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Sleep

Daniel Novak

Wednesday, 29.3, Prague


Bionics

"Sleep, the brother of death."


[From Theogeny by Hesiod {8th century BC}]

Department of Cybernetics, Czech Technical University


Biological rhythms

Types of rhythms

1. Homeostatic: determines sleep need


2. Ultradian (Basic Rest-Activity Cycle,
shorter than a day, REM cycle of sleep)
3. Circadian (24h cycle, sleep-wake cycles)
4. Infradian (menstrual cycle)
5. Circannual (annual breeding cycles,
hybernation/activity)

*All rhythms allow us to anticipate change!

Department of Cybernetics, Czech Technical University


Measuring biological rhythms

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Architecture of a night’s sleep

-regular bouts of REM sleep


-most deep NREM sleep is early in the sleep period
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Sleep over the lifespan I - early sleep patterns

Department of Cybernetics, Czech Technical University


Sleep over the lifespan II: Patterns through adulthood

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Sleep architecture over the lifespan

Department of Cybernetics, Czech Technical University


Comparative studies of sleep

-virtually all animals sleep


-birds have short NREM and REM (9
seconds)
-waterfowl can sleep while
swimming
-transoceanic migrators can sleep
while flying
-reptiles have no REM
-homeothermy? (but echidna have
no REM either)
-smaller body size, more sleep -->
regulation of body temp?
-longer life, less sleep

Department of Cybernetics, Czech Technical University


The amazing bottle-nosed dolphin

Each hemisphere
takes turns sleeping
Department of Cybernetics, Czech Technical University
The need for sleep is insistent

We can abstain from food or water long enough to


kill ourselves

Ultimately, we cannot abstain from sleep (much as


we cannot stop ourselves from breathing)

So….sleep must have some important function, right?


Right…..???

Department of Cybernetics, Czech Technical University


The effects of sleep deprivation I

Sleep deprivation stunts

Peter Tripp -- radio DJ sleep deprived self for 260


hours
--> became psychotic

Randy Gardner -- sleep deprived for 264 hours under


supervision of sleep researcher Dement

--> few reported ill-effects (played a mean game of


pinball)

Department of Cybernetics, Czech Technical University


The effects of sleep deprivation II

Rebound phenomena

-following sleep deprivation,


we recover much of our lost
sleep but there is some
segregation of recovery of
different types of sleep.

-following selective SWS or


REM deprivation, there is
selective recovery

Department of Cybernetics, Czech Technical University


The effects of sleep deprivation III

Sleep deprivation MAY cause death

EXTREME sleep deprivation in animals will eventually


cause death (thermoregulatory irregularities, loss of
inflammatory responses, infection)

Fatal familial insomnia leads to death but actual cause


of death is unknown

*there’s a big stress confound here

Department of Cybernetics, Czech Technical University


Theories of sleep function

1. Sleep is adaptive
-sleep forces us to be quiet at certain times of the day
-this allows us to share ecological niches with other
species
-allows us to conserve energy (species with high
metabolic demands sleep more, though metabolism is
high during REM)
-allows us to avoid predators (rough correlation
between predatory status and sleep properties, though
many animals are predator AND prey
-thermoregulation (sleep may help keep us cool -
alternating REM and SWS may prevent overcooling)

Department of Cybernetics, Czech Technical University


Theories of sleep function

2. Sleep is restorative

-sleep helps us to get back something we lose during


waking
-growth hormone is only secreted during sleep
(though not in kids under 4, not in adults over 60 and
not in all animals)
-correlational studies not THAT convincing
-small increase in SWS after ultramarathon
-no decreases in sleep in quadraplegics

Department of Cybernetics, Czech Technical University


Theories of sleep function

3. Sleep promotes learning

-there is NO good evidence that we can learn while


asleep
-sleep deprivation can have small effects on ability to
learn, but impossible to disentangle other effects of
deprivation
-some studies show a slight increase in REM after
difficult cognitive tasks
-some people sleep little or not at all and show no
obvious deficits in ability to learn

Department of Cybernetics, Czech Technical University


Theories of sleep function

No single theory of sleep function is completely


satisfactory

Perhaps sleep is multifactorial -- originally served to keep


us quiet and still but now other functions (those that work
best when we’re quiet and still?) piggy back onto the sleep
state.

