Additional Information
Book Details
Abstract
Sleep Medicine is a rapidly growing and changing field. Experienced sleep medicine clinicians and educators Richard B. Berry, MD and Mary H. Wagner, MD present the completely revised, third edition of Sleep Medicine Pearls featuring 150 cases that review key elements in the evaluation and management of a wide variety of sleep disorders. The cases are preceded by short fundamentals chapters that present enough basic information so that a physician new to sleep medicine can start reading page 1 and quickly learn the essential information needed to care for patients with sleep disorders. A concise, practical format makes this an ideal resource for sleep medicine physicians in active practice, sleep fellows learning sleep medicine, and physicians studying for the sleep boards.
- Consult this title on your favorite e-reader , conduct rapid searches, and adjust font sizes for optimal readability.
- Zero in on the practical, "case-based" information you need to effectively interpret sleep studies (polysomnography, home sleep testing, multiple sleep latency testing), sleep logs, and actigraphy.
- Get clear, visual guidance with numerous figures and sleep tracings illustrating important concepts that teach the reader how to recognize important patterns needed to diagnose sleep disorders.
- Confer on the go with short, templated chapters—ideal for use by busy physicians. A combination of brief didactic material followed by case-based examples illustrates major points.
- Stay current with knowledge about the latest developments in sleep medicine by reading updated chapters using the new diagnostic criteria of the recently published International Classification of Sleep Disorder, 3rd Edition and sleep staging and respiratory event scoring using updated versions of the scoring manual of the American Academy of Sleep Medicine Manual for the Scoring of Sleep and Associated Events.
- Benefit from Drs. Berry and Wagner’s 25+ years of clinical experience providing care for patients with sleep disorders and educational expertise from presenting lectures at local, regional and national sleep medicine courses. Dr Berry was awarded the AASM Excellence in Education Award in 2010.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Inside Front Cover | ES2 | ||
| Sleep Medicine Pearls | iii | ||
| Copyright | iv | ||
| Dedication | v | ||
| Preface | vi | ||
| Contents | vii | ||
| Video Contents | xii | ||
| Fundamentals 1: Sleep Stage Nomenclature and Basic Monitoring of Sleep | 1 | ||
| Time Window for Staging Sleep | 1 | ||
| Electroencephalography Monitoring | 1 | ||
| Electroencephalography Derivations | 2 | ||
| Recommended Electroencephalography Derivations | 2 | ||
| Electrooculography Monitoring of Sleep | 3 | ||
| Chin (Submental) Electromyography Monitoring | 5 | ||
| References | 5 | ||
| Patient 1: EEG Derivations and Eye Movements | 6 | ||
| References | 9 | ||
| Fundamentals 2: Electroencephalography and Electrooculography Patterns of Interest for Staging Sleep | 10 | ||
| Eye Movement Electrooculography Patterns | 12 | ||
| References | 14 | ||
| Patient 2: Eye Movements, Alpha Rhythm, and Sleep Spindles in a 20-year-old Man | 14 | ||
| References | 16 | ||
| Fundamentals 3: Sleep Staging in Adults I | 17 | ||
| Sleep Cycles | 17 | ||
| Overview of Sleep Stages | 17 | ||
| Scoring by Epochs | 19 | ||
| Stage W (Wakefulness) Rules | 19 | ||
| Stage N1 | 20 | ||
| Stage N2 | 20 | ||
| Start of Stage N2 | 20 | ||
| Continuation and End of Stage N2 | 22 | ||
| End of Stage N2: Effects of Arousals | 22 | ||
| End of Stage N2: Effect of Major Body Movement | 22 | ||
| Stage N3 | 24 | ||
| References | 25 | ||
| Patient 3: A 35-year-old Woman Who Is Taking Fluoxetine and a Benzodiazepine | 26 | ||
| References | 28 | ||
| Patient 4: Scoring Stage N1 Versus Stage W in Two Patients | 28 | ||
| References | 30 | ||
| Patient 5: Recognizing Stages N1 and N2 | 31 | ||
| References | 33 | ||
| Patient 6: Recognizing Stage N3 in a Normal Individual and a Patient with Chronic Pain | 33 | ||
| References | 36 | ||
| Fundamentals 4: Scoring Stage R | 37 | ||
| Rules for Scoring Stage R | 38 | ||
| Definite Stage R | 38 | ||
| Start of Stage R | 38 | ||
| Continuation of Stage R | 39 | ||
| End of Stage R | 40 | ||
| Scoring Sleep with a Mixture of K-complexes or Sleep Spindles and Rapid Eye Movements | 41 | ||
