301 99. Introduction - p. 302 100. Patient 51. A Patient with a High Residual AHI on PAP - p. 306 101. Patient 52. Intervention for PAP Problems - p. 308 102. Patient 53. Nasal Congestion and Oronasal Masks - p. 313 103. Patient 54. Auto-Titration - p. 317 104. Patient 55. A Man with OSA Still Sleepy on Nasal CPAP - p. 321 105. Patient 56. A Retired Nurse with Nocturia and Snoring - p. 325 106. Patient 57. A Patient with Claustrophobia - p. 328 107. Patient 58. An Obese 12-Year-Old with Sleep Apnea and Enlarged Tonsils - p. 330 108. Patient 59. Persistent OSA after TNA - p. 332 109. Patient 60. CPAP Treatment in a Child - p. 335 110. Patient 61. A 20-Year-Old Female with Daytime Sleepiness Since Childhood - p. 337 111. Fundamentals 26. Surgical Treatment for Obstructive Sleep Apnea - p. 340 112. Introduction - p. 341 113. Patient 62. A Man with Severe OSA and Limited Treatment Options - p. 347 114. Patient 63. Upper Airway Surgery in Two Patients - p. 350 115. Fundamentals 27. Oral Appliance Treatment for Obstructive Sleep Apnea - p. 353 116. Introduction - p. 353 117. Patient 64. A 40-Year-Old Man with Sleep Apnea Unable to Accept CPAP Treatment - p. 359 118. Patient 65. A 45-Year-Old Woman Experiencing Daytime Sleepiness After UPPP - p. 361 119. Fundamentals 28. Asthma and COPD - p. 364 120. Introduction - p. 364 121. Patient 66. 35-Year-Old Woman with Asthma and Poor Sleep at Night - p. 370 122. Patient 67. A 55-Year-Old Man with Chronic Obstructive Pulmonary Disease and Snoring - p. 372 123. Patient 68. A 55-Year-Old Man with COPD and Nocturnal Desaturation - p. 377 124. Patient 69. A Patient with Snoring and Heart Failure - p. 380 125. Fundamentals 29. Central Sleep Apnea and Sleep-Related Hypoventilation Disorders - p. 384 126. Introduction - p. 384 127. Patient 70. A Man with Unexplained Central Sleep Apnea - p. 394 128. Fundamentals 30. Advanced PAP Modes and NPPV Titration - p. 397 129. Introduction - p. 399 130. Patient 71. Three Patients with Central Apneas on CPAP - p. 408 131. Patient 72. Treatment-Emergent Central Sleep Apnea - p. 414 132. Patient 73. A Patient with CHF and Central Apnea - p. 418 133. Patient 74. A Patient with Sleep Apnea on Pain Medications - p. 423 134. Patients 75. A Newborn with Cyanosis and a Young Child with Hypoventilation - p. 426 135. Patient 76. A Young Woman with Headaches and Central Apnea and a Man with Breathing Pauses After Stroke - p. 430 136. Patient 77. Bilevel Positive Airway Pressure (BPAP) and Adaptive Servoventilation (ASV) - p. 433 137. Patients 78. Patients with a Neuromuscular Disorder - p. 435 138. Fundamentals 31. Diagnosis of RLS and PLMD - p. 440 139. Introduction - p. 440 140. Patients 79. Patients with Leg Kicks on a Sleep Study - p. 448 141. Patient 80. A 58-Year-Old Man with Sleep Apnea and Leg Jerks on CPAP - p. 451 142. Fundamentals 32. Treatment of RLS and PLMD - p. 454 143. Introduction - p. 454 144. Patient 81. Problems with Dopamine Agonist Treatment for RLS - p. 463 145. Patient 82. Patients on Dopamine Agonists with Worsening RLS - p. 465 146. Patient 83. A Patient with RLS and Pain and a Patient with Ropinirole-Induced Nausea - p. 468 147. Patient 84. Patients with RLS and Treatment Challenges - p. 470 148. Patient 85. A Child with Difficulty Staying Asleep and Leg Kicks - p. 473 149. Fundamentals 33. Hypersomnolence of Central Origin-I - p. 476 150. Introduction - p. 476 151. Patient 86. A 20-Year-Old Woman with Emotion-Induced Weakness - p. 485 152. Patient 87. A 45-Year-Old Male with Severe Sleepiness - p. 488 153. Patient 88. A Patient with Frequent Cataplexy and Sleep Paralysis - p. 491 154. Patient 89. A Patient with Sleep Apnea and Possible Narcolepsy - p. 494 155. Patient 90. A Child with Sleepiness and “Syncope” - p. 498 156. Patient 