BREATHING RELATED

SLEEP DISORDERS
Group 3 members
Department of psychiatry
Mattu University
Objectives of this lesson is to know and
understand the:-
 Definition of BRSDs
 Epidemiology of BRSDs
 Etiology of BRSDs
 Clinical feature of BRSDs
 Diagnosis of BRSDs
 Dsm criteria(general) for BRSDs
 Specifiers of BRSDs
 Differential diagnosis of BRSDs
 Comorbidity of BRSDs
 Course and prognosis of BRSDs
 The treatment of BRSDs
 Introduction
 “Sleep related breathing disorders” is a
term used to describe a wide spectrum of abnormalities of
respiration during sleep including abnormal respiratory pattern
(e.g., apneas, hypopneas, or respiratory effort related arousals)
or abnormal reduction in gas exchange (e.g., hypoventilation)
during sleep.
The International Classification of Sleep Disorders – Third
Edition (ICSD-3)1 has defined four major categories of sleep
related breathing disorders: 1) obstructive sleep apnea (OSA)
disorders, 2) central sleep apnea disorders, 3) sleep related
hypoventilation disorders, and 4) sleep related hypoxemia
disorder in addition to isolated symptoms and normal variants
like snoring and catathrenia.
 DEFINITIONS
 Respiratory Events are defined as breathing abnormalities during
sleep
 Apnea cessation of airflow (90% decrease in apnea sensor
excursions compared to baseline of a minimum duration of 10 s in
adults. Apneas are classified as obstructive, mixed, or central
based on the pattern of respiratory effort.
 Obstructive apnea occurs when airflow is absent or nearly
absent, in the presence of respiratory effort.
 Central apnea occurs when both airflow and ventilatory effort are
absent.
 Mixed apnea occurs when there is an interval during which there
is no respiratory effort (i.e. central apnea pattern) followed by an
interval during which there is obstructed respiratory efforts.
 Hypopnea is a reduction in airflow with the minimum amplitude
and duration as specified in the hypopnea rules for adults. The
reduction in airflow must be accompanied by a 3% desaturation or
an arousal or a 4% desaturation.
Continued……………..
 Respiratory effort related arousals are sequences of breaths
characterized by increasing respiratory effort (esophageal
manometry); inspiratory flattening in the nasal pressure or positive
airway pressure (PAP). Respiratory effort related arousals do
not meet criteria for hypopnea and have a minimum duration of
10 s in adults or the duration of at least two breaths in children.
Respiratory effort related arousals (RERAs) (> 5 events/h)
associated with daytime sleepiness were previously called upper
airway resistance syndrome (UARS), which was considered as a
subtype of OSA. These patients have abnormal sleep and cardio
respiratory changes typically found in OSA.
 Hypoventilation is a specified period of increased PaCO2 of >
50 mmHg in children or > 55 mmHg in adults, or a rise of PaCO2
during sleep of 10 mmHg that exceeds 50 mmHg for a specified
period of time in adults.
Continued…..
 Apnea hypopnea index (AHI) is the total number of apneas and
hypopneas per hour of sleep.
 Respiratory disturbance index (RDI) is the total number of events
(e.g., apneas, hypopneas, and RERAs) per hour of sleep. The RDI is
generally higher than the AHI, because the RDI includes the
frequency of RERAs, while the AHI does not.
 Oxygen desaturation is a frequent consequence of apnea and
hypopnea. Several measures are used to quantify the severity of
desaturation.
 Arousal index (ArI) is the total number of arousals per hour of
sleep.
 Apnea index (AI) is the total number of apneas per hour of sleep.
 Cheyne-Stokes breathing (CSB) is a breathing rhythm with a
specified crescendo and decrescendo change in breathing
amplitude separating central apneas or hypopneas.
