Neuro-biology of Sleep
By Dr.Manvir Bhatia & Ananya Sleep is an important and essential part of our lives. It rejuvenates us from all the fatigue. However, sleep is a very complex phenomenon. It mainly consists of alternating phases of the rapid eye movement (REM) and the non-eye eye (NREM) phase. The NREM is the first phase of sleep and consists of three phases followed by REM sleep. The first stage of NREM sleep lasts only for the initial ten minutes when we start falling asleep. Muscle activity and eye movement start slowing down. The second and third stages are those of deep sleep. The brain waves become slower, and during stage 3, there is the presence of delta waves. This is followed by REM sleep, during which brain activity is the same as that in the awakened state. It is characterized by heavy breathing, an increased heart rate, rapid eye movement, and muscle atonia. Anatomical regions of the brain involved in sleep and wakefulness: Basal forebrain : This region plays a primary role in promoting cortical activity due to the activity of the cholinergic neurons during wake and REM sleep. It has a number of inputs from the hypothalamus and brainstem. It also acts as a relay system between the afferent neurons of the reticular activating system to the cortex. Neurotransmitters in this area include glutamate, vesicular glutamate transporter 3, and gamma-aminobutyric acid (GABA). It is this heterogeneity that makes it involved in both sleep and wakefulness. Reticular Activating System: It is formed from a group of neurons that extend from the medulla to the posterior hypothalamus. It receives afferent neurons from various sensory organs and sends excitatory signals to the basal forebrain, hypothalamus, and thalamus. It plays a major role in wakefulness. Thalamus: It has the ability to modulate the sleep-wake cycle. It acts as a relay center for the input of glutamatergic neurons to the cortex. Hypothalamus: The lateral part of the hypothalamus is the only region that has two arousal-promoting neurons – hypocretin 1 and 2. The tuberomammillary nucleus(TMN, the only centre in the brain for the release of histamine, a wake-promoting substance) is present in the posterior part of the hypothalamus. This nucleus receives excitatory inputs from the hypocretin(or orexin)- containing neurons as well as GABAergic inhibitory connections from the neurons containing melanin-concentrating hormones(MCH). The slow and graded discharge of histamine from the histaminergic neurons of the TMN induces and maintains wakefulness. Light can induce the silencing of these neurons, which leads to the rapid generation of slow-wave sleep. The preoptic area(ventrolateral and median) in the hypothalamus contains neurons that can inhibit the arousal-promoting neurons with the help of GABA and galanin. These arousal-inhibiting neurons function most actively during REM and NREM sleep states. According to a study published in The Journal of Neuroscience, lesions in the ventrolateral preoptic area reduce sleep and affect the normal sleep of an individual. Neurotransmitters involved in the sleep-wake cycle include -Serotonin, norepinephrine, histamine, hypocretin, acetylcholine, dopamine, glutamate, and GABA. Proposed models of Neurobiology of Wakefulness and Sleep: Wakefulness: The neurotransmitters involved in inducing and maintaining wakefulness are a part of the ascending arousal system. These include orexin, norepinephrine, acetylcholine, serotonin, histamine, etc. There are two main pathways present in the lateral hypothalamus that cause arousal. These include: Sleep: The normal human sleep cycle is constituted by alternating phases of REM and NREM sleep. During this period, the ascending arousal system is inhibited by GABA and galanin via the ventrolateral preoptic area(VLPO). The VLPO has two groups of neurons that are involved in sleep: NREM Sleep: The VLPO and MNPO hypothalamic neurons majorly contribute to NREM sleep. These neurons are inactive during the awakened state and discharge preferentially during NREM sleep. The basal forebrain and the lateral hypothalamus also play a role in this through GABAergic neuromodulation. In this pathway, the VLPO sends the inhibitory signals to the monoaminergic system(histaminergic neurons of the tuberomammillary nucleus) and the orexinergic neurons(of the lateral hypothalamus). The VLPO also receives weak mutual inhibitory signals from the arousal systems during this stage. REM Sleep: The cholinergic excitatory neurons extend from the laterodorsal tegmental nucleus and the pedunculopontine tegmental nucleus to the reticular pontine formation, thereby promoting sleep. The activity of the neurons of the sublaterodorsal nucleus plays a role in muscle atonia, which is a characteristic of REM sleep. This is enhanced by the inhibitory projections of the ventrolateral medulla to the glycinergic spinal motoneurons. There is a sudden increase in muscle activity(twitches) in association with rapid eye movement. This is because of the motor neurons which send out glutaminergic excitatory outputs during activation of the central nervous system. Circadian control of sleep: The internal clock of our body also plays a major role in sleep and wakefulness. The circadian rhythm has two main processes – Process C and Process S. When Process S reaches its threshold, it induces sleep and the state of wakefulness prevails when it reaches its minimum intensity. NREM sleep is regarded as the principal marker of Process S. Process C denotes the sleep pattern during the 24-hour cycle. Although an internal clock runs in every cell of the body, it is only the suprachiasmatic nucleus that has the ability to directly receive light cues from the external environment and synchronize it with our internal clock. The neurons of the SCN nucleus are increased when one is awake and in REM sleep while its activity decreases during NREM sleep. There are several genes and their transcription factors that are involved in this namely: CLOCK and BMAL1 – the activating genes PER and CRY – repressing genes The SCN also regulates the release of melatonin from the pineal glands via the GABAergic neurons. During the day, it induces an inhibitory effect on the release of melatonin while at night promotes its secretion through the activity of these neurons. Hence, we conclude that the integrated efforts of the various pathways, neurotransmitters, hormones, and nuclei are necessary for good sleep. It requires the combined effort
HOW TO HANDLE CPAP PROBLEMS IN CLINICAL SETTINGS?