Department of Cybernetics, Czech Technical University


There are specialized centres for particular varieties of sleep

2,hypothalamus: circadian activity (light)

REM
SWS

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Dreams…

− What is a dream?
“Dreams are conventionally defined as mental
experiences during REM sleep that are often based in
vivid imagery, have a storylike quality, are often
bizarre, and seem real to the dreamer.”
− This definition has been challenged for
several reasons. One being people dream in
non-REM too, although the dreams are less
story-like and vivid in imagery.
− Also, content is usually not bizarre, and that
dreamers are often aware that they are
dreaming.

Department of Cybernetics, Czech Technical University


What is in a dream?

− Freud said that the contents of waking life tend to spill into
dreams; he called this day residue.

− Content of dreams is usually familiar.


– Common Themes: falling, being pursued, trying repeatedly
to do something, school, sex, being late, eating, being
frightened, etc.
− People in Western cultures pay little attention to dreams as
meaningful messages in their lives, while people from many
non-Western cultures are likely to view dreams as important
information about themselves, the future, or the spiritual world.

Department of Cybernetics, Czech Technical University


Developmental Differences in REM

− Infants spend much more time in REM than do adults.


− During adulthood, sleep changes continue with the
percentage of slow-wave sleep declining and the
percentage of time spent in stage 1 increasing.
− One explanation for older adults “needing” more sleep
is that they spend less time in slow-wave sleep than
younger adults.

Department of Cybernetics, Czech Technical University


Dreaming is a Cognitive Ability?!?

− Children’s dreams appear to differ from those of adults, with


preschool children reporting bland images with no story lines
when awoken from REM sleep.
− Children report dreaming only 20-30% of the time when awoken
from REM sleep, as opposed to an adult’s 80% of the time.
− Children age 5 - 8 report dream narratives, but these are not
well developed.
− Around age 11 – 13 adult like dreams develop
− This pattern suggests dreaming is a cognitive ability that
develops gradually.

Department of Cybernetics, Czech Technical University


Sleep Disorders…

− Narcolepsy - sudden and irresistible onsets of sleep


during normal waking hours. Those with this disorder
go directly into REM sleep.
− Sleep apnea - involves frequent, reflexive gasping
for air that periodically occurs, waking the person who
has it. Literally breathing stops for 15 to 60 seconds,
may result in heart and lung damage.
− Nightmares usually occur in REM sleep and are
anxiety-arousing dreams.
− Night terrors are associated with non-REM sleep
and are characterized by intense autonomic arousal
and feelings of panic…more common in children.

Department of Cybernetics, Czech Technical University


Altered Reality?

− Hypnosis
– heightened state of suggestibility as well as relaxation,
narrowed attention, and enhanced fantasy.
− People differ in how easily they can be hypnotized…this is termed
hypnotic susceptibility…10% of people are especially easy to hypnotize,
10% especially difficult.
− Susceptibility is linked to higher levels of absorption in a task and in a
person’s imaginativeness. Highly dependant on expectations. Research
shows that people who are highly susceptible to hypnosis are just as
responsive to suggestion without being hypnotized.
− Researchers argue about whether hypnosis is really an altered state of
awareness or if it is simply people doing what they think they are
supposed to do when they are hypnotized.

Department of Cybernetics, Czech Technical University


Meditation

− An ancient discipline which has recently become an area of growing interest.


Grew out of Eastern religions, though many mediate separately from
religious practice.
− Attempts to bring attention to heighten awareness and mental processes
under greater voluntary control
− Tibetan Buddhist meditators show high activity in the prefrontal cortex (an
area important for focused attention) and low activity in parts of the parietal
lobe that are known to process information about the body’s location in
space. This may explain some of the transcendent experiences reported by
many meditators.
− Potential physiological benefits
− Bodily arousal is suppressed, but it is unclear how
meditation differs from other systematic relaxation
training procedures which produce very similar
effects.
− Relaxed EEG mainly theta & alpha waves.
− decreased heart rate, respiration rate

Department of Cybernetics, Czech Technical University


Reliability of manual scoring
of PSG data

Department of Cybernetics, Czech Technical University


History

− Hippocrates (4th Century BC): “Disease exists, if either sleep or watchfulness be


excessive”.