| References | 43 | ||
| Patient 7: An Arousal Interrupts Stage N2 and Stage R Sleep | 43 | ||
| Fundamentals 5: Arousals and Major Body Movements | 46 | ||
| Arousal Rules | 46 | ||
| Major Body Movements | 47 | ||
| References | 48 | ||
| Patient 8: Scoring Stage R | 48 | ||
| Reference | 49 | ||
| Patient 9: Identifying Stage R in a Woman with Violent Behavior During Sleep | 50 | ||
| References | 52 | ||
| Patient 10: A Patient with a Major Body Movement During Sleep | 53 | ||
| References | 54 | ||
| Fundamentals 6: Sleep Staging in Infants and Children | 55 | ||
| Sleep Staging in Infants and Children | 55 | ||
| Ages for Which AASM Pediatric Sleep Scoring Apply | 55 | ||
| Terminology of Sleep Stages | 55 | ||
| Posterior Dominant Rhythm | 56 | ||
| Additional Waveforms of Wakefulness | 56 | ||
| Pediatric Stage W Rules (Adapted from AASM Scoring Manual)1 | 57 | ||
| Pediatric Stage N1 | 57 | ||
| Pediatric Stage N1 Rules (Adapted from AASM Scoring Manual) | 58 | ||
| Pediatric Stage N2 | 58 | ||
| Pediatric Stage N3 | 58 | ||
| Pediatric Stage R | 58 | ||
| Pediatric Arousal Rules | 60 | ||
| References | 60 | ||
| Patient 11: A 3-Year-Old Male Undergoes a Sleep Study | 61 | ||
| References | 63 | ||
| Fundamentals 7: Sleep Architecture Terminology and Normal Patterns | 64 | ||
| Sleep Architecture Parameters | 64 | ||
| Normal Sleep in Adults | 64 | ||
| Sleep Architecture | 65 | ||
| Changes in Sleep Architecture with Age in Adults | 65 | ||
| TST and Sleep Efficiency | 65 | ||
| Sleep Latency | 66 | ||
| REM Latency | 66 | ||
| WASO and Stage N1 (as a Percentage of TST) | 66 | ||
| Stage N2 (as a Percentage of TST) | 66 | ||
| Stage N3 (as a Percentage of TST) | 66 | ||
| Stage R (as a Percentage of TST) | 66 | ||
| Changes in Arousal Index with Age | 66 | ||
| First-Night Effect | 67 | ||
| Comparison of Normative Values Using the AASM Scoring Manual Versus the Manual of Rechtschaffen and Kales | 67 | ||
| Normal Sleep in Infants and Children | 67 | ||
| Infants | 68 | ||
| Children | 68 | ||
| References | 68 | ||
| Patient 12: Sleep in a 20-year-old Man, a 2-month-old Infant, and a 6-month-old Child | 69 | ||
| References | 70 | ||
| Patient 13: Short REM Latency | 70 | ||
| References | 73 | ||
| Sleep Latency and Insomnia | 75 | ||
| REM Latency | 75 | ||
| Amount of REM Sleep | 76 | ||
| Amount of Stage N3 | 76 | ||
| Medications and Nightmares | 76 | ||
| References | 77 | ||
| Patient 14: Medications and Sleep | 78 | ||
| References | 79 | ||
| Fundamentals 9: Polysomnography I | 80 | ||
| Referential and Bipolar Recording | 81 | ||
| PSG Channels | 81 | ||
| Impedance Checking, Calibration, and Biocalibrations | 82 | ||
| Information Flow During Digital PSG | 84 | ||
| Sampling Rate and Digital Resolution | 84 | ||
| Low-frequency and High-frequency Filters and Notch Filters | 86 | ||
| Video-audio PSG | 87 | ||
| References | 87 | ||
| Patient 15: A Patient with Artifact in Many Channels | 88 | ||
| References | 90 | ||
| Fundamentals 10: Indications for Polysomnography, Portable Monitoring, and Actigraphy | 91 | ||
| Diagnostic PSG | 91 | ||
| Patients at High Risk for OSA | 92 | ||
| PSG Titration | 92 | ||
| OCST (Unattended Limited Channel Sleep Testing) | 93 | ||
| Indications for OCST and Patient Selection | 94 | ||
| OCST Devices | 95 | ||
| Actigraphy | 96 | ||
| References | 97 | ||
| Patient 16: Out-of-center Sleep Testing Versus Portable Monitoring | 98 | ||
| References | 101 | ||
| Fundamentals 11: Artifacts | 102 | ||
| ECG and Pulse Artifact | 105 | ||
| Pulse Artifact | 105 | ||
| Muscle Artifact | 105 | ||
| Snoring or Respiratory Chin EMG Artifact | 105 | ||
| References | 107 | ||
| Patient 17: Patients with Eye Movements of Interest | 108 | ||
| Bibliography | 110 | ||
| Patient 18: A Patient with Artifacts in the EEG and EOG Derivations | 111 | ||
| References | 113 | ||
| Fundamentals 12: Monitoring Respiration | 114 | ||
| Air Flow | 114 | ||
| Alternative Sensors for Apnea and Hypopnea | 115 | ||
| Respiratory Effort | 117 | ||
| Arterial Oxygen Saturation | 118 | ||
| Other Respiratory Sensors | 119 | ||
| References | 120 | ||
| Patient 19: Respiratory Monitoring Questions | 120 | ||
| References | 123 | ||
| Fundamentals 13: Respiratory Event Definitions in Adults | 124 | ||
| Apnea | 124 | ||
| Hypopnea | 124 | ||
| Classification of Hypopneas | 125 | ||