By Dr. Manvir Bhatia and Ms. Garima Sharma “Patience and perseverance is the key to success.” We know how a new foreign object on the face can be intimidating for patients who are already dealing with breathing difficulty day or night time. The right motivation and guidance are a must to begin any therapy. CPAP (continuous positive airway pressure) therapy can work as a life-saving asset for a number of disease conditions. The root of problems can range from respiratory failure to breathing difficulty due to various underlying pathologies of the lungs, heart, kidney, or nervous system. Chronic obstructive pulmonary disease, Asthma, and Obstructive sleep apnea are some of the major issues that require CPAP to improve oxygenation and keep the airway open while they sleep. CPAP gives the positive airway pressure that is important to keep the airway open and also helps in improving oxygenation by pushing the fluid out of the lungs in diseases like pulmonary edema. It can be an asset to avoid invasive mechanical ventilation that’s difficult to wean off. There can be many challenges that a patient and clinician might come across while initiating CPAP therapy for the patient. But every problem has a solution. We will guide you on how to troubleshoot those problems with ease. PATIENT-RELATED CPAP PROBLEMS: First and foremost is the comfort of the patient. The first impression of the therapy to the patient can make a difference. STARTING TROUBLE: Starting the therapy directly without informing and guiding the patient about how to adjust to the therapy, getting him comfortable with the mask, air pressure, and new change in his regular lifestyle, might scare him off completely can lead him to abandon and deny the life-saving therapy that’s crucial for him. A patient might be scared to use a mask at first as it gives him the sense that he won’t be able to breathe against a lot of air pressure, or claustrophobia may make him agitated. INFORM THE PATIENT: TIPS FOR THE HEALTH PROFESSIONAL. Set the RAMP time to 5 to 15 minutes according to the need. CLAUSTROPHOBIA: Fear of closed space. A full-face mask might be difficult for a patient having claustrophobia. How to give CPAP therapy for Claustrophobia patients: A nasal mask or nasal pillow may be a boon for such patients. MASK FIT: If the mask is small or larger than the required size of the patient, it may cause leakage or discomfort for the patient. HOW to find the right size mask? The right size of the mask is selected by the size chart that your health professional will use to measure the size between the nasal bridge and upper lip. Even if the size suggests the best fit, the patient should be allowed to try one size smaller and on size larger mask and choose what’s best for them. Various sizes of masks are available- small, medium, and large. For example, some feature full-face masks that cover your mouth and nose, with straps that stretch across your forehead and cheeks. These may make some people feel claustrophobic, but they work well if you prefer to breathe through your mouth during sleep. They also provide a stable fit if you move around a lot in your sleep. Other masks feature nasal pillows that fit under your nose and straps that cover less of your face. These can feel less cumbersome. Nasal pillows may work well if you wear glasses or read with the mask on because some don’t block your eyes as much as full-face masks do. However, this mask style may not be an option if you move around a lot in your sleep or sleep on your side. LEAK AND SOUND COMING FROM THE SIDE OF MASk CUSHION OR THE MASK: If the size is larger than required, or the head straps are not tightened appropriately, this can cause leakage and the gushing sound of air coming out may cause disturbance in sleep and leads to ineffective therapy. HOW TO PROPERLY FIT THE MASK? The straps should be rightly placed in the connectors provided on the mask. The broader part of the strap goes towards the head and narrower towards the neck. The straps are equally tightened on both sides at a time, facing toward the patient. DISCOMFORT DUE TO TIGHT MASK: Pressure sores on the nasal bridge due to a very tight mask can be painful for the patient. How to ensure the mask isn’t too tight? There should be a minimum of 2 fingers gap between the face and the straps to make sure the mask isn’t too tight or loose. A silicon-made cushioned tape can be used on the nasal bridge and the chin to prevent pressure sores. A mask with a light face cushion and silicon face cover can be more beneficial. MOUTH DRYNESS: The patient may complain of mouth dryness and may disconnect the mask repeatedly to drink water which causes disturbance in sleep and disruptions in the therapy. Mask leakage can cause this and also a stuffy nose. HUMIDIFIER TO THE RESCUE: A heated Humidifier adds water at a certain temperature to the air before giving it to the patient. The level of humidification can be adjusted between 1 to 5, where 1 is the minimum to 5 is the maximum humidification. Nowadays, inbuilt humidifiers come in the form of filters that can be used during travel with certain kinds of traveling, compact CPAP machines. For a stuffy nose, a nasal saline spray can be used to clear the nasal passage before bedtime. HIGH PRESSURE: A patient may complain of discomfort due to high Pressure. SWITCH THE THERAPY TO BIPAP The patient should be instructed to breathe along with air pressure and try to relax in the sitting position while holding the mask on the face. If still the pressure feels too much, the therapy can be changed to BIPAP, which gives BI- level Pressure, lower pressure at the expiratory time, and higher pressure at the inspiration
SLEEP CENTER SETUP: HOW TO GET STARTED