− Babylonian Talmud (5th Century): classified three stages of sleep – one being “eye
lid sleep”

− Avicenna(10th Century): accurate recommendations about sleep hygiene

− Gelineau (19th Century): documented 14 instances of excessive somnolence –


coined the term narcolepsy

− 1917 encephalitis epidemic: suggested the existence of cerebral centres controlling


sleep – posterior hypothalamus – vigilance, anterior hypothalamus – sleep centre.

Department of Cybernetics, Czech Technical University


History

− Berger(1930): cerebral EEG - sleep,wake differences,

− Loomis(1937) – first description of sleep based on EEG (five stages, failed to


identify REM)

− Kleitman, Dement, Aserinsky (1950s) REM related to dreaming predictable,


orderly pattern = sleep architecture, hypnogram

− 1968 – Manual of Standardized Terminology, Techniques and Scoring


System for Sleep Stages of Human Subjects (Rechtscaffen and Kales)

− First sleep centre – 1970 – Stanford

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Polysomnography - Sleep scoring

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Nathaniel Kleitman
and the first sleep lab

Department of Cybernetics, Czech Technical University


Rechtscaffen and Kales, 1968

30 sec window
One channel of EEG, two
channels of EOG and one
channel of EMG

EEG derivations
C4/A1 or C3/A2
according to the 10-20
electrode placement
system.
slow wave
Large, sleep
slow delta waves

Similar to stage I

Department of Cybernetics, Czech Technical University


Sleep stages

– Stage 1, with near-disappearance of the alpha waves seen in awake


states, and appearance for the first time of theta waves. The stage is
sometimes referred to as somnolence, or "drowsy sleep". It appears at
sleep onset (as it is mostly a transition state into Stage 2), and can be
associated with so-called hypnagogic hallucinations. In this period, the
subject loses some muscle tone, and conscious awareness of the external
environment: Stage 1 can be thought of as a gateway state between wake
and sleep.
– Stage 2, with "sleep spindles" (12–16 Hz) and "K-complexes". The EMG
lowers, and conscious awareness of the external environment all but
disappears. This occupies 45-55% of total sleep.
– Stage 3, with delta waves, also called delta rhythms (1–2 Hz), is
considered part of slow-wave sleep (SWS) and functions primarily as a
transition into stage four. Overall it occupies 3-8% of total sleep time.
– Stage 4 is true delta sleep. It predominates the first third of the night
and accounts for 10-15% of total sleep time. This is often described as the
deepest stage of sleep; it is exceedingly difficult to wake a subject in this
state. This is the stage in which night terrors and sleepwalking occur.
– Stage 5, or Rapid eye movement (REM) sleep, associated with dreaming,
especially bizarre, visual, and seemingly random dreams. REM sleep is
predominant in the final third of a sleep period, its timing linked to
circadian rhythm and body temperature. The EEG in this period is aroused
and looks similar to stage 1, and sometimes includes beta waves.

Department of Cybernetics, Czech Technical University


Brain Waves

− Four different types


– Beta waves – alertness or problem solving (>12Hz)

– Alpha waves - resting and relaxation (8-12Hz)

– Theta waves - low alertness and sleep (4-8Hz)

– Delta waves - deep, dreamless sleep (1-2Hz)

Department of Cybernetics, Czech Technical University


Rechtscaffen and Kales, 1968 - MANUAL

− WAKE-There is a low voltage (10 . 30µV) and mixed frequency EEG


during wakefulness. Possible features are alpha activity in EEG and
relatively high tonic EMG.

