Periodic Sleep Apnea: Chronic Sleep Deprivation Related to Intermittent Upper Airway Obstruction and Central Nervous System Disturbance* Marvin A. Sackner, M.D., F.C.C.P.; Jose Landa, M.D.; Tom Forrest, B.S.; and Delmas Greeneltch

Periodic sleep apnea may be due to repeated episodes of upper airway obstnaction in patients who have a short thick neck and/ or large jowls. Apnea due to complete cessation of breathing may occur to a lesser extent. Aoalysis of the sleep electroencephalogram shows that these patients rarely achieve deep sleep and have less stage 1-REM sleep than normal subjects of comparable age. They are chronically sleep-deprived, a manifestation expressed by daytime somnolence, chronic fatigue and often by personaHty disturbances marked by paranoia, agitated depression and hostility. The definitive diagnosis of this sYDdrome may be established by moni-

0 nein ofwhom us recently described three obese patients upper airway obstruction during nighttime sleep interfered with nonnal sleep, resulting in marked daytime somnolence. 1 The daytime somnolence was due to deprivation of normal nighttime sleep caused by frequent awakenings at the termination of apneic periods. The obstruction of the upper airway was demonstrated from the cessation of airflow at the nostrils in the presence of thoracoabdominal respiratory efforts. These patients appeared to be sleeping, but nighttime electroencephalographic tracings revealed arousals every few minutes. The daytime somnolence and nighttime apneas were ameliorated by a nasopharyngeal airway and abolished by a permanent tracheostomy. This study confirmed the reports of Gastaut et al2.3 who showed that periodic breathing in certain patients with a diagnosis of Pickwickian syndrome could be explained by obstruction of the upper airways due to backward movement of the tongue and hypotonus of the floor of the mouth. In addition to obesity, other conditions marked by upper airway obstruction, such as greatly enlarged tonsils and •From the Division of Pulmonary Diseases, Deparbnent of Internal Medicine, Mount Sinai Medical Center, Miami Beach. Supported in part by a grant from the Herbert Jerome Research Foundation and General Research Grant, PHS FR05622. Manuscript received June 6; accepted July 15. Reprint requests: Dr. Sackner, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach 33140

164 SACKNER ET AL

toriog during sleep, the electroencephalogram, measuring abdominal excursions through a mercury-inSilastic-strain gauge and recording air flow at the nose by means of a thermocouple. As demonstrated by other investigators, chronic hypoventilation during sleep leads to both pulmonary and systemic arterial hypertension, which may produce generatized cardiac enlargement and congestive heart failure. The abnormalities in the periodic sleep apnea syndrome are abolished by establishing a patent airway either through tracheostomy or weight reduction.

adenoids, acquired micrognathia and posterior nasal packing for nasal hermorrhage have been reported to cause daytime somnolence because of deprivation of nighttime sleep. 1 A symposium conducted on this subject was published as a series of 25 papers in recent issue of the Bulletin de Physio-Pathologie Respiratoire [Nancy]. 4 The syndrome probably is quite common; over a two-year period since our initial publication, 1 we have encountered 12 additional cases, without systematically searching for such patients. The purpose of this study is to describe: (1) the clinical features; ( 2) the quantitative analysis of the sleep electroencephalogram; and ( 3) the characteristics of the apneas that occur in these patients. METIIODS

Sleep electroencephalograms and monitoring of reSPiration were conducted in the patient's private hospital room. The polygraph recorder (Grass Model 78B) was placed in the hallway and long leads from the electroencephalographic and respiratory sensors were led through an opening in the doorway. Continuous recordings were made from about ten o'clock at night to eight o'clock in the morning from three electroencephalographic leads ( EEG) , two electro-oculographic leads ( EOG), airflow at the nostril using a thermocouple, and abdominal excursions measured by a mercury-inSilastic-strain gauge. The scoring of sleep stages was based on the system of Dement and Kleitman.t~ Stage 0 (wakefulness): the EEG is composed of at least 30 seconds in a minute epoch of 8 through 12 cycles per second occipital activity ( 11), with a