By Dr. Manvir Bhatia/MS. Garima Sharma INTRODUCTION “Turn your fears into excitement. Your anxieties into enthusiasm. Your passion into energy.”― Sanober Khan If you are a neurologist especially interested in the field of neurological disorders which are often associated with sleep disorders such as sleep apnea, hypersomnia, insomnia, and restless legs syndrome, this article is worth your time. For sleep laboratories that currently accept or plan to take on patients, several key aspects of their structure and processes must be considered in order to ensure a cohesive and effective team effort. Developing a sleep disorders center requires commitment from the very beginning. It includes the types of centers that can be established, accreditation requirements, choosing equipment and supplies, and estimates of costs. How to establish a sleep center This course will guide you to identifying cost-related factors based on the number of beds, developing a business plan, and the related financial proforma required by most sponsors or lenders. A range of tasks, including interviewing, hiring, writing job descriptions, training, innovating scheduling methods for work shifts, evaluating employment records, and drafting personnel and technical policies and procedures. Also included are details about the Occupational Safety and Health Administration, quality assurance, and accreditation requirements. Understanding the requirement: This course will help you build a strong base to meet the following requirements:[2] Staff training: A trained Neurology and sleep medicine doctor, nurses, sleep technicians/therapists for night duties and daytime shifts, receptionist, and trained non-technical staff like sweepers, and caretakers. A sleep lab manager acts as a link between the administration, technical, and medical staff, as well as other personnel connected with the lab in tangential ways. Finances: It’s important to have a business strategy and manage the finances. Technical equipment: All the equipment required for Level-1, 2, and 3 of the sleep study. Computer systems, software, CPAP/BIPAP devices, etc are covered in detail with their technical positives and negatives. Take home message: It ain’t easy but worth the efforts and time you put into it with the patience and passion for the betterment of sleep medicine. We are here to help you make the process smooth. To seek help or know more about teenagers and sleep issues you can visit the Neurology and Sleep Centre, the 1st sleep centre in the country accredited by the Indian Board of Sleep Medicine at L-23, Hauz Khas Enclave, New Delhi, Delhi-110016 (INDIA) Or give a call at +91-11-46070321, +91-9643500270, Or write to info@neurologysleepcentre.com BIBLIOGRAPHY Amartogtokh, T., and D. Shuren. “Establishing First Sleep Center in Mongolia.” Sleep Medicine, Abstracts from the 15th World Sleep Congress, September 20-25, 2019 World Sleep 2019 in Vancouver, Canada, 64 (December 1, 2019): S14. https://doi.org/10.1016/j.sleep.2019.11.041. Polnaszek, Nancy L. “How to Start a Sleep Lab or Center.” Journal of Clinical Sleep Medicine 03, no. 03 (April 15, 2007): 322–322. https://doi.org/10.5664/jcsm.26809. [1] Amartogtokh and Shuren, “Establishing First Sleep Center in Mongolia.” [2] Polnaszek, “How to Start a Sleep Lab or Center.”
When-is-snoring a sign of a deeper problem?
“I was not able to sleep last night; you were snoring so loud” “No, I don’t snore, you are not saying right.” Everyone who snores has had to deal with this issue at some point in their lives. So, let’s talk about what snoring is and why it occurs. In simple words, snoring is a sound one makes while sleeping. Scientifically, snoring is a breathing sound that occurs when air moves past calm tissues in the throat, causing the tissues to vibrate when one breathes. According to the American Academy of Otolaryngology, up to 45% of American adults snore and 25% do it on a regular basis. Snoring is common, can disturb sleep, occurs more frequently in men than women, and can get worse with age. Why do people snore? Snoring can occur because of a number of reasons and influences. When a person breathes, the air is pushed through the nose, mouth, and throat, and snoring occurs when the flow of air through the mouth and nose is congested, which is rattling and shaking of tissues. Some common reasons which block the airway and cause snoring are: • Nasal Airways: The nasal airway is choked either due to allergies, infection, or difficulties like a prolonged nasal blocking barrier between the nostrils, which is known as a deviated nasal septum, which can block the airways and cause snoring. • Alcohol: People who drink alcohol snore more than those who do not, because alcohol relaxes the throat muscles that causing snoring. Drinking alcohol right before bedtime can increase snoring. • Lack of Sleep – Sleep deficit is another factor of snoring as similar to Alcohol, lack of sleep can also relax the throat muscles too much. • Mouth Anatomy – People with distended tissues and tonsils that limit airflow generally produce slight snores. • Obesity – People who are slightly overweight have a habit of snoring more, as they might have additional tissues in the back of their throats that may thin the airways. • Sleeping Position: Sleeping on the back can be a source of the sound, as can using a too-soft or too-big pillow. Symptoms of Snoring Snoring is an indication of sleep apnea, a sleeping disorder called Obstructive Sleep Apnea (OSA). And the symptoms of snoring are: • Consistent snoring, more than 3-4 times a week • Heavy and loud snoring sounds • Worry in sleep • Excessive daytime sleep • Morning headaches • Chest pain at night • Painful throat in the morning • High Blood pressure • High recurrent nighttime urination • Obesity • Blocking at night or breathing breaks during sleep Risk Factor Snoring can be really dangerous at times, and the danger can rise with age. Some of the risk factors which may enhance snoring are, • Having a thin airway – Some people have enormous tonsils, adenoids, or long soft palates, which can slim the airways. • Alcohol – A person who drinks alcohol is more likely to snore than someone who does not. • Men – Males are more probable to snore or have OSA than women • Obesity – Bulky people have more danger to have snoring problems. • Family history – Sometimes genetics is a risk factor for OSA Complications Snoring can be common and simple as well as occasionally risky. The risk level of snoring depends upon its types, severity and frequency. • Light or Irregular snoring Irregular snoring is regular and common with some people and doesn’t need much medical help. The person sleeping next to you might have problems, other than that light snoring is usual. • Restlessness during night Primary snoring happens more than 3 times a week and the occurrence can cause poor night sleep, however, this is not much of a health worry as snoring this much will not affect the health much or cause obstruction but this can make one feel giddy in the morning or tired at daytime, which can disturb the quality of life. • Sleeping Disorder It’s time to see a doctor when most of the symptoms of snoring can be troublesome for your health. OSA can cause major problems, affect a person’s sleep, and even cause serious health matters like high blood pressure, diabetes, stroke, or depression. One