− STAGE 1 is characterized by low voltage, mixed frequency EEG with the


highest amplitude in 2-7 Hz range. The vertex sharp waves may occur;
their amplitude can reach the value of about 200 µV. In Stage 1 after
wakefulness slow eye movements can be present. The EMG level is lower
than in the wakefulness. Stage 1 is also scored when the epoch is
characterized with alpha activity combined with mixed frequency EEG and
the amount of alpha activity is less than 50% of an epoch.
− Associated with hypnagogic hallucinations, gateway between wake
and sleep

Department of Cybernetics, Czech Technical University


Rechtscaffen and Kales, 1968

− STAGE 2 is characterized by wave patterns sleep spindles and K complexes and


the absence of slow waves. K complex is a sharp negative wave followed by a
slower positive one. Sleep spindles occur in 12-14 Hz frequency range. The
duration of these patterns should be 0.5 s at minimum. If the time between two
succeeding occurrences of sleep spindles or K complexes is lower than 3 min, this
interval is scored as Stage 2, unless there are movement arousals or increased
tonic activity. If the time interval is 3 min or more, it is scored as Stage 1.

− STAGE 3: 20%-50% of the epoch of EEG record should contain waves with 2 Hz or
slower and with the amplitudes above 75 µV if the epoch is scored as Stage 3, see
Fig. 3. Sleep spindles and K complexes may occur during Stage 3.

Department of Cybernetics, Czech Technical University


Rechtscaffen and Kales, 1968

− STAGE 4 has the same attributes as Stage 3, but waves with 2 Hz and
slower with the amplitudes greater than 75 µV 50 appear more than
50% of the epoch.

− STAGE REM shows low voltage and mixed frequency (similarly to


Stage 1) of EEG, sawtooth wave pattern is often present (see Fig. 3).
EMG reaches the lowest level and episodic rapid eye movements
occur (REMs).

Department of Cybernetics, Czech Technical University


Hypnogram

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R&K68- DISADVANTAGES

− Ignore events shorter than 30 seconds (omits microstructure of sleep). If the interval contains
features from more than one Stage, it is scored as the Stage whose features have the longest
duration.

They are designated for healthy adult people and hence, it is not possible to score atypical
patterns in cases of ill people or children (sleep apnea).

− Some wave patterns (sleep spindles or K complexes) are not well defined, especially with
respect to automated sleep scoring.

− More EEG derivations, introduction of more states using EEG morphology

− Shorter periods of sleep can not be detected in hypnogram. Smooth excessively the dynamics of
sleep process.

− No good evaluation of elderly people – because of definition S2 and S3

Department of Cybernetics, Czech Technical University


Conclusion

− R&K68 is gold standard that must be updated


– Hori (1994) established 9 stages by EEG morphology

− Use of shorter epochs


– They are used only in vigilance studies

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Automatic scoring of PSG data

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Automatic Scoring

− Function of PGS
– Replace conventional chart recorders
– Documentation (EDF format)
– Sleep evaluation
– Reporting

− Spectral analysis (alfa,beta,delta,theta)


− Temporal analysis (spindles, K-complexes)
− Adaptive segmentation (avoid 30 sec)

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2
PGS-automatic analysis

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PGS-automatic analysis

− Removal of artifacts
– ECG, EOG, movement,respiration

− Feature extraction & selection


– Delta, alpha,theta,beta spindles, K-complexes, vertex waves

− Classification&Clustering
– Artificial neural networks, adaptive segmentation, fuzzy logic

Department of Cybernetics, Czech Technical University


Multichannel approach – sleep disorders

− Respiration – sleep apnea, respiratory disturbance index (RDI), (number of


apneas plus hypopneas per h of sleep);
− Microphones-snoring
− Oxygen saturation drop – sleep apnea
− ECG & HRV – abnormalities during REM and NREM
− Leg movements – at least four bursts (0.5-5sec) over 25% initial calibration
movements, periodic leg movement (PLM)
− Blood pressure
– REM related hypertension
– PPT calculation

− All above-improvement of R&K

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EEG preprocessing

− EEG denoising using wavelet transform


− Artifact removal using ICA analysis
– electrocardiogram (ECG), electrooculogram (EOG),
electromyograph (EMG), body movement, respiration

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Feature extraction

− Spectral entropy
– quantifies the spectral complexity of time series
− Complexity stochastic measure
– measure of complexity
− Autoregressive parameters
– 7th order and Yule-Walker approach
− Hjorth parameters
– mobility
– complexity

