Atlas of Clinical Sleep Medicine 1st

330 Chapter 18 / GALLERY OF POLYSOMNOGRAPHIC RECORDINGS

CHIN(1)
C3-A2
C4-A1
O1-A2
O2-A1
ROC-A1
LOC-A2
ECG

LEG(L)
125 uV
LEG(R)
125 uV

100
SaO2

%
80

THOR RES
x1

ABDO RES
x1

120
PULSE

bpm
40
76

PCO2
mmHg

-4
POSITION

30
CPAP
cmH2O

2
AIRFLOW

62.5 uV

Figure 18-92.
Central sleep apnea in stroke. These data are from a 72-year-old male who had daytime sleepiness that
began after a stroke. His wife also witnessed apneas during his sleep. The patient had a periodic breathing
pattern, a variant of Cheyne Stokes, during both sleep (as shown here) and wakefulness. The top window
is 30 sec; the bottom is 20 min.

CHIN(1)
C3-A2
C4-A1
O1-A2
O2-A1
ROC-A1
LOC-A2
ECG

LEG(L)
125 uV
LEG(R)
125 uV

100
SaO2

%
80

THOR RES
x1

ABDO RES
x1

120
PULSE

bpm
40
76

PCO2
mmHg

-4
POSITION

30
CPAP
cmH2O

2
AIRFLOW

62.5 uV

Figure 18-93.
Central sleep apnea in stroke. Same patient as in Figure 18-92. Here, later in the night, the patient was
assessed on an adaptive servo-ventilation (ASV) system. The CPAP channel shows increases in pressure
generated by the servo-ventilator when the patient became apneic. Figure 18-94 shows the 20 minutes of
transition onto ASV. The top window is 30 sec; the bottom is 5 min.

Atlas of Clinical Sleep Medicine 331

CHIN(1)
C3-A2
C4-A1
O1-A2
O2-A1
ROC-A1
LOC-A2
ECG

LEG(L)
125 uV
LEG(R)
125 uV

100
SaO2

%
80

THOR RES
x1

ABDO RES
x1

120
PULSE

bpm
40
76

PCO2
mmHg

-4
POSITION

30
CPAP
cmH2O

2
AIRFLOW

62.5 uV

Figure 18-94.
Central sleep apnea in stroke. Same patient as in Figure 18-92. The bottom window shows 20 minutes of
data on adaptive servo-ventilation (ASV). There is a gradual normalization of SaO2 and reduction of periodic
breathing as ASV entrains and normalizes the breathing pattern. There was dramatic improvement in
symptoms on home use of ASV.

NARCOLEPSY

REMs

REM

N1

N2

N3

Hour 1 2 3 4 5 6 7 8

Figure 18-95.
Narcolepsy. This is a sleep histogram from a 15-year-old female complaining of sleepiness with an Epworth
sleepiness score of 19. The top part of the histogram shows the presence of REMs; the bottom part,
sleep stages. N3 is made up of stage 3 (shorter blue bands) and stage 4 (longer blue bands). The first episode
of REM sleep occurred 6.5 minutes after lights out. The multiple sleep latency test done the next day was
terminated after three naps during which the patient was in REM sleep. The mean sleep latency was 6
minutes.

EMG1-EMG2 Moaning, trying to call for help

1.02 mV

C3-A2

128 uV

C2-A1

128 uV

ROC-A1

128 uV

LOC-A2

128 uV

ECG1-ECG2

2.05 mV

LAT-LAT-

512 uV

RAT-RAT-

512 uV
100

SaO2

%
80

THOR EFFORT

4.1 mV

ABDO EFFORT

2.05 mV

120

Pulse

bpm

40
40

ETCO2

mmHg

0
20

CPAP Pres

cmH2O
0

NASAL PRES

2.05 mV

Figure 18-96.
Sleep paralysis. This 10-minute PSG epoch is from a 49-year-old female with a 15-year history of sleep
paralysis. Notice the notation of moaning during the REMs. The patient stated that she was awake, but
paralyzed, and was trying to call for help by making moaning noises. This patient did not have any other
features of narcolepsy.

REM SLEEP BEHAVIOR DISORDER

CHIN(+1/-1)

250 ␮V

C3-A2

125 ␮V

C4-A1

125 ␮V

O1-A2

125 ␮V

O2-A1

125 ␮V

ROC-A1

125 ␮V

LOC-A2

125 ␮V

ECG

2.5 mV

LEG(L)
LEG(R)
SaO2

THOR RES

ABDO RES

PULSE

PCO2
POSITION

CPAP

SOUND
Nasal pressure

Flow

Figure 18-97.
REM sleep behavior disorder. From a woman with a long history of reacting to dream content in which she was
being attacked (see Video 15, chapter 19). The patient is in REM sleep and has movements noted in her legs. The
blue vertical lines synchronize the top and bottom windows. The top window is 30 sec; the bottom is 5 min.

Atlas of Clinical Sleep Medicine 333

EMG1-EMG2
1.02 mV
C3-A2
128 uV
C2-A1
128 uV
O1-A2
128 uV
O2-A1
128 uV

ROC-A1
128 uV

LOC-A2
128 uV

ECG1-ECG2
2.05 mV

LAT-LAT-
512 uV

RAT-RAT-
512 uV
100

SaO2
%

0

HOR EFFOR
4.1 mV

BDO EFFOR
4.1 mV

120

Pulse
bpm

40
75

ETCO2
mmHg

0
POSITION

BACK
LEFT
RIGHT
PRONE

20
CPAP Pres

cmH2O
0

ASAL PRES
500 mV

Figure 18-98.
REM sleep behavior disorder. From a 53-year-old woman with a long history of reacting to dream content.
Four to five nights a week she strikes out during dreams about “a bad man who is deformed and ugly” who
might be attacking her. On examination of synchronized digital video during this episode of REM sleep one
could see that the patient was moving her right hand (see Video 61, chapter 20).

SEIZURES

CHIN(1)

250 uV

C3-A2

125 uV

C4-A1

125 uV

O1-A2

125 uV

O2-A1

125 uV

ROC-A1

125 uV

LOC-A2

125 uV

ECG

2.5 mV

LEG(L)
LEG(R)

100

SaO2

%
0

THOR RES

x1

ABDO RES

x1
120

PULSE

bpm 40
76

PCO2

mmHg
-4

POSITION

30

CPAP

cmH2O
2

AIRFLOW

62.5 uV

Figure 18-99.
Seizure disorder. The seizure activity lasting about 5 sec in this epoch is not associated with any other
recorded abnormality. The top window is 15 sec; the bottom is 30 sec.

334 Chapter 18 / GALLERY OF POLYSOMNOGRAPHIC RECORDINGS

CHIN(1)

250 uV

C3-A2

125 uV

C4-A1

125 uV

O1-A2

125 uV

O2-A1

125 uV

ROC-A1

125 uV

LOC-A2

125 uV

ECG

2.5 mV

LEG(L)

125 uV

LEG(R)

125 uV
100

SaO2
%
90

ABDO RES
x8

AIRFLOW
62.5 uV

Figure 18-100.
Seizure disorder. The first episode of central apnea is not associated with apparent seizure activity. The
second one is. The top and bottom windows are 1 min.

LOC-A1
ROC-A1
C3-A1
O2-A1
CHIN1-CHIN2
FP1-F7

F7-T3
T3-T5
T5-O1
FP2-F8
F8-T4
T4-T6
T6-O2
FP1-F3
F3-C3
C3-P3
P3-O1
FP2-F4
F4-C4
C4-P3
P3-O2
ECG1-ECG2
RIGHT IC 1-RIGHT IC 2

Airflow2

125 uV

THOR

1.02 mV

ABD 100.0
80.0
1.37 mV

SaO2

%

Figure 18-101.
Seizure disorder. Central apneic episode associated with significant oxygen desaturation is the sole
manifestation of the seizure. The true nature of the event (a right-sided seizure) would not be evident without a
full seizure montage. Blue EEG traces refer to left side, black to right side. The top and bottom windows are
1 min. (Courtesy of M. Mahowald.)

Atlas of Clinical Sleep Medicine 335

LOC-A2

170.7 uV

ROC-A1

170.7 uV

C3-A2

170.7 uV

O2-A1

170.7 uV

Chin1-Chin2
512 uV
Fp1-F7
85.3 uV
F7-T3
85.3 uV
T3-T5
85.3 uV
T5-O1
85.3 uV
Fp2-F8
85.3 uV
F8-T4
85.3 uV
T4-T6
85.3 uV
T6-O2
85.3 uV
Fp1-F3
85.3 uV
F3-C3
85.3 uV
C3-P3
85.3 uV
P3-O1
85.3 uV
Fp2-F4
85.3 uV
F4-C4
85.3 uV
C4-P4
85.3 uV
P4-O2
85.3 uV

ECG1-ECG2
1.02 mV

Figure 18-102.
Seizure disorder. Rare, very localized spikes over the right anterior temporal region in a patient with nocturnal
seizures. Only a few such spikes occurred during the entire study, underscoring the necessity of personally
reviewing each epoch when looking for evidence of spikes. This activity could not have been identified
the conventional sleep stage scoring montage. The window is 30 sec. (Contributed by M. Mahowald.)

E1-M2

125 uV

E2-M2

125 uV

C3-M2

125 uV

O2-M1

125 uV

Chin1-Chin2

125 uV

Fp1-F7

125 uV

F7-T3

125 uV

T3-T5

125 uV

T5-O1

125 uV

Fp2-F8

125 uV

F8-T4

125 uV

T4-T6

125 uV

T6-O2

125 uV

Fp1-F3

125 uV

F3-C3

125 uV

C3-P3

125 uV

P3-O1

125 uV

Fp2-F4

125 uV

F4-C4

125 uV

C4-P4

125 uV

P4-O2

125 uV

ECG1-ECG2
2 mV

Figure 18-103.
Seizure disorder. This is an example of an electrical seizure emanating from the right hemisphere followed by
isolated spikes over the same region. There are no clinical correlates of this electrical seizure. This could not
be identified on the sleep scoring montage. The tendency is often for the technicians to “mark” only clinically
obvious events–which are often nothing but movement artifact. The true nature of the events is only identified
by finding subclinical electrical seizure activity such as on this epoch. (Contributed by M. Mahowald.)

336 Chapter 18 / GALLERY OF POLYSOMNOGRAPHIC RECORDINGS

LOC-A2

128 uV

ROC-A1

128 uV

C3-A2

128 uV

O2-A1

128 uV

Chin1-Chin2

125 uV

Fp1-F7

128 uV

F7-T3

128 uV

T3-T5

128 uV

T5-O1

128 uV

Fp2-F8

128 uV

F8-T4

128 uV

T4-T6

128 uV

T6-O2

128 uV

Fp1-F3

128 uV

F3-C3

128 uV

C3-P3

128 uV

P3-O1

128 uV

Fp2-F4

128 uV

F4-C4

128 uV

C4-P4

128 uV

P4-O2

128 uV

ECG1-ECG2
2.05 mV

Figure 18-104.
Seizure disorder. Very periodic spikes emanating from the left midtemporal region (without clinical correlates).
Localization would not be possible on the conventional sleep scoring montage. The window is 30
sec. (Courtesy of M. Mahowald.)

E1

250 uV

E2-M1

284.4 uV

C3-M1

125 uV

O2-M1

125 uV

Chin1-Chin2

500 uV

Fp1-F7

125 uV

F7-T3

125 uV

T3-T5

125 uV

T5-O1

125 uV

Fp2-F8

125 uV

F8-T4

125 uV

T4-T6

125 uV

T6-O2

125 uV

Fp1-F3

125 uV

F3-C3

125 uV

C3-P3

125 uV

P3-O1

125 uV

Fp2-F4

125 uV

F4-C4

125 uV

C4-P4

125 uV

P4-O2

125 uV

ECG1-ECG2

2 mV

Figure 18-105.
Seizure disorder. On the conventional sleep scoring montage, this would appear to be a simple, nonspecific
arousal. The EEG montage reveals periodic spikes from the right midtemporal region culminating in an arousal
followed by residual postictal slowing over the same region. This “arousal” was actually the sole clinical
manifestation of a focal temporal lobe epileptic discharge. (These may occur hundreds of times a night, resulting
in frequent arousals [sleep fragmentation] presenting as excessive daytime sleepiness.) For this reason, it is
prudent to employ a full seizure montage in all patients with a history of seizures and the complaint of excessive
daytime sleepiness. If these arousals are associated with extremity movements, an erroneous diagnosis of
PLMS might be made. The window is 30 sec. (Courtesy of M. Mahowald.)

Atlas of Clinical Sleep Medicine 337

LOC-A2

85.3 uV

ROC-A1

170.7 uV

C3-A2

170.7 uV

O2-A1

170.7 uV

Chin1-Chin2
128 uV

Fp1-F7

85.3 uV

F7-T3

85.3 uV

T3-T5

85.3 uV

T5-O1

85.3 uV

Fp2-F8

85.3 uV

F8-T4

85.3 uV

T4-T6

85.3 uV

T6-O2

85.3 uV

Fp1-F3

85.3 uV

F3-C3

85.3 uV

C3-P3

85.3 uV

P3-O1

85.3 uV

Fp2-F4

85.3 uV

F4-C4

85.3 uV

C4-P4

85.3 uV

P4-O2

85.3 uV

ECG1-ECG2
1.02 mV

Figure 18-106.
Seizure disorder. These spikes are characteristic of “Rolandic” spikes (seen in benign Rolandic
epilepsy). The spikes are most prominent over the central and midtemporal regions. They are
often only present during NREM sleep, when they may become very active. Clinically, there
may be twitching of the mouth on the contralateral side with or without drooling. Occasionally
these usually trivial seizures will generalize. The prognosis is generally very good, with a
natural history of spontaneous resolution over time, hence the name “benign Rolandic
epilepsy.” Epoch length is 15 seconds. (Courtesy of M. Mahowald.)

HEAD TRAUMA

EMG1-EMG2

1.02 mV

C3-A2

128 uV

C4-A1

128 uV

Fr3-A2

128 uV

Fr4-A1

128 uV

O1-A2

128 uV

O2-A1

128 uV

ROC-A1

128 uV

LOC-2

128 uV

ECG1-ECG2

2.05 uV

LAT-LAT- 100
90
512 uV

RAT-RAT-

512 uV

SaO2

%

THOR EFFORT

2.05 mV

ABDO EFFORT

2.05 mV

Pulse 120

bpm 40
50
ETCO2
0
mmHg

NASAL PRES

250 mV

Figure 18-107.
Head trauma in NREM sleep. As a result of head trauma and fractures of his jaw and facial structures, this 57-
year-old patient spent 3 years in the hospital for rehabilitation. He had a periodic breathing pattern, but there
was no history of snoring. During the sleep study, one could not hear this patient breathe.

338 Chapter 18 / GALLERY OF POLYSOMNOGRAPHIC RECORDINGS

EMG1-EMG2

1.02 mV

C3-A2

128 uV

C4-A1

128 uV

Fr3-A2

128 uV

Fr4-A1

128 uV

O1-A2

128 uV

O2-A1

128 uV

ROC-A1

128 uV

LOC-2

128 uV

ECG1-ECG2

2.05 uV

LAT-LAT- 100
90
512 uV

RAT-RAT-

512 uV

SaO2

%

THOR EFFORT

1.02 mV

ABDO EFFORT

8.19 mV

Pulse 120

bpm 40
50
ETCO2
0
mmHg

NASAL PRES

250 mV

Figure 18-108.
Head trauma in REM sleep. Same patient as in Figure 18-107. The breathing pattern now has the
configuration of Cheyne Stokes breathing, with long central apneic episodes. The patient had an underlying
breathing pattern that was slow. During the 5-minute epoch seen in the lower window, he had fewer than
30 breaths. The top window is 30 sec; the bottom is 5 min.

Multiple Sclerosis

CHIN(1)
250 uV
C3-A2
125 uV
C4-A1
125 uV
O1-A2
125 uV
O2-A1
125 uV

ROC-A1
125 uV

LOC-A2
125 uV
ECG
2.5 mV

LEG(L)
125 uV
LEG(R)
125 uV

100

SaO2
%

80

ABDO RES
x1

120

PULSE
bpm

40
50

PCO2
mmHg

CPAP -4
cmH2O 20

2

AIRFLOW
62.5 uV

Figure 18-109.
Multiple sclerosis. This PSG fragment is taken from a 56-year-old male with a 5-year history of multiple
sclerosis. The main symptom was severe daytime sleepiness. He had put on between 50 and 60 pounds
since the diagnosis of multiple sclerosis. During wakefulness, the patient had central apnea; during
sleep, shown here, the patient demonstrated mixed apnea episodes. The top window is 30 sec; the
bottom is 5 min.

Atlas of Clinical Sleep Medicine 339

CHIN(1)

250 uV

C3-A2

125 uV

C4-A1

125 uV

O1-A2

125 uV

O2-A1

125 uV

ROC-A1

125 uV

LOC-A2

125 uV

ECG

2.5 mV

LEG(L)

125 uV

LEG(R)

125 uV
100

SaO2

%

80

ABDO RES

x4

120
PULSE

bpm
40
50

PCO2

mmHg

CPAP -4
20
cmH2O
2

AIRFLOW

62.5 uV

Figure 18-110.
Multiple sclerosis. Same patient as in Figure 18-109. The patient, now in REM sleep, was treated with a bilevel
device, which led to resolution of his mixed apneas. He had a great deal of REM sleep on starting bilevel
treatment. The top window is 30 sec; the bottom is 5 min.

Artifacts in Sleep Recordings

EMG1-EMG2

1.02 mV

C3-A2

128 uV

C4-A1

128 uV

Fr3-A2

128 uV

Fr4-A1

128 uV

O1-A2

128 uV

O2-A1

128 uV

ROC-A1

128 uV

LOC-A2

128 uV

EC1-ECG2

2.05 mV

LAT-LAT- 100
512 uV 80

RAT-RAT-
512 uV

SaO2
%

THOR EFFORT
1.64 mV

120

Pulse
bpm

40
75

ETCO2
mmHg

POSITION 0
BACK
ETCO2 LEFT
cmH2O RIGHT
PRONE

20

0

NASAL PRES
500 mV

Figure 18-111.
60 Hz interference. Note the obvious broad band of black that appears in four of the channels. Modern data
acquisition systems allow the frequency analysis (visual or numerical) of channels. The inset, which shows
1 second of one of the channels, clearly shows that there is an underlying 60 Hz wave in the channel. This is
60-cycle electrical interference. Lead A2 is the cause, because that artifact was found in all the channels that
include this lead. Figure 18-112 shows ways of dealing with such noise. The top window is 30 sec.

340 Chapter 18 / GALLERY OF POLYSOMNOGRAPHIC RECORDINGS

EMG1-EMG2

1.02 mV

C3-A2

128 uV

C4-A1

128 uV

Fr3-A2

128 uV

Fr4-A1

128 uV

O1-A2

128 uV

O2-A1

128 uV

ROC-A1

128 uV

LOC-A2

128 uV

EC1-ECG2

2.05 mV

LAT-LAT- 100
512 uV 80

RAT-RAT-
512 uV

SaO2
%

THOR EFFORT
1.64 mV

120

Pulse
bpm

40
75

ETCO2
mmHg

POSITION 0
BACK
ETCO2 LEFT
cmH2O RIGHT
PRONE

20

0

NASAL PRES
500 mV

Figure 18-112.
60 Hz interference corrected. This is the same epoch as in Figure 18-111, except that the montage has
been modified so that the A1 lead is used instead of lead A2. Digital filters can also be used to
remove 60 Hz noise.