can have the danger of losing one life during sleep if the breath gets obstructed and remains ignored. When is the correct time to see a doctor? For primary snoring or OSA, one can see a doctor at either time, although when one sees a few of the given signs, it is better to visit a doctor. • Snoring more than 3 times a week • Heavy and loud snoring • Choking during sleep • High blood pressure • Rise in snoring sounds while sleeping Preventions Lifestyle plays annn essential role when any medical problem needs avoidance, simple alterations in the lifestyle can really help in retaining a healthy lifestyle and avoiding similar concerns. Home therapies for snoring problems • Sleeping at the same time every night • Sleeping on one side • Avoiding Alcohol • Healthy diet, the perfect weight • Put on nasal strips to the bridge of the nose • Right pillow • Rising the head of your bed and relaxing position while sleeping Treatments Although prevention and care might help in decreasing snoring problems or ending them when light snoring happens, recurrent snoring and OSA require treatment. The doctor, after reviewing the symptoms and reasons for your snoring, will also implement a physical examination to propose a flawless treatment for snoring. Before providing treatment for such concerns, it is vital for the doctor to comprehend the family history and sleep cycle of the patient. The doctor can advise, a few or any of the following actions to the person, • Oral appliances: minor plastic devices that are form-fitting dental mouthpieces are provided to help in determining the location of the jaw, tongue, and soft palate to keep the air passage open to avoid snoring. • Continuous Positive Airway Pressure (CPAP) Masks are common practice following COVID, and we are certainly accustomed to them, so CPAP is not the firm trick when it comes to snoring treatment. CPAP is a treatment that
CBT-I for Insomnia
CBT-I for InsomniaInsomnia is a sleep disorder that results in loss of sleep. A person might fight difficulty in falling asleep orwake up too early. This drains out all of the energy and makes one feel tired throughout the day. Itadversely affects an individual’s regular life and efficiency and needs to be addressed as soon as possible.There are various approaches that can be used to treat insomnia.What is CBT-I?CBT-I stands for Cognitive Behavioural Therapy for Insomnia. It is an approach that helps to identify thosethoughts, beliefs, and actions that cause and worsen insomnia so that one can replace them. In short, ithelps identify the root cause of insomnia and take productive measures to deal with it. It is oftenreferred to as a multi-component therapy as the sessions include behavioral, educational, and cognitivecomponents.Techniques used in CBT-I :Stimulus Control Therapy: It is often observed that people suffering from insomnia develop habits thatdo not promote sleep. They use the bed for almost all activities other than sleep like watching television,eating, using the phone or computer, etc. Patients are instructed to use the bed only for sleep and sex.They are advised to avoid naps and to get out of their bed if they cannot fall asleep for more than 10minutes and get back only when they are tired.Sleep Restriction: This is a method by which the time a person spends sleepless in bed is reduced. Forexample, if a person is trying to sleep for 7 hours but actually falls asleep only for 4 hours, he is made tospend only 4 hours and 30 minutes in bed. Gradually, as the duration of sleep increases, the time isfurther increased to 7 hours of quality sleep.Relaxation techniques: Lying awake in bed can become very frustrating and lead to racing thoughts,tension and anxiety. These techniques stimulate the natural relaxation process of the body. It includes:● Breathing exercises – Focussed, slow breathing can increase slow heart rate and reduce tension,anxiety, anger, and depression. It very effectively helps us calm down.● Autogenic training – An individual is trained to focus on a certain part of the body to feelsensations such as warmth, heaviness, etc.● Progressive Muscle Relaxation(PMR) – It involves tensing and relaxing different groups ofmuscles. It is often combined with breathing exercises to get better results.● Meditation – Practising meditation has a variety of health benefits as it is relaxing and reducesstress and anxiety.● Biofeedback – A sleep specialist uses technology to get information about brain waves, muscletension, heart rate, breathing, and body temperature.● Sleep hygiene – It aims at eliminating habits that are detrimental to sleep and including the onesthat promote sleep. For example, consumption of caffeine late in the day, smoking, etc are notgood for sleep whereas following a sleep ritual such as staying away from electronic devices atleast one hour before bed time, exercising regularly, etc can help in achieving good sleep.Psychoeducation: It is important to educate an individual about the practices of good sleep hygiene andits importance. One can follow it only if she is mentally convinced about it. Going to bed at a particulartime on a clean and comfortable bed, with dim lights in the bedroom are some of the practices that oneshould follow on a regular basis.Effectiveness of CBT-I :Approximately, 70-80% of the patients with primary insomnia are benefitted from CBT-I. Practicing itregularly has numerous benefits like falling asleep quickly, and getting an improved quality and quantity ofsleep. It is also recommended as the first line of treatment for adults suffering from insomnia. Somepeople such as pregnant women, people suffering from post-traumatic stress disorder(PTSD), those whoare undergoing cancer treatment are more prone to insomnia. CBT-I is observed to work well for themalso. It is more effective as compared to medications with almost no side effects.CBT-I is generally administered by trained professionals such as doctors, counselors, psychiatrists,s or atherapist. It is a widespread need that has been digitized now. Online applications have beendeveloped for the same. This reduces the cost of treatment and makes it available to a wider audience.Hence, we conclude that identifying and dealing with insomnia is the most important for the mental andphysical well-being of an individual. If practiced sincerely with a positive attitude one experiences areduction in the amount of time required to fall asleep and also gets a sound sleep. Therefore, it isimportant that one seeks professional help and pours in a personal effort to cure insomnia.References:https://www.sleepfoundation.org/insomnia/treatment/cognitive-behavioral-therapy-insomniahttps://www.mayoclinic.org/diseases-conditions/insomnia/symptoms-causesTrauer, J. M., Qian, M. Y., Doyle, J. S., Rajaratnam, S. M., & Cunnington, D. (2015). Cognitive BehavioralTherapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Annals of internal medicine,163(3), 191–204. https://doi.org/10.7326/M14-284