| Respiratory Effort-related Arousal (RERA) | 126 | ||
| Hypoventilation | 128 | ||
| Cheyne-stokes Breathing | 128 | ||
| AHI and RDI | 129 | ||
| References | 130 | ||
| Patient 20: Identifying Respiratory Events | 131 | ||
| Bibliography | 134 | ||
| Patient 21: Two Patients with Possible Central Apnea | 134 | ||
| References | 137 | ||
| Patient 22: Why Is the Arterial Oxygen Desaturation Severe? | 137 | ||
| References | 139 | ||
| Fundamentals 14: Respiratory Events in Children | 140 | ||
| Ages for Which Pediatric Respiratory Scoring Rules Apply | 140 | ||
| Pediatric Apnea Rule2 | 140 | ||
| Obstructive Apnea Rule2 | 140 | ||
| Mixed Apnea Rule2 | 140 | ||
| Central Apnea Rule2 | 140 | ||
| Pediatric Hypopnea Rule2 | 142 | ||
| Obstructive Hypopnea Rule2 | 142 | ||
| Central Hypopnea Rule2 | 142 | ||
| Pediatric RERA Rule2 | 142 | ||
| Pediatric Hypoventilation Rule2 | 142 | ||
| Periodic Breathing Rule | 142 | ||
| Obstructive Hypoventilation | 143 | ||
| Respiratory Parameters Reported in Pediatric Polysomnography | 143 | ||
| References | 143 | ||
| Patient 23: Sickle Disease and an Unexplained Low Arterial Oxygen Saturation | 144 | ||
| Bibliography | 149 | ||
| Patient 24: Central Apnea and Obstructive Hypoventilation in Children | 149 | ||
| References | 151 | ||
| Fundamentals 15: Electrocardiography Monitoring During Sleep Studies | 152 | ||
| Sinus Rhythm During Sleep | 152 | ||
| Heart Rate Changes in Obstructive Sleep Apnea | 153 | ||
| Bradycardia and Sinus Pauses | 153 | ||
| Atrioventricular Block | 153 | ||
| Tachycardia During Sleep | 154 | ||
| Premature Beats | 156 | ||
| Pacemakers | 156 | ||
| Bibliography | 158 | ||
| Patient 25: A Patient with Slowing of Heart Rate During Sleep | 159 | ||
| References | 161 | ||
| Patient 26: Patients with a Sudden Increase in Heart Rate | 162 | ||
| References | 164 | ||
| Fundamentals 16: Monitoring Limb and Other Movements During Sleep | 166 | ||
| Criteria for Leg Movements and Periodic Limb Movements in Sleep | 166 | ||
| Leg Movements Associated with Respiratory Events Are Not Scored | 167 | ||
| Association of Arousals with Periodic Limb Movements | 168 | ||
| Leg Movements and Arousals | 168 | ||
| Periodic Limb Movements in Sleep | 168 | ||
| Periodic Limb Movements in Wakefulness | 169 | ||
| Other Leg Movement Activity | 169 | ||
| Excessive Fragmentary Myoclonus | 169 | ||
| Bruxism | 169 | ||
| Rhythmic Movements in Sleep and Rhythmic Movement Disorder | 171 | ||
| REM Sleep Behavior Disorder | 171 | ||
| References | 173 | ||
| Patient 27: Identifying Movements During Sleep | 174 | ||
| Bibliography | 177 | ||
| Patient 28: A Child with Repeated Movements During Sleep | 178 | ||
| References | 180 | ||
| Fundamentals 17: Subjective and Objective Measures of Sleepiness | 181 | ||
| Subjective Measures | 181 | ||
| Objective Measures of Sleepiness or the Ability to Stay Awake | 182 | ||
| Multiple Sleep Latency Test | 182 | ||
| Mean Sleep Latency Findings | 182 | ||
| MSLT Protocol | 182 | ||
| Indications for the MSLT | 183 | ||
| Diagnosis of Narcolepsy with the MSLT | 183 | ||
| Interpretation of the MSLT | 183 | ||
| Diagnosis of Narcolepsy in a Patient with OSA | 184 | ||
| Maintenance of Wakefulness Test | 184 | ||
| Specific Indications for the Use of the MWT | 185 | ||
| MWT Protocol | 185 | ||
| MWT Normative Data | 185 | ||
| Relationship Between the MSLT and the MWT | 186 | ||
| References | 186 | ||
| Patient 29: Two Patients with Questionable MSLT Results | 187 | ||
| Bibliography | 189 | ||
| Patient 30: Evaluating an MSLT | 190 | ||
| Bibliography | 194 | ||
| Patient 31: Scoring an MSLT and an MWT | 195 | ||
| References | 198 | ||
| Fundamentals 18: Sleepiness and Sleep Complaints in Children | 200 | ||
| Normal Sleep Duration | 200 | ||
| MSLT in Children and Adolescents | 201 | ||
| References | 202 | ||
| Patient 32: A Teenager with Sleep-onset REM | 203 | ||
| References | 205 | ||
| Patient 33: Sleep in Children | 206 | ||
| References | 207 | ||
| Fundamentals 19: Diagnosis of Obstructive Sleep Apnea Syndromes in Adults | 208 | ||
| Adult Obstructive Sleep Apnea: Diagnostic Criteria | 208 | ||
| Evaluation of Patients | 208 | ||
| OSA Symptoms and Key Historical Points | 209 | ||
| Physical Examination | 209 | ||
| Laboratory Testing in OSA | 209 | ||
| Prediction of the Presence of OSA | 210 | ||