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Example of polysomnography recording

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New approaches

− Adaptive segmentation
– EEG is not stationary
– Fixed (30s for sleep scoring, 3s for arousal & adaptive segment)
– New segment is detected when there is a change in the EEG
pattern
– Solves temporal resolution of R&K

− New parameters
– Hjorth parameters, chaos theory (Lyapunov exponent, correlation
dimension)

Department of Cybernetics, Czech Technical University


Conclusion

− Reliability of automatic system


– 70-90% in normals
– 65-87% in selected sleep disorders
– R&K mimic
− Stage 1 and REM sleep difficult to distinguish – EOG must
wakefulness and REM sleep difficult to distinguish - depending on EMG
quality

− Adaptive segmentation & Multisignal measurement


– R&K improvement

− More new parameters are needed

Department of Cybernetics, Czech Technical University


Commercial software

− http://www.sleepreviewmag.com/SR_Products_2005/SR_Products_Polysom.htm
− SIESTA Project
– https://www.thesiestagroup.com/index.php?id=50
− http://www.grass-telefactor.com/products/clinsystems/twin1.html
− http://www.stellate.com/en/harmonie_s.html
− http://www.nkusa.com/neuro_sleep-comb-eeg-psg.htm
− http://www.cadwell.com/nav_components/index_pc.htm
− http://www.medcare.com/products/analysis/rembrandt/index.asp
− http://www.sandmansleep.com/products/elite.cfm
− http://www.bio-logic.com/sleep/slpvision2.html

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Insomnia

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Insomnia

− 3 different patterns…
– trouble falling asleep – young adults
– trouble remaining asleep – middle-aged & elderly
– persistent early morning awakening middle-aged & elderly
− Estimates of the prevalence of insomnia vary, but it appears that about 34-35%
of adults report problems with insomnia and about 15-17% have severe or
frequent insomnia.
− Prevalence increases with age and is 50% more common in men than in
women.

Department of Cybernetics, Czech Technical University


What Causes Us To Be Sleepy?

− If the average amount of sleep is not met, a sleep debt is


created.
− All lost sleep accumulates progressively as a larger and larger
sleep indebtedness.
− The size of your sleep debt is zero, sleep is impossible.
− If your sleep debt is very low, only a small amount of
stimulation is required to keep you awake.
− If your sleep debt is very large, no amount of stimulation can
keep you awake (Dement, 2).

Department of Cybernetics, Czech Technical University


What is Insomnia?

− The perception of inadequate or poor-quality sleep


accompanied by significant distress or impaired
function.
− Chronic if it occurs on most nights and lasts a month
or more (National Institute of Health).
− You might suffer from insomnia if:
– It takes you more than 30 to 45 minutes to get to
sleep
– You wake up during the night
– If you wake up early and cannot get back to sleep
– You wake up feeling un-refreshed in the morning
– You can only get to sleep with the aid of sleeping
aids or alcohol (Alpha Sleep, 1999)

Department of Cybernetics, Czech Technical University


What Causes Insomnia?

− Most reasons for insomnia are subtly woven into the fabric of
your life (Dryer, 17)
– Changes in sleep patterns because of different work hours
or travel.
– Depression, anxiety, worries, or stress
– Use of caffeine or other stimulants
– Use of alcohol or other sedatives which are depressants of
the central nervous system but can alter normal sleep
patterns, especially if used long-term
– Sleeping or napping during the day (Alpha Sleep, 1999)
– Death of a loved one, job loss or failing in school (Kirkwood
Community College, 1).