ROLE OF A DENTIST IN THE MANAGEMENT OF OSA AND SNORING
ROLE OF A DENTIST IN THE MANAGEMENT OF OSA AND SNORING Snoring is the sound that occurs when air flows past relaxed tissues in your throat, causing the tissues to vibrate as you breathe. Nearly half of adults snore and over 25 percent are habitual snorers. Snoring problem and sleeping disorders are more frequent in males and people who are overweight and usually worsens with age. Snoring can also be a sign of a more serious condition known as obstructive sleep apnea (OSA), which occurs in 24% of young middle-aged men and 9% of women, and in 70% of older men and 56% of older women. OSA is characterized by multiple pauses in breathing greater than 10 seconds due to upper airway narrowing or collapse. Untreated OSA can contribute to high blood pressure, stroke, heart disease, workplace or motor vehicle accidents, and more. Sleep Apnea’s relation to Dentistry Sleep apnea is known to contribute to oral health problems and vice versa. Good, quality sleep keeps you healthy and reduces bad breath, mouth ulcers, and the development and progression of periodontal disease (gum disease). Dental problems associated with sleep apnea include TMJ disorders, bruxism, and mouth breathing. What SYMPTOMS can help you identify OSA in your patients? Some symptoms of sleep apnea are specific to dental problems. Dental symptoms to look out for in both adults and children include: Advantages of suggesting dental devices for the treatment of sleep apnea A study by the American academy of dental sleep medicine shows that oral appliances are a proven and effective treatment for OSA and snoring. Worn during sleep, the appliance fits in the mouth and supports the jaw in a forward position to help maintain an open upper airway. There are many reasons why orthodontists should consider recommending dental devices and an improvement in oral and dental health to people with sleep apnea. If you are an orthodontist, then discussing orthodontic treatments such as rapid maxillary expansion can also help. This orthodontic treatment involves temporarily applying a screw device into the upper teeth and tightening this regularly. Rapid maxillary expansion can also be recommended for those with a narrow upper jaw. This is a nonsurgical orthodontic procedure that is effective in reducing nasal pressure and improving breathing patterns. Sleep Medicine is an exciting & emerging field of medicine. It has a strong correlation with Dentistry & has hence it is highly recommended for a dentist to get acquainted in this area. To learn more about Dentistry’s role in Sleep Medicine explore the various learning options pls check the website www.sleepmedicintinstitute.in To know more about our offerings, feel free to reach us at 8527119474 or can write to us on sleepmedicineinstitute@gmail.com.
Multiple Sleep Latency Test
What is the Multiple Sleep Latency Test? The Multiple Sleep Latency Test (MSLT) checks for excessive daytime sleepiness by measuring how quickly you fall asleep in a quiet environment during the day. Also known as a daytime nap study, the MSLT is used to diagnose narcolepsy and hypersomnia. How to prepare for the Multiple Sleep Latency Test? (One to Two weeks before the MSLT) Keep a sleep diary for two weeks and attempt to maintain a regular sleep schedule, this will allow the doctor to see your sleep patterns. This may help identify other factors that could be causing daytime sleepiness. Decreased the use of caffeine If you are on any medications, your doctor will help you to determine when you can use your medications before the MSLT. Some medications may need to be discontinued for a weeks before the MSLT. (Once you have finished these steps, you will be ready for the MSLT.) Procedure (During the test) A sleep technologist will place sensors on Patient head (C3-C4, O1- O2, A1 – A2 & Ground), face (LOC & ROC) and chin (Chin EMG). These sensors are connected to a computer. The sensors show when patient is asleep and awake, and used to determine the onset of REM sleep. Calibration is conducted in the following manner: Eyes —open closed(3- 4 times) Asked to Look Right, Left , Up & Down(3-4 times) Make the Chin Tight & Loose (3 to 4 Times) Instructions will be given to take a nap –During each nap ,Once the lights off, attempt to fall asleep Each nap is in a dark and quiet sleep environment Patient will be awakened after sleeping 15 minutes. If patient does not fall asleep within 20 minutes, the nap trial will end. Instructions for Patient (During the day) The MSLT is a full-day test that consists of 4 to 5 scheduled naps separated by two-hour breaks. This test is always done following a sleep study that measures your sleep quality and duration. Cell phone must be turned off during testing. No radio or TV may be on during the testing period Between naps, the patient is instructed to not fall asleep, lie down or even sit in bed: The patient can sit in a chair outside, the testing room read, listen to music What is to be avoided/ what can you take? Caffeine (coffee, colas, tea, chocolates) are not allowed during the day of the testing, but patient can have juices. Can have food How is Multiple Sleep Latency Test results scored? A doctor will review the data, note when you fell asleep during each nap, (Sleep latency – in between Light Off to Sleep onset time Look at sleep stages and determine whether you entered REM sleep. Patients with narcolepsy – have two or more REM sleep stages during an MSLT. People with hypersomnia fall asleep easily but do not reach REM sleep during the nap trial. The night before your MSLT you will have a sleep study.( Sleep at least 6 hours during the sleep study. ) Gold cup electrodes Used EEG Electrodes – 7 Electrodes used Some Electrodes placed on Right hemisphere on the Head (C4, O2 & A2) & some electrodes placed on the Left hemisphere on the Head (C3 , O1 & A2) & ground placed on forehead EOG Electrodes: (4 gold cup electrodes used) EOG electrodes are placed 1 cm out and 1 cm up or down from the outer canthus of both eyes Chin EMG : (2 Electrodes) : There are two Electrode used for MSLT Test , one electrodes used for Right side of chin muscle & Second one used for Left side of Chin Muscles