1. OBSTRUCTIVE SLEEP APNEA
(OSA)
 OSA, also referred to as obstructive sleep
apnea-hypopnea, is a sleep disorder
characterized by cessation or significant
decrease in airflow in the presence of
breathing effort caused by repetitive collapse
of the upper airway during sleep. It is the
most common type of sleep-disordered
breathing. Recent data demonstrated that
the estimated prevalence of moderate to
severe OSA ranges from 10 to 17% in
middle-aged and elderly.
Continued…….
 While obtaining history, it is usually helpful to have
the patient's bed partner or a family member present
during the interview because they may be able to
give extra information about patient condition when
asleep. Most patients with OSA present with
complaint of daytime sleepiness, snoring, gasping or
interruptions in breathing while asleep. These
symptoms may be reported during the evaluation of
another complaint, detected during health
maintenance screening, reported during
preoperative screening or as a part of the
comprehensive evaluation of patients at high risk for
OSA.
A hypnogram of a patient with
obstructive sleep apnea.
 2. CENTRAL SLEEP APNEA
SYNDROMES
 Central sleep apnea syndromes (CSAS) are a group of disorders,
which are characterized by cessation of airflow due to absence of
respiratory effort compared to patients with OSA, in whom the
respiratory event occurs despite the presence of respiratory effort.
CSAS comprise several disorders. According to the ICSD-3,1
central sleep apnea syndromes (CSAS) are classified into:
 • Central sleep apnea (CSA) with Cheyne-Stokes breathing (CSB)
 • Central apnea due to a medical disorder without CSB
 • Central sleep apnea due to high altitude periodic breathing
 • Central sleep apnea due to a medication or substance
 • Primary central sleep apnea
 • Primary central sleep apnea of infancy
 • Primary central sleep apnea of prematurity
 • Treatment-emergent central sleep apnea
3. Cheyne-Stokes Breathing
 The AASM defines CSB as a breathing disorder in
which there are cyclical fluctuations in breathing, with
periods of central apneas or hypopneas that
alternate with periods of hyperpnea in a gradual
waxing and waning fashion. CSB is seen mostly in
patients with heart failure (HF) but has also been
described in patients recovering from acute
pulmonary edema, advanced renal failure, and
central nervous system lesions.34 Numerous clinical
and epidemiological studies have shown that a large
proportion of patients with left ventricular systolic
dysfunction suffer from CSB or another sleep-related
breathing disorders.
4. SLEEP RELATED
HYPOVENTILATION DISORDERS
 Sleep related hypoventilation disorders, as defined by the
most recent version of the AASM Manual (ICSD-3 ) are
characterized by insufficient sleep related ventilation
leading to abnormally elevated PaCO2 during sleep.
Sleep-related hypoventilation disorders include: -
 -Obesity hypoventilation syndrome (OHS).
 - Congenital central alveolar hypoventilation.
 - Late-onset central hypoventilation with hypothalamic
dysfunction.
 - Idiopathic central alveolar hypoventilation.
 - Sleep-related hypoventilation due to a medication or
substance.
 - Sleep-related hypoventilation due to a medical disorder
5. Obesity Hypoventilation Syndrome
(OHS)
 OHS is also called hypercapnic sleep apnea or sleep
related hypoventilation associated with obesity.
Previously, it used to be called Pickwickian
syndrome; however, the use of this term is
discouraged now.
 On examination, obesity is the main feature. The
prevalence of OHS increases with the increase in
BMI.OHS patients tend to have crowded oropharynx
and an increase in neck circumference. They may
also exhibit signs of corpulmonale or circulatory
congestion including plethora, scleral injection,
peripheral edema and a prominent pulmonic
component of the second heart.
Epidemiology
 In study by young and associates, 24% of men
and 9% of women aged 3-60years were
reported to have sleep disordered breathing.
 Obstructive sleep apnea(OSA) may affect as
many as 30% of adults and is more common in
men than women. The condition is likely under
diagnosis.