CHIN(1)
250 uV
C3-A2
125 uV
C4-A1
125 uV
O1-A2
125 uV
O2-A1
125 uV

ROC-A1
125 uV

LOC-A2
125 uV
ECG
2.5 mV

100
LEG(L)

125 uV
LEG(R)

125 uV

SaO2 80
%

THOR RES
x1

ABDO RES
x1

120

PULSE
bpm

40
40

PCO2
mmHg

CPAP -4
cmH2O 20

2

AIRFLOW
62.5 uV

Figure 18-113.
Artifacts affecting EEG and respiratory channels. What is the main finding in this epoch? Is it leg movements
or sleep apnea? There is an EKG artifact in all the EEG channels. That sometimes makes scoring for sleep
stage difficult. In the bottom window there is an artifact affecting both the thoracic and abdominal respiration
channels. The leg movements and breathing are very closely linked; leg movements occur precisely
during the peak of respiratory effort. Many would interpret this as the apneas causing the movements. This is
a situation in which examining the synchronized video is helpful. The orange vertical lines synchronize the
upper (30 sec) and lower (5 min) windows.

Atlas of Clinical Sleep Medicine 341

CHIN(1)
250 uV
C3-A2
125 uV
C4-A1
125 uV
O1-A2
125 uV
O2-A1
125 uV

ROC-A1
125 uV

LOC-A2
125 uV
ECG
2.5 mV

100
LEG(L)

125 uV
LEG(R)

125 uV

SaO2 80
%

THOR RES
x1

ABDO RES
x1

120

PULSE
bpm

40
40

PCO2
mmHg

CPAP -4
cmH2O 20

2

AIRFLOW
62.5 uV

Figure 18-114.
Artifacts affecting EEG and respiratory channels. The vertical orange lines have moved forward about 5.5
seconds. An arousal has occurred in the EEG channels. There has been a dramatic movement of the
legs evident in the synchronized digital video. The question still remains whether the apneas are causing the
movements. The answer comes in the fragment shown in Figure 18-115, after the patient has been placed
on CPAP.

CHIN(1)
250 uV
C3-A2
125 uV
C4-A1
125 uV
O1-A2
125 uV
O2-A1
125 uV

ROC-A1
125 uV

LOC-A2
125 uV
ECG
2.5 mV

LEG(L)
125 uV
LEG(R)
125 uV

100
SaO2

%
80

THOR RES
x2

ABDO RES
x2

120

PULSE
bpm

40
40

PCO2
mmHg

CPAP -4
cmH2O 20

2

AIRFLOW
62.5 uV

Figure 18-115.
Artifacts affecting EEG and respiratory channels. With the above patient placed on CPAP, the apneas have
been abolished, but the movements remain. Notice that they still cause an artifact in the thoracic and
abdominal channels. Notice also that each twitch is associated with a reproducible increase in heart rate,
suggesting that subcortical arousals are recurring. The nasal pressure channel reflects the pressure being
delivered by the CPAP machine. The patient is in stage N3.

342 Chapter 18 / GALLERY OF POLYSOMNOGRAPHIC RECORDINGS

CHIN(1)
250 uV
C3-A2
125 uV
C4-A1
125 uV
O1-A2
125 uV
O2-A1
125 uV

ROC-A1
125 uV

LOC-A2
125 uV
ECG
2.5 mV

LEG(L)
125 uV
LEG(R)
125 uV

100
SaO2

%
80

THOR RES
x2

ABDO RES
x4

120

PULSE
bpm

40
40

PCO2
mmHg

CPAP -4
cmH2O 20

2

AIRFLOW
62.5 uV

Figure 18-116.
Artifacts affecting EEG and respiratory channels. The patient is now in REM sleep. There has been a dramatic
decrease in both the leg movements and the artifacts in the thoracic and abdominal channels. The EEG
still contains EKG artifact. Notice the regular movements in the two eye channels. This patient has both
obstructive sleep apnea and periodic limb movements in sleep.

CH1-CH2

250 ␮V

C3-A2

125 ␮V

C4-A1

125 ␮V

O1-A2

125 ␮V

O2-A1

125 ␮V

ROC-A1

125 ␮V

LOC-A2

125 ␮V

ECG

1.25 mV
LEG(L)
125 ␮V
LEG(R)
125 ␮V

100
SaO2

%
85

THOR RES

x5

ABDO RES

x5

120
PULSE

bpm
40
76

PCO2

mmHg
-4

FLOW

10 V

Figure 18-117.
Cardiac artifact in EEG. There are two types of cardiac artifacts that may be observed in the EEG. One is
caused by the transmission of electrical waves from the EKG to the EEG (seen in Fig. 18-116), whereas the
other is related to, or caused by, a beating heart. Here, three of the EEG channels have a high-amplitude
sinusoidal wave embedded in them. These waves are exactly synchronous with the heartbeat. In addition,
examination reveals that the three channels have something in common, that is, an A1 electrode as one of the
pair. Figure 18-118 shows how this is remedied. Both windows are 30 sec.

CH1-CH2

250 ␮V

C3-A2

125 ␮V

C4-A2

125 ␮V

O1-A2

125 ␮V

O2-A2

125 ␮V

ROC-A2

125 ␮V

LOC-A2

125 ␮V

ECG

1.25 mV
LEG(L)
125 ␮V
LEG(R)
125 ␮V

100
SaO2

%
85

THOR RES

x5

ABDO RES

x5
120

PULSE

bpm
40
76

PCO2

mmHg
-4

FLOW

10 V

Figure 18-118.
Cardiac artifact in EEG rectified. This is the same epoch as shown in Figure 18-117. Modern computer
systems allow the user to digitally re-reference electrode pairs. By removing A1 from the montage and using
A2 instead, the problem has been solved. Presumably the original artifact was caused by motion that affected
the A1 electrode. This is a 30-sec epoch.

Figure 18-119.
When an artifact helps make a diagnosis. Here, there is a very high-amplitude, low-frequency wave superimposed
on all the EEG channels. Clearly the high-amplitude deflections are synchronous with breathing. The technician
might call this a sweat artifact, but it is really a breathing artifact in a sweaty patient. This patient did indeed have
severe night sweats, and the EKG showed atrial fibrillation. Based on the clues presented in this PSG fragment, the
patient was evaluated for hyperthyroidism, and the diagnosis was confirmed. This is a 30-sec epoch.

344 Chapter 18 / GALLERY OF POLYSOMNOGRAPHIC RECORDINGS

EMG1-EMG2

1.02 mV

C3-A2

128 uV

C4-A1

128 uV

O1-A2

128 uV

O2-A1

128 uV

ROC-A1

128 uV

LOC-A2

128 uV

EC1-ECG2

1.02 mV

LAT-LAT- 100
512 uV 70

RAT-RAT-
512 uV

SaO2
%

THOR EFFORT
2.05 mV

ABDO EFFORT
4.1 mV

120

Pulse
bpm

40
75

ETCO2 0
mmHg 20

CPAP Pres 0
cmH2O

NASAL PRES
250 mV

Figure 18-120.
Eye channel artifacts. Scoring technicians most often have no contact with the patient whose study they are
scoring. Nighttime technicians are often too busy to evaluate findings that are abnormal and therefore may
attribute them to artifact. Here, at the beginning of the night, there was a low-frequency oscillation in the left
eye channel that was dismissed as probably a breathing artifact.

EMG1-EMG2

1.02 mV

C3-A2

128 uV

C4-A1

128 uV

O1-A2

128 uV

O2-A1

128 uV

ROC-A1

128 uV

LOC-A2

128 uV

EC1-ECG2

1.02 mV

LAT-LAT- 100
512 uV 70

RAT-RAT-
512 uV

SaO2
%

THOR EFFORT
1.02 mV

ABDO EFFORT
2.05 mV

120

Pulse
bpm

40
75

ETCO2 0
mmHg 20

CPAP Pres 0
cmH2O

NASAL PRES
250 mV

Figure 18-121.
Eye channel artifacts. Originally the patient was scored as having no REM sleep. The eye movements in the
left eye channel were interpreted as being artifacts. The clinician who evaluated the patient later that morning
examined the patient’s extraocular movements, shown in Figure 18-122.

Atlas of Clinical Sleep Medicine 345

AB
Figure 18-122.

Eye channel artifacts. A, When the patient looked straight ahead, everything seemed normal.
B, When he was asked to look to his right, only his right eye moved. What is going on, and how
did this affect the eye channels the previous night? The patient had a left glass eye. What the
EOG channel was detecting was only the movements of the right eye. Figure 18-121 actually
does show REM sleep. The night technician had also mixed up the right and left eye channels
and was actually recording movements of the right eye.

CHIN(1)

250 uV

C3-A2

125 uV

C4-A1

125 uV

O1-A2

125 uV

O2-A1

125 uV

ROC-A1

125 uV

LOC-A2

125 uV

ECG

2.5 mV

LEG(L)

125 uV

LEG(R)

125 uV
100

SaO2

%
90

THOR RES

x16

ABDO RES

x10
120

PULSE

bpm
40
50

PCO2

mmHg
0

AIRFLOW

62.5 uV

Figure 18-123.
Recording artifact in both leg channels. An artifact-free leg movement recording could not be attained in this
patient. She had massive peripheral edema related to right heart failure. There was probably 2 cm of edema
fluid between the recording electrode and the anterior tibialis muscle. The EMG channels were not recording
EMG but were recording electrical noise.

30s346 Chapter 18 / GALLERY OF POLYSOMNOGRAPHIC RECORDINGS

CHIN(1)

125 uV

C3-A2

125 uV

C4-A1

125 uV

O1-A2

125 uV

O2-A1

125 uV

ROC-A1

125 uV

LOC-A2

125 uV

ECG

1.25 mV

LEG(L)

125 uV

LEG(R)

125 uV
100

SaO2

%
70

THOR RES

x1

ABDO RES

x1

120
PULSE

bpm
40
50

PCO2

mmHg

0
AIRFLOW

62.5 uV

Figure 18-124.
Periodic artifact in the chin EMG and in the EKG. High-frequency noise is present with regular periodicity in
both the chin EMG and EKG. The noise is clearly linked to the patient’s breathing and is actually being caused
by snoring. The top and bottom windows are 30 sec.

Fp2-F8
F8-T4
T4-T6
T6-O2
F4-M1
C4-M1
O2-M1
Fp1-F7
F7-T3
T3-T5
T5-O1
F3-M2
C3-M2
O1-M2
E2-M1
E1-M1
Chin1
Chin2
EKG
R-R
RLeg
LLeg
Snore
Thor
Abdm
SAO2
(%)

Figure 18-125.
A seizure? The scoring technician, on observing the high-amplitude activity and EEG channels at the end of
this epoch, scored the event as a seizure. Synchronized digital video showed that the patient was simply
scratching himself at this time. One should always view the synchronized digital video when such a finding is
made. Notice also the EKG artifact in most of the EEG channels. This is a 30-sec epoch.

............................. CHAPTER ....................
.............
GALLERY OF PATIENT INTERVIEW VIDEOS 19....
........ ........... . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . . .. . . . . . .. . . . . . . .

Meir Kryger

The video clips referred to here are of interviews of
patients with sleep disorders and can be seen on the Web
at www.expertconsult.com.

Sleep-related Breathing Disorders A 43-YEAR-OLD WOMAN WITH DOWN SYNDROME
(VIDEO 3)
AN 8-YEAR-OLD WITH SLEEP APNEA
(VIDEO 1) This woman with Down syndrome had sleep apnea.

This 8-year-old has a strong family history of sleep apnea and
is being treated with continuous positive airway pressure
(CPAP). He had cardiovascular complications of apnea.

AN 82-YEAR-OLD WOMAN WITH SLEEP APNEA APNEA WITH CARDIOVASCULAR COMORBIDITIES
(VIDEO 2) (VIDEO 4)

This woman, aged 82, had been on CPAP for 13 years. This patient had heart failure and treatment-resistant
hypertension that resolved with treatment.

347

348 Chapter 19 / GALLERY OF PATIENT INTERVIEW VIDEOS

APNEA PRESENTING AS RESTLESS SLEEP EXPLAINING THE RESULTS
(VIDEO 5) (VIDEO 7)

This patient had as his main complaint restless sleep and It is extremely important that the patient understand the
frequent awakenings. He also had difficulty in walking results of the sleep test. An effective way of accomplishing
due to osteoarthritis caused by his weight. that is to show the patient the actual study and the syn-
chronized digital video. This is often a “teachable moment”
that not only can have a great effect on the patient but also
is likely to improve CPAP compliance and motivate the
patient to deal with comorbidities.

APNEA IN A TRUCK DRIVER TEACHING AND CPAP MASK FITTING
(VIDEO 6) (VIDEO 8)

Sleepiness can be particularly dangerous in a truck driver. Once a patient is diagnosed with sleep apnea, there is a
The patient recounts some near misses while he was very important aspect of management to consider and that
driving a truck. is to ensure proper teaching about and fitting of the CPAP
mask. If unsuccessful, the patient may become noncompli-
ant and not benefit from treatment. This patient who was
being taught about her mask was apprehensive.

Neurologic and Other Disorders Atlas of Clinical Sleep Medicine 349

UNDIAGNOSED NARCOLEPSY PATIENT WITH CATAPLEXY HALLUCINATIONS IN A MALE NARCOLEPSY PATIENT
(VIDEO 9) (VIDEO 11)
Vivid hypnagogic hallucinations and dream imagery are
This young woman was evaluated for the first time and common in narcolepsy. Some patients may have the per-
found to have narcolepsy and prominent cataplexy ception that they are floating out of their body. This
symptoms. patient had almost all of the symptoms of narcolepsy.

THIRTY-FIVE YEARS OF UNDIAGNOSED NARCOLEPSY NARCOLEPSY PATIENT WITH SLEEP APNEA
(VIDEO 10) (VIDEO 12)

Patients with classic narcolepsy frequently go undiagnosed This patient was referred for evaluation because of
for decades, as did this patient. suspected OSA. The history revealed some classic narco-
lepsy symptoms.

350 Chapter 19 / GALLERY OF PATIENT INTERVIEW VIDEOS

RESTLESS LEGS SYNDROME IN A MALE REM SLEEP BEHAVIOR DISORDER
(VIDEO 13) (VIDEO 15)

Restless legs syndrome is common and is found in all age REM sleep behavior disorder can be terrifying. It is a sleep
groups, as in this young adult male. He is French Canadian disorder in which the reaction to a dream can result in
and the disorder is common in that population. harm to the patient’s bed partner.

MIDDLE-AGED WOMAN WITH RESTLESS LEGS PARKINSON’S DISEASE WITH REM BEHAVIOR DISORDER
SYNDROME AND SLEEP APNEA
(VIDEO 14) (VIDEO 16)

Different people use different terms to discuss the sensation This patient with Parkinson’s disease had several common
of restless legs. This patient said it felt like insects crawling sleep complications including REM sleep behavior disorder
under her skin. and sleep apnea.

Atlas of Clinical Sleep Medicine 351

MULTIPLE SCLEROSIS, SLEEP APNEA, AND HYPNAGOGIC SYRINGOMYELIA
HALLUCINATIONS (VIDEO 19)
(VIDEO 17)
In this patient, the syrinx affected the brain stem. This had
This patient had multiple sclerosis and developed central an effect not only on the structures that control breathing
apnea that required treatment. He also had the features of and the centers involved in REM sleep, but also on the
narcolepsy. motor pathways that control the legs.

ARNOLD-CHIARI MALFORMATION BECKER’S MUSCULAR DYSTROPHY
(VIDEO 18) (VIDEO 20)

Patients with Arnold-Chiari malformation may have abnor- The muscular dystrophies may be associated with sleep
mal control of breathing and develop sleep apnea. apnea as in this patient with Becker’s muscular dystrophy.

352 Chapter 19 / GALLERY OF PATIENT INTERVIEW VIDEOS

PSYCHIATRIC DISORDERS
(VIDEO 21)

Psychiatric disorders and their treatment may result in
sleep problems. Hypnagogic hallucinations (in this patient
associated with sleep apnea) differ from psychotic halluci-
nations, and both may be found in the same patient.

............................. CHAPTER ....................
.............
GALLERY OF SLEEP LABORATORY VIDEO FINDINGS 20...
. ........ ........... . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . .. . . . . . . . .. . . . . . .. . . . . . . .

Meir Kryger

This chapter contains examples of video findings obtained NASAL OBSTRUCTION AND APNEA
in a typical sleep medicine clinic polysomnography lab.
They are grouped into categories. Most modern sleep lab This patient had been a boxer, had his nose fractured
acquisition systems allow the collection of synchronized several times, and could not breathe via his nasal airway.
digital videos. The videos can be played back in real time He demonstrated periods of silence, noisy breathing, and
or can be sped up. Video clips referred to here are of restlessness (Video 23).
patients with sleep disorders obtained during sleep studies
and can be seen on the Web at www.expertconsult.com.

Obstructive Sleep Apnea

APNEA, RESTLESSNESS IN CHILD

This 12-year-old boy presented with restless sleep. This is a
common presentation of sleep apnea in children of all ages.
The restlessness is often present the entire night (Video 22).

AROUSAL THRESHOLD TO NOISE IN OSA

This patient with sleep apnea is snoring loudly and sleep-
ing on his side when a fire alarm goes off. The patient does
not arouse and awaken in response to the noise (Video 24).

353

354 Chapter 20 / GALLERY OF SLEEP LABORATORY VIDEO FINDINGS

OSA, VIOLENT BODY MOVEMENTS ATYPICAL SNORING POST-UPPP

Excessive body movements linked to the episodes of apnea This patient had uvulopalatopharyngoplasty, which re-
are evident in this patient with obstructive sleep apnea moved part of the soft palate. The patient continued to
(OSA) (Video 25). have sleep apnea, but the snoring noises were atypical
and quite different than preoperatively (Video 27).

OSA, VIOLENT BODY MOVEMENTS Â 10 VIGOROUS MOVEMENTS IN OSA Â 10

In this same patient with OSA, this video is sped up by a In many patients with sleep apnea, there are vigorous
factor of 10 to better show the frequency and vigor of movements often associated with the apnea. These some-
the movements (Video 26). times result in the patient being diagnosed as having peri-
odic limb movements disorder. These movements often
resolve with treatment. This clip has been sped up by a
factor of 10 (Video 28).

ϫ10 ϫ10

Obstructive Sleep Apnea in Special Populations Atlas of Clinical Sleep Medicine 355

OBESITY HYPOVENTILATION OBESITY HYPOVENTILATION, TREATED
The same patient was treated with bilevel pressure with an
This patient had obesity hypoventilation syndrome and excellent response (Video 31).
evidence of both obstructive apnea and hypoventilation
(Video 29).

OBESITY HYPOVENTILATION, HEART FAILURE OSA IN PREGNANCY

The same patient as above had the features of severe right- This pregnant woman had severe obstructive apnea related
sided heart failure with massive peripheral edema. During to obesity. She had a very high breathing frequency that
times when he hypoventilates, he is relatively quiet. When was especially noticeable during unobstructed breathing
obstructed, he demonstrates chest wall abdominal paradox (Video 32).
and then loud snoring (Video 30).

356 Chapter 20 / GALLERY OF SLEEP LABORATORY VIDEO FINDINGS

OSA POSTPARTUM APNEA IN ACROMEGALY

This woman was 4 months’ postpartum and had difficulty This 71-year-old woman had acromegaly with abnormal-
caring for her new baby. She had had undiagnosed apnea ities in her jaw structure and an enlarged tongue. She had
for years. A previous pregnancy ended with a miscarriage stridor noted (Video 35).
(Video 33).

OSA POSTPARTUM ON TREATMENT APNEA IN ACROMEGALY Â 10

The same patient as above is on continuous positive airway In the same patient with acromegaly, the video has been
pressure (CPAP) and sleeps with her mouth closed. The sped up by a factor of 10 to show the marked movements
CPAP is much quieter than her snoring (Video 34). of the jaw during sleep (Video 36).