LEVEL-3 HOME SLEEP TEST
What is a home sleep apnea test? (HSAT): It’s a convenient,simple and affordable sleep apnea test that can be prescribed by a physician to diagnose Obstructive sleep apnea (OSA) in the comfort of your home. It is also called Limited channel sleep study/a portable sleep study or LEVEL-3 sleep study test. What parameters Level-3 of the sleep study can record? Level 3 devices record at least 3 channels of data (e.g., oximetry, airflow, respiratory effort). Level-3 records the following parameters: El Shayeb et al., “Diagnostic Accuracy of Level 3 Portable Sleep Tests versus Level 1 Polysomnography for Sleep-Disordered Breathing.” Cardiopulmonary parameters; two respiratory variables (e.g., effort to breathe, airflow), oxygen saturation, and a Cardiac variable (e.g., heart rate or electrocardiogram). Unlike level 1, level 3 testing cannot measure the duration of sleep, the number of arousals, or sleep stages, nor can it detect non-respiratory sleep disorders. Level 4 devices are also portable, but they capture less data — usually only 1 or 2 channels typically oxygen saturation and heart rate, or in some cases, just airflow. Indications for HSAT: AASM-2007 Guidelines suggests that the HSAT or portable sleep test can be used as an alternate to PSG for the diagnosis of OSA in the patients, if the following is indicated: With high clinical possibility of moderate to severe OSA. An increased risk of moderate to severe OSA is indicated by the presence of excessive daytime sleepiness and at least two of the following three criteria: 1.1. habitual loud snoring, 1.2. witnessed apnea or gasping or choking, 1.3. diagnosed hypertension. For whom in lab PSG is not possible due to immobility or critical illness. HSAT is not appropriate for the diagnosis of OSA in patients: With significant comorbid medical conditions that may degrade its accuracy. i.e., non-obstructive sleep-disordered breathing (e.g., central sleep apnea, hypoventilation, and sleep-related hypoxemia): For example- advanced cardiopulmonary disease potential respiratory muscle weakness due to neuromuscular conditions, history of stroke and chronic opiate medication use. Kundel and Shah, “Impact of Portable Sleep Testing.” BIBLIOGRAPHY: El Shayeb, Mohamed, Leigh-Ann Topfer, Tania Stafinski, Lawrence Pawluk, and Devidas Menon. “Diagnostic Accuracy of Level 3 Portable Sleep Tests versus Level 1 Polysomnography for Sleep-Disordered Breathing: A Systematic Review and Meta-Analysis.” CMAJ : Canadian Medical Association Journal 186, no. 1 (January 7, 2014): E25–51. https://doi.org/10.1503/cmaj.130952. Kundel, Vaishnavi, and Neomi Shah. “Impact of Portable Sleep Testing.” Sleep Medicine Clinics 12, no. 1 (March 2017): 137–47. https://doi.org/10.1016/j.jsmc.2016.10.006. Upon evaluation suspected of comorbid sleep disorders disorders of central hypersomnolence, parasomnias- like sleepwalking, talking, nightmares, sleep-related movement disorders or severe insomnia. With the screening of belonging to an asymptomatic population. Environmental or personal factors that preclude the adequate acquisition and interpretation of data from HSAT. If a single home sleep apnea test is negative, inconclusive or technically inadequate, polysomnography be performed for the diagnosis of OSA. Drawbacks of HSAT: HSAT devices in comparison to attended studies raises the risk for technical failures due to a lack of real-time monitoring. Level-3 can’t define sleep versus wake. Positive airway pressure (PAP) cannot be initiated during an HSAT, but can be initiated during a PSG if needed. Measurement error is inevitable in HSAT, compared against PSG, as standard sleep staging channels are not typically monitored in HSAT (e.g., EEG, EOG, and EMG monitoring are not typically performed), which results in use of the recording time rather than sleep time to define the denominator of the respiratory event index (REI; the term used to represent the frequency of apneas and hypopneas derived from HSAT). HSAT devices that use conventional sensors are unable to detect hypopneas only associated with cortical arousals, which are included in the recommended AHI scoring rule in the AASM Scoring Manual. Sensor dislodgement and poor quality signal during HSAT are additional contributors to the measurement error of the REI. All these factors can result in the underestimation of the “true” AHI, and may result in the need for repeated studies due to inadequate data for diagnosis. Harms could result from misdiagnosis and subsequent inappropriate therapy or lack of therapy. ADVANTAGES OF HSAT OVER PSG: Use of HSAT may provide potential benefits to patients with suspected OSA. Such benefits could include convenience, comfort, increased access to testing, decreased cost. HSAT can be performed in the home environment with fewer attached sensors during sleep. May improve access to diagnostic testing in resource-limited settings, or when the patient is unable to leave the home or healthcare setting for testing. These benefits must be weighed against the potential for harm. If HSAT is used in the context described in the recommendations and remarks, the risk of harm is minimized and the probability of potential economic benefits increased. How is HSAT done? A single HSAT recording is conducted over at least one night. A technically adequate the diagnostic test includes a minimum of 4 hours of technically adequate oximetry and flow data, obtained during a recording attempt that encompasses the habitual sleep period. Devices available with us: Alice night one Apnea link The device and Its sensors (pulse-oximeter, nasal prongs, chest belt with the device in the centre to connect all the channels) have to be connected 5 minutes before you sleep and then to be removed in the morning on waking up. These should not be removed if you wake up in between for a brief period in the night for any reason like drinking water or urination. After the completion of the test, the report is generated by the sleep technologist and approved by a physician. CONCLUSION: HSAT is a cost-effective, convenient, portable sleep study test, done at the comfort of the home setting. When prescribed for the appropriate patients, it can be of greater use and help to establish the diagnosis of OSA and treat them accordingly by giving appropriate therapy. HOME SLEEP TEST 3 min 49 sec read By Dr.Manvir Bhatia Garima Sharma
ONLINE SLEEP MEDICINE COURSE: WHY TO ENROLL? WHO SHOULD ENROLL?