| Diagnostic Testing for Suspected Sleep Apnea | 211 | ||
| Out-of-Center Sleep Testing | 213 | ||
| References | 214 | ||
| Patient 34: A Patient with a Negative Out-of-center Sleep Test | 215 | ||
| Bibliography | 217 | ||
| Patient 35: A 30-year-old Woman with Unexplained Daytime Sleepiness | 218 | ||
| References | 222 | ||
| Patient 36: Women with Loud Snoring | 222 | ||
| References | 225 | ||
| Fundamentals 20: Obstructive Sleep Apnea in Adults: Epidemiology and Variants | 226 | ||
| Epidemiology of Adult OSA | 226 | ||
| Risk Factors for OSA | 226 | ||
| Variants of Snoring and OSA | 227 | ||
| Primary (Simple) Snoring | 227 | ||
| Upper Airway Resistance Syndrome | 228 | ||
| Obesity Hypoventilation Syndrome | 228 | ||
| Overlap Syndrome | 228 | ||
| References | 229 | ||
| Patient 37: A 45-year-old Man with a Distinct Pattern of Desaturation | 230 | ||
| Bibliography | 233 | ||
| Patient 38: A Patient with Severe Obesity and Hypercapnia | 234 | ||
| References | 237 | ||
| Fundamentals 21: Pediatric Obstructive Sleep Apnea | 238 | ||
| Epidemiology | 238 | ||
| Consequences of Childhood OSA | 239 | ||
| Neurobehavioral Consequences | 239 | ||
| Metabolic and Inflammatory Consequences | 240 | ||
| Diagnosis | 240 | ||
| PSG in Pediatric OSA | 240 | ||
| Treatment of Pediatric OSA | 241 | ||
| Medical Treatment of OSA in Pediatric Patients | 241 | ||
| Tonsillectomy and Adenoidectomy | 241 | ||
| Rapid Maxillary Expansion and Distraction Osteogenesis | 242 | ||
| PAP Treatment in Pediatric Patients | 243 | ||
| References | 244 | ||
| Patient 39: A 5-year-old Child with Behavior Problems | 245 | ||
| Bibliography | 246 | ||
| Patient 40: A Snoring Patient Goes to Surgery | 247 | ||
| References | 249 | ||
| Patient 41: A 50-year-old Man with Severe Hypertension | 249 | ||
| References | 251 | ||
| Patient 42: A Patient with Insomnia and Snoring | 252 | ||
| References | 254 | ||
| Patient 43: A Patient with Snoring and Recent Cerebrovascular Accident | 254 | ||
| References | 256 | ||
| Patient 44: An Patient with Obstructive Sleep Apnea Gets Sleepy While Driving | 256 | ||
| Bibliography | 259 | ||
| Fundamentals 22: Obstructive Sleep Apnea: Treatment Overview and Medical Treatments | 260 | ||
| Choosing Treatment | 260 | ||
| Patient Education Before Treatment | 261 | ||
| Follow-up and Outcomes Assessment | 261 | ||
| Medical Treatment | 261 | ||
| Weight Loss | 262 | ||
| Posture and Positional Treatment | 263 | ||
| Medical Therapies to Improve Nasal Patency | 263 | ||
| Supplemental Oxygen | 264 | ||
| Persistent Daytime Sleepiness on CPAP | 264 | ||
| Modafinil, Armodafinil, and Stimulants | 264 | ||
| References | 265 | ||
| Patient 45: Patient with OSA and Weight Loss | 266 | ||
| References | 269 | ||
| Patient 46: Postural OSA | 269 | ||
| References | 271 | ||
| Fundamentals 23: PAP Modes and Treatment | 272 | ||
| Modes of PAP | 272 | ||
| Auto-BPAP | 274 | ||
| PAP and Supplemental Oxygen | 274 | ||
| Comfort Measures | 274 | ||
| Flexible PAP | 274 | ||
| Ramp | 275 | ||
| Humidification | 276 | ||
| Interfaces | 276 | ||
| References | 277 | ||
| Patient 47: Unable to Tolerate Nasal CPAP Because of ``too Much Pressure´´ | 279 | ||
| References | 283 | ||
| Fundamentals 24: PAP Titration and Auto-titration | 284 | ||
| General Titration Considerations | 284 | ||
| Pediatric Considerations | 284 | ||
| Monitoring During Positive Pressure Titration | 284 | ||
| Titration Protocol | 288 | ||
| Treatment Emergent Central Apneas | 289 | ||
| PAP and Supplemental Oxygen | 289 | ||
| Alternative Methods of Starting PAP Treatment | 290 | ||
| Patient Selection for Alternative Titrations | 290 | ||
| Technique of Auto-titration | 290 | ||
| References | 291 | ||
| Patient 48: Questions About PAP Titration | 293 | ||
| Bibliography | 295 | ||
| Patient 49: PAP Titration Questions | 296 | ||
| Bibliography | 298 | ||
| Patient 50: A 50-year-old Man with Problems During a CPAP Titration | 299 | ||
| Bibliography | 301 | ||
| Fundamentals 25: PAP Adherence | 302 | ||
| Adherence-definitions and Measurement | 302 | ||
| PAP Adherence in Large Studies | 302 | ||
| Factors Influencing Adherence and Importance of Early Adherence | 302 | ||
| How Much Adherence Is Enough? | 303 | ||
| Interventions to Improve Adherence | 304 | ||
| Interventions for Side Effects | 304 | ||
| Hypnotics, Alcohol, and CPAP | 305 | ||