ϫ10

Atlas of Clinical Sleep Medicine 357

APNEA AND DOWN SYNDROME UARS, QUIET SNORING Â 7

Sleep apnea is common in children and adults with Down This is the same patient with UARS with the clip sped up
syndrome (Video 37). by a factor of 7. Note the movements of the jaw at the
beginning and the end of the clip and that she closes her
mouth to reestablish breathing (Video 39).

ϫ7

Upper Airway Resistance Syndrome UARS, VARIABLE SNORING

UARS, QUIET SNORING This patient had UARS and snoring with different sounds.
Note that the sensor over the mouth is likely to miss when
This woman has upper airway resistance syndrome he breathes via his mouth. Notice that at the end of the
(UARS). Notice the initially quiet and high-pitched snor- clip he reestablishes unobstructed breathing (Video 40).
ing noises. Notice at 1 minute 10 seconds she closes her
mouth and moves her head to reestablish breathing. When
the patient breathes via her mouth, the nasal sensor will
not detect the breaths (Video 38).

ϫ7

358 Chapter 20 / GALLERY OF SLEEP LABORATORY VIDEO FINDINGS

UARS, VARIABLE SNORING Â 5 RETINITIS PIGMENTOSA, CENTRAL APNEA

The same patient with UARS with the clip sped up by a An older male with retinitis pigmentosa had severe central
factor of 5. At such high speed, the movements of the apnea. There is little effort to breathe during the episodes
mouth and jaw become apparent in this patient with upper (Video 43).
airway resistance syndrome (Video 41).

ϫ5

Central Sleep Apnea and Cheyne Stokes Respiration CENTRAL APNEA, OBESITY

IDIOPATHIC CENTRAL APNEA An obese male with symptoms of obstructive apnea was
found to have primarily central apnea. Note the deep
This young adult male had idiopathic central apnea. Dur- unobstructed breaths after apnea termination (Video 44).
ing apnea there is virtually no effort to breathe. At apnea
termination there is sometimes a snort (Video 42).

OSA AND CHEYNE STOKES BREATHING Atlas of Clinical Sleep Medicine 359

This patient with obstructive apnea developed heart failure, Respiratory Diseases
which led to Cheyne Stokes breathing. Thus the patient ASTHMA
had evidence of two types of abnormal breathing patterns
and pathology (Video 45). Patients with asthma wheeze on expiration. This obese
patient with asthma makes loud inspiratory snoring noises
and higher-pitched expiratory wheezing sounds (Video 47).

PULMONARY EDEMA COPD

This patient has obstructive sleep apnea and pulmonary This chronic obstructive pulmonary disease (COPD) patient
edema caused by left heart failure. He had Cheyne Stokes made loud sounds on expiration (from his lung disease)
breathing while awake and asleep. The loud gurgling noises that could be confused with inspiratory snoring (Video 48).
are made by the edema fluid (Video 46).

360 Chapter 20 / GALLERY OF SLEEP LABORATORY VIDEO FINDINGS

COPD, UPPER AIRWAY OBSTRUCTION COPD, AIRWAY SECRETIONS, PLMS Â 10

This is the same COPD patient as above. Here the sounds This is the same COPD patient as above. The video has
are inspiratory due to upper airway obstruction (Video 49). been sped up by a factor of 10 to make the periodic move-
ments more apparent. Look at the patient’s feet beneath the
cover (Video 51).

ϫ10

COPD, AIRWAY SECRETIONS, PLMS OVERLAP SYNDROME

This COPD patient has poor-quality sleep because of This patient has the overlap syndrome, the combination of
secretions in her airways that make her breathing noisy. COPD and obstructive sleep apnea. This clip in REM sleep
She also has periodic limb movements disorder (Video 50). shows the patient hypoventilating. Toward the end of the
clip the upper airway obstruction becomes more apparent
(Video 52).

OVERLAP SYNDROME ON TREATMENT Atlas of Clinical Sleep Medicine 361

The same patient with overlap syndrome is being treated Neurologic and Other Disorders
with bilevel positive airway pressure and oxygen. One
can hear the machine generating the pressure changes RLS, INSOMNIA
(Video 53).
This patient had sleepiness and obesity, which were
thought to be caused by sleep apnea. Her main problem
was severe restless legs syndrome (RLS), which led to her
being awake for much of the night (Video 55).

PULMONARY FIBROSIS RLS AND PLM Â 25

This patient has severe interstitial pulmonary fibrosis This patient with restless legs syndrome was originally
caused by rheumatoid lung disease. This shows severe dys- referred for sleep apnea. Her problem ended up being a
pnea, and the patient had difficulty achieving persistent movement disorder caused by iron deficiency (ferritin level
sleep (Video 54). was 12). Note that she keeps her feet exposed in this video,
sped up 25 times to show the periodic limb movements
(PLM) in sleep (Video 56).

ϫ25

362 Chapter 20 / GALLERY OF SLEEP LABORATORY VIDEO FINDINGS

RLS, SLEEP APNEA PLMD, APNEA Â 10

Restless legs syndrome in a patient with sleep apnea. The Periodic limb movements disorder masquerading as sleep
irresistible urge to move the legs and the onset of apnea. The patient had frequent movements and move-
obstructed breathing cause sleep-onset insomnia in this ments that resulted in overbreathing followed by apnea.
patient (Video 57). Video sped up by a factor of 10 (Video 59).

ϫ10

RLS, SLEEP APNEA Â 10 PLMD, SUBTLE MOVEMENTS Â 10

Same patient as above. The video has been sped up to In the same patient as above, this video sped up by a factor
emphasize the frequency and severity of the movements of 10 shows more subtle movements in the legs (Video 60).
(Video 58).

ϫ10 ϫ10

Atlas of Clinical Sleep Medicine 363

REM SLEEP BEHAVIOR DISORDER SLEEP PARALYSIS

This patient had REM behavior disorder. At times the Sleep paralysis in a patient without narcolepsy. The
movements during REM can be subtle, as in this study. patient recalled trying to call the technician but was heard
This is REM sleep. Notice the movement of the right hand only to moan. REMs were present throughout this segment
toward the end of the clip (Video 61). (Video 63).

REM SLEEP BEHAVIOR DISORDER, OSA DELAYED SLEEP PHASE SYNDROME

This patient had OSA and was being treated with CPAP. Delayed sleep phase. This is a time-lapse clip of the entire
This treatment, which restores more normal sleep and night of a patient referred for severe sleep-onset insomnia.
amounts of stages R and N3 sleep, may unmask parasomnia. Notice the activities during the night, including watching a
This patient developed REM sleep behavior disorder on movie on a laptop. Once asleep, all findings were normal
CPAP (Video 62). (Video 64).

364 Chapter 20 / GALLERY OF SLEEP LABORATORY VIDEO FINDINGS

EPILEPSY PSYCHOGENIC “SEIZURES”

This patient had two seizures during the night. One was at This patient presented with “seizures” during sleep.
about 12:29 A.M. and another at about 2:15 A.M. (Video 65). This video clip is sped up to emphasize the movements.
This patient had psychiatric problems, and it was con-
cluded that she was “simulating” seizures. She was awake
during this clip (Video 67).

SEIZURE INVOLVING LEG PSYCHOGENIC “SEIZURES,” EDGE ENHANCED

This patient had a history of seizures. During a multiple The same patient and video clip as above modified to show
sleep latency test, she had a seizure that resulted in move- additional detail. Note that during the seizure, she at times
ment only of her right leg (Video 66). straightens her hair (Video 68).

Index

.......................................................................................................................................

Page numbers followed by f indicate figures; those followed by t indicate tables; those followed by b indicate boxes.

A Amphetamine(s) Artifact(s), in polysomnography (Continued)
mechanism of action of, 77f in chin EMG, 346f
Abdomen, in sleep apnea, 165, 165f to promote wakefulness, 76t, 77 in EEG, 340f, 341f, 342f
Abnormal sleep, consequences of, 68, 68f breathing, 343f
Accessory respiratory muscles, during REM sleep, Amphetamine-dextroamphetamine (Adderall), to cardiac, 340f, 342f, 343f
promote wakefulness, 77t in EKG, 346f
44–45 due to electrical interference, 339f, 340f
Acid mucosal response, 238, 238f Amyotrophic lateral sclerosis (ALS), sleep disorders eye channel, 344f, 345f
Acromegaly in, 146 leg channel, 345f
movement, 346f
clinical features of, 234b Anacin PM (diphenhydramine in combination), for respiratory channel, 340f, 341f, 342f
defined, 234 sleep promotion, 75t
diagnosis of, 234 Ascending reticular activating system, 20f
gradual evolution of, 235f Angina pectoris, due to obstructive sleep apnea, 219 Aserinsky, Eugene, 80
obstructive sleep apnea with, 289f Anticonvulsants, for restless legs syndrome, 121t Association for the Psychophysiological Study of Sleep
Antidepressants
sleep laboratory video(s) on, 356 (APSS), 13
sleep-disordered breathing in, 233–234, 235f REM suppressant action of, 256–257, 257t, 258f Asthma, sleep laboratory video on, 359
treatment of, 234–236 sedating ASV (adaptive servo-ventilation), for central sleep
AD (Alzheimer’s disease). See Alzheimer’s disease
characteristics of, 75b apnea, 302f, 303f
(AD). for sleep promotion, 74–75, 75f with stroke, 330f, 331f
AD (adenosine), in sleep drive, 23f structure of, 75f atomoxetine, to promote wakefulness, 77t
Adams, Laurie Schneider, 3–4 Antiepileptic drugs, effect on sleep organization and Atonia, REM sleep without, 209f
Adaptive servo-ventilation (ASV), for central sleep Atrial fibrillation
architecture of, 125, 125t heart failure with, 317f, 318f
apnea, 302f, 303f Anxiety disorders, 259
with stroke, 330f, 331f with obstructive apnea during wakefulness, 312f
Adderall (amphetamine-dextroamphetamine), to with insomnia, 102 with periodic breathing and paroxysmal nocturnal
polysomnographic features of, 255t, 259
promote wakefulness, 77t Anxiety dreams, 83 dyspnea, 309f
Adenoidal hypertrophy, obstructive sleep apnea due Aortic bodies, in control of breathing, 38f in hyperthyroidism, 230f
Aortic dilatation, due to obstructive sleep apnea, 216, in sleep apnea, 316f
to, 184–187, 285f, 286f Atrioventricular (AV) blocks, 319f
Adenoma, pituitary, 233, 234f 217f Mobitz second degree, 320f
Adenosine (AD), in sleep drive, 23f Apnea Wenckebach second degree, 319f
Adjustment sleep disorder, 105t Automatic behaviors, 108
ADNFLE (autosomal dominant nocturnal frontal lobe awake obstructive, 291f, 292f Autonomic neuropathy, due to diabetes, 241t
vs. hypopnea, 283f Autonomic regulation, in cardiovascular physiology,
epilepsy), 131 sleep (See Sleep apnea)
Adolescents, impact of sleep deprivation on, 85, 86b Apnea Questionnaire, 90, 90f 44–48
Adult(s), sleep architecture of, 64, 65f APSS (Association for the Psychophysiological Study Autosomal dominant nocturnal frontal lobe epilepsy
Advanced sleep phase disorder, 93
of Sleep), 13 (ADNFLE), 131
clinical presentation of, 93, 96t Arbilla, S., 16 Awake obstructive apnea, 291f, 292f
melatonin profile in, 93, 93f Aristotle, 8, 9f
rest-activity cycle in, 93, 93f, 96t Arjun, 7 with heart failure, 311f, 312f
treatment for, 93, 96t Arnold-Chiari malformation, 351
Age differences, in sleep architecture, 64, 65f Arousal(s) B
Aging. See also Elderly.
changes in sleep with, 67f, 275 confusional, 206t “Baby blues,”, 247
and growth hormone secretion, 57, 58f in obstructive sleep apnea, 216 Bacterial infection(s), and sleep, 34–36, 35f, 36f
Airflow thermistor, in diagnostic assessment, 262t parameters for evaluating, 276t Barbiturates
Airway collapse, promotion of, 40f respiratory effort–related, 168–170, 170f, 270
Airway patency Arousal disorder(s), 206–207 historical background of, 10, 11
in obstructive sleep apnea, 41–42, 42f clinical manifestations of, 206, 206t for sleep promotion, 69t
promotion of, 40f confusional arousals as, 206t Bariatric surgery, 165, 165f
Airway secretions, 360 epidemiology of, 206 BBB (blood-brain barrier), permeability to glucose of,
Alcohol examples of, 206t
and dreaming, 83 management of, 207 50, 50f
for sleep promotion, 76 pathogenesis of, 206 Becker muscular dystrophy, 327f, 351
Alcohol abuse, polysomnographic features of, 255t, predisposing or precipitating factors for, 206–207 Behavioral interventions, for delayed sleep phase
sleep terrors as, 206t, 208f
259 disorder, 91–92
Alcohol withdrawal syndromes, 76, 76f vs. nocturnal seizures, 212b Behaviorally induced insufficient sleep syndrome, 110
Alpha activity, 264t sleep-related eating disorder as, 207, 207b, 208f Benzer, S., 14
Alpha delta sleep, in fibromyalgia and chronic fatigue sleepwalking as, 206t, 207b Benzodiazepines
Arousal scoring, 267–268
syndrome, 143–144, 144f, 252, 252f cyclic alternating pattern in, 267–268, 268f, 269f binding site of, 72f
Alprazolam, for sleep promotion, 69t EEG speeding and CNS arousals in, 267, 268f historical background of, 13
ALS (amyotrophic lateral sclerosis), sleep disorders in, Arousal systems, 20, 20f, 21f for restless legs syndrome, 121t
Arousal threshold, in obstructive sleep apnea, 41f, for sleep promotion, 69, 69t
146 Berceau, le, 5, 5f
Alzheimer’s disease (AD), sleep disorders in, 140–142 42f, 353 Berger, Hans, 11
Arrhythmia(s). See Cardiac arrhythmia(s). Berlin Apnea Questionnaire, 90, 90f
consequences of, 140, 140f Art, sleep in, 1–7 Bhishma, 7, 7f
due to external (indirect) mechanisms, 140–141, Arterial blood pressure, during sleep, 45, 47f Bilevel pressure
Arterial hypertension, due to obstructive sleep apnea, central sleep apnea on, 301f
140t for COPD, 202f
due to internal (direct) mechanisms, 140, 140t 221, 221f heart failure and obstructive apnea on, 313f
pathophysiology of, 140–141, 140t, 141f Arthritis Blood flow, sleep and, 49–53
spectrum of, 140, 140f Blood gas chemistry, effect of obstructive sleep apnea
sundowning syndrome as, 141–142, 141f vs. restless legs syndrome, 120t
American Sleep Disorders Association, 15 rheumatoid, and pulmonary fibrosis, 201, 203f on, 216, 217f
Artifact(s), in polysomnography, 339

365

366 Index

Blood pressure Cardiac events, nocturnal, physiologic mechanisms Central sleep apnea (CSA) (Continued)
effect of obstructive sleep apnea on, 217f of, 46, 48t sleep laboratory video(s) on, 358
during sleep, 45, 47f
Cardiorespiratory sensors, for obstructive sleep apnea, due to medication, 173f, 299f, 300f
Blood pressure surges, during REM sleep, 51, 52f 284f in multiple sclerosis, 142–143, 142f, 143f
Blood-brain barrier (BBB), permeability to glucose of, with obesity, 358
Cardiovascular disease(s), 216–227 pathophysiology of, 41–42, 42f, 44f
50, 50f aortic dilatation as, 216, 217f period limb movements in, 196f
Bloodshot eyes, with overlap syndrome, 150, 199f cardiac arrhythmias as, 216, 217–219, 219f, 220f polysomnography of, 301
BMAL1 protein, in circadian clock, 25f coronary artery disease as, 219–220, 220f
Body position, in diagnostic assessment, 262t heart failure as with 5-minute epoch, 173f, 174f
Bonnard, Pierre, 3, 3f and central sleep apnea with 20-minute epoch, 173f
Botticelli, Sandro, 1–2, 2f Cheyne Stokes respirations in, 223–224, with 30-second epoch, 173f, 175f
BPD (bronchopulmonary dysplasia), and sleep- 223f, 224f with Cheyne Stokes respirations, 174f
clinical features of, 222–223, 222f, 223f with compressed 10-minute epochs, 172f
disordered breathing, 188f consequences of, 223–224, 224f with compressed 30-minute epoch, 174f
Bradyarrhythmia, during sleep, 32f epidemiology of, 222–223, 222f idiopathic, 299f, 300f
Brain with irregular rhythm and escape beats, 318f
vs. obstructive sleep apnea, 223–224 on adaptive servo-ventilation, 302f, 303f
in control of sleep, 20, 20f treatment of, 225–226, 225f, 226f on bilevel pressure, 301f
sleep as localized phenomenon of, 27–29 and obstructive sleep apnea, 221–223 on CPAP, 301f
Brain activity, in sleep staging, 261, 262t vs. central sleep apnea, 223–224 in infant, 188f
Brain gray matter loss, heart failure and, 45, 45f Cheyne Stokes respirations in, 313f due to medication, 299f, 300f
Brain-derived neurotrophic factor, and sleep, 34t clinical features of, 221, 222–223 treatment-emergent, 176f
Brainstem “arousal” centers, 21f epidemiology of, 221–223, 222f, 222t relationship between obstructive and, 44f
Breathing treatment of, 226–227, 226f with retinitis pigmentosa, sleep laboratory video(s)
control of impact of, 216, 216b, 216t
pathophysiology of, 216, 217f, 218f on, 358
central, 37, 37f patient interview video of apnea patient with, 347 risk factors for, 167–168
modulators of respiration chemoreceptors in, 38f pulmonary edema as, 216, 217f with seizures, 128f, 334f, 335f
in normal sleep, 37–40 sudden cardiac death as, 219 sleep laboratory video(s) on, 358–359
in sleep apnea, 41–43 systemic hypertension as, 221, 221f
during sleep, 29, 31f, 32f idiopathic, 358
Breathing artifacts, on EEG, 343f Cardiovascular exam, 88 with obesity, 358
Breathing disorders Cardiovascular physiology with retinitis pigmentosa, 358
with cerebrovascular accidents, 144–145, 145f, 145t sleep stage and, 170, 173f, 174f
sleep-related (See Sleep-disordered breathing [SDB]) central and autonomic regulation in, 44–48 sleep studies of, 172f, 173f, 174f, 175f, 176f, 188f
Bremer, F., 20f, 21f effect of sleep disorders on, 216, 217f, 218f Centrotemporal spikes, benign epilepsy of childhood
Brief sleep symptom checklist, 277–280, 277f Carotid bodies, in control of breathing, 38f
Bright light exposure Carskadon, Mary, 15, 15f with, 129, 130f
for advanced sleep phase disorder, 93 Cataplexy Cerebral blood flow (CBF)
for delayed sleep phase disorder, 91–92 clinical evaluation of, 87
for shift work sleep disorder, 95 defined, 87 nitric oxide and, 50, 50f
Bromocriptine, for growth hormone hypersecretion, medications for, 76t sleep and, 49–53, 49f
muscle groups affected in, 109f Cerebral perfusion pressure (CPP), and cerebral blood
234–236 narcolepsy with, 108, 109
Bronchopulmonary dysplasia (BPD), and sleep- flow, 50f
patient interview video on, 349 Cerebral vascular resistance (CVR), in REM sleep, 50f
disordered breathing, 188f narcolepsy without, 109 Cerebrovascular accident(s) (CVA)
Bruxism, 211–213 symptoms of, 108, 109f
treatment for, 114, 114b polysomnography of
clinical presentation of, 211–212, 213f triggers for, 108, 109f with excessive daytime sleepiness, 329f
consequences of, 211–212, 213f Catapres (clonidine), for restless legs syndrome, 121t with insomnia, 329f
polysomnogram of, 212, 213f, 214f Catastrophic disasters, sleepiness and, 85, 85f with sleep apnea, 330f, 331f
with small mandible, 155f CBF (cerebral blood flow)
treatment of, 212–213 nitric oxide and, 50, 50f sleep disorder(s) and, 144–146
“Buck teeth,” 154, 154f sleep and, 49–53, 49f breathing disturbances and, 144–145, 145f, 145t
Bundle branch blocks, 319f CBT (core body temperature), as circadian phase central sleep apnea as, 144–145, 144f
Burning feet, vs. restless legs syndrome, 120t polysomnography of, 329f, 330f, 331f
Burwell, C. S., 12, 13f marker, 27 excessive daytime sleepiness as, 329f, 330f
CBT (core body temperature) rhythm, in delayed sleep insomnia as, 329f
C obstructive sleep apnea as, 144–145, 146, 146f
Caffe´, Dr., 10 phase disorder, 91, 92f
Caffeine, to promote wakefulness, 78, 79f CCK (cholecystokinin), and sleep, 54, 54t Cervantes Saavedra, Miguel de, 9, 9f
Calf cramp, 326f, 327f Center for Sleep Disorders Research, 18 Cerveau isole, 20f
CAP (cyclic alternating pattern), of arousals, 267–268, Centers for Disease Control and Prevention (CDC), 19 Cesarean delivery, sleep disturbance(s) after, 247f, 248t
Central nervous system (CNS) arousals, EEG speeding CFS (chronic fatigue syndrome), 251–253
268f, 269f
Carbamazepine, for REM sleep behavior disorder, and, 267, 268f characteristics of, 251, 251b
Central regulation, in cardiovascular physiology, sleep disturbances in, 251–252, 252f
138–139 “Charlie horse cramps,” vs. restless legs syndrome, 120t
Carbon dioxide. See CO2. 44–48 Chemoreceptors, in control of breathing, 38f
Cardiac arrhythmia(s), 315–323 Central sleep apnea (CSA) Chest sweating, during sleep, 31f
Cheyne, John, 9
atrial fibrillation as after arousals, 170, 172f Cheyne Stokes respirations (CSR)
with heart failure, 317f, 318f with cerebrovascular accidents, 144–145, 144f with cerebrovascular accident, 144–145, 145f
with obstructive apnea during wakefulness, with heart failure
312f polysomnography of, 329f, 330f, 331f
with periodic breathing and paroxysmal in children, 184–187, 188f and atrial fibrillation, 317f, 318f
nocturnal dyspnea, 309f and central sleep apnea, 223–224, 223f, 224f
with sleep apnea, 316f due to neuromuscular disorders, 184–187, 188f in child, 307f, 308f
defined, 41–42, 299f with irregular rhythm and escape beats, 318f
due to heart blocks, 319f forms of, 42f with multiple abnormalities, 310f
Mobitz second degree, 320f due to growth hormone hypersecretion, 233–234 and obstructive sleep apnea, 313f
third degree, 320f heart failure and, 42f sleep laboratory video(s) on, 359
Wenckebach second degree, 319f and tachycardia, 322f
Cheyne Stokes respirations in, 223–224, 223f, while asleep, 309f
irregular rhythm and escape beats as, 318f 224f while awake, 305f, 306f
premature ventricular contractions as, 321f, 323f historical background of, 9, 10, 11
sinus arrest and junctional escape rhythm as, 315f clinical features of, 222–223, 222f, 223f sleep study of, 170, 174f
due to sleep apnea, 15, 15f consequences of, 223–224, 224f Child(ren)
epidemiology of, 222–223, 222f congestive heart failure in, 307f, 308f
atrial fibrillation as, 316f vs. obstructive sleep apnea, 223–224 periodic limb movements in sleep in, 189f
obstructive, 216, 217–219, 219f, 220f treatment of, 225–226, 225f, 226f sleep architecture of, 64, 65f, 66f
tachycardia as, 322f, 323f idiopathic, 299f, 300f sleep stages in, 275
ventricular, 322f, 323f on adaptive servo-ventilation, 302f, 303f sleep-disordered breathing in, 184–189
due to upper airway resistance syndrome, 298f on bilevel pressure, 301f central, 184–187
Cardiac artifacts, on EEG, 340f, 342f, 343f on CPAP, 301f
defined, 300f due to neuromuscular disorders, 184–187, 188f

