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Sleepy Since Adolescence

Reviewed By Sleep and Respiratory Neurobiology Assembly

Submitted by

James A. Rowley, MD

Associate Professor of Medicine

Wayne State University School of Medicine

Detroit, MI

Submit your comments to the author(s).

History

A 28-year-old woman presents for evaluation of excessive daytime sleepiness since she was a teenager. Her Epworth Sleepiness Score is 22/24. She complains of falling asleep at traffic lights, and she has had five to six near-miss accidents. She admits to three naps per day, two in the afternoon and one in the evening. Sleep-related symptoms include choking sensation at night, morning headaches, and vivid dreams at sleep onset. Her sleep habits include going to bed around 12 AM with a latency to sleep within 5 minutes, and getting out of bed at 7 AM. She arrives at work by 9 AM and is generally home by 9 PM.

Past medical history is significant only for hyperlipidemia. She is not presently taking any medications. Social history is significant for having three children (ages 6 years, 2 years, and 6 months) and drinking one to two cups of coffee per day. She does not admit to drinking alcohol, and she does not smoke. There is no significant family history.

Physical Exam

Height 62 inches; weight 211 pounds; BMI 39 kg/m2. Oral examination demonstrates Mallampati class 3 airway with 3+ tonsils. Remainder of examination is normal.

Lab

PSG     Total sleep time:  474 minutes; Time in bed: 479 minutes; Sleep efficiency: 99%    

Latency to sleep onset: 1 minute; Latency to REM sleep 58.5 minutes 

            %Stage 1: 8.3, %Stage 2: 72.3, %Slow wave 3.4, %REM 16.0

            AHI 7.5/hr (NREM AHI 10.3/hr; REM AHI 6.9/hr; supine AHI 7.5/hr; non-supine AHI 7.0/hr)             %TST spent with SaO2<90%: 0%

            PLMI 0.0/hr

A representative 2 minute fragment from REM sleep is shown.

MSLT  4 naps performed

            Mean latency 1.1 minutes with 2 REM-onset naps

Figures


Question 1

In the representative trace shown, which of the following respiratory events is illustrated?

References

  1. Iber C, Ancoli-Israel S, Chesson AL, Quan SF. The AASM manual for the scoring of sleep and associated events. American Academy of Sleep Medicine 2007.
  2. American Academy of Sleep Medicine. The international classification of sleep disorders diagnostic and coding manual. 2nd ed. Westchester, IL 2005.
  3. Chervin RD, Aldrich MS. Sleep onset REM periods during multiple sleep latency tests in patients evaluated for sleep apnea. Am J Respir Crit Care Med 2000;161(2(1)):426-431.
  4. Mignot E, Lin L, Finn L, Lopes C, Pluff K, Sundstrom ML et al. Correlates of sleep-onset REM periods during the multiple sleep latency test in community adults. Brain 2006;129(6):1609-1623.
  5. Sleep apnea, sleepiness, and driving risk. Am J Respir Crit Care Med 1994;150:1463-1473.
  6. Powell NB, Schechtman KB, Riley RW, Guilleminault C, Chiang RP, Weaver EM. Sleepy driver near-misses may predict accident risks. Sleep 2007;30:331-342.
  7. Arand DL. The MSLT/MWT should be used for the assessment of workplace safety. J Clin Sleep Med 2006;2:124-127.
  8. Bonnet MH. The MSLT/MWT should not be used in the assessment of workplace safety. J Clin Sleep Med 2006;2:128-131.
  9. Hartenbaum N, Collop N, Rosen IM, Phillips B, George CF, Rowley JA et al. Sleep apnea and commercial motor vehicle operators: Statement from the joint task force of the American College of Chest Physicians, the American College of Occupational and Environmental Medicine, and the National Sleep Foundation. Chest 2006;130(3):902-905.
  10. Miller CM, Khanna A, Strohl KP. Assessment and policy for commercial driver license referrals. J Clin Sleep Med 2007;3(4):417-423.
  11. Young TJ, Silber MH. Hypersomnias of central origin. Chest 2006;130(3):913-920.
  12. Kushida CA, Littner MR, Hirshkowitz M, Morgenthaler TI, Alessi CA, Bailey D et al. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. Sleep 2006;29(3):375-380.
  13. Kakkar RK, Berry RB. Positive airway pressure treatment for obstructive sleep apnea. Chest 2007; 132(3):1057-1072.
  14. Littner MR, Kushida C, Wise M, Davila DG, Morgenthaler T, Lee-Chiong T et al. Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. Sleep 2005;28(1):113-121.
  15. Pack AI, Black JE, Schwartz JR, Matheson JK. Modafinil as adjunct therapy for daytime sleepiness in obstructive sleep apnea. Am J Respir Crit Care Med 2001;164(9):1675-1681.
  16. Black JE, Hirshkowitz M. Modafinil for treatment of residual excessive sleepiness in nasal continuous positive airway pressure-treated obstructive sleep apnea/hypopnea syndrome. Sleep 2005;28(4):464-471.
  17. Littner M, Johnson SF, McCall WV, Anderson WM, Davila D, Hartse SK et al. Practice parameters for the treatment of narcolepsy: an update for 2000. Sleep 2001;24(4):451-466.