| PAP Adherence in Pediatric Patients | 305 | ||
| References | 306 | ||
| Patient 51: A Patient with a High Residual AHI on PAP | 307 | ||
| Bibliography | 310 | ||
| Patient 52: Intervention for PAP Problems | 310 | ||
| Bibliography | 313 | ||
| Patient 53: Nasal Congestion and Oronasal Masks | 314 | ||
| Bibliography | 317 | ||
| Patient 54: Auto-titration | 318 | ||
| References | 321 | ||
| Patient 55: A Man with OSA Still Sleepy on Nasal CPAP | 322 | ||
| Bibliography | 325 | ||
| Patient 56: A Retired Nurse with Nocturia and Snoring | 326 | ||
| References | 327 | ||
| Patient 57: A Patient with Claustrophobia | 328 | ||
| Bibliography | 330 | ||
| Patient 58: An Obese 12-year-old with Sleep Apnea and Enlarged Tonsils | 331 | ||
| Bibliography | 333 | ||
| Patient 59: Persistent OSA After TNA | 333 | ||
| Bibliography | 335 | ||
| Patient 60: CPAP Treatment in a Child | 336 | ||
| Bibliography | 338 | ||
| Patient 61: A 20-year-old Female with Daytime Sleepiness Since Childhood | 338 | ||
| Bibliography | 340 | ||
| Fundamentals 26: Surgical Treatment for Obstructive Sleep Apnea | 341 | ||
| Surgical Treatments for Obstructive Sleep Apnea | 341 | ||
| Indications for Surgical Treatment | 341 | ||
| Evaluation for Possible Surgical Treatment | 341 | ||
| Tracheosotomy | 342 | ||
| Surgery for Nasal Obstruction | 342 | ||
| Palatal Implants | 342 | ||
| Laser-assisted Uvuloplasty | 343 | ||
| Radiofrequency Ablation (also Known as Radiofrequency Volumetric Tissue Reduction [RFVTR]) | 343 | ||
| Uvulopalatopharyngoplasty | 343 | ||
| Uvulopalatal Flap | 344 | ||
| Genioglossus Advancement or Hyoid Advancement | 344 | ||
| Maxillomandibular Advancement | 345 | ||
| Tongue Procedures | 346 | ||
| Tongue Base Suspension Suture | 346 | ||
| Overall Surgical Approach | 346 | ||
| Success Rates of Upper Airway Surgery | 346 | ||
| References | 347 | ||
| Patient 62: A Man with Severe OSA and Limited Treatment Options | 348 | ||
| References | 350 | ||
| Patient 63: Upper Airway Surgery in Two Patients | 351 | ||
| Bibliography | 353 | ||
| Fundamentals 27: Oral Appliance Treatment for Obstructive Sleep Apnea | 354 | ||
| Oral Appliances | 354 | ||
| Indications for Oral Appliances | 354 | ||
| Evaluation of the Patient | 354 | ||
| Exclusions and Contraindications | 355 | ||
| Devices | 356 | ||
| Titration or Adjustment of Oral Appliances | 356 | ||
| Adherence to Oral Appliance Treatment | 357 | ||
| Effectiveness Compared with Other Treatments | 357 | ||
| Side Effects and Complications | 357 | ||
| Combinations of Oral Appliance with Other Treatments | 358 | ||
| Follow-Up | 358 | ||
| References | 359 | ||
| Patient 64: A 40-Year-Old Man with Sleep Apnea Unable to Accept CPAP Treatment | 360 | ||
| Bibliography | 362 | ||
| Patient 65: A 45-Year-Old Woman Experiencing Daytime Sleepiness After UPPP | 362 | ||
| Bibliography | 364 | ||
| Fundamentals 28: Asthma and COPD | 365 | ||
| Obstructive Ventilatory Dysfunction | 365 | ||
| Nocturnal Desaturation in COPD (Nonapneic) | 367 | ||
| Time of Night and Circadian Variation in Lung Function | 369 | ||
| Sleep Quality in COPD | 370 | ||
| Asthma | 370 | ||
| Bibliography | 370 | ||
| Patient 66: 35-Year-Old Woman with Asthma and Poor Sleep at Night | 371 | ||
| Bibliography | 373 | ||
| Patient 67: A 55-year-old Man with Chronic Obstructive Pulmonary Disease and Snoring | 373 | ||
| References | 377 | ||
| Patient 68: A 55-year-old Man with COPD and Nocturnal Desaturation | 378 | ||
| Bibliography | 381 | ||
| Patient 69: A Patient with Snoring and Heart Failure | 382 | ||
| Bibliography | 385 | ||
| Fundamentals 29: Central Sleep Apnea and Sleep-related Hypoventilation Disorders | 386 | ||
| Central Sleep Apnea Syndromes | 386 | ||
| Primary Central Sleep Apnea | 388 | ||
| CSA with Cheyne-stokes Breathing (CSA-CSB) | 388 | ||
| Central Sleep Apnea Caused by High-altitude Periodic Breathing | 390 | ||
| Treatment-emergent Central Sleep Apnea | 390 | ||
| Central Sleep Apnea Caused Due to Medication or Substance | 391 | ||
| Central Apnea Due to a Medical Disorder Without Cheyne-stokes Breathing | 391 | ||
| Primary Central Sleep Apnea of Infancy | 391 | ||
| Primary Central Sleep Apnea of Prematurity | 392 | ||
| Sleep-related Hypoventilation Disorders | 392 | ||
| Congenital Central Alveolar Hypoventilation (CCAHS) | 393 | ||