Index 367

Child(ren) (Continued) Circadian rhythm sleep disorder(s) (CRSDs) (Continued) Congestive heart failure (Continued)
obstructive, 184–187 treatment for, 95, 96t treatment of, 226–227, 226f
due to craniofacial abnormalities, 184–187,
186f jet lag sleep disorder, 95–96 oxygen therapy for, 314f
due to Down syndrome, 184–187, 187f clinical presentation of, 95, 96t polysomnography of, 305
due to laryngomalacia, 184–187, 185f, 186f rest-activity cycle in, 96f, 96t
due to mandibular insufficiency, 152, 152f treatment for, 95, 96t with atrial fibrillation, 309f, 312f
due to obesity, 184–187, 184f with Cheyne Stokes respirations
due to pharyngolaryngomalacia, 184–187, 186f psychiatric consequences of, 260t
polysomnography of, 285f, 286f shift work sleep disorder as, 95 in child, 307f, 308f
sleep laboratory video(s) on, 299 with multiple abnormalities, 310f
due to tonsillar and adenoidal hypertrophy, clinical presentation of, 95, 96t and obstructive sleep apnea, 313f
184–187, 184f, 285f, 286f epidemiology of, 95 while asleep, 309f
patient interview video of, 347–348 rest-activity cycle in, 95f, 96t while awake, 305f, 306f
periodic respirations as, 184–187, 189f treatment for, 95, 96t in child, 307f, 308f
treatment of, 192, 194f, 195f Circadian system, 26f CO2 oscillations in, 306f, 311f
Circulation, during sleep, 29, 32f with irregular rhythm and escape beats, 318f
Chin, receding, due to mandibular insufficiency, 152, Circulatory homeostasis, during sleep, 44–48 with multiple abnormalities, 310f, 311f
153f CKD. See Chronic kidney disease (CKD). and obstructive apnea, 311f
Cleopatra, 4–5, 4f on bilevel pressure, 313f
Chin EMG, artifacts in, 346f Clinical evaluation, 86–88 on CPAP, 314f
Chloral betaine, for sleep promotion, 69t of excessive sleepiness, 87, 87b on ventilatory support, 312f
Chloral hydrate family history in, 88 with obstructive apnea during wakefulness, 311f,
history of present illness in, 86
discovery of, 10 impact on patient in, 88 312f
for sleep promotion, 69t of insomnia, 87, 87b with paroxysmal nocturnal dyspnea, 305f, 309f,
Chlormethiazole, for sleep promotion, 69t medical history in, 88, 88b
Cholecystokinin (CCK), and sleep, 54, 54t medication history in, 88 312f
Chronic fatigue syndrome (CFS), 251–253 patient complaints in, 86, 86b with periodic breathing, 309f, 310f, 314f
characteristics of, 251, 251b of sleep behaviors, 87–88, 88b with periodic leg movements, 310f
sleep disturbances in, 251–252, 252f of sleep-disordered breathing, 86, 87b during sleep, 309f
Chronic kidney disease (CKD), sleep disorder(s) in, social history in, 88 with sleep-onset insomnia, 305f
Clock gene, 18 Conjunctival injection, in burnt-out Graves’ disease, 231f
241–242 CLOCK protein, in circadian clock, 25f Continuous positive airway pressure (CPAP)
common, 241, 241t Clomipramine, for cataplexy, 76t central sleep apnea on, 301f
due to diabetes, 241t Clonazepam (Klonopin) for COPD, 199f, 200f
factors influencing development of, 241, 241f for REM sleep behavior disorder, 138–139 and growth hormone secretion, 58, 59f
obstructive sleep apnea as, 241 for restless legs syndrome, 121t for heart failure
restless legs syndrome as, 241, 242f for sleep promotion, 69t with central sleep apnea, 225–226, 225f, 226f
Chronic obstructive pulmonary disease (COPD), Clonidine (Catapres), for restless legs syndrome, 121t with obstructive sleep apnea, 226–227, 226f, 314f
CNS (central nervous system) arousals, EEG speeding historical background of, 15
197–200 patient interview video on teaching and fitting mask
abnormal sleep physiology in, 197b and, 267, 268f
all-night oximetry in, 197f CO2, in control of breathing, 38f for, 348
with insomnia, 102, 102f CO2 channel, in heart failure with obstructive sleep for sleep-disordered breathing, 190–192
in nonobese patients, 197, 198f, 199f
in obese patients, 199, 199f, 200f apnea, 313f adverse effects of, 192, 192f, 193f
in overlap syndrome, 197 CO2 measurement, end-tidal in children, 192, 195f
flow generators for, 190, 190f
sleep laboratory videos on, 360, 361 for obstructive sleep apnea, 285f titration of, 190–192, 191f, 192f
periodic limb movements in sleep with, 197, 199f, 360 for sleep-disordered breathing, 269 types of masks for, 190, 190f
severe, 199, 201f, 202f CO2 oscillations, in congestive heart failure, 306f, 311f Continuous spike waves during slow-wave sleep
sleep disturbances in, 197, 197b Codeine, for restless legs syndrome, 121t
sleep laboratory videos on, 359, 360 Cognitive behavioral therapy, for insomnia, 106, 106t (CSWS), epilepsy with, 131
spectrum of, 197 Cognitive processes, in dreaming, 80–81, 80f, 81t COPD. See Chronic obstructive pulmonary disease
Chronic pain, sleep disorders with, 143, 143f Collar size, large, 164, 164f, 165f
Chronotherapy, for delayed sleep phase disorder, Comorbid conditions (COPD).
with narcolepsy, 114, 114f Core body temperature (CBT), as circadian phase
91–92 with restless legs syndrome, 115–116, 116f, 117f
Cigarette smoking, COPD due to, 198f Comorbid insomnia, 101–103 marker, 27
Circadian clock, 24f, 25–27, 25f with congestive heart failure, 102, 103f Core body temperature (CBT) rhythm, in delayed
Circadian genes, 18
Circadian mutant mammals, historical background of, with COPD, 102, 102f sleep phase disorder, 91, 92f
defined, 98, 100–101 Corneal injection, in hyperthyroidism, 229f
18, 18f with depression, 102, 103f, 104f Coronary artery disease, and sleep apnea, 316f
Circadian phase markers, 27 epidemiology of, 101f
Circadian rhythm(s) historical background of, 16 obstructive, 219–220, 220f
with medical conditions, 102b Coronary blood flow, during sleep, 46, 46f, 47f
historical background of, 9 with psychiatric conditions, 102, 102b, 103f Cortical arousal, 21f, 22f
regulation of, 25–27 Compensatory breathing mechanisms, during REM Corticotroph-releasing hormone (CRH), ghrelin and,
Circadian rhythm sleep disorder(s) (CRSDs), 25,
sleep, 44–45 53–54, 55f
91–97 Complex sleep apnea, 303f, 304f Cortisol secretion, temporal variations in, 57, 57f
advanced sleep phase disorder as, 93 Conditioned reflexes, historical background of, 11, 11f CPAP. See Continuous positive airway pressure
Confusional arousals, 206t
clinical presentation of, 93, 96t Congestive heart failure (CPAP).
melatonin profile in, 93, 93f CPP (cerebral perfusion pressure), and cerebral blood
rest-activity cycle in, 93, 93f, 96t and central sleep apnea, 42f
treatment for, 93, 96t Cheyne Stokes respirations in, 223–224, flow, 50f
defined, 91 223f, 224f Cradle, The, 5, 5f
delayed sleep phase disorder as, 91–92 clinical features of, 222–223, 222f, 223f Craniofacial abnormalities, obstructive sleep apnea due
clinical presentation of, 91, 96t consequences of, 223–224, 224f
core body temperature rhythm in, 91, 92f epidemiology of, 221–223, 222f to, 184–187, 186f
epidemiology of, 91 vs. obstructive sleep apnea, 223–224 Creased tongue, 154, 155f
melatonin profile in, 91, 92f treatment of, 225–226, 225f, 226f Crescendo-decrescendo pattern of breathing, in central
rest-activity cycle in, 91, 91f, 96t
treatment for, 91–92, 96t in child, 307f, 308f sleep apnea, 42f
free-running disorder/nonentrained disorder as, 94 clinical features of, 221 CRH (corticotroph-releasing hormone), ghrelin and,
clinical presentation of, 94, 96t epidemiology of, 221–223
epidemiology of, 94 with insomnia, 102, 103f 53–54, 55f
rest-activity cycle in, 94, 94f, 96t and obstructive sleep apnea, 221–223 Crowded teeth, 152, 152f
treatment for, 94, 96t CRSDs. See Circadian rhythm sleep disorder(s).
irregular sleep-wake disorder as, 94–95 vs. central sleep apnea, 223–224 CRY protein, in circadian clock, 25f
clinical presentation of, 94, 96t Cheyne Stokes respirations in, 313f CSA. See Central sleep apnea (CSA).
epidemiology of, 94 clinical features of, 221, 222–223 CSR. See Cheyne Stokes respirations (CSR).
rest-activity cycle in, 94f, 96t epidemiology of, 221–223, 222f, 222t CSWS (continuous spike waves during slow-wave

sleep), epilepsy with, 131
CVA. See Cerebrovascular accident(s) (CVA).
CVR (cerebral vascular resistance), in REM sleep, 50f
Cyanosis, with COPD and sleep apnea, 199f
Cyclic alternating pattern (CAP), of arousals, 267–268,

268f, 269f
Cytokines

368 Index

Cytokines (Continued) Diagnosis (Continued) DLMO (dim light melatonin onset) (Continued)
abbreviations used for, 34b of insomnia, 87, 87b in delayed sleep phase disorder, 91, 92f
and sleep, 34–36, 34t, 35f, 36f medical history in, 88, 88b
medication history in, 88 DMH (dorsomedial hypothalamic nucleus), in control
Czeisler, Chuck, 15, 16f patient complaints in, 86, 86b of timing of sleep, 24f
of sleep behaviors, 87–88, 88b
D of sleep-disordered breathing, 86, 87b Dopamine agonists, for restless legs syndrome, 121t
social history in, 88 Dopaminergic agents, for restless legs syndrome, 121t
Danger, sleep and, 6 Dorsal respiratory group (DRG), in control of
Darvocet (propoxyphene), for restless legs syndrome, physical exam in, 88, 88b, 89b
self-administered instrument(s) in, 89–90 breathing, 37f
121t Dorsomedial hypothalamic nucleus (DMH), in control
Darvon (propoxyphene), for restless legs syndrome, Berlin Apnea Questionnaire as, 90, 90f
Epworth Sleepiness Scale as, 90, 90f of timing of sleep, 24f
121t sleep diaries as, 89, 89f Double vision, in hyperthyroidism, 229f
Day residue effect, of dreaming, 81 Diagnostic assessment method(s), 261–282 Down syndrome
Daytime sleepiness arousal scoring as, 267–268
cyclic alternating pattern in, 267–268, 268f, 269f inspection of face for, 150, 150f
and catastrophic disasters, 85, 85f EEG speeding and CNS arousals in, 267, 268f sleep apnea in
clinical evaluation of, 87, 87b electrocardiogram as, 262t, 273
with depression, 254 home sleep testing as, 273–274, 273f, 274f obstructive
in epilepsy patients, 130f, 131 for movements, 271–272 in children, 184–187
medications for, 76t leg movement recording technique for, 271 polysomnography of, 187f, 293f
in multiple sclerosis, 338f, 339f other, 271–272 sleep laboratory video(s) on, 357
in narcolepsy, 107–108, 107b periodic leg movement scoring rules for, 271, 272f
in older patients, 99f overall assessment as, 274–281 patient interview video on, 347
in Parkinson’s disease, 132, 132f parameters, pathophysiology, and interpretation Doxylamine (Unisom Nighttime), for sleep promotion,
during pregnancy, 245–246
with stroke, 329f, 330f in, 275–281, 276t 75t
treatment for, 114 sleep center health and family questionnaire in, 279f Dream(s)
De Mairan, Jean-Jacques d’Ortous, 9, 10f sleep center medication log in, 277–280, 281f
Death, sleep and, 1, 7 sleep clinic screening questionnaire in, 277–280, anxiety, 83
Death of Bhishma, 7f in art, 6–7
Delayed sleep phase disorder (DSPD), 91–92 277f enhanced realism of, 83
clinical presentation of, 91, 96t sleep problems checklist in, 277–280, 278f violent, 82
core body temperature rhythm in, 91, 92f sleep stage changes in Dream curtailment, 82, 82t
epidemiology of, 91 Dream disturbance(s)
melatonin profile in, 91, 92f across night, 275, 275f, 276t continuum of, 82, 82f
with mood disorders, 254 as function of age, 275 nightmares as, 83, 83f
rest-activity cycle in, 91, 91f, 96t sleep staging as, 261–267 with simulation attenuation, 82, 82f, 82t
sleep laboratory video on, 363 classification in, 263 with simulation augmentation, 82, 82f, 83t
treatment for, 91–92, 96t of stage N1, 263, 265f treatment of, 83
Delayed sleep phase syndrome (DSPS). See Delayed of stage N2, 265, 265f Dream impoverishment, 82, 82t
of stage N3, 265, 266f Dream interruption insomnia (DII), 82
sleep phase disorder (DSPD). of stage R, 266, 266f Dream of Constantine, 3–4, 3f
della Francesca, Piero, 3–4, 3f of stage W, 263, 264f Dream of Reason Brings Monsters, The, 6, 6f
Delvaux, Laurent, 4–5, 4f of waves, 263, 264t Dream stereotypy, 82, 83t
Dement, William C., 13, 13f, 14, 14f, 17 recording in, 261–263, 262t Dream, The, 6, 6f
Dementia, sleep disorders in, 140–142 of EEG of brain activity, 261, 262f, 262t, 263f Dreaming, 80–84
of EMG of skeletal muscle tone, 262t, 263 cessation of, 82, 82t
consequences of, 140, 140f of eye movements, 261–263, 262t cognitive processes in, 80–81, 80f, 81t
due to external (indirect) mechanisms, 140–141, smoothing rules in, 266–267 defined, 80
for sleep-related breathing disorders, 269–270 drug and alcohol effects on, 83
140t definitions and scoring rules for, 269–270 excessive, 82, 83t
due to internal (direct) mechanisms, 140, 140t for hypopnea, 269–270, 271f experiential content of, 80f, 81–82, 81t
pathophysiology of, 140–141, 140t, 141f for respiratory effort related arousals, 270 nature of, 80–82, 80f
spectrum of, 140, 140f for sleep apnea, 269, 270f perceptual processes in, 80, 81t
sundowning syndrome as, 141–142, 141f recording technique in, 267t, 269 reasons for assessing, 82
Dental abnormalities, sleep apnea due to, 154, 154f Diazepam, for sleep promotion, 69t in sleep medicine, 82–83
Dental device, for sleep-disordered breathing, 192 Dickens, Charles, 10, 10f Dream-lag effect, 81
mandibular advancement device as, 192, 194f DII (dream interruption insomnia), 82 Dream-reality confusion, 82, 83t
rapid maxillary expansion as, 192, 194f Dim light melatonin onset (DLMO) DRG (dorsal respiratory group), in control of
due to retrognathia, 193f in advanced sleep phase disorder, 93, 93f
Depression as circadian phase marker, 27 breathing, 37f
daytime sleepiness with, 254 in delayed sleep phase disorder, 91, 92f Driving, impact of sleep deprivation on, 85, 85b
EEG analysis of, 258, 259f Dionysus, 8, 8f Drug(s). See Pharmacologic agent(s).
with insomnia, 102, 103f, 104f Diphenhydramine (Nytol, Sleep-Eze, Sominex), for Drug effects, on dreaming, 83
Drug-induced REM sleep behavior disorder, 136, 136f,
vignette on, 256b sleep promotion, 74, 75t
polysomnographic features of, 256, 258, 258f Diphenhydramine in combination (Anacin PM, 209b, 210f
postpartum, 247 Drug-related hyperthyroidism, 228t
REM suppressant action of treatments for, 256–257, Excedrin PM, Tylenol PM), for sleep DSPD. See Delayed sleep phase disorder (DSPD).
promotion, 75t DSPS (delayed sleep phase syndrome). See Delayed
257t, 258f, 258t Disasters, sleepiness and, 85, 85f
sleep disorder(s) in, 255–258 Discoloration, due to chronic peripheral edema, sleep phase disorder (DSPD).
166, 166f Duodenal ulcer disease, 237
as barrier to treatment, 254–255, 255f Disorder(s) of arousal, 206–207 Dyspepsia, functional, 239, 239f
and relapse, 255–256, 256f clinical manifestations of, 206, 206t Dyspnea, paroxysmal nocturnal
as risk factors, 255–256 confusional arousals as, 206t
types of, 255–256, 255f, 255t epidemiology of, 206 and Cheyne Stokes respirations, 174f
Desaturation, due to obstructive sleep apnea, 216, 218f examples of, 206t with heart failure, 305f, 309f, 312f
Dexmethylphenidate (Focalin), to promote management of, 207 Dysrhythmia(s). See Cardiac arrhythmia(s).
pathogenesis of, 206
wakefulness, 77t predisposing or precipitating factors for, 206–207 E
Diabetes mellitus, 240–241 sleep terrors as, 206t, 208f
vs. nocturnal seizures, 212b Ear oximeter, fiberoptic-based, 15
clinical features of, 240t sleep-related eating disorder as, 207, 207b, 208f Early morning awakening, 99f
sleep disturbances and, 240, 240f, 241t sleepwalking as, 206t, 207b Earthly Paradise, 3, 3f
symptoms of, 240 Dissolute Household, The, 4, 4f Eating disorder, sleep-related, 207, 207b, 208f
Diabetic neuropathy DLMO (dim light melatonin onset) Edema
autonomic, 241t in advanced sleep phase disorder, 93, 93f
peripheral, 241t as circadian phase marker, 27 peripheral, 166
Diagnosis discoloration due to, 166, 166f
clinical evaluation in, 86–88 with hypoventilation syndrome, 166, 166f
infection due to, 166, 166f
of excessive sleepiness, 87, 87b not always present, 166f
family history in, 88 pitting, 166f
history of present illness in, 86
of impact on patient, 88 pulmonary
due to heart failure, 359
due to obstructive sleep apnea, 216, 217f, 359