What is online education? The lives of people in the field of healthcare and medicine are very eventful and busy. Be it doctors, interns, nurses, pathologists etc. all of them have packed schedules. Their devotion to the profession is what gives them the strength to keep working hard and learn something new everyday. Online education can boost their knowledge and skills irrespective of the time constraints. Online education is the use of the internet via electronic devices such as laptops, mobile phones and other electronic devices to gain knowledge about a variety of topics. It allows mentors to reach out to a large number of learners. It allows students without access to traditional classes, working individuals and home-makers to learn new skills and topics. This mode of education has an edge over classroom learning because of its flexibility with respect to speed and time of learning, cost effectiveness and networking opportunities with people of different backgrounds. What is sleep medicine? Sleep is essential to survival. It is important for growth, normal functioning of the brain and other organs of the body and helps our tired body to re energize itself. Getting good quality sleep regularly is a priority. The duration depends mainly upon the health and age of an individual. Sleep medicine is the field of study that focuses on diagnosis and treatment of sleep disorders. Specialists in this field have special training that gives them the expertise to diagnose and treat sleep problems and disorders. They can treat a wide range of disorders related to sleep, such as breathing problems, abnormal activity during sleep, insomnia, hypersomnia, etc. Patients with sleep issues can present to all disciplines and sleep issues can occur alone or co-exist with other medical conditions. Thus it is essential for specialists, physician’s surgeons in all disciplines of medicine to be familiar with the conditions. Factors responsible for sleep problems: A number of factors are responsible for sleep disorders and its disruption. This can vary depending on the type of disorder. A few of them are listed below. Gender – Females are more prone to sleep disorders( Insomnia , RLS) as compared to males. Lung disease – Both obstructive and restrictive lung diseases are associated with sleep problems. Renal diseases – About 80% of patients suffering from end stage renal disorders have reported sleep disorders. The symptoms include difficulty falling asleep, awakenings in the middle of the night, waking up too early, restless legs, jerking legs, and daytime sleepiness. Endocrine disorders – Hypothyroidism and acromegaly are associated with Obstructive Sleep Apnea(OSA). Diabetes is associated with sleep disturbance, difficulty in falling asleep and maintaining a good quality sleep. Short duration sleepers are more prone to diabetes as compared to long duration sleepers. Also, glucose tolerance is impaired in patients with OSA. According to a study published in the Journal of Family Medicine and Primary Care(Bhaskar et al; 2016), with increasing age, diabetic patients are more likely to suffer from insomnia. Infectious diseases – People with acute infection need more sleep. This may be due to the action of the immune system by the release of cytokines. People infected with influenza virus tend to sleep more during the symptomatic phase as compared to the incubation phase. Lyme disease, hepatitis B and C, brucellosis are infections in which the patient suffers from difficulty in getting a good quality sleep. Patients with HIV have reported insomnia, excessive daytime sleepiness, and multiple awakenings at night very frequently. In a longitudinal study by Choudhary et al, published in Cureus, a significant prevalence of insomnia has been reported in COVID-19 patients upto 30 days post recovery. The social confinement and financial constraints experienced by people worldwide during the pandemic is a reason for sleep problems, fatigue and excessive sleepiness that they experienced. Menopause – Most women experience a lot of sleep related problem during menopause because of hot flashes, sleep apnea, restless legs syndrome, depression, and symptoms of fibromyalgia. Cancer – Patients undergoing cancer therapy(especially lung and breast cancer) commonly report hypersomnolence, excessive fatigue, insomnia and multiple awakenings. Neurologic disorders – These include Alzheimer’s, Parkinsons, epilepsy, etc. these patients report poor night sleep, rapid eye movement (REM) sleep behaviour disorder, insomnia, restless legs syndrome, etc. Pregnancy – According to a study by Mindell et al(Sleep medicine, 2015), around 75% women experience poor quality sleep during the whole period of pregnancy. All of the subjects reported night time awakenings. This is mainly due to the frequent urinations and the difficulty in finding a comfortable sleep position. Theyalso reported insomnia, day time sleep, restless leg syndrome, etc. Hence, keeping in mind the range of factors and diseases which can affect and be affected by sleep, it becomes extremely important for all physicians and specialists to screen and treat all their patients for any sleep related problems. Online sleep medicine courses can be extremely helpful for them. Who should enrol? Doctors who preferably should have additional training in sleep medicine include: Anesthesiologists (surgical care and anaesthesia) Cardiologists (heart) Family physicians Internal medicine doctors Neurologists (brain and nervous system) Otolaryngologists (ear, nose and throat, or ENT, specialists) Paediatricians Psychiatrists Pulmonologists (lungs) Psychologists – for special training in treating sleep related behaviours and insomnia Dentists – some of them create and fit dental devices used to treat sleep apnea. Sleep medicine and management is emphasised upon very less in both undergraduate and postgraduate medical education in India. As a result, awareness about sleep(even among physicians) and presence of sleep labs across the country is very less. This also leaves patients unaware about the importance of sleep. They seldom realise that a health reason might be a result of sleep deprivation. Knowing the importance and significance of sleep in our life, online comprehensive courses on sleep medicine in India should be extremely helpful for medical practitioners at all levels. It will increase sleep awareness among people in the society, improve the quality of life of the individual and have a long lasting effect on the community . References:
Blog on Basic Course in Sleep Medicine