| Late-onset Central Hypoventilation with Hypothalamic Dysfunction | 393 | ||
| Idiopathic Central Alveolar Hypoventilation | 393 | ||
| Sleep-related Hypoventilation Due to Medication or Substance | 393 | ||
| Sleep-related Hypoventilation Due to a Medical Disorder | 394 | ||
| Sleep-related Hypoxemia | 394 | ||
| Bibliography | 394 | ||
| Patient 70: A Man with Unexplained Central Sleep Apnea | 395 | ||
| Bibliography | 398 | ||
| Fundamentals 30: Advanced PAP Modes and NPPV Titration | 399 | ||
| Advanced PAP Modes | 399 | ||
| BPAP-ST and BPAP-T | 399 | ||
| Adaptive Servoventilation | 402 | ||
| Volume-assured Pressure Support | 404 | ||
| Use of AVAPS Versus ASV Versus BPAP-ST | 405 | ||
| NPPV Titration and Treatment | 406 | ||
| Goals of NPPV Titration and Treatment | 407 | ||
| NPPV Titration Protocol | 407 | ||
| Reimbursement for NPPV Devices | 407 | ||
| Bibliography | 409 | ||
| Patient 71: Three Patients with Central Apneas on CPAP | 409 | ||
| Bibliography | 414 | ||
| Patient 72: Treatment-emergent Central Sleep Apnea | 415 | ||
| Bibliography | 418 | ||
| Patient 73: A Patient with CHF and Central Apnea | 419 | ||
| Bibliography | 424 | ||
| Patient 74: A Patient with Sleep Apnea on Pain Medications | 424 | ||
| Bibliography | 427 | ||
| Patient 75: A Newborn with Cyanosis and a Young Child with Hypoventilation | 427 | ||
| References | 430 | ||
| Patient 76: A Young Woman with Headaches and Central Apnea and a Man with Breathing Pauses After Stroke | 431 | ||
| Bibliography | 433 | ||
| Patient 77: Bilevel Positive Airway Pressure (BPAP) and Adaptive Servoventilation (ASV) | 434 | ||
| Bibliography | 436 | ||
| Patient 78: Patients with a Neuromuscular Disorder | 436 | ||
| Bibliography | 441 | ||
| Fundamentals 31: Diagnosis of RLS and PLMD | 442 | ||
| Restless Leg Syndrome (willis-ekbom Disease), Periodic Limb Movements in Sleep, and the Periodic Limb Movement Disorder-dia... | 442 | ||
| Restless Legs Syndrome | 442 | ||
| The Essential RLS Diagnostic Criteria (box F31-1 and F31-2)2,4,5 | 442 | ||
| Supportive Clinical Features | 444 | ||
| Causes of RLS | 444 | ||
| Epidemiology of RLS | 445 | ||
| Sleep Disturbance Associated with RLS | 445 | ||
| Medical Evaluation in RLS | 445 | ||
| PSG Findings in Patients with RLS | 445 | ||
| RLS in Children | 446 | ||
| Periodic Limb Movements in Sleep | 446 | ||
| PLMS and Arousals | 446 | ||
| Differential Diagnosis of PLMS | 446 | ||
| Clinical Significance of the PLMSi and the PLMS Arousal Index | 446 | ||
| PLMS and Other Disorders | 447 | ||
| Periodic Limb Movement Disorder | 447 | ||
| Prevalence and Manifestations of PLMD | 447 | ||
| PSG Findings in PLMD | 448 | ||
| References | 448 | ||
| Patient 79: Patients with Leg Kicks on a Sleep Study | 449 | ||
| References | 451 | ||
| Patient 80: A 58-year-old Man with Sleep Apnea and Leg Jerks on CPAP | 452 | ||
| Bibliography | 454 | ||
| Fundamentals 32: Treatment of RLS and PLMD | 455 | ||
| Nonpharmacologic Treatments | 455 | ||
| Dopaminergic Medications | 456 | ||
| Dopaminergic Side Effects | 457 | ||
| Augmentation | 458 | ||
| Opioids or Opiates | 459 | ||
| Anticonvulsant Medications (Alpha-2-Delta Ligands) | 459 | ||
| Sedative Hypnotics | 460 | ||
| RLS Treatment Algorithm | 460 | ||
| References | 462 | ||
| Patient 81: Problems with Dopamine Agonist Treatment for RLS | 463 | ||
| Bibliography | 465 | ||
| Patient 82: Patients on Dopamine Agonists with Worsening RLS | 466 | ||
| Bibliography | 469 | ||
| Patient 83: A Patient with RLS and Pain and a Patient with Ropinirole-induced Nausea | 469 | ||
| Bibliography | 471 | ||
| Patient 84: Patients with RLS and Treatment Challenges | 471 | ||
| Bibliography | 474 | ||
| Patient 85: A Child with Difficulty Staying Asleep and Leg Kicks | 474 | ||
| References | 476 | ||
| Fundamentals 33: Hypersomnolence of Central Origin-I | 477 | ||
| Narcolepsy | 477 | ||
| Core Symptoms of Narcolepsy | 479 | ||
| HLA Typing, Genetics, and CSF Hypocretin | 479 | ||
| PSG-MSLT Criteria for Diagnosis of Narcolepsy | 480 | ||
| Narcolepsy Type I | 480 | ||
| Narcolepsy Type II (N-t2) | 481 | ||
| Treatment of Narcolepsy | 481 | ||
| Daytime Sleepiness | 481 | ||
| Cataplexy | 482 | ||
| Narcolepsy in Children | 482 | ||
| Narcolepsy Due to Medical Condition (NDMC Type 1 and Type 2) | 482 | ||
| Idiopathic Hypersomnia | 483 | ||
| Diagnostic Approach for IH | 484 | ||