Index 369

EDS. See Excessive daytime sleepiness (EDS). Esophageal pressure, in diagnostic assessment, 262t Gastroesophageal reflux (GER) (Continued)
EEG. See Electroencephalography (EEG). Esophagitis, 237 epidemiology of, 237
Ekbom, K. A., 12 Eszopiclone esophageal pH recordings of, 238f
EKG (electrocardiogram) pulmonary complications of, 239
pharmacokinetics of, 73f symptoms of, 237, 237f
artifacts in, 346f for sleep promotion, 74f therapeutic considerations for, 232f, 238
in diagnostic assessment, 262t, 273 structure of, 73f in waking vs. sleeping, 237, 238f
EKG (electrocardiographic) artifacts, on EEG, 340f, Ethanol
for sleep promotion, 76 Gastrointestinal disorder(s), 236–240
342f, 343f structure of, 76f duodenal ulcer as, 237
Elderly. See also Aging. Excedrin PM (diphenhydramine in combination), for gastroesophageal reflux as
defenses against, 238, 238f
changes in sleep in, 67f, 275 sleep promotion, 75t epidemiology of, 237
factors affecting sleep in, 66f Excessive body movement, sleep laboratory videos on esophageal pH recordings of, 238f
insomnia in, 99, 99f pulmonary complications of, 239
patient interview video of sleep apnea in, 347 obstructive sleep apnea with, 354 symptoms of, 237, 237f
restless legs syndrome in, 117, 117f Excessive daytime sleepiness (EDS) therapeutic considerations for, 232f, 238
sleep architecture in, 64, 65f in waking vs. sleeping, 237, 238f
Electrical interference, artifacts on polysomnography and catastrophic disasters, 85, 85f irritable bowel syndrome as, 239, 239f
clinical evaluation of, 87, 87b nocturnal symptoms of, 236–238, 237b
due to, 339f, 340f with depression, 254
Electrocardiogram (EKG) in epilepsy patients, 130f, 131 Ge´lineau, Jean Baptiste Edouard, 11
medications for, 76t Genioglossus muscle
artifacts in, 346f in multiple sclerosis, 338f, 339f
in diagnostic assessment, 262t, 273 in narcolepsy, 107–108, 107b during obstructive sleep apnea, 41f
Electrocardiographic (EKG) artifacts, on EEG, 340f, in older patients, 99f during sleep, 37, 40f
in Parkinson’s disease, 132, 132f GER. See Gastroesophageal reflux (GER).
342f, 343f during pregnancy, 245–246 GH. See Growth hormone (GH).
Electroencephalographic (EEG) speeding, and CNS with stroke, 329f, 330f Ghrelin
treatment for, 114 diurnal variation in, 57, 58f
arousals, 267, 268f Exophthalmos, of Graves’ disease, 231f and sleep, 53–54, 54t, 55f
Electroencephalography (EEG), 261, 262t Experiential content, of dreams, 80f, 81–82, 81t sleep deprivation and, 58–60, 59f
Extraocular muscle weakness, in hyperthyroidism, 229f Gigantism
artifacts in, 340f, 341f, 342f Eye(s), bloodshot, with overlap syndrome, 150, 150f defined, 234
breathing, 343f Eye channel artifacts, 344f, 345f diagnosis of, 234
cardiac, 340f, 342f, 343f Eye movements, in sleep staging, 261–263, 262t, 267t treatment of, 234–236
Eyelid drooping Giorgione, 2, 2f
for depression, 258, 259f in burnt-out Graves’ disease, 231f Glossitis, and restless legs syndrome, 117f
derivations for recording, 262f, 263f with sleep apnea, 150, 150f Glucose, permeability of blood-brain barrier to,
of stage N1 sleep, 62f
of stage N2 sleep, 63f F 50, 50f
of stage N3 sleep, 63f Falstaff, 8 Glucose regulation
of stage R sleep, 64f Family history, 88
of stage W sleep (wakefulness), 62f Family questionnaire, 279f and hunger, 57, 57f, 58f
Electromyography (EMG), 262t, 263, 267t Fatal familial insomnia, 147–148 sleep and circadian effect on, 57f
chin, artifacts in, 346f Fatigue, chronic, 251–253 Goiter, toxic, 228t
of stage N1 sleep, 62f Goya, Francisco Jose´ de, 6, 6f
of stage N2 sleep, 63f characteristics of, 251, 251b Graves’ disease
of stage N3 sleep, 63f sleep disturbances in, 251–252, 252f burnt-out, 231f
of stage R sleep, 64f Fatigue severity scale (FSS), for narcolepsy, 112 hypothyroidism due to treatment of, 231f
of stage W sleep (wakefulness), 62f Feeding, interactive regulation of sleep and, 53–56, 54f symptoms of, 228b, 228t
Electro-oculography (EOG), 261–263, 262t Ferrous sulfate, for restless legs syndrome, 121t Graves’ ophthalmopathy, 228b, 229f
of stage N1 sleep, 62f FFND (frontofacionasal dysostosis), 186f Gray matter loss, heart failure and, 45, 45f
of stage N2 sleep, 63f Fibromyalgia (FM), 251–253 Growth hormone (GH) hypersecretion, 233–236
of stage N3 sleep, 63f alpha delta sleep in, 143–144, 144f, 252, 252f clinical feature(s) of, 234, 234b
of stage R sleep, 64f characteristics of, 251, 251b
of stage W sleep (wakefulness), 62f sleep disorders in, 143–144, 143f, 144f, 251–252 enlarged hands as, 236f
EMG. See Electromyography (EMG). sleep spindles in, 252, 252f enlarged tongue as, 236f
Encephale isole, 20f tender points in, 251, 251f frontal bossing as, 235f
Encephalitis lethargica, 20f Fischer, Emil, 11 in jaw and dental structures, 236f
Endocrine physiology, 56–60 Fluoxetine, for cataplexy, 76t slow evolution of, 235f
aging and, 57, 58f Fluvoxamine, for cataplexy, 76t diagnosis of, 234
glucose regulation and hunger in, 57, 57f, 58f FM. See Fibromyalgia (FM). pathophysiology of, 233–234, 234f
mechanism controlling pituitary hormone secretion Focalin (dexmethylphenidate), to promote sleep-disordered breathing with, 233–234, 235f
treatment of, 234–236
in, 56, 56f wakefulness, 77t Growth hormone releasing hormone, and sleep, 34t
overview of, 56–57 Food intake, interactive regulation of sleep and, 53–56, Growth hormone (GH) secretion
in sleep apnea syndrome, 58, 59f aging and, 57, 58f
sleep deprivation and, 58–60, 59f 54f sleep apnea and, 58, 59f
temporal variations of plasma hormone levels in, Forehead bossing, in acromegaly, 235f temporal variations in, 57, 57f
Fragmented nighttime sleep, in narcolepsy, 108 Guilleminault, Christian, 15, 16, 16f
57, 57f Free-running disorder, 94 Guthrie, Samuel, 10
End-tidal CO2 measurement
clinical presentation of, 94, 96t H
for obstructive sleep apnea, 285f epidemiology of, 94 H+ concentration, in control of breathing, 38f
for sleep-disordered breathing, 269 rest-activity cycle in, 94, 94f, 96t Hair loss, in hypothyroidism, 232f
EOG. See Electro-oculography (EOG). treatment for, 94, 96t Hallucinations
Epilepsy, 125–131 Frontal bossing, in acromegaly, 235f
benign childhood (with Rolandic spikes), 129, Frontal lobe epilepsy, nocturnal, 126, 127f hypnagogic
autosomal dominant, 131 defined, 87, 108, 109f
130f, 337f vs. parasomnias, 125, 125t in narcolepsy, 107–108, 107b
epidemiology of, 125 Frontofacionasal dysostosis (FFND), 186f patient interview videos of
frontal lobe, 126, 127f FSS (fatigue severity scale), for narcolepsy, 112 with multiple sclerosis and sleep apnea, 351
Functional dyspepsia, 239, 239f with psychiatric disorders, 352
autosomal dominant, 131 Fuseli, Henry, 6, 6f, 9f
vs. parasomnias, 125, 125t hypnopompic, 87, 108, 109f
hypersomnia in, 130f, 131 G in narcolepsy, 349
nocturnal seizures in (See Nocturnal seizures) GABA-A receptor complex, and hypnotic agents, 69f, Hamlet, 7
obstructive sleep apnea and, 131 Hammond, William, 11
temporal lobe, 126, 127–129, 129f 70–71, 70f Hand enlargement, in acromegaly, 236f
polysomnography of, 335f, 336f Gabapentin (Neurontin), for restless legs syndrome, 121t Harrison, W. R., 11, 12f
with tonic-clonic seizures upon awakening, 131 Gastaut, H., 13 HD (Huntington’s disease), sleep disorders in,
Episodic memories, in dreaming, 81 Gastroesophageal reflux (GER)
Episodic referencing, in dreaming, 81 146–147, 147b, 147f, 328f
Epworth Sleepiness Scale (ESS), 90, 90f, 277–280, defenses against, 238, 238f

277f
for narcolepsy, 112
Escape beats, heart failure with, 318f
Esophageal pH recordings, 238f

370 Index Hyperpnea, during sleep, 33f Hypopnea (Continued)
Hypersomnia(s) scoring of, 168–170
Head trauma, 337f, 338f with 10-minute compressed epoch, 168f, 318f
Health and family questionnaire, 279f classification of, 109–110, 109b with 30-second epoch, 169f, 324f
Health care utilization, sleep apnea and, 86, 86f due to drug or substance, 110 scoring rules for, 270, 271f
Heart blocks, 319f in epilepsy patients, 130f, 131
idiopathic Hypotension, and cerebral blood flow, 50f
Mobitz second degree, 320f Hypothalamic temperature, during sleep, 30f
third degree, 320f defined, 108 Hypothalamus, lateral, in sleep regulation, 21f, 22f
Wenckebach second degree, 319f with long sleep time, 110 Hypothyroidism, 229–232
Heart failure without long sleep time, 110
and brain gray matter loss, 45, 45f vs. narcolepsy, 108, 108f causes of, 231t
and central sleep apnea due to medical condition, 110 sleep findings in, 231b
menstrual-associated, 110 symptom(s) of, 231b
Cheyne Stokes respirations in, 223–224, nonorganic, 110
223f, 224f not due to substance or known physiologic of eyes, 232f
of hair, 232f
clinical features of, 222–223, 222f, 223f condition, 110 macroglossia as, 232f
consequences of, 223–224, 224f not otherwise specified over time, 232f
epidemiology of, 221–223, 222f due to treatment of Graves’ disease, 231f
vs. obstructive sleep apnea, 223–224 nonorganic, 110 Hypoventilation
treatment of, 225–226, 225f, 226f organic, 110 vs. obstructive sleep apnea, 290f
clinical features of, 221 physiologic, unspecified, 110 upper airway resistance syndrome with prolonged
epidemiology of, 221–223 recurrent, 110
left ventricular, 305f, 306f, 309f Hypersomnolence obstructive, 297f
obesity ventilation syndrome with, 355 brain in, 20f Hypoventilation syndrome, 150
and obstructive sleep apnea, 221–223 clinical evaluation of, 87, 87b
vs. central sleep apnea, 223–224 Hypertension, systemic, due to obstructive sleep with heart failure, 355
clinical features of, 221, 222–223 peripheral edema in, 166, 166f
epidemiology of, 221–223, 222f, 222t apnea, 221, 221f sleep laboratory video(s) on, 355
polysomnography of, 311f Hyperthyroidism, 228 Hypoxemia
nonapneic, 183, 183f
on bilevel pressure, 313f atrial fibrillation in, 230f due to obstructive sleep apnea, 216, 217f
on CPAP, 314f causes of, 228t Hypoxia, response to, 39f
on ventilatory support, 312f Graves’ ophthalmopathy in, 228b, 229f
sleep laboratory video(s) on, 359 polysomnogram of sweat artifact in, 230f I
treatment of, 226–227, 226f sleep findings in, 228b IBS (irritable bowel syndrome), 239, 239f
oxygen therapy for, 314f symptoms of, 228b ICSD-2 (International Classification of Sleep Disorders:
polysomnography of, 305 thyroid stare in, 228f
with atrial fibrillation, 309f, 312f, 317f, 318f Hyperventilation, central sleep apnea due to, 42f Diagnostic and Coding Manual, 2nd edition), on
with Cheyne Stokes respirations Hypnagogic hallucinations hypersomnias, 109–110, 109b
in child, 307f, 308f defined, 87, 108, 109f ICU (intensive care unit) dream delirium, 82
with multiple abnormalities, 310f in narcolepsy, 107–108, 107b Idiopathic hypersomnia (IH)
and obstructive sleep apnea, 313f patient interview videos of defined, 108
and tachycardia, 322f with long sleep time, 110
while asleep, 309f with multiple sclerosis and sleep apnea, 351 without long sleep time, 110
while awake, 305f, 306f with psychiatric disorders, 352 vs. narcolepsy, 108, 108f
in child, 307f, 308f Hypnogram, for sleep-disordered breathing, 178, 181f Idiopathic pulmonary fibrosis, 201, 202f
CO2 oscillations in, 306f, 311f Hypnopompic hallucinations, 87, 108, 109f mixed sleep apnea with, 305f
with irregular rhythm and escape beats, 318f Hypnotic agent(s), 69–76, 69t IH. See Idiopathic hypersomnia (IH).
with multiple abnormalities, 310f, 311f barbiturates as, 69t Imipramine, for REM sleep behavior disorder, 138–139
and obstructive apnea, 311f benzodiazepines as, 69, 69t, 72f Impact, of sleep disorders, 85
on bilevel pressure, 313f chloral hydrate/betaine as, 69t on adolescents, 85, 86b
on CPAP, 314f chlormethiazole as, 69t in clinical evaluation, 88
on ventilatory support, 312f diphenhydramine as, 74, 75t on disasters, 85, 85f
with obstructive apnea during wakefulness, eszopiclone as, 74f on driving, 85, 85b
pharmacokinetics of, 73f on workplace productivity, 85, 85b
311f, 312f structure of, 73f Infants
with paroxysmal nocturnal dyspnea, 305f, ethanol as, 76 sleep stages in, 275
structure of, 76f sleep-disordered breathing in, 149, 188f, 189f
309f, 312f GABA-A receptor complex and, 69f, 70–71, 70f Infection(s)
with periodic breathing, 309f, 310f, 314f over-the-counter, 75t due to chronic peripheral edema, 166, 166f
with periodic leg movements, 310f promethazine as, 69t due to CPAP treatment, 193f
during sleep, 309f ramelteon as, 74, 75f and sleep, 34–36, 35f, 36f
with sleep-onset insomnia, 305f structure of, 74f Inflammatory states, and sleep, 34
Heart rate sedating antidepressants (trazodone) as, 74–75, 75f Influenza virus, and NREM sleep, 35f
during sleep, 32f, 45f characteristics of, 75b Ingenious Hidalgo Don Quixote of La Mancha, The, 9
surges in, 45–46, 46f, 47f structure of, 75f Insomnia, 98–106
Heart rate deceleration, in REM sleep, 46, 47f site of action of, 71, 71f brain in, 20f
Heart rhythm, parameters for evaluating, 276t triazolam as, 71, 71t classification of, 98
Heart rhythm pauses, in REM sleep, 46, 47f site of action of, 71f clinical evaluation of, 87, 87b
Heartburn, 237, 237f structure of, 72f comorbid, 101–103
HEENT exam, 88, 89b zaleplon as, 69t, 74f with congestive heart failure, 102, 103f
Hippocrates, 8, 8f binding site of, 72f with COPD, 102, 102f
History structure of, 74f defined, 98, 100–101
of present illness, 86 zolpidem as, 69t, 72 with depression, 102, 103f, 104f
of sleep medicine and physiology, 8–19 binding site of, 72f epidemiology of, 101f
Home sleep testing (HST), 273–274, 273f, 274f modified-release (extended-release), 72, 72f, 73f historical background of, 16
Homeostatic sleep drive, 22, 23f, 26f plasma concentration of, 72f with medical conditions, 102b
Hormone levels, temporal variations of plasma levels structure of, 72f with psychiatric conditions, 102, 102b, 103f
zopiclone as, 69t as causative factor, 254, 254f
of, 57, 57f Hypocretin, and narcolepsy, 110, 111f prevalence of, 254, 254f
Host defenses, sleep and, 36 animal studies on, 110 with stroke, 329f
Hot flashes, during menopause, 248–250, 249f history of, 19, 19f daytime consequences of, 98
HST (home sleep testing), 273–274, 273f, 274f Hypoglossal motor system, 40f defined, 98, 98b
Hunger, glucose regulation and, 57, 57f, 58f Hypoglossal nerve, factors affecting, 40f in diabetes, 240
Hunter–Cheyne Stokes breathing. See Cheyne Stokes Hypopnea dream interruption, 82
vs. apnea, 283f epidemiology of, 98–99
respirations (CSR). COPD and, 200f by gender and age, 98, 98f
Huntington’s disease (HD), sleep disorders in, defined, 269–270 evaluation of, 98
obstructive, vs. upper airway resistance syndrome, fatal familial, 147–148
146–147, 147b, 147f, 328f
Hyperarousal, in insomnia, 99, 100f, 101f 298f
Hypercapnia