Department of Cybernetics, Czech Technical University


Types of Insomnia

− There are five types of insomnia, including:


– Initial Insomnia, where an individual finds
difficulty in falling asleep
– Mental Insomnia, where an individual wakes up
frequently from sleep
– Terminal Insomnia, characterized by waking up
early and not being able to get back to sleep
– Hypersomnia, where one has trouble staying
awake during the regular day
– Parasomnia, shown through abnormal behaviors
occurring during sleep (Morin, 3)

Department of Cybernetics, Czech Technical University


Treatment Modalities

− Treatment of insomnia includes alleviating any


physical and emotional problems that are contributing
to the condition and exploring changes in lifestyle that
will improve the situation (Barstow, 3).
− There are a myriad of treatments available for
insomniacs, which fall into three major categories
– Drug Therapy
– Cognitive-Behavioral Therapy
– Alternative Treatments

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Treatments: Prescription Drug Therapy

− Sedating Antidepressants are prescription medications that have


been developed for the treatment of depression, but are known
to have sedative side effects.
− The most common of these are
– Desyrel
– Elavil
– Sinequan
− A major concern is the association with more troubling, adverse
effects than prescription sedative-hypnotic medications
(AmericanInsomniaAssociation.org, 4).

Department of Cybernetics, Czech Technical University


Treatment: Cognitive-Behavioral Therapies

− This component is aimed at achieving two goals:


– To strengthen the association between sleep behaviors and
such stimuli as the bed, bedtime, and the bedroom
surroundings (Sammons, 120).
− This is designed to eliminate both overt and covert
sleep—incompatible activities.
– To consolidate sleep over shorter periods of time spent in
bed.
− This curtails the amount of time spent in bed. (Morin,
110)
− Behavioral therapy can be an alternative to medication for the
treatment of persistent primary insomnia, a sleep disorder that
affects up to 5 percent of Americans (Koepke, 1).

Department of Cybernetics, Czech Technical University


Insomnia & College Students

− College students who have difficulty falling asleep are the largest
group of the growing community with sleep disorders – 77
percent – according to a national study.
− College students often face insomnia because of the varying
sleep schedules between weeknights and weekend nights.
− Sunday is “insomnia night” and Mondays can be problematic
while the body is trying to readjust to the weekday sleep
schedule, he said. Wednesday is the most efficient day of the
week for sleeping (Hanek, 1).
− Drinking coffee to improve alertness, taking naps to make up for
last sleep, and drinking alcohol to promote sleepiness are
common strategies students use to counter their varying sleep
schedules. These are poor sleep-hygiene practices (Brown, 3).

Department of Cybernetics, Czech Technical University


Insomnia & College Students

− Solutions
– If you can’t sleep within 20 minutes, get up and do something
else.
– Learn to work on difficult tasks when you feel most productive and
awake.
– Allocate schedule to do things you enjoy.
– Employ relaxation techniques.
– Use down-time before bed (Maynard, 1).

Department of Cybernetics, Czech Technical University


Conclusion

− Insomnia is a growing problem with America,


especially across college students.
− Insomnia can be problematic if not dealt with.
− Although many treatments are available, few people
seek treatment.
− Proper sleep hygiene is integral to daily life.

Department of Cybernetics, Czech Technical University


Bibliography

− Barstow, David. “Insomnia”. Main Search Index. Online. Internet Explorer. 12 Nov. 2003. Available:
http://www.ehendrick.org/healthy/000764.htm
− Dryer, Bernard, M.D., Ellen S. Kaplan. Inside Insomnia. Villard Books. New York. 1986.
− “Insomnia”. Alpha Sleep Diagnostic Centers. Online. Internet Explorer. 26 Oct. 2003.
− “Many College Students Suffer from Insomnia” The Daily Illini Online. Online. Internet Explorer. 26
Oct. 2003. Available:
– http://dailyillini.com/apr01/apr10/news/stories/news07.shtml
− “Treatment Options: Medication and Behavior Treatments” Americans Insomnia Association. Online.
Internet Explorer. 12 Nov. 2003. Available:
http://www.americansomniaassociation.org/treatment.htm
− “Insomnia rate highest amoung college students”. The Daily Illini Online. Online. Internet Explorer.
12 Nov. 2003. Available:
– http://dailyillini.com/jan03/jan29/news/printer/campus01-printer.shtml
− Sammons, Morgan T. and Norman B. Schmidt. Combined Treatments for Mental Disorders.
Washington DC: American Psychological Association, 2001.
AmericanInsomniaAssociation.org.2002 11/12/2003.
http://www.americaninsomniaassociation.org/causes.htm
− Brown, Franklin C., Walter C. Buboltz Jr., and Barlow Soper. “Relationships of Sleep Hygiene
Awareness, Sleep Hyiene Practices, and Sleep Quality in University Students.”Behavioral Medicine.
28.1 (2002):33. Academic Search Elite. EBSCOHost.11/01/03
− “Sleepless at Stanford”. Stanford University of Excellence. Online . Internet Explorer. Sept.1997.
– http://www.stanford.edu/~dement/sleepless.html