| Subtype: IH with Long Sleep Time | 484 | ||
| Treatment of IH | 485 | ||
| References | 485 | ||
| Patient 86: A 20-year-old Woman with Emotion-induced Weakness | 486 | ||
| Bibliography | 488 | ||
| Patient 87: A 45-year-old Male with Severe Sleepiness | 489 | ||
| Bibliography | 492 | ||
| Patient 88: A Patient with Frequent Cataplexy and Sleep Paralysis | 492 | ||
| Bibliography | 495 | ||
| Patient 89: A Patient with Sleep Apnea and Possible Narcolepsy | 496 | ||
| Bibliography | 498 | ||
| Patient 90: A Child with Sleepiness and ``syncope´´ | 499 | ||
| References | 501 | ||
| Patient 91: Modafinil and Narcolepsy | 502 | ||
| References | 503 | ||
| Patient 92: A 25-year-old Woman with Narcolepsy Who Is Still Sleepy on Medication | 504 | ||
| Bibliography | 508 | ||
| Patient 93: Patients with Daytime Sleepiness and Cataplexy | 508 | ||
| Bibliography | 511 | ||
| Patient 94: A Patient with Extreme Difficulty Getting Out of Bed in the Morning | 512 | ||
| Bibliography | 514 | ||
| Fundamentals 34: Hypersomnolence of Central Origin II | 515 | ||
| Kleine-levin Syndrome (KLS) | 515 | ||
| Hypersomnia Due to a Medication or Substance | 516 | ||
| Insufficient Sleep Syndrome (ISS) | 516 | ||
| Hypersomnia Due to a Medical Disorder (HDMD) | 517 | ||
| Selected HDMD Conditions | 517 | ||
| Posttraumatic Hypersomnia | 517 | ||
| Residual Hypersomnia in Patients with Adequately Treated Obstructive Sleep Apnea | 517 | ||
| Parkinson Disease (PD) | 517 | ||
| Myotonic Dystrophy (MD) | 518 | ||
| Hypersomnia Associated with a Psychiatric Disorder (HAPD) | 518 | ||
| Hypersomnia Associated with Mood Disorder | 518 | ||
| References | 518 | ||
| Patient 95: A 35-year-old Man Requesting Stimulant Medication | 519 | ||
| Bibliography | 521 | ||
| Patient 96: Insufficient Sleep | 522 | ||
| Bibliography | 524 | ||
| Patient 97: A Patient with Prader-willi Syndrome and Daytime Sleepiness | 524 | ||
| Bibliography | 526 | ||
| Patient 98: Sleepiness After Head Trauma | 527 | ||
| Bibliography | 530 | ||
| Patient 99: A Patient with Possible Narcolepsy and Weakness in the Hands | 530 | ||
| Bibliography | 532 | ||
| Fundamentals 35: Parasomnia | 533 | ||
| Evaluation of Parasomnias | 533 | ||
| Nrem Parasomnia | 533 | ||
| Common Characteristics of NREM Parasomnia | 534 | ||
| Types of NREM Parasomnia | 535 | ||
| PSG in NREM Parasomnia | 535 | ||
| Treatment of NREM Parasomnia | 536 | ||
| Sleep-related Sexual Behavior and Sleep-related Violence | 536 | ||
| Parasomnia Usually Associated with REM Sleep | 536 | ||
| REM Sleep Behavior Disorder (RBD) (including Variants) | 536 | ||
| RBD-causes and Associations | 536 | ||
| Pseudo-RBD | 537 | ||
| PSG in RBD | 537 | ||
| Diagnosis of RBD | 538 | ||
| Variants of RBD | 538 | ||
| REM Sleep Without Atonia | 538 | ||
| Parasomnia Overlap Disorder | 538 | ||
| Treatment of RBD | 539 | ||
| Recurrent Isolated Sleep Paralysis | 539 | ||
| Nightmare Disorder | 539 | ||
| Diagnosis of Nightmare Disorder | 539 | ||
| Treatment of Nightmare Disorder | 540 | ||
| Bibliography | 540 | ||
| Patient 100: A 20-year-old Student with Severe ``nightmares´´ | 541 | ||
| Bibliography | 544 | ||
| Patient 101: Violent Behavior During Sleep | 545 | ||
| Bibliography | 547 | ||
| Patient 102: Patients with Violent Dreams | 547 | ||
| Bibliography | 549 | ||
| Patient 103: A Woman Who Eats During the Night and Does Not REMember | 550 | ||
| Bibliography | 552 | ||
| Patient 104: A Woman Who Moans at Night and a Woman Who Experiences Jerks When Falling Asleep | 552 | ||
| Bibliography | 554 | ||
| Fundamentals 36: Clinical Electroencephalography and Epilepsy | 556 | ||
| Monitoring with Electroencephalography (EEG) | 556 | ||
| Bipolar Monitoring and Standard Montages | 557 | ||
| Waveform and Seizure Terminology | 558 | ||
| Interictal and Ictal Activity | 558 | ||
| Phase Reversal | 559 | ||
| Localization in Referential and PSG Montages | 560 | ||
| Ictal Activity | 560 | ||
| Classification of Seizures and Terminology | 562 | ||
| Bibliography | 563 | ||
| Patient 105: Rhythmic Electroencephalography Pattern During Polysomnography | 564 | ||
| Bibliography | 566 | ||
| Patient 106: A 55-year-old Man with Unusual Movements During Sleep | 567 | ||
| Bibliography | 572 | ||
| Patient 107: Abnormal Behavior During Sleep | 573 | ||
| Bibliography | 576 | ||