due to obstructive sleep apnea, 217f
response to, 39f

Index 371

Insomnia (Continued) KF (Kolliker-Fuse) nucleus, in control of breathing, 37f Major depressive disorder (MDD). See also Depression.
historical background of, 11, 16, 19 KFS (Klippel-Feil syndrome), 164, 165f, 186f EEG analysis of, 258, 259f
hyperarousal in, 99, 100f, 101f Kidney disease, chronic, sleep disorder(s) in, 241–242 relapse of, 256, 256f
idiopathic, 105t sleep architecture and, 256, 258, 258f
management of, 106, 106t common, 241, 241t sleep changes with, 255t
medications for (See Sleep-promoting agent[s]) due to diabetes, 241t
paradoxical, 105t factors influencing development of, 241, 241f Mandibular advancement device, for obstructive sleep
pathophysiology of, 99, 100f obstructive sleep apnea as, 241 apnea, 192, 194f
perpetuating factors for, 99, 100f restless legs syndrome as, 241, 242f
precipitating factors for, 99, 100f Kleine-Levin syndrome (KLS), 110 Mandibular arch, abnormal, 154, 155f
predisposing factors for, 99, 100f Kleitman, Nathaniel, 11, 12, 12f, 18, 18f, 80 Mandibular insufficiency
primary, 105 Klippel-Feil syndrome (KFS), 164, 165f, 186f
defined, 98, 100–101, 105 Klonopin (clonazepam) in child, 152, 152f
epidemiology of, 101f for REM sleep behavior disorder, 138–139 crowded teeth due to, 152, 152f
evaluation of, 105, 105f for restless legs syndrome, 121t overjet due to, 152, 153f
types of, 105t for sleep promotion, 69t receding chin due to, 152, 153f
with primary sleep disorders, 100–101, 104, 105f KLS (Kleine-Levin syndrome), 110 Manual of Standardized Terminology, Techniques and Scoring
psychiatric consequences of, 260t Kolliker-Fuse (KF) nucleus, in control of breathing, 37f
psychophysiologic, 105t Konopka, R. J., 14 System for Sleep Stages in Human Subjects, A, 261
with restless legs syndrome, 361 Kryger, Meir, 15, 15f, 17 MAOIs (monoamine oxidase inhibitors), REM
risk factors for, 98, 98f Kyphoscoliosis
secondary, 101 lung restriction due to, 203, 204f suppression due to, 257t
sleep maintenance, 99f sleep-disordered breathing with, 188f Mars and Venus, 1–2, 2f
sleep onset, 99f Maxillary insufficiency, 152, 152f
with heart failure, 305f L MD (myotonic dystrophy), sleep disorders in, 147
sleep laboratory video on, 363 Labor and delivery, sleep disturbance(s) during, 246, MDD. See Major depressive disorder (MDD).
symptoms of, 98, 98f Mean arterial pressure (MAP), during sleep, 47f, 52f, 53f
in older patients, 99, 99f 247f, 247t, 248t Medical condition(s)
types of, 100–105, 101f Langer, S. Z., 16
Laryngomalacia, obstructive sleep apnea due to, hypersomnia due to, 110
Insufficient sleep syndrome with insomnia, 102b
behaviorally induced, 110 184–187, 185f, 186f with narcolepsy, 109, 114, 114f
clinical evaluation of, 87 Lateral hypothalamus (LH), in sleep regulation, 21f, Medical history, 88, 88b
Medication(s). See Pharmacologic agent(s).
Insulin secretion, sleep and circadian effect on, 57f 22f Medication history, 88
Intensive care unit (ICU) dream delirium, 82 Lateral pontine tegmentum (LPT), in REM sleep, 23f Medication log, 277–280, 281f
Interleukin-1 beta, and sleep, 34t Laterodorsal tegmental (LDT) nucleus, in sleep Meditation, sleep and, 7
Interleukin-6, and sleep, 34t Melanocyte-stimulating hormone, leptin and, 54–55
International Classification of Sleep Disorders: Diagnostic and regulation, 22f Melatonin
LC (locus coeruleus), in sleep regulation, 21f, 22f and circadian clock, 26f, 27
Coding Manual, 2nd edition (ICSD-2), on LDT (laterodorsal tegmental) nucleus, in sleep for delayed sleep phase disorder, 91–92
hypersomnias, 109–110, 109b historical background of, 15, 15f
Interstitial pulmonary fibrosis, sleep laboratory video regulation, 22f for REM sleep behavior disorder, 138–139
on, 361 Left ventricular heart failure for sleep promotion, 75t
Intestinal motility, and irritable bowel syndrome, Melatonin profile
239, 239f central sleep apnea due to, 42f in advanced sleep phase disorder, 93, 93f
Intrathoracic pressure (Pepi) clinical features of, 221 in delayed sleep phase disorder, 91, 92f
effect of obstructive sleep apnea on, 216, 217f epidemiology of, 221–223 Menaker, M., 15
during obstructive sleep apnea, 41f polysomnography of, 305f, 306f, 309f Mendelson, W. B., 69
Iron, for restless legs syndrome, 121t Leg channel activity, mixed sleep apnea with, 288f, Menopause, 248–250
Iron deficiency, restless legs syndrome in defined, 248
brain tissue in, 119f 289f sleep studies during, 249–250, 250f
glossitis and, 117f Leg channel artifacts, 345f thermoregulation and vasomotor symptoms of,
pathophysiology of, 118–119, 119f Leg movement(s)
in vegetarians, 119f, 325f 248–250, 249f
Irregular sleep-wake disorder, 94–95 in obstructive sleep apnea, 287f, 288f Menstrual cycle, 243–245
clinical presentation of, 94 periodic (See Periodic limb movements in sleep
epidemiology of, 94 in polycystic ovary syndrome, 244, 244f
rest-activity cycle in, 94f, 96t [PLMS]) premenstrual syndrome in, 243, 243f, 244
treatment for, 95, 96t recording of, 271 sleep changes in, 243, 243f
Irritable bowel syndrome (IBS), 239, 239f scoring of, 271, 272f Menstrual-associated hypersomnia, 110
Leptin Metabolic rate, during sleep, 30f
J diurnal variation in, 57, 58f Methylphenidate, to promote wakefulness, 76t
Jaw abnormality(ies), 149–155 and sleep, 54–55, 54t, 55f Microbial infection(s), and sleep, 34–36, 35f, 36f
sleep deprivation and, 58–60, 59f Micrognathia, 154
of mandibular arch, 154, 155f Levodopa/carbidopa (Sinemet), for restless legs Midlife transition, 248–250
mandibular insufficiency as defined, 248
syndrome, 121t sleep studies during, 249–250, 250f
in child, 152, 152f LH (lateral hypothalamus), in sleep regulation, 21f, 22f thermoregulation and vasomotor symptoms of,
crowded teeth due to, 152, 152f Life span, sleep through, 64, 65f, 67f, 67t
overjet due to, 152, 153f Light, and circadian clock, 25, 27 248–250, 249f
receding chin due to, 152, 153f Light to Deep and Dreaming Sleep, 1f Mignot, Emmanuel, 19
maxillary insufficiency as, 152, 152f Limb movements, periodic. See Periodic limb Millet, Jean-Franc¸ois, 4–5, 4f
micrognathia as, 154 Minor, Vernon Hyde, 4
prognathia as, 152 movements in sleep (PLMS). Minute volume ventilation, during sleep, 31f
retrognathia as, 152–155, 153f Literature, sleep in, 1–7 Mirapex (pramipexol), for restless legs syndrome, 121t
Jaw enlargement, in acromegaly, 236f Locus coeruleus (LC), in sleep regulation, 21f, 22f Mixed sleep apnea, 293f
Jet lag sleep disorder, 95–96 Long sleeper syndrome, clinical evaluation of, 87
clinical presentation of, 95, 96t Loomis, Alfred E., 12 becoming complex, 303f, 304f
rest-activity cycle in, 96f, 96t Lorazepam, for sleep promotion, 69t with congestive heart failure, 178f
treatment for, 95, 96t Lormetazepam, for sleep promotion, 69t with idiopathic pulmonary fibrosis, 305f
Jouvet, Michel, 13, 13f Lotto, Lorenzo, 2, 2f with leg channel activity, 288f, 289f
Junctional escape rhythm, in sleep apnea, 315f Lo¨ wenfeld, 11 with leg movements, 179f
Jung, Carl, 13 LPT (lateral pontine tegmentum), in REM sleep, 23f Mobitz second degree heart block, 320f
Juvenile myoclonic epilepsy, 131 Lugaresi, E., 13 Modafinil
Lung diseases. See Pulmonary disease(s). efficacy of, 78f
K historical background of, 18
K complexes, 264t, 267t M mechanism of action of, 77f, 78f
Kales, Anthony, 14, 14f, 261 Macbeth, 7 pharmacokinetics of, 78t
Keats, John, 4 Macbeth, Lady, 8, 9f as wakefulness-promoting agent, 76t, 77
Macroglossia Monoamine oxidase inhibitors (MAOIs), REM

in acromegaly, 236f suppression due to, 257t
in hypothyroidism, 232f Monroe, L. J., 13
Magoun, H. W., 12, 20f Mood disorders
Mahowald, Mark W., 16, 17f
Maintenance of wakefulness test (MWT), for polysomnographic features of, 255t

narcolepsy, 114

372 Index

Mood disorders (Continued) Narcolepsy (Continued) Nocturnal frontal lobe epilepsy (NFLE), 126, 127f
sleep disorders with, 254 caffeine as, 78, 79f autosomal dominant, 131
mechanism of action of, 77f vs. parasomnias, 125, 125t
Moore, Robert, 14, 14f modafinil as, 76t, 77
Morisot, Berthe, 5, 5f efficacy of, 78f Nocturnal leg cramps, vs. restless legs syndrome, 120t
Moruzzi, G., 12, 20f mechanism of action of, 77f, 78f Nocturnal paroxysmal dystonia, 129
Movement(s) pharmacokinetics of, 78t Nocturnal polysomnography. See Polysomnography
relative efficacy of, 79f
parameters for evaluating, 276t sodium oxybate as, 76t, 78 (PSG).
recording of, 271–272, 272f Nocturnal seizures, 127, 209–211
Movement artifacts, 346f Narcotic-induced central sleep apnea, 42f
Movement disorder(s), 324–327 Nasal disorders, 156–158 with central sleep apnea, 128f, 334f, 335f
calf cramp as, 326f, 327f with centrotemporal (Rolandic) spikes, 129,
Parkinson’s disease as, 324f rhinophyma due to rosacea as, 156, 156f
periodic limb movements in sleep as (See Periodic due to traumatic injury 130f, 337f
clinical manifestations of, 127f, 206t
limb movements in sleep [PLMS]) from fracture, 157–158, 157f, 158f with continuous spikes during slow-wave activity,
restless legs syndrome as (See Restless legs syndrome polysomnography of, 285f
sleep laboratory video on, 303 131
[RLS]) diagnosis of, 126–127
Moving toes, vs. restless legs syndrome, 120t from gunshot wound, 157, 157f epidemiology of, 125
Multiple sclerosis (MS), sleep disorders in, 142–143, Nasal fracture, sleep apnea due to, 157–158, 157f, 158f frontal lobe, 126, 127f

142f, 143f, 143t polysomnography of, 285f autosomal dominant, 131
patient interview video on, 351 sleep laboratory video(s) on, 303 vs. parasomnias, 125, 125t
polysomnography of, 338f, 339f Nasal obstruction, and apnea, 303 infrequent, 128f
Multiple sleep latency test (MSLT), for narcolepsy, Nasal pressure, in diagnostic assessment, 262t juvenile myoclonic, 131
Nasal pressure monitors, for obstructive sleep apnea, medications and, 125, 125t
112–113, 113f in nocturnal paroxysmal dystonia, 129
Muscle tone, in sleep staging, 262t, 263 283f, 284f obstructive sleep apnea and, 131
Muscular dystrophy, Becker, 327f, 351 Nasal trauma, sleep apnea due to vs. parasomnias, 125, 125t
MWT (maintenance of wakefulness test), for polysomnography of, 333
from fracture, 157–158, 157f, 158f with central apnea, 334f, 335f
narcolepsy, 114 polysomnography of, 285f frontal lobe, 127f
Myocardial dysfunction, due to obstructive sleep sleep laboratory video on, 303 infrequent, 128f
with no other abnormalities, 333f
apnea, 217f from gunshot wound, 157, 157f right-sided, 128f
Myoclonic epilepsy, juvenile, 131 National Sleep Foundation, 18 with Rolandic spikes, 130f, 337f
Myotonic dystrophy (MD), sleep disorders in, 147 National Sleep Foundation diary, 89, 89f temporal lobe, 129f, 335f, 336f
Mythology, sleep in, 1–2 Nauta, W. J. A., 21f psychogenic, 364
Neck abnormality(ies), 164 regional anatomy in facilitation of, 126
N right-sided, 128f
NA (nucleus ambiguous), in control of breathing, 37f in Klippel-Feil syndrome, 164, 165f sleep laboratory videos on, 364
Narcolepsy, 107–115 large collar size as, 164, 164f, 165f sleep state and, 125, 126f, 209–211
Nerve growth factor, and sleep, 34t vs. sleep terrors, 212b
animal studies on, 110 Nervous system, in control of sleep, 20, 20f sleep-related choking due to, 211b, 212f
brain in, 20f Neurodegenerative disorders, REM sleep behavior supplementary sensorimotor, 129
with cataplexy, 108, 109 syndromes associated with, 126–131
disorder in, 135–136, 209b, 210f temporal lobe, 126, 127–129, 129f
patient interview video on, 349 Neuroleptic-induced akathisia, vs. restless legs polysomnography of, 129f, 335f, 336f
without cataplexy, 109 treatment of, 211
clinical evaluation of, 87 syndrome, 120t Nonapneic hypoxemia, 183, 183f
comorbidities with, 114, 114f Neurologic disease(s), 324–327 Nonapneic respiratory events, 183, 183f
complications and consequences of, 114, 114f Nonchaloire, 4–5, 5f
defined, 107–108, 107b genetic, 327 Nonentrained disorder, 94
diagnosis of, 112–114 Becker’s muscular dystrophy as, 327f clinical presentation of, 94, 96t
retinitis pigmentosa as, 328f epidemiology of, 94
sleep study(ies) in, 112–114 rest-activity cycle in, 94, 94f, 96t
maintenance of wakefulness test as, 114 Huntington disease as, 00018:s0060, 328f treatment for, 94, 96t
multiple sleep latency test as, 112–113, 113f movement disorder(s) as, 324–327 Nonrapid eye movement (NREM) sleep
nocturnal polysomnogram as, 112, 112f cerebral blood flow during, 49, 49f, 50f
calf cramp as, 326f, 327f in children, 64, 65f
subjective assessment in, 112 Parkinson’s disease as, 324f with depression, 255t
Epworth Sleepiness Scale for, 112 periodic limb movements in sleep as (See Periodic as facilitator of epilepsy, 125, 126f
fatigue severity scale for, 112 with head trauma, 337f, 338f
limb movements in sleep [PLMS]) heart rate during, 44, 45f, 46f
epidemiology of, 107 restless legs syndrome as (See Restless legs historical background of, 12
genetics of, 110–111 physiologic regulation in, 29–34
with hallucinations, 349 syndrome [RLS]) and sleep stages, 64t
historical background of, 11, 19, 19f patient interview video on, 349–352 spinal cord blood flow during, 50, 50f
vs. idiopathic hypersomnia, 108, 108f REM sleep behavior disorder in, 136 sympathetic activity during, 46f
management of, 114 stroke as, 328 terms used to describe, 64t
Nonrapid eye movement (NREM) sleep parasomnias, 88
for abnormal REN sleep intrusions, 114, 114b with excessive daytime sleepiness, 329f Noon, 4–5, 5f
for excessive daytime sleepiness, 114 with insomnia, 329f Noon: Rest from Work, 4–5, 5f
pharmacotherapy for, 114 Neurologic exam, 88 Noonday Rest, 4–5, 4f
due to medical condition, 109 Neuromuscular disorders, sleep apnea due to, 184–187, Noradrenaline reuptake inhibitors (NRIs), REM
pathophysiology of, 110
hypocretin in, 110, 111f 188f suppression due to, 257t
Neurontin (gabapentin), for restless legs syndrome, Normal respiratory sinus arrhythmia, 44, 45f
animal studies on, 110 Normal sleep, 64–65
REM sleep in, 110, 111f 121t
Neuropathy, diabetic control of breathing during, 37–40, 37f, 38f, 39f
animal studies on, 110 Nose, 156–158
patient interview videos on autonomic, 241t
peripheral, 241t rhinophyma due to rosacea of, 156, 156f
with cataplexy, 349 Neuropeptide Y (NPY) trauma to
with hallucinations, 349 ghrelin and, 53–54, 55f
with sleep apnea, 349 leptin and, 54–55 from fracture, 157–158, 157f, 158f
undiagnosed, 349 Newborns, sleep-disordered breathing in, 149, 188f, polysomnography of, 285f
polysomnography of, 112, 112f, 331, 331f sleep laboratory video(s) on, 303
and pregnancy, 247–248 189f
psychiatric consequences of, 260t NFLE (nocturnal frontal lobe epilepsy), 126, 127f from gunshot wound, 157, 157f
REM sleep disorder with, 107–108, 107b, NPBM (nucleus parabrachialis medialis), in control of
autosomal dominant, 131
211b, 211f vs. parasomnias, 125, 125t breathing, 37f
with sleep apnea, 349 Night sweats NPY (neuropeptide Y)
sleep laboratory video on, 363 in hyperthyroidism, 230f
symptoms of, 107, 107b, 107f, 108, 108f during menopause, 249
unspecified, 109 Nightmare(s), 83, 83f
wakefulness-promoting agent(s) for, 76–78, 76t treatment of, 83
Nightmare, The, 6, 6f
amphetamines and related compounds as, 76t, 77 Nitrazepam, for sleep promotion, 69t
mechanism of action of, 77f Nitric oxide (NO), and cerebral blood flow, 50, 50f
Nocturnal awakenings, in diabetes, 240
Nocturnal cardiac events, physiologic mechanisms of,