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Introduction to Sleep Apnea
& Home Diagnosis

Department of Cybernetics, Czech Technical University


Content

American Sleep Apnea Association (ASAA) Fact Sheet

Definition of Sleep Apnea


Obstructive Sleep Apnea (OSA)
Risk factors of Sleep Apnea
Prevalence of Sleep Apnea

Polysomnography (PSG)

Home diagnosis of Sleep Apnea


Portable monitors
Signals used for detecting events

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ASAA Fact Sheet

Sleep apnea is a common sleep disorder characterized by brief interruptions of


breathing during sleep.

"Apnea" is a Greek word meaning "without breath." An apnea is clinically defined as a


cessation of breath that lasts at least ten seconds.

"Hypopnea" also comes from Greek: "hypo" meaning "beneath" or "less than normal"
and "pnea" meaning "breath." A hypopnea is not a complete cessation of breath but can
be defined as a perceptible reduction in airflow that leads to sleep fragmentation or to a
decrease in the oxygen level in the bloodstream.

The apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) refers to the
total number of apneas and hypopneas divided by the total sleep study in a patient’s
sleep study. The AHI gives one measure of the severity of the sleep apnea.

There are three types of apnea: obstructive, central, and mixed (a combination of
obstructive and central). Obstructive sleep apnea (OSA) is the most common.

Source: American Sleep Apnea Association

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Definition of Sleep Apnea
APNEIC EPISODE = cessation of breathing for > 10 seconds
<5 episodes/hr is NORMAL
5-10 episodes/hr is BORDERLINE (correlate with symptoms)
10-20 episodes/hr (most experts would treat regardless of symptoms)
[Some people have as many as 50 episodes/hr]

 Obstructive - absence of airflow in the presence of continuous respiratory effort


(pharyngeal obstruction)
 Central - absence of airflow during which no respiratory effort is present

CENTRAL SLEEP APNEA = The body simply "forgets" to breath. It is a


neurological function; no "mechanical" obstruction is involved These
episodes are believed to occur in the Thalmus area of the brain.

Department of Cybernetics, Czech Technical University


Obstructive Sleep Apnea (OSA)
Typically the soft tissue in the rear of the throat
collapses and closes the airway, forcing victims
of sleep apnea to stop breathing repeatedly

during sleep, as frequently as a hundred .


• AHI > 5
• AHI > 20 increases risk of mortality
• AHI 20-40 = moderate, > 40 = severe
• Upper Airway Resistance Syndrome
• Shares pathophysiology with OSA
• No desaturation, continuous ventilatory effort
• Snoring

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Pathophysiology of OSA
Normal Breathing Simple Snoring

Obstructive Sleep Apnea

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Pathophysiology of OSA

 Symptoms of OSA
 Snoring (most commonly noted complaint)
 Daytime Sleepiness

 Hypertension and Cardiovascular Disease are associated

 Pulmonary Disease

o Cardiovascular:
• Systemic and pulmonary hypertension
• Ischemic episodes (cerebral and cardiac), (especially nocturnal)
• Nocturnal angina and arrhythmias

o Neurocognitive:
• Daytime sleepiness
• Motor vehicle accidents
• Poor work performance
• Disrupted social interaction
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Treatment of OSA

Weight loss
Position Therapy, avoid supine position (tennis ball/vest)
Tracheostomy
CPAP (Continuous Positive Airway Pressure)

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Treatment of OSA

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Treatment of OSA

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Risk factors of Sleep Apnea
Some studies have shown that a family history of sleep apnea increases the risk of OSA two to
four times
Being overweight is a risk factor for OSA, as is having a large neck. However, not all with sleep
apnea are obese.
Sleep apnea is more likely to occur in men than in women.
Abnormalities of the structure of the upper airway contribute to sleep apnea.
Sleep apnea may be more common among African-Americans, Pacific Islanders, and Mexicans.
Smoking and alcohol use increase the risk of sleep apnea.

Department of Cybernetics, Czech Technical University


Prevalence of Sleep Apnea

Sleep apnea is very common, as common as


adult diabetes
Incidence: 4 % of adult population [M>F]

More than twelve million Americans suffer from


sleep apnea, and it is estimated conservatively that
ten million remain undiagnosed.

Untreated, sleep apnea can cause high blood pressure and


other cardiovascular diseases, memory problems, weight gain,
impotency, and headaches.

Department of Cybernetics, Czech Technical University


Prevalence of Sleep Apnea
While obesity is clearly a risk factor for sleep apnea, sleep apnea is
multi-factorial and occurs among people in all weight categories. It
should be noted that the relationship between BMI and OSA is
weaker among the elderly and children.

According to Nieto et al, the majority of subjects with an AHI ≥ 5 are not obese.
As the AHI increases, the proportion of subjects with OSA who are obese does
increase:

Department of Cybernetics, Czech Technical University


Polysomnography (PSG)
POLYSOMNOGRAM: Simultaneous recording of parameters below
during sleep

EEG
EKG
Electro-oculogram (EOG)
Submental electromyogram (EMG)
Leg muscle EMG
Upper airway airflow
Chest and abdominal movement
Transcutaneous O2 saturation monitor

Department of Cybernetics, Czech Technical University


Polysomnography (PSG)

Requires technical expertise


Is labor intensive
Time-consuming.

Timely access is a problem for many patients, the majority of


whom continue to have undiagnostic sleep apnea

Department of Cybernetics, Czech Technical University


Portable Monitoring

Portable monitors were classified according to the approach used in the


1994 American Sleep Disorders Association review.

Type 1: Standard polysomnography.


Considered the reference standard to be compared to.

Type 2: Comprehensive portable polysomography

Type 3: Modified portable sleep apnea testing

Type 4: Continuous single or dual bioparameters

Department of Cybernetics, Czech Technical University


Comprehensive portable polysomography

These monitors incorporate a minimum of seven channels,


including:

EEG
Electrooculogram
Chin EMG
ECG or heart rate
Airflow
Respiratory effort
Oxygen saturation

This type of monitor allows for sleep staging and therefore


for the calculation of an AHI.

Department of Cybernetics, Czech Technical University


Modified portable sleep apnea testing

This type of monitor incorporates a minimum of four


monitored channels, including:

− Ventilation or airflow
− At least two channels of respiratory movement, or
respiratory movement and airflow
− Heart rate or ECG
− Oxygen saturation

Department of Cybernetics, Czech Technical University


Continuous single or dual bioparameters

Most monitors of this type measured a single parameter or


two parameters, for example

Oxygen saturation
Airflow

A monitor that did not meet the criteria for type 3 was
classified as type 4

(i.e. a monitor that measured one to three channels or did not include airflow
despite having four channels)

Department of Cybernetics, Czech Technical University


Signals used for detecting events

− Similarities and differences in the ways that different monitors record


signals and how those signals are used to define a breathing event.

− The most common methods to detect breathing events are reduction in airflow measured by a thermistor
or by a nasal pressure signal, and oxygen desaturation

− Flow
– Thermistor
– Nasal Pressure
− Respiratory inductance plethysmography
− Oxygen Saturation
− Others

Department of Cybernetics, Czech Technical University


Sleep – portable home use systems

− SOMNOwatch

•Siesta provides 32 amplified channels for data


collection: any physiological signal may be recorder on
any channel.

•Differential or Referential
•True 16 bit resolution
•Sampling rates to 512Hz
•Two expansion ports for accessory modules; oximeter,
pressure transducers, event button....interface up to 32
additional signals

Department of Cybernetics, Czech Technical University


Good idea - SleepSense

Department of Cybernetics, Czech Technical University