 The prevalence of OSAS and other sleeping
breathing disorders among children is
estimated to be 1-5.8%
 OSA is the most common BRSDs
 Etiology …
 Although the 4 main BRSDs have different etiologies …lets see the
general one..
 Excess weight
 Neck circumference :- people with thicker necks might have narrower
airways
 Being male
 Being older
 Family history
 Use of alcohol & smoking
 Due to interaction between unfavourable anatomic upper airway(UA)
susceptibility and sleep related changes in UA function.
 Due to lifestyle
 Due to another medical condition(CHF, HYPERTENSION DM(type 2),
polycystic ovary syndrome, chronic lung disease…)
 After surgery
 Nasal congestion
 clinical features(general)
 Loud snoring
 Episodes in which you stop breathing during
sleep- which would be reported by another
person.
 Gasping for air during sleep
 Awakening with dry mouth
 Morning headache
 Difficulty staying asleep, known as insomnia
 Excessive daytime sleepiness, AKA hypersomnia.
 Difficulty paying attention while awake
 Irritability……….
Diagnosis of BRSDs
 Polysomnography(most common one)
 Questionnaires(interviewing)
 Acitgraphy(allows recording of motor
activity through determining limb
movements over 24 hour period.)
 ABG, pulmonary function tests, chest
imaging, laboratory tests,
electrocardiography (ECG), transthoracic
echocardiogram and polysomnography
 DSM criteria
(let us see for some BRSDs)
Diagnostic criteria for obstructive sleep apnea (OSA).
(A and B) or C satisfy the criteria for the diagnosis of OSA
A. The presence of one or more of the following:
 1. The patient complains of sleepiness, non restorative sleep, fatigue, or
insomnia symptoms.
 2. The patient wakes with breath holding, gasping, or choking.
 3. The bed partner or other observer reports habitual snoring, breathing
interruptions, or both during the patient’s sleep.
 4. The patient has been diagnosed with hypertension, a mood disorder,
cognitive dysfunction, coronary artery disease, stroke, congestive heart failure,
atrial fibrillation, or type 2 diabetes mellitus.
B. Polysomnography (PSG) or OCST demonstrates: Five or more predominantly
obstructive respiratory events (obstructive and mixed apneas, hypopneas, or
respiratory effort related arousals (RERAs) per hour of sleep during a PSG or per
hour of monitoring (OCST). OR
C. PSG or OCST demonstrates: Fifteen or more predominantly obstructive
respiratory events (apneas, hypopneas, or RERAs) per hour of sleep during a PSG
or per hour of monitoring (OCST)
Continued…….
Diagnostic criteria for Cheyne-Stokes breathing
(A or B) + C + D satisfy the criteria:
A. The presence of one or more of the following:
 1. Sleepiness
 2. Difficulty initiating or maintaining sleep, frequent awakenings, or non
restorative sleep
 3. Awakening short of breath
 4. Snoring 5. Witnessed apneas
B. The presence of atrial fibrillation/flutter, congestive heart failure, or a
neurological disorder.
C. PSG (during diagnostic or positive airway pressure titration) shows all of the
following:
 1. Five or more central apneas and/or central hypopneas per hour of sleep
 2. The total number of central apneas and/or central hypopneas is > 50% of
the total number of apneas and hypopneas2
 3. The pattern of ventilation meets criteria for Cheyne-Stokes breathing (CSB)
 4. The disorder is not better explained by another current sleep disorder,
medication use (e.g., opioids), or substance use disorder .
 Obesity Hypoventilation Syndrome
(OHS)
 To diagnose OHS(obesity hypoventilation syndrome), the
following criteria must be met:
A. Presence of hypoventilation during wakefulness (PaCO2 >
45 mmHg) as measured by arterial PaCO2 , end-tidal PaCO2 ,
or transcutaneous PaCO2 .