46, 48t

NPY (neuropeptide Y) (Continued) Obstructive sleep apnea (OSA) (Continued) Index 373
ghrelin and, 53–54, 55f sleep laboratory videos on, 360, 361
leptin and, 54–55 Oximetry
pathophysiology of, 41–42, 41f, 42f of COPD, 197f
NRA (nucleus retroambigualis), in control of breathing, period limb movements in, 196f, 294f in diagnostic assessment, 262t
37f due to pharyngolaryngomalacia, 186f
polysomnography of, 283 Oxygen therapy, for congestive heart failure, 314f
NREM sleep. See Nonrapid eye movement (NREM)
sleep. with acromegaly, 289f P
with awake obstructive apnea, 291f, 292f Pain, sleep disorders with chronic, 143, 143f
NRIs (noradrenaline reuptake inhibitors), REM cardiorespiratory sensors in, 284f Painful feet, vs. restless legs syndrome, 120t
suppression due to, 257t in child, 285f, 286f PaO2, in control of breathing, 39f
due to craniofacial anomalies, 187f Parabrachial nucleus (PB), in REM sleep, 23f
Nucleus ambiguous (NA), in control of breathing, 37f with Down syndrome, 293f Parafacial respiratory group (PRG), in control of
Nucleus parabrachialis medialis (NPBM), in control of end-tidal CO2 analyzer in, 285f
due to enlarged tonsils and adenoids, 285f, breathing, 37f
breathing, 37f Parasomnia(s), 206–215
Nucleus retroambigualis (NRA), in control of 286f
hypopneas vs. apneas in, 283f bruxism as, 211–213
breathing, 37f vs. hypoventilation, 290f clinical presentation of, 211–212, 213f
Nytol (diphenhydramine), for sleep promotion, 74, 75t leg movement monitoring in, 287f, 288f consequences of, 211–212, 213f
due to nasal fracture, 285f polysomnogram of, 212, 213f, 214f
O nasal pressure monitors in, 283f, 284f treatment of, 212–213
due to obesity, 184f
Obesity with periodic limb movements, 294f clinical evaluation of, 87–88, 88b
COPD with, 199, 199f, 200f due to pharyngolaryngomalacia, 186f clinical features of, 206t
sleep apnea with, 165, 165f due to retrognathia, 286f, 287f defined, 206
central, sleep laboratory video(s) on, 358 sleep stage recording in, 171f, 291f disorder(s) of arousal as, 206–207
obstructive, in children, 184–187, 184f thermal sensors in, 283f, 284f
postpartum, 356 clinical manifestations of, 206, 206t
Obesity hypoventilation syndrome, 150 during pregnancy, 246 confusional arousals as, 206t
with heart failure, 355 sleep laboratory video on, 355 epidemiology of, 206
peripheral edema in, 166, 166f psychiatric consequences of, 260t examples of, 206t
sleep laboratory video(s) on, 355 relationship between central and, 44f management of, 207
REM sleep behavior disorder with, 363 pathogenesis of, 206
Obstructive apnea during wakefulness, 291f, 292f due to retrognathia, 286f, 287f predisposing or precipitating factors for, 206–207
with heart failure, 311f, 312f risk factors for, 167–168 sleep terrors as, 206t, 208f
sleep laboratory video(s) on, 353–354
Obstructive hypopnea, vs. upper airway resistance with acromegaly, 356 vs. nocturnal seizures, 212b
syndrome, 298f in child, 299 sleep-related eating disorder as, 207, 207b, 208f
in Down syndrome, 357 sleepwalking as, 206t, 207b
Obstructive sleep apnea (OSA) with heart failure, 359 vs. nocturnal frontal lobe epilepsy, 125, 125t
with acromegaly, 289f with lack of arousal in response to noise, 353 nocturnal seizures as, 209–211
sleep laboratory video(s) on, 356 due to nasal fracture, 303 clinical features of, 206t
arousal threshold to noise in, 41f, 42f, 353 in obesity hypoventilation syndrome, 355 sleep state and, 209–211
Berlin Apnea Questionnaire for, 90, 90f postpartum, 356 vs. sleep terrors, 212b
and cardiovascular disease(s) during pregnancy, 355 sleep-related choking due to, 211b, 212f
aortic dilatation as, 216, 217f after uvulopalatopharyngoplasty, 354 treatment of, 211
cardiac arrhythmias as, 216, 217–219, 219f, 220f with violent body movements, 354 during pregnancy, 246
coronary artery disease as, 219–220, 220f sleep stage effect in, 171f, 291f primary, 206
heart failure as, 221–223 sleep studies of, 171f, 184f, 186f, 187f REM sleep behavior disorder as, 209
on bilevel pressure, 313f symptoms of, 168, 168b clinical features of, 206t, 209
vs. central sleep apnea, 223–224 due to thyroid mass lesions, 233f drug-induced, 209b, 210f
clinical features of, 221, 222–223 treatment of, 190–194 epidemiology of, 209
on CPAP, 314f CPAP for, 190–192 etiology of, 209
epidemiology of, 221–223, 222f, 222t idiopathic, 209b
polysomnography of, 311f, 312f, 313f, 314f adverse effects of, 192, 192f, 193f with narcolepsy, 211b, 211f
treatment of, 226–227, 226f in children, 192, 195f with Parkinson’s disease, 209b, 210f
with ventilatory support, 312f flow generators for, 190, 190f REM sleep without atonia in, 209f
pathophysiology of, 216, 217f, 218f titration of, 190–192, 191f, 192f secondary, 206
and pulmonary edema, 216, 217f, 359 types of masks for, 190, 190f Parkinson’s disease (PD)
sudden cardiac death as, 219 oral appliance or dental device for, 192 epidemiology of, 131
systemic hypertension as, 221, 221f mandibular advancement device as, 192, 194f pathophysiology of, 131
cardiovascular effects of, 216, 217f, 218f rapid maxillary expansion as, 192, 194f polysomnography of, 324f
with cerebrovascular accidents, 144–145, 146, 146f due to retrognathia, 193f sleep disorder(s) in, 131–134
in children upper airway muscles and arousal threshold in, 41f excessive daytime sleepiness as, 132, 132f
due to craniofacial abnormalities, 184–187, 186f after uvulopalatopharyngoplasty, 354 laboratory findings on, 132–133
due to Down syndrome, 184–187, 187f vigorous movements in, 354 REM sleep behavior disorder as, 135, 209b, 210f
due to laryngomalacia, 184–187, 185f, 186f with violent body movements, 354
due to obesity, 184–187, 184f Octreotide, for growth hormone hypersecretion, patient interview video on, 350
due to pharyngolaryngomalacia, 184–187, 186f sleep apnea as, 134f, 324f
polysomnography of, 285f, 286f 234–236
sleep laboratory video(s) on, 299 Older patients. See Elderly. patient interview video on, 350
due to tonsillar and adenoidal hypertrophy, Ophthalmopathy, Graves’, 228b, 229f spectrum of, 131–132, 132f
184–187, 184f, 285f, 286f Opioids, for restless legs syndrome, 121t symptoms of, 119f, 131–132
in chronic kidney disease, 241 Oral appliance, for sleep-disordered breathing, 192 treatment for, 134
due to craniofacial anomalies, 187f tremor as, 133f
cycle of ventilatory instability in, 42f mandibular advancement device as, 192, 194f yawning during wakefulness as, 133f
defined, 41–42 rapid maxillary expansion as, 192, 194f Paroxysmal nocturnal dyspnea
in Down syndrome due to retrognathia, 193f and Cheyne Stokes respirations, 174f
in children, 184–187 Orexin, ghrelin and, 53–54, 55f with heart failure, 305f, 309f, 312f
polysomnography of, 187f, 293f Orexin neurons Patient complaints, 86, 86b
sleep laboratory video(s) of, 357 in REM sleep, 23f Patient interview video(s), 347–352
due to enlarged tonsils and adenoids, 285f, 286f in sleep regulation, 21f, 22f of Arnold-Chiari malformation, 351
and epilepsy, 131 OSA. See Obstructive sleep apnea (OSA). of Becker muscular dystrophy, 351
exam for, 168 Osler, William, 11, 11f of hypnagogic hallucinations
due to growth hormone hypersecretion, 233–234, Overjet, due to mandibular insufficiency, 152, 153f with multiple sclerosis and sleep apnea, 351
235f Overlap syndrome, 150, 197 with psychiatric disorders, 352
and health care utilization, 86, 86f bloodshot eyes in, 150, 150f of multiple sclerosis, 351
heart failure and, 359 sleep laboratory videos on, 360, 361 of narcolepsy
historical background of, 12, 12f, 13 Over-the-counter agents, for sleep promotion, 75t with cataplexy, 349
with insomnia, 104, 105f with hallucinations, 349
due to nasal fracture, 285f, 303 with sleep apnea, 349
due to obesity, 184–187, 184f undiagnosed, 349
in obesity hypoventilation syndrome, 355 of neurologic and other disorder(s), 349–352
in overlap syndrome, 150, 197

374 Index

Patient interview video(s) (Continued) Pharmacologic agent(s) (Continued) Polysomnography (PSG) (Continued)
of psychiatric disorders, 352 promethazine as, 69t due to heart blocks, 319f
of REM sleep behavior disorder, 350 ramelteon as, 74, 75f Mobitz second degree, 320f
with Parkinson disease and sleep apnea, 350 structure of, 74f third degree, 320f
of restless legs syndrome, 350 sedating antidepressants (trazodone) as, 74–75, Wenckebach second degree, 319f
of sleep-disordered breathing, 347–348 75f irregular rhythm and escape beats as, 318f
with Arnold-Chiari malformation, 351 characteristics of, 75b premature ventricular contractions as, 321f, 323f
with Becker muscular dystrophy, 351 structure of, 75f sinus arrest and junctional escape rhythm as, 315f
with cardiovascular comorbidities, 347 site of action of, 71, 71f tachycardia as, 322f, 323f
in child, 347 triazolam as, 71, 71t ventricular, 322f, 323f
with Down syndrome, 347 site of action of, 71f
in elderly, 347 structure of, 72f of central sleep apnea, 301
explaining results to patient with, 348 zaleplon as, 69t, 74f with 5-minute epoch, 173f, 174f
with multiple sclerosis, 351 binding site of, 72f with 20-minute epoch, 173f
with narcolepsy, 349 structure of, 74f with 30-second epoch, 173f, 175f
with Parkinson’s disease and REM sleep behavior zolpidem as, 69t, 72 with Cheyne Stokes respirations, 174f
disorder, 350 binding site of, 72f with compressed 10-minute epochs, 172f
presenting as restless sleep, 348 modified-release (extended-release), 72, 72f, with compressed 30-minute epoch, 174f
teaching and CPAP mask fitting for, 348 73f idiopathic, 299f, 300f
in truck driver, 348 plasma concentration of, 72f on adaptive servo-ventilation, 302f, 303f
of syringomyelia, 351 structure of, 72f on bilevel pressure, 301f
zopiclone as, 69t on CPAP, 301f
Pavlov, Ivan, 11, 11f in infant, 188f
PB (parabrachial nucleus), in REM sleep, 23f REM sleep behavior disorder due to, 136, 136f, due to medication, 299f, 300f
pCO2, in control of breathing, 38f, 39f 209b, 210f treatment-emergent, 176f
PCOS (polycystic ovary syndrome), 244, 244f
PC/PB (precoeruleus/parabrachial nucleus), in REM wakefulness-promoting (stimulants), 76–78, 76t of complex sleep apnea, 303f, 304f
amphetamines and related compounds as, 76t, 77 of depression, 256, 258, 258f
sleep, 23f mechanism of action of, 77f of head trauma, 337, 337f, 338f
PD. See Parkinson’s disease (PD). caffeine as, 78, 79f of heart failure, 305
Pedunculopontine tegmental (PPT) nucleus, in sleep for cataplexy, 76t
clinical characteristics of, 77t with atrial fibrillation, 309f, 312f
regulation, 22f for excessive daytime sleepiness/irresistible with Cheyne Stokes respirations
Pemoline, to promote wakefulness, 76t episodes of sleep, 76t
Pepi (intrathoracic pressure) mechanism of action of, 77f in child, 307f, 308f
modafinil as, 76t, 77 with multiple abnormalities, 310f
effect of obstructive sleep apnea on, 216, 217f efficacy of, 78f and obstructive sleep apnea, 313f
during obstructive sleep apnea, 41f mechanism of action of, 77f, 78f while asleep, 309f
PER protein, in circadian clock, 25f pharmacokinetics of, 78t while awake, 305f, 306f
Perceptual processes, in dreaming, 80, 81t for narcolepsy, 76t, 79f in child, 307f, 308f
Periodic breathing, with heart failure, 309f, 310f, 314f for poor sleep, 76t CO2 oscillations in, 306f, 311f
Periodic limb movements in sleep (PLMS), 121–123 relative efficacy of, 79f with irregular rhythm and escape beats, 318f
calf cramp in, 326f, 327f sodium oxybate as, 76t, 78 with multiple abnormalities, 310f, 311f
in children, 189f and obstructive apnea, 311f
in chronic kidney disease, 241, 242f Pharyngolaryngomalacia, obstructive sleep apnea due on bilevel pressure, 313f
clinical manifestations of, 121–123, 122f to, 184–187, 186f on CPAP, 314f
in COPD, 197, 199f, 360 on ventilatory support, 312f
diagnostic evaluation of, 123, 123f, 124f Pharynx during wakefulness, 311f, 312f
drugs and, 115–116 collapse of, 40f with paroxysmal nocturnal dyspnea, 305f, 309f,
epidemiology of, 121 soft palate tumor of, 163, 163f
with heart failure, 310f and tongue, 158–160 312f
management of, 123, 124f Mallampati Class I, 158, 159f with periodic breathing, 309f, 310f, 314f
polysomnography of, 325f, 326f Mallampati Class II, 158, 159f with periodic leg movements, 310f
recording of, 271 Mallampati Class III, 160, 160f during sleep, 309f
vs. restless legs syndrome, 00010:p0020, 121–123, Mallampati Class IV, 160, 160f with sleep-onset insomnia, 305f
trauma to, due to snoring, 163, 163f of mixed sleep apnea, 293f
123t uvulopalatopharyngoplasty of, 163, 164f becoming complex, 303f, 304f
scoring of, 271, 272f with congestive heart failure, 178f
with sleep apnea, 362 Phenelzine, to promote wakefulness, 76t with idiopathic pulmonary fibrosis, 305f
Physical exam, 88, 88b, 89b with leg channel activity, 288f, 289f
obstructive, 294f Physiologic regulation, in sleep, 29–34, 33f with leg movements, 179f
sleep laboratory videos on, 362 Pickwickian syndrome, 10, 11f, 12, 13, 13f of multiple sclerosis, 338, 338f, 339f
sleep-disordered breathing and, 195, 196f Pinto, L. H., 18 of narcolepsy, 112, 112f, 331, 331f
Periodic respirations, in infants, 184–187, 189f Pitting edema, 166f of neurologic disease(s), 324–327
Peripheral edema, 166 Pituitary adenoma, 233, 234f genetic, 327
discoloration due to, 166, 166f Pituitary hormone secretion, mechanisms controlling,
with hypoventilation syndrome, 166, 166f Becker’s muscular dystrophy as, 327f
infection due to, 166, 166f 56, 56f retinitis pigmentosa as, 328f
not always present, 166f PLMS. See Periodic limb movements in sleep (PLMS). Huntington disease as, 00018:s0060, 328f
pitting, 166f PMS (premenstrual syndrome), 243, 243f, 244 movement disorder(s) as, 324–327
Peripheral neuropathy Pneumotaxic center, in control of breathing, 37f calf cramp as, 326f, 327f
due to diabetes, 241t pO2, in control of breathing, 38f Parkinson’s disease as, 324f
vs. restless legs syndrome, 120t Polio, sleep disorders after, 146 periodic limb movements in sleep as, 325f,
Pharmacologic agent(s), 69–79 Polycystic ovary syndrome (PCOS), 244, 244f
central sleep apnea due to, 173f, 299f, 300f Polysomnography (PSG), 283–346 326f
and dreaming, 83 restless legs syndrome as, 324f
hypersomnia due to, 110 artifact(s) in, 339 stroke as, 328
hyperthyroidism due to, 228t in chin EMG, 346f with excessive daytime sleepiness, 329f
with hypnotic properties, 69–76, 69t in EEG, 340f, 341f, 342f with insomnia, 329f
breathing, 343f normal values ranges on, 276t
barbiturates as, 69t cardiac, 340f, 342f, 343f of obstructive apnea during wakefulness, 291f, 292f
benzodiazepines as, 69, 69t, 72f in EKG, 346f with heart failure, 311f, 312f
chloral hydrate/betaine as, 69t due to electrical interference, 339f, 340f of obstructive sleep apnea, 283
chlormethiazole as, 69t eye channel, 344f, 345f with acromegaly, 289f
diphenhydramine as, 74, 75t leg channel, 345f with awake obstructive apnea, 291f, 292f
eszopiclone as, 74f movement, 346f cardiorespiratory sensors in, 284f
respiratory channel, 340f, 341f, 342f in child, 285f, 286f
pharmacokinetics of, 73f due to craniofacial anomalies, 187f
structure of, 73f of bruxism, 212, 213f, 214f with Down syndrome, 293f
ethanol as, 76 of cardiac arrhythmia(s), 315–323 end-tidal CO2 analyzer in, 285f
structure of, 76f due to enlarged tonsils and adenoids, 285f, 286f
GABA-A receptor complex and, 69f, 70–71, 70f atrial fibrillation as hypopneas vs. apneas in, 283f
over-the-counter, 75t with heart failure, 309f, 312f, 317f, 318f
with sleep apnea, 316f