91. Modafinil and Narcolepsy - p. 501 157. Patient 92. A 25-Year-Old Woman with Narcolepsy Who Is Still Sleepy on Medication - p. 503 158. Patient 93. Patients with Daytime Sleepiness and Cataplexy - p. 507 159. Patient 94. A Patient with Extreme Difficulty Getting Out of Bed in the Morning - p. 511 160. Fundamentals 34. Hypersomnolence of Central Origin II - p. 514 161. Introduction - p. 514 162. Patient 95. A 35-Year-Old Man Requesting Stimulant Medication - p. 518 163. Patient 96. Insufficient Sleep - p. 521 164. Patient 97. A Patient with Prader-Willi Syndrome and Daytime Sleepiness - p. 523 165. Patient 98. Sleepiness After Head Trauma - p. 526 166. Patient 99. A Patient with Possible Narcolepsy and Weakness in the Hands - p. 529 167. Fundamentals 35. Parasomnia - p. 532 168. Introduction - p. 532 169. Patient 100. A 20-Year-Old Student with Severe “Nightmares” - p. 540 170. Patient 101. Violent Behavior During Sleep - p. 543 171. Patient 102. Patients with Violent Dreams - p. 546 172. Patient 103. A Woman Who Eats During the Night and Does Not Remember - p. 549 173. Patient 104. A Woman Who Moans at Night and a Woman Who Experiences Jerks When Falling Asleep - p. 551 174. Fundamentals 36. Clinical Electroencephalography and Epilepsy - p. 555 175. Introduction - p. 555 176. Patient 105. Rhythmic Electroencephalography Pattern During Polysomnography - p. 563 177. Patient 106. A 55-Year-Old Man with Unusual Movements During Sleep - p. 566 178. Patient 107. Abnormal Behavior During Sleep - p. 572 179. Patient 108. A Child with Mouth Movements During Sleep and a Teenager with Jerks in the Morning After Awakening - p. 576 180. Patient 109. Patients with Parkinsonism and Sleep Problems - p. 577 181. Fundamentals 37. Evaluation of Insomnia - p. 582 182. Introduction - p. 582 183. Patient 110. A 30-Year-Old Woman Having Difficulty Falling and Staying Asleep - p. 592 184. Patient 111. A Patient with Insomnia and an Irregular Sleep Pattern - p. 594 185. Patient 112. A Woman with Sleepless Nights - p. 596 186. Fundamentals 38. Behavioral Treatment of Insomnia - p. 599 187. Introduction - p. 599 188. Patient 113. Behavioral Insomnia of Childhood - p. 603 189. Patient 114. Patient with Unfavorable Sleep Habits - p. 606 190. Fundamentals 39. Pharmacologic Treatment of Insomnia - p. 609 191. Introduction - p. 609 192. Patient 115. Sleep-Maintenance Insomnia While Taking a Hypnotic - p. 619 193. Patient 116. Middle-of-the-Night Awakening and a Patient with Drug Dependence and Insomnia - p. 621 194. Fundamentals 40. Circadian Rhythm Sleep-Wake Disorders - p. 625 195. Introduction - p. 625 196. Patient 117. A 20-Year-Old with Difficulty Falling Asleep - p. 633 197. Patient 118. A 60-Year-Old Man with Early-Morning Awakening - p. 637 198. Patient 119. A Patient with Periods of Insomnia and Daytime Sleepiness - p. 640 199. Patient 120. An Older Woman with an Irregular Sleep Schedule - p. 642 200. Patient 121. A Patient with Night Shift Work - p. 645 201. Patient 122. Patients with Jet Lag - p. 649 202. Fundamentals 41. Psychiatry and Sleep - p. 653 203. Introduction - p. 653 204. Patient 123. Patients with Fatigue and Abnormal Sleep - p. 660 205. Patient 124. A 45-Year-Old Man with Persistent Insomnia While on Treatment for Depression - p. 664 206. Patient 125. A 30-Year-Old Woman Who Has Difficulty Getting Out of Bed - p. 667 207. Patient 126. Patients with Terrifying Awakenings - p. 670 208. Patient 127. A 50-Year-Old Combat Veteran with Upsetting Dreams - p. 673 209. Appendix 1: Normal Ranges for Sleep Architecture - p. e1 210. Appendix 2: Typical Values for Sleep Parameters in Normal Children - p. e1 211. Appendix 3: Medicare Guidelines for Reimbursement for Respiratory Assist Device - p. e3 212. Glossary - p. e6 213. Index - p. 677