B. Presence of obesity (BMI > 30 kg/ m2 ).

C. Hypoventilation is not primarily due to lung parenchymal or

airway disease, pulmonary vascular pathology, chest wall
disorder (other than mass loading from obesity), medication
use, neurologic disorder, muscle weakness, or a known
congenital or idiopathic central alveolar hypoventilation
syndrome.
Sleep-Related Hypoventilation
diagnostic criteria
 A. Polysomnography demonstrates
episodes of decreased respiration
associated with elevated CO2 levels.
(Note: In the absence of objective
measurement of CO2 , persistent low
levels of haemoglobin oxygen saturation
unassociated with apneic/hypopneic
events may indicate hypoventilation.)
 B. The disturbance is not better explained
by another current sleep disorder
Central Sleep Apnea diagnostic
criteria
 A. Evidence by polysomnography of five
or more central apneas per hour of
sleep.
 B. The disorder is not better explained
by another current sleep disorder.
Specify if…….
 With snoring
 With excessive day time sleepiness
 With Congenital central alveolar
hypoventilation
 With Idiopathic hypoventilation
 With Comorbid sleep-related
hypoventilation
 With decreased slow-wave sleep stage
N3(CSB)
Additionally……..
 Specify current severity: (for OSA)
 Mild: Apnea hypopnea index is less than
15.
 ■Moderate: Apnea hypopnea Index is
15-30.
 Severe: Apnea hypopnea index is
greater than 30
 Differential diagnosis
 The differential diagnosis of sleep-disordered
breathing
 simple snoring
 Non obstructive alveolar hypoventilation
 Periodic limb movement disorder
 Narcolepsy
 Other disorders that cause daytime sleepiness
(e.g. insufficient sleep, a circadian rhythm
abnormality…)
 Panic attacks
 Insomnia disorders
 Comorbidity(GENERAL)
 Stroke
 Diabetes
 Heart disease
 Cancer
 Depression
 Asthma
 GERD(in OSA)
 Insomnia
 COPD
 Cervical spinal cord injury
 Alcohol, opiate, or benzodiazepine use
 Hypertension
 ADHD
 Edema
Course and prognosis
 The prognosis of sleep disorders
depends widely on the cause of the
sleep disorders …which is breathing….
 Good prognostic factors
# High quality life (lifestyle)
#Decreased risk of depression
#Less obese
#No comorbid medical conditions
#Early age of onset
Continued …..
 Poor prognostic factors
#Obesity( BMI greater than 25)
#Presence of comorbid medical conditions
#Poor lifestyles
#Depression
#Family history
#Unhealthy diet
 Treatment(general)
 A dietician for weight reduction planning; a respirologist for
respiratory failure management; and a surgeon for potential
bariatric surgery when needed patients with OHS
 Oral appliances (OA)
 Upper airway surgery(for OSA)
 Hypoglossal nerve stimulation or upper airway stimulation
 Drugs that might act by stimulating respiratory drive directly
(e.g., theophylline) or indirectly (e.g., acetazolamide(for OSA)
 The most commonly administered drugs are methylxanthines
(theophyllines), acetazolmide, and benzodiazepines( for CSB)
 Positive airway pressure (PAP) therapy(first line
treatment)
 Oxygen supplementation
 Tracheostomy( if pt. is non-adherent to PAP)
Continued….
 Behaviour modification aimed at improving
sleep hygiene and avoiding sleep
deprivation
 Avoidance of supine positioning during sleep
 Avoidance of ethanol and sedative
medications
 Cognitive Behavioral Therapy(CBT)
 Weight Loss(OHS)
 Average Volume-Assured PressureSupport
(AVAPS)
 REFERENCES
 DSM made easy-TR
 Research gate (website)
 Google
 Text books(breathing related sleep
disorders)
 DSM-5
………………………………
………
We are grateful!

THANK-YOU!
 Members
Group members name Id number
Yordanos Teferi 0462
Biruktawit Yimer 0712
Amin Hassen 4418
Tong Ruach 3946