Polysomnography (PSG) (Continued) Pregnancy, sleep disturbance(s) during (Continued) Index 375
vs. hypoventilation, 290f sleep laboratory video(s) on, 355
leg movement monitoring in, 287f, 288f sleep-disordered breathing as, 246, 246t Q
due to nasal fracture, 285f snoring as, 246 QRS duration, 273
nasal pressure monitors in, 283f, 284f in third trimester, 245–246, 245t Quiet sleep, heart rate during, 45f
due to obesity, 184f Quiet wakefulness, heart rate during, 46f
with periodic limb movements, 294f Premature ventricular contraction (PVC), 321f, 323f
due to pharyngolaryngomalacia, 186f Prematurity, and central sleep apnea, 149 R
due to retrognathia, 286f, 287f Premenstrual syndrome (PMS), 243, 243f, 244 Ramelteon
sleep stage recording in, 171f, 291f PRG (parafacial respiratory group), in control of
thermal sensors in, 283f, 284f for sleep promotion, 74, 75f
breathing, 37f structure of, 74f
of Parkinson’s syndrome, 132 Principles and Practice of Sleep Medicine, 17f Rapid eye movement (REM) period, sleep-onset, in
with sleep apnea, 134f Productivity, impact of sleep disorders on, 85, 85b
with tremor, 133f Prognathia, 152 narcolepsy, 112, 112f, 113f
with yawning during wakefulness, 133f Prolactin, temporal variations in, 57, 57f Rapid eye movement (REM) sleep, 110, 111f
Promethazine, for sleep promotion, 69t
of psychiatric disorders, 254, 255t Propoxyphene (Darvocet, Darvon), for restless legs accessory respiratory muscles and compensatory
recommended parameters for, 276t breathing mechanisms during, 44–45
of REM sleep behavior disorder, 135f, 138, 332, syndrome, 121t
Proptosis, in Graves’ disease, 229f, 231f in alcohol withdrawal syndromes, 76, 76f
332f, 333f PSG. See Polysomnography (PSG). animal studies on, 110
of seizure(s), 127, 333 Psychiatric disease, 254–260 blood pressure surges during, 51, 52f
cerebral blood flow during, 50, 50f, 52f
with central apnea, 334f, 335f anxiety as, 255t, 259 in children, 64, 65f, 66f
frontal lobe, 127f depression as control of, 22–24, 23f
infrequent, 128f with depression, 255t
with no other abnormalities, 333f daytime sleepiness with, 254 and epilepsy, 125, 126f
right-sided, 128f EEG analysis of, 258, 259f with head trauma, 337f, 338f
with Rolandic spikes, 130f, 337f polysomnographic features of, 256 heart rate during, 44, 45f
temporal lobe, 129f, 335f, 336f REM suppressant action of treatments for,
of sleep paralysis, 332f surges in, 45–46, 46f, 47f
of sleep-disordered breathing, 168 256–257, 257t, 258t heart rhythm pauses in, 46, 47f
with apneas and possible hypopnea, 169f sleep disorder(s) in, 255–258 historical background of, 9, 13
Cheyne Stokes respirations in, 174f in narcolepsy
data obtained in, 168 as barrier to treatment, 254–255, 255f
hypopnea as, 168f, 169f, 179f and relapse, 255–256, 256f multiple sleep latency test of, 112, 113f
with nonapneic hypoxemia, 183f as risk factors, 255–256 polysomnography of, 112, 112f, 113f
with periodic limb movements, 189f types of, 255–256, 255f, 255t physiologic measurements of, 63f
periodic respirations as, 189f vignette on, 256b physiologic regulation in, 29–34
respiratory effort–related arousal as, 170f insomnia with, 102, 102b, 103f polysomnography of, 266, 266f
scoring interval(s) in, 178–182 as causative factor, 254, 254f and psychiatric disorders, 254f
prevalence of, 254, 254f and sleep stages, 64t
5-minute compressed epoch as, 174f, 178, 180f with narcolepsy, 114, 114f spinal cord blood flow during, 50, 50f
10-minute compressed epoch as, 168f, 169f, polysomnographic features of, 254, 255t suppression due to antidepressants of, 256–257,
post-traumatic stress disorder as, 259, 269b
172f, 178, 178f, 180f, 183f schizophrenia as, 255t, 259 257t, 258f, 258t
20-minute epoch as, 173f shortened REM sleep in, 254f sympathetic activity during, 45, 46f
30-second compressed epoch as, 174f, 178 sleep disorder(s) and terms used to describe, 64t
30-second epoch as, 169f, 173f, 175f, 178, 179f, bidirectional relation between, 254, 254f waveforms in, 264t
patient interview video on, 352 Rapid eye movement (REM) sleep behavior disorder
181f, 183f and response to psychotherapy, 254–255, 255f
choice of, 178, 181f, 182f as risk factors, 254, 254f (RBD), 135–139, 209
compression of, 178, 180f due to untreated sleep disorders, 259, 260t behavioral spectrum of, 136–138, 138f
split screen for, 178, 181f, 182f, 183f Psychogenic seizures, 364 classification of, 136f
of upper airway resistance syndrome, 283 Psychomotor vigilance task (PVT), sleep deprivation clinical features of, 206t, 209
with cardiac arrhythmia, 298f diagnosis of, 136–138
drilling down in, 295f, 296f effect on, 28f, 68, 68f
vs. obstructive hypopnea, 298f Psychotherapy, disturbed sleep and response to, clinical, 135, 136–138, 138f
with prolonged obstructive hypoventilation, 297f polysomnography in, 135f, 138
with respiratory effort related arousal, 296f, 297f 254–255 diagnostic criteria for, 138b
time compression in, 295f PTSD (post-traumatic stress disorder), 259, 269b differential diagnosis of, 138
Pontine tegmentum, in REM sleep behavior disorder, Pulmonary complications, of gastroesophageal dream stereotypy in, 82
drug-induced, 136, 136f, 209b, 210f
136, 137f reflux, 239 epidemiology of, 135–136, 209
Positional discomfort, vs. restless legs syndrome, 120t Pulmonary disease(s), 197–205 etiology of, 209
Posthumous Papers of the Pickwick Club, The, 10, 11f idiopathic, 209b
Postpartum depression, 247 obstructive, 197–200 with narcolepsy, 107–108, 107b, 211b, 211f
Postpartum period abnormal sleep physiology in, 197b in neurodegenerative disorders, 135–136
all-night oximetry in, 197f in neurologic diseases, 136
obstructive sleep apnea in, 356 in nonobese patients, 197, 198f, 199f with obstructive sleep apnea, 363
sleep during, 245t, 246 in obese patients, 199, 199f, 200f in Parkinson’s disease, 135, 209b, 210f
in overlap syndrome, 197 patient interview video on, 350
and mental health, 247 sleep laboratory video(s) on, 360, 361 pathophysiology of, 136, 137f
Post-polio syndrome (PPS), sleep disorders in, 146 severe, 199, 201f, 202f patient interview videos on, 347–352
Post-traumatic stress disorder (PTSD), 259, 269b sleep disturbances in, 197, 197b polysomnography of, 332f, 333f
Postures, of sleep, 61, 61f sleep laboratory video(s) on, 359, 360 REM sleep without atonia in, 209f
PPT (pedunculopontine tegmental) nucleus, in sleep spectrum of, 197 secondary forms of, 136
sleep laboratory videos on, 363
regulation, 22f restrictive, 201–202, 202f, 203f treatment for, 138–139, 139f
Pramipexol (Mirapex), for restless legs syndrome, 121t extrapulmonary, 203–204, 204f Rapid eye movement (REM) sleep intrusions, in
Pre-Botzinger complex, in control of breathing, 37f
Precoeruleus/parabrachial nucleus (PC/PB), in REM sleep laboratory video(s) on, 359–361 narcolepsy, 108
asthma as, 359 treatment for, 114, 114b
sleep, 23f COPD as, 359, 360 Rapid eye movement (REM) sleep parasomnias, 88
Preeclampsia, 245t, 246, 246t interstitial pulmonary fibrosis as, 361 Rapid eye movement sleep (REM) without atonia
Pregnancy, sleep disturbance(s) during, 245–248 overlap syndrome as, 360, 361
(RWA), 209f
daytime sleepiness as, 245–246 Pulmonary edema Rapid maxillary expansion, 192, 194f
features of, 245t due to heart failure, 359 Rapoport, David, 15, 16f
in first trimester, 245–246, 245t due to obstructive sleep apnea, 216, 217f, 359 RBD. See Rapid eye movement (REM) sleep behavior
narcolepsy as, 247–248
obstructive sleep apnea as, 246, 355 Pulmonary exam, 88 disorder (RBD).
parasomnias as, 246 Pulmonary fibrosis, 201, 203f Reaction time performance, sleep deprivation and, 28, 28f
pathogenesis of, 245–246 Receding chin, due to mandibular insufficiency, 152, 153f
with preeclampsia, 245t, 246, 246t idiopathic, 201, 202f Rechtschaffen, Allan, 13, 13f, 14, 14f, 261
restless legs syndrome as, 246 mixed sleep apnea with, 305f Reflux, gastroesophageal
in second trimester, 245–246, 245t
interstitial, 361 defenses against, 238, 238f
PVC (premature ventricular contraction), 321f, 323f epidemiology of, 237
PVT (psychomotor vigilance task), sleep deprivation

effect on, 28f, 68, 68f

376 Index Restless legs syndrome (RLS) (Continued) Seizure(s) (Continued)
genetics of, 119 diagnosis of, 126–127
Reflux, gastroesophageal (Continued) historical background of, 9, 12, 19 epidemiology of, 125
esophageal pH recordings of, 238f with insomnia, 361 frontal lobe, 126, 127f
pulmonary complications of, 239 intermittent, 120f autosomal dominant, 131
symptoms of, 237, 237f due to iron deficiency vs. parasomnias, 125, 125t
therapeutic considerations for, 232f, 238 brain tissue in, 119f infrequent, 128f
in waking vs. sleeping, 237, 238f glossitis and, 117f juvenile myoclonic, 131
pathophysiology of, 118–119, 119f medications and, 125, 125t
Relaxation, for insomnia, 106t in vegetarians, 119f, 325f in nocturnal paroxysmal dystonia, 129
Religion, sleep in, 3–4, 6–7 pathophysiology of, 118–119, 119f obstructive sleep apnea and, 131
REM sleep. See Rapid eye movement (REM) sleep. patient interview videos on, 350 vs. parasomnias, 125, 125t
Renal disease, chronic, sleep disorder(s) in, 241–242 vs. periodic limb movements in sleep, 120t, 121–123, polysomnography of, 127, 333
123t with central apnea, 334f, 335f
common, 241, 241t polysomnography of, 324f frontal lobe, 127f
due to diabetes, 241t during pregnancy, 246 infrequent, 128f
factors influencing development of, 241, 241f primary daily, 121f with no other abnormalities, 333f
obstructive sleep apnea as, 241 psychiatric consequences of, 260t right-sided, 128f
restless legs syndrome as, 241, 242f and quality of life, 117–118, 118f with Rolandic spikes, 130f, 337f
Reoxygenation, in obstructive sleep apnea, 216 sleep apnea with, 362 temporal lobe, 129f, 335f, 336f
Repose, 4–5, 5f sleep laboratory videos on, 361, 362 psychogenic, 364
Requip (ropinirole), for restless legs syndrome, 121t treatment for, 107–148, 120f, 121f, 121t regional anatomy in facilitation of, 126
RERA (respiratory effort–related arousal), 168–170, right-sided, 128f
Restless sleep, apnea presenting as sleep laboratory videos on, 364
170f, 270 patient interview video of, 348 sleep state and, 125, 126f, 209–211
Respiration sleep laboratory video of, 299 vs. sleep terrors, 212b
sleep-related choking due to, 211b, 212f
parameters for evaluating, 276t Restrictive lung diseases, 201–202, 202f, 203f supplementary sensorimotor, 129
during sleep, 29, 31f, 32f extrapulmonary, 203–204, 204f syndromes associated with, 126–131
Respiration chemoreceptors, modulators of, 38f temporal lobe, 126, 127–129, 129f
Respiratory channel artifacts, 340f, 341f, 342f Retinal ganglion cells (RGC), in circadian system, 26f polysomnography of, 129f, 335f, 336f
Respiratory control centers, central, 37, 37f Retinitis pigmentosa, 328f treatment of, 211
Respiratory disease(s), 197–205
obstructive, 197–200 central sleep apnea with, 358 Seizure drugs, effect on sleep organization and
Retinohypothalamic tract (RHT), in circadian system, architecture of, 125, 125t
abnormal sleep physiology in, 197b
all-night oximetry in, 197f 26f Selective serotonin reuptake inhibitors (SSRIs), REM
in nonobese patients, 197, 198f, 199f Retrognathia, 152–155, 153f suppression due to, 257t
in obese patients, 199, 199f, 200f
in overlap syndrome, 197 CPAP for, 190f Selegiline, to promote wakefulness, 76t
obstructive sleep apnea due to, 286f, 287f Self-administered instruments, 89–90
sleep laboratory video(s) on, 360, 361 oral appliance for, 193f
sleep laboratory video(s) on, 359, 360 Retrotrapezoid nucleus (RTN), in control of breathing, Berlin Apnea Questionnaire as, 90, 90f
restrictive, 201–202, 202f, 203f Epworth Sleepiness Scale as, 90, 90f
extrapulmonary, 203–204, 204f 37f, 38f sleep diaries as, 89, 89f
severe, 199, 201f, 202f RGC (retinal ganglion cells), in circadian system, 26f SEM (slow eye movements), 264t
sleep disturbances in, 197, 197b Rheumatoid arthritis, and pulmonary fibrosis, 201, 203f Semantic references, in dreaming, 81
sleep laboratory video(s) on, 359–361 Serotonin and norepinephrine reuptake inhibitors
asthma as, 359 sleep laboratory video on, 361
COPD as, 359, 360 Rhinophyma, 156, 156f (SNRIs), REM suppression due to, 257t
interstitial pulmonary fibrosis as, 361 RHT (retinohypothalamic tract), in circadian system, Shakespeare, William, 7, 8
overlap syndrome as, 360, 361 Shapiro, Mahla, 1f
spectrum of, 197 26f Shift work sleep disorder, 95
Respiratory effort, in diagnostic assessment, 262t Rimini Symposium on Hypersomnia and Periodic
Respiratory effort–related arousal (RERA), 168–170, clinical presentation of, 95, 96t
Breathing, 14f, 15 epidemiology of, 95
170f, 270 RLS. See Restless legs syndrome (RLS). rest-activity cycle in, 95f, 96t
upper airway resistance syndrome with, 296f, 297f Rolandic spikes, benign epilepsy of childhood with, treatment for, 95, 96t
Respiratory event(s), in sleep-disordered breathing, Shivering, during sleep, 30f
129, 130f, 337f Siegel, Jerome, 19
168–182 Ropinirole (Requip), for restless legs syndrome, 121t Siesta, 4–5, 5f
apneas as, 168–170, 169f Rosacea, sleep apnea due to, 156, 156f Simulation attenuation, dream disturbances with, 82,
Roth, Thomas, 16, 17, 17f
central, 170, 172f, 173f, 174f Rousseau, Henri, 6, 6f 82f, 82t
mixed, 170, 176f, 178f, 179f RTN (retrotrapezoid nucleus), in control of breathing, Simulation augmentation, dream disturbances with, 82,
obstructive, 171f
Cheyne Stokes respirations as, 170, 174f 37f, 38f 82f, 83t
hypopnea as, 168–170, 168f, 169f, 179f Rubens, Peter Paul, 8f Sinemet (levodopa/carbidopa), for restless legs
nonapneic, 183, 183f Ruvoldt, Maria, 2
respiratory effort as, 170, 175f RWA (rapid eye movement sleep without atonia), 209f syndrome, 121t
respiratory effort–related arousal as, 168–170, 170f Rye, David B., 19 Sinoatrial (SA) node heart blocks, 319f
Respiratory muscle activity, during sleep, 31f, 32f,
S third degree, 320f
40f SA (sinoatrial) node heart blocks, 319f Sinus arrest, with sleep apnea, 315f
Respiratory sinus arrhythmia, normal, 44, 45f
Rest, sleep as, 4 third degree, 320f obstructive, 219f
Rest-activity cycle Sagittal section, landmarks and anatomy of, 151f Sinus arrhythmia, normal respiratory, 44, 45f
Sanders, Mark, 15, 16f Skull, landmarks and bones of, 151f
in advanced sleep phase disorder, 93, 93f, 96t Sargent, John Singer, 4–5, 5f SLD (sublaterodorsal) nucleus, in REM sleep, 23f
in delayed sleep phase disorder, 91, 91f, 96t Scalloped tongue, 154, 155f Sleep
in free-running/nonentrained disorder, 94, 94f, 96t Scheemakers, Peter, 4–5, 4f
in irregular sleep-wake disorder, 94f, 96t Schenck, Carlos H., 16, 17f adequate, 64, 64t
in jet lag sleep disorder, 96f, 96t Schizophrenia, 255t, 259 in art and literature, 1–7
in shift work sleep disorder, 95f, 96t SCI (spinal cord injury), sleep disorders with, 146 biology of, 20–60
Restless legs syndrome (RLS), 115–124 SCN. See Suprachiasmatic nucleus (SCN).
age and, 117, 117f Screening questionnaire, 277–280, 277f central and autonomic regulation in
in chronic kidney disease, 241, 242f SDB. See Sleep-disordered breathing (SDB). cardiovascular physiology in, 44–48
clinical manifestations of, 115–116, 115f, 116t Sedating antidepressants
comorbid conditions with, 115–116, 116f, 117f circadian rhythms in, 25–27
and daytime function, 117–118, 118f characteristics of, 75b control of breathing in, 37–44
diagnostic criteria for, 115, 115f, 116t for sleep promotion, 74–75, 75f cytokines in, 34–36
diagnostic evaluation of, 120 structure of, 75f endocrine physiology in, 56–60
Seizure(s), 209–211 host defense in, 34–36
recording leg movements in, 271 with central sleep apnea, 128f, 334f, 335f physiologic regulation in, 29–34, 33f
scoring rules for, 271, 272f with centrotemporal (Rolandic) spikes, 129, 130f, and blood flow, 49–53
differential diagnosis of, 119, 120t control of timing of, 24f, 25, 26f
drugs and, 115–116 337f defined, 61b
early-onset vs. late-onset, 115–116, 116f, 116t clinical manifestations of, 127f, 206t factors affecting, 66–67, 67t
epidemiology of, 117, 117f with continuous spikes during slow-wave activity, interactive regulation of feeding and, 53–56

131

Index 377

Sleep (Continued) Sleep apnea (Continued) Sleep apnea (Continued)
as localized phenomenon of brain, 27–29 for rhinophyma due to rosacea, 156, 156f polysomnography of, 187f, 293f
mechanisms of, 20–25 for traumatic injury, 157–158, 157f, 158f sleep laboratory video(s) on, 357
postures of, 61, 61f
of neck, 164 due to enlarged tonsils and adenoids, 285f, 286f
Sleep, publication of, 15, 16f in Klippel-Feil syndrome, 164, 165f and epilepsy, 131
Sleep and His Half-Brother Death, 7, 7f for large collar size, 164, 164f, 165f exam for, 168
Sleep and Its Derangement, 11 due to growth hormone hypersecretion, 233–234,
Sleep and Poetry, 4 overall inspection in, 149
Sleep and Wakefulness, 12 of pharynx and tongue, 158–160 235f
Sleep apnea, 167–196 heart failure and, 221–223
Mallampati Class I, 158, 159f
and cardiac arrhythmia(s), 15, 15f Mallampati Class II, 158, 159f on bilevel pressure, 00013:f0305
atrial fibrillation as, 316f Mallampati Class III, 160, 160f vs. central sleep apnea, 223–224
sinus arrest and junctional escape rhythm as, 219f, Mallampati Class IV, 160, 160f Cheyne Stokes respirations in, 313f
315f for soft palate tumor, 163, 163f clinical features of, 221, 222–223
tachycardia as, 323f for trauma due to snoring, 163, 163f on CPAP, 00013:f0310
after uvulopalatopharyngoplasty, 163, 164f epidemiology of, 221–223, 222f, 222t
central of tonsils, 161–163 polysomnography of, 311f, 312f, 313f, 314f
after arousals, 170, 172f enlarged, 149f, 163, 163f sleep laboratory video(s) on, 359
with cerebrovascular accidents, 144–145, 144f Grade 0, 161, 161f treatment of, 226–227, 226f
polysomnography of, 329f, 330f, 331f Grade 1, 161, 161f on ventilatory support, 312f
in children, 184–187, 188f Grade 2, 161, 161f with insomnia, 104, 105f
due to neuromuscular disorders, 184–187, Grade 3, 161, 162f due to nasal fracture, 285f, 303
188f Grade 4, 161, 162f due to obesity, 184–187, 184f
defined, 41–42, 299f in families, 149, 149f in obesity hypoventilation syndrome, 355
forms of, 42f growth hormone secretion in, 58, 59f oral appliance or dental device for, 192
due to growth hormone hypersecretion, 233–234 and health care utilization, 86, 86f mandibular advancement device as, 192, 194f
and heart failure, 42f historical background of, 8, 12, 12f, 13 rapid maxillary expansion for, 192, 194f
Cheyne Stokes respirations in, 223–224, 223f, due to jaw abnormality(ies), 149–155 for retrognathia, 193f
224f of mandibular arch, 154, 155f in overlap syndrome, 150, 197
clinical features of, 222–223, 222f, 223f mandibular insufficiency as sleep laboratory videos on, 360, 361
consequences of, 223–224, 224f in child, 152, 152f pathophysiology of, 41–42, 41f, 42f
epidemiology of, 222–223, 222f crowded teeth due to, 152, 152f period limb movements in, 196f, 294f
vs. obstructive sleep apnea, 223–224 with overjet, 152, 153f due to pharyngolaryngomalacia, 186f
treatment of, 225–226, 225f, 226f receding chin due to, 152, 153f polysomnography of, 283
idiopathic, 299f, 300f maxillary insufficiency as, 152, 152f with acromegaly, 289f
on adaptive servo-ventilation, 302f, 303f micrognathia as, 154 with awake obstructive apnea, 291f, 292f
on bilevel pressure, 301f prognathia as, 152 cardiorespiratory sensors in, 284f
on CPAP, 301f retrognathia as, 152–155, 153f in child, 285f, 286f
defined, 300f mixed, 293f due to craniofacial anomalies, 187f
sleep laboratory video(s) on, 358 becoming complex, 303f, 304f with Down syndrome, 293f
in