Learn everything about the science of Sleep The sleep medicine field has grown up fast over the past few years. It has developed as a documented subspecialty in Western countries, but yet to be in developing markets. General Medical practitioner and professionals may encounter patients with sleep problems and may often initiate therapy. It would be significant to know sleep disorders initially and treat them to prevent complications. Failure of primary management or absence of transparency on the careful nature of the sleep disorder should prompt recommendation to Sleep Medicine experts. In the present landscape there is an increasing demand for skilled physicians, technologists, and other personnel for accurate diagnosis, effective treatment and efficient management of sleep related problems and sleep disorders. This may be largely credited to the exponential increase in number of patients facing sleep related issues having a troublesome influence and impression on their day to day life. In order to satisfy to this increasing request, there are valuable few opportunities other than teaching and awareness upgradation of all worried connected to this field from physicians, technologists to patients. Active diagnosis and management is an result of the growth of information base of all allocated participants, who play an essential and pivotal role, in the diagnosis and action of sleep related problems and sleep disorders. Keeping this in view, a first of its kind sleep medicine concerned with online platform has been launched in 2020 by Dr. Manvir Bhatia for physicians, technicians, technologists, patients and to all those who wish to improve their awareness of sleep related problems and sleep disorders. Sleep medicine institute deals a wide change of educational chances. Our devoted faculty is committed to improving the information in a loyal, collective, and courteous environment. We aim to prepare our students with the skills to assimilate clearly into the ever-changing landscape of healthcare which helps them stay up to date in their industry. Sleep Medicine Institute, a division of Neurology & Sleep Centre is a one stop solution for treatment, training, teaching & community awareness for sleep related issues & neurological disorders. Started with Two Major Courses in 2020 – Basic courses in Sleep Medicine and Advance Modules in Sleep Medicine, the institute has trained more than 150 Doctors/Therapists and Technicians, majority of them rating the quality of course 5 star. Basic course in sleep medicine is intended to offer a complete state-of-the-art method to the diagnosis of sleep disorders. It aims to growth information and abilities in this exact, stimulating and energetic field of sleep medicine. This 3 month online course, covers all structures of sleep medicine and technology. Starting with base knowledge about normal respiratory and sleep physiology, it will also cover all sleep disorders and their treatment, including applied application of sleep disorders assessment and management. You will be trained about existing practice in sleep science, as well as introduced to new and sensational developments for the future. This course is an concentrated introduction to the ground of sleep medicine. It is significant for all those new to the field and mentioned for those who would like to revive their information base. Contributors will be able to review thoughts, obtain up-to-date systematic data and applied tips, to proficiently and truthfully analyze sleep disorders. What this course will entail: Essentials of Sleep: Converses common sleep, why we sleep? And determinations of sleep. Part of a Sleep Technologist: Defines responsibilities of a sleep tech. The vocation path of a sleep and the concern and supplies for each pole. Organization and Means to a Patient with a Sleep Disorder: We will define the newest arrangement of sleep disorders, and history taking in a patient with sleep disorder. Dimension of Sleep: The particulars of Overnight sleep study – what is dignified? How it is measured? Levels of PSG. We will also include gathering on home sleep testing, the indications, contraindications, advantages and disadvantages will be underlined. PAP Titration: Basics of manual CPAP titration for OSA patient based on full night titration and split night study protocols. Learn how to start manual titration, how to score the results of manual titration and how to fixed pressure on fixed CPAP after manual titration Examination of PSG data & Report: Indication of Polysomnography sleep stage scoring. Features of EEG respiratory, limb and EKG waveforms. Review of AASM Practice Parameters for Polysomnography and home sleep tests. Apparatus Safety, Infection Control and Centre Difficulties: How to take maintenance of Equipment? Foundations of infection and how to switch infection will be described. The common problems in the center and how they should be handled. History of Patient: Role play, ask specific question regarding sleep like- name, age, problems, symptoms, case study. Preparing Patient for Sleep Test: Briefly describe about sleep test, provide information about do’s and don’ts before test, payment and address conformation, finalizing date for test. Demo Equipment / Sensor: Sensor / Sleep study device / level 1, level 2 and level 3. Hook Up: EOG, EEG, Electrode Placement, 10-20 system, respiratory sensor, and leg movement sensor. Calibration: EEG / EMG / Respiratory Sensor Performing the Study: After hookup recording of study, patient treatment during test. Titration: PAP device introduction, employed, how to choice device for patient. Mask: Outline with diverse types, how to choose best for patient. Trouble Shooting: How to handle issues faced by technician during sleep test, any case. Documentation: During test evidence noted by technician – diagnostic timing, titration timing, any kind uneven activity of patient, type of device and mask used. Completion of the Study: Data downloading from diagnostic device and titration device, cleaning of all sensors and device, handover all document to concerned person. Knowledge & Skills you stand to gain: Recognize the essentials of sleep functioning Assess a sleep patient Classify the main corresponding tests in sleep medicine Recognize the specific necessities for execution of sleep lab Be able to make a patient to complete a sleep study Gain involvement with polysomnography scoring Cover the basic applied skills required including wiring up, troubleshooting and report explanation – develop and improve these core practical skills Interaction with new research and