| Patient 108: A Child with Mouth Movements During Sleep and a Teenager with Jerks in the Morning After Awakening | 577 | ||
| Bibliography | 579 | ||
| Patient 109: Patients with Parkinsonism and Sleep Problems | 579 | ||
| Bibliography | 583 | ||
| Fundamentals 37: Evaluation of Insomnia | 584 | ||
| Short-term Insomnia Disorder | 585 | ||
| Other Insomnia Disorder | 585 | ||
| Major Components of Chronic Insomnia Disorder | 585 | ||
| Insomnia Evaluation | 586 | ||
| Differential Diagnosis | 587 | ||
| Questionnaires, Sleep Logs, and Actigraphy | 587 | ||
| Sleep Logs | 588 | ||
| Actigraphy | 589 | ||
| Polysomnography | 591 | ||
| Co-Morbid Insomnia | 591 | ||
| References | 592 | ||
| Patient 110: A 30-Year-Old Woman Having Difficulty Falling and Staying Asleep | 593 | ||
| Bibliography | 594 | ||
| Patient 111: A Patient with Insomnia and an Irregular Sleep Pattern | 595 | ||
| Bibliography | 597 | ||
| Patient 112: A Woman with Sleepless Nights | 598 | ||
| Bibliography | 599 | ||
| Fundamentals 38: Behavioral Treatment of Insomnia | 600 | ||
| Cognitive and Behavioral Therapy for Insomnia (CBT-I) | 600 | ||
| Elements of CBT- I | 600 | ||
| Cognitive Therapy | 600 | ||
| Evidence for Behavioral Treatment | 602 | ||
| Brief Behavioral Therapy for Insomnia | 602 | ||
| Behavioral Treatment of Insomnia in Children | 602 | ||
| References | 603 | ||
| Patient 113: Behavioral Insomnia of Childhood | 604 | ||
| Bibliography | 607 | ||
| Patient 114: Patient with Unfavorable Sleep Habits | 607 | ||
| Bibliography | 609 | ||
| Fundamentals 39: Pharmacologic Treatment of Insomnia | 610 | ||
| GABA-BZ-chloride Ionophore Complex | 610 | ||
| BZRA Effects on Sleep | 611 | ||
| Side Effects of BZRAS | 613 | ||
| Using BZRA Hypnotics | 614 | ||
| General Considerations | 614 | ||
| Choice of BZRA Hypnotic Medication | 615 | ||
| Pharmacotherapy of Insomnia: Overall Strategy | 618 | ||
| References | 619 | ||
| Patient 115: Sleep-Maintenance Insomnia While Taking a Hypnotic | 620 | ||
| Bibliography | 622 | ||
| Patient 116: Middle-of-the-night Awakening and a Patient with Drug Dependence and Insomnia | 622 | ||
| Bibliography | 624 | ||
| Fundamentals 40: Circadian Rhythm Sleep-wake Disorders | 626 | ||
| Markers of Circadian Phase | 627 | ||
| Shifting the Circadian Rhythms | 628 | ||
| Phase Shifting by Light | 628 | ||
| Phase-response Curve for Light | 628 | ||
| Phase Shifting by Exogenous Melatonin | 629 | ||
| Summary of Effects of Light and Melatonin | 630 | ||
| Circadian Rhythm Sleep-wake Disorders (CRSWD) | 630 | ||
| Sleep Logs and Actigraphy | 632 | ||
| References | 633 | ||
| Patient 117: A 20-year-old with Difficulty Falling Asleep | 634 | ||
| Bibliography | 638 | ||
| Patient 118: A 60-year-old Man with Early-morning Awakening | 638 | ||
| Bibliography | 640 | ||
| Patient 119: A Patient with Periods of Insomnia and Daytime Sleepiness | 641 | ||
| Bibliography | 643 | ||
| Patient 120: An Older Woman with an Irregular Sleep Schedule | 643 | ||
| Bibliography | 646 | ||
| Patient 121: A Patient with Night Shift Work | 646 | ||
| Bibliography | 649 | ||
| Patient 122: Patients with Jet Lag | 650 | ||
| Bibliography | 653 | ||
| Fundamentals 41: Psychiatry and Sleep | 654 | ||
| Mood Disorders | 654 | ||
| Major Depressive Disorder | 654 | ||
| Bipolar 1 Disorder | 655 | ||
| Bipolar 2 Disorder | 656 | ||
| Treatment of Mood Disorders | 657 | ||
| Major Depressive Disorder | 657 | ||
| Bipolar Disorder | 657 | ||
| Effects of Antidepressants on Sleep | 657 | ||
| Panic Disorder | 658 | ||
| Posttraumatic Stress Disorder | 658 | ||
| References | 660 | ||
| Patient 123: Patients with Fatigue and Abnormal Sleep | 661 | ||
| Bibliography | 664 | ||
| Patient 124: A 45-year-old Man with Persistent Insomnia While on Treatment for Depression | 665 | ||
| Bibliography | 667 | ||
| Patient 125: A 30-year-old Woman Who Has Difficulty Getting Out of Bed | 668 | ||
| Bibliography | 670 | ||
| Patient 126: Patients with Terrifying Awakenings | 671 | ||
| Bibliography | 672 | ||
| Patient 127: A 50-year-old Combat Veteran with Upsetting Dreams | 673 | ||
| Bibliography | 675 | ||
| Appendix 1: Normal Ranges for Sleep Architecture | e1 | ||
| Appendix 2: Typical Values for Sleep Parameters in Normal Children | e2 | ||
| Appendix 3: Medicare Guidelines for Reimbursement for Respiratory Assist Device | e4 | ||
| Glossary | e6 | ||
| Index | 677 |