Sleep Disorders

Chapter 58 Sleep Disorders




Clinical Case Problem 1 A 48-Year-Old Man with a 6-Month History of Snoring, Nocturnal Breath Cessations, and Excessive Daytime Sleepiness


A 48-year-old man comes to your office with his wife. His wife tells you that “he is constantly snoring” and she has put up with all she can. This has been going on for a number of years, but it has been getting worse lately. His wife also tells you that “sometimes he even stops breathing during the night.” When you ask the patient directly, he says, “Well, I may snore a bit, but I think my wife is exaggerating.” You somehow doubt this statement. There is a history of sleepiness during the day; he has fallen asleep at his desk at work.


On examination, the patient weighs 310 pounds. His blood pressure is 200/105   mm Hg (measured with a large cuff). Head, ears, eyes, nose, and throat examination shows boggy nasal mucosa but a normal pharynx. A grade 3/6 systolic murmur is present along the left sternal edge. You believe that there is elevated jugular venous pressure when he lies at a 45-degree angle. Chest is normal to auscultation and percussion. His abdomen is obese, and his extremities are without edema.



Select the best answer to the following questions




1. What is the most likely diagnosis in this patient?


a. narcolepsy

b. obstructive sleep apnea (OSA) syndrome

c. generalized poor physical condition

d. central sleep apnea syndrome

e. adult-onset adenoid hypertrophy

2. To what is the pathophysiology of this condition related?


a. collapse of the pharyngeal walls repetitively during sleep

b. failure of upper airway dilator muscle activity

c. sleep-related upper airway obstruction and cessation in ventilation (apneas)

d. a and c

e. a, b, and c

3. This condition is accompanied by which of the following?


a. hypoxemia

b. hypercarbia

c. metabolic acidosis

d. respiratory acidosis

e. a, b, and d

f. a, b, c, and d

4. What is (are) the major symptom(s) of this disorder?


a. loud snoring

b. daytime hypersomnolence

c. disturbed nonrefreshing sleep

d. weight gain

e. a, b, and c

f. a, b, c, and d

5. What is (are) the clinical feature(s) associated with the condition described?


a. systemic hypertension

b. inhibited sexual desire

c. depression

d. a and b

e. a, b, and c

6. What is (are) the factor(s) predisposing to this condition?


a. alcohol intake

b. benzodiazepines

c. hyperthyroidism

d. a and b

e. a, b, and c

7. What is the treatment of first choice for this disorder?


a. uvulopalatopharyngoplasty surgery (UPP)

b. tracheostomy

c. continuous positive airway pressure (CPAP)

d. nortriptyline

e. alprazolam

8. Which of the following drugs is contraindicated in the treatment of the disturbed, nonrefreshing sleep that is associated with the condition described?


a. fluoxetine

b. sertraline

c. alprazolam

d. phenelzine

e. paroxetine


Clinical Case Problem 2 A 76-Year-Old Woman with an 8-Month History of Poor Sleep


A 76-year-old woman presents to your office with a chief complaint of poor sleep during most nights for the past 8   months. On further questioning, you find that the patient recently moved into an assisted living facility after an extended rehab stay postoperatively for a right hip fracture.



9. What is your tentative diagnosis?


a. chronic insomnia

b. depression

c. physiologic aging

d. cerebrovascular accident

e. narcolepsy

10. The patient is taking a total of 10 prescription medications. She is concerned that some of these could be causing her to not sleep well. Which of the following medications is not associated with insomnia?


a. Lipitor

b. beta blocker

c. Synthroid

d. corticosteroids

e. albuterol

11. The patient states that she had been living with her husband in the same house for the past 30   years. Her husband passed away 8   months ago. At that time, she insisted on continuing to live in the house alone with minimal help. She denies being depressed. What other symptom(s) besides insomnia would lead you to confirm your suspicion that the patient is depressed?


a. decreased energy

b. poor concentration

c. decreased appetite

d. loss of interest

e. all of the above

12. This patient wants some advice to improve her sleep. Which of the following is (are) a helpful tip(s)?


a. consider the effects of medications on sleep

b. avoid caffeine and alcohol after lunch

c. avoid naps or limit to one nap of less than 30 minutes in the early afternoon

d. limit liquids in the evening, especially if urinary frequency is a problem

e. all of the above

13. Besides sleep hygiene, is (are) there any other nonpharmacologic modality(ies) to treat chronic insomnia?


a. stimulus-control therapy

b. sleep-restriction therapy

c. cognitive therapy

d. cognitive-behavioral therapy

e. all of the above


Clinical Case Management Problem


Discuss the principles of the use of hypnotic agents in the management of sleep disorders.



Answers




1. b. This patient has OSA. Polysomnography will confirm the diagnosis and will demonstrate disordered sleep with periods of apnea and hypopnea.


2. e. The pathophysiology of OSA syndrome includes the following: (1) the pharyngeal walls collapse repetitively during sleep, causing intermittent sleep-related upper airway obstruction and cessation in ventilation (apneas); (2) the cessation of ventilation is related to a concomitant loss of inspiratory effort; and (3) upper airway closure in OSA results from a failure of the genioglossus and other upper airway dilator muscles, and apnea results.


3. e. OSA produces the following acid-base balance situation: (1) apnea causes hypercarbia, hypoxemia, and a resulting respiratory acidosis; and (2) only if there is another preexisting condition associated with OSA will metabolic acidosis be produced.


4. f. The major symptoms of OSA syndrome are as follows: (1) loud snoring, (2) reports of prolonged pauses in respiration during sleep, (3) daytime hypersomnolence, (4) disturbed nonrefreshing sleep, and (5) weight gain.


5. e. Associated clinical features of OSA include systemic hypertension; inhibited sexual desire; impotence; ejaculatory impairment; depression; deficits in attention, motor efficiency, and graphomotor ability; deterioration in interpersonal relationships; marital discord; and occupational impairment.


6. d. Factors that predispose to OSA include sedating pharmacologic agents such as alcohol and benzodiazepines (all are contraindicated in OSA); nasal obstruction; large uvula; low-lying soft palate; retrognathia, micrognathia, and other craniofacial abnormalities; pharyngeal masses such as tumors or cysts; macroglossia; tonsillar hypertrophy; vocal cord paralysis; obesity; hypothyroidism; and acromegaly.


7. c. Polysomnography demonstrates that CPAP devices reverse apnea and hypopnea. In randomized controlled trials, CPAP devices also reduce daytime somnolence and improve mood and alertness. Compliance ranges from 50% to 80%. Although CPAP is the best choice of those listed, always recommend weight reduction in obese individuals.


8. c. The most established management options, in addition to weight loss, in order of preference are as follows: (1) CPAP, (2) UPP, and (3) tracheostomy. Additional measures are antidepressants that are stimulating, such as protriptyline, fluoxetine, sertraline, and paroxetine, particularly with coexistent depression. Chronic anxiety, which may complicate the OSA picture, should not be managed with benzodiazepines. Instead, the nonbenzodiazepine buspirone, which does not appear to aggravate OSA, should be used, along with behavioral treatments. Thus, alprazolam is contraindicated.


9. a. Chronic insomnia is defined as any insomnia lasting more than 6   months and is associated with a wide variety of disorders, including depression. More information is needed before depression can be diagnosed in this case.


10. a. Many medications are associated with insomnia (Table 58-1). However, Lipitor, a statin used to treat hyperlipidemia, does not have the side effect of insomnia.


11. e. Symptoms of depression include SIGECAPS:


Sleep problems

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Oct 1, 2016 | Posted by in GENERAL SURGERY | Comments Off on Sleep Disorders

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