CHEST, 67: 2, FEBRUARY, 1975

Table 1--Ciinical Featuru Age, Yr

Weight, Kg

Height, Cm

Relative Normal* Body Wt, %

Daytimet Somnolence

Personality Disturbance

Snoring

Orthopnea

M

49

89

177

116

4+

4+

yes

no

0

2

M

19

108

157

195

4+

4+

yes

no

3+

3

M

57

76

170

108

1+

0

yes

no

0

4

M

57

115

172

158

2+

2+

yes

no

0

5

F

69

69

147

126

3+

3+

yes

yes

3+

6

M

55

107

170

148

4+

0

yes

no

0

7

M

50

158

170

222

4+

1+

yes

no

0

8

M

52

109

167

4+

2+

yes

yes

3+

9

M

46

151

172

209

4+

3+

yes

no

1+

10

M

58

112

175

148

3+

3+

yes

no

2+

11

F

57

83

157

125

0

3+

yes

no

0

12

M

71

94

167

138

4+

1+

yes

no

0

Patient, Sex No.

158

Peripheral t Edema

*Based on predictions reported by Consolazio et al. 1 tGrade 0 to 4+ minimwn amplitude of 20 ~· Stage 1: contains less than 30 seconds in a minute epoch of " activity and no more than one well defined spindle or K-complex. Stage 1-REM : distinguished by the large rapid deflections on the EOG corresponding to rapid eye movements. Stage 2: contains at least two well defined spindles or two K-complexes or one of each, and no more than 12 seconds of one to three cycles per

second slow waves (A) of at least 20 ~in amplitude. Stage 3 : contains at least 13 seconds of one through three cycles per second waves of at least 20 ~ in amplitude but not more than 30 seconds of this activity. Stage 4: contains at least 30 seconds in a minute epoch of one through three cycles per second waves of at least 20 ~ in amplitude.

Frontal ~~

Parietal

EEG

] 50

,.v

Occipital LE- Nasion

---(~ Nasion - RE

Flow - - - - - - - - vr--\\.J(\'-0( Respiration 1. reM. cent

FIGURE 1. Electroencephalogram ( EEG) of stage 2 sleep in association with obstructive-type apnea. Upper three tracings denote three EEG leads, frontal, parietal and occipital placements. Sleep spindles ( SP) on tracings place record in stage 2. Immediately below EEG leads are two leads, left and right of electro-oculogram ( EOG) for recording of rapid eye movements (REM) . Below EOG is signal of air flow at nose from thermocouple and respiratory movements from Silastic strain gauge placed around upper abdomen. Abdominal movements persist while air flow is absent at nose, indicating upper airway obstruction. Toward end of tracing, upper airway is cleared and normal respiratory pattern is established.

CHEST, 67: 2, FEBRUARY, 1975

PERIODIC SLEEP APNEA 165

Frontal

..._. . . . . . .,.. ...........,.--~....""""~'i'I~~.,...,.,.,.._~~~W!M.o.J"'-o~"""'"uJ'"'YI•'~~/i\\'\v'/1;''\"'.-.~ EEG ]50,..,

Parietal

~~tlll(l/1\~.\.~~~~\'~~tri'...J¥"""~»1.~."1tt'-•J'-''J,)'/f,\',i'vi\~N4','fll~..,. Occipital

ap

ap

~'t,.,.~,.......\VJ~~"J'fVA~~'WA'Jo~·~~1~\vM~:~~ LE- Nasion

~~~:i/.'.J..'/ttllt'f'1~~·/IV.~.J;Io.;«.,.lf'-.r-J~' I I

EOG

Nasion- RE

)50p.v

f

___...,....,...._lloloo\~'lt't-'""""''*"-""''f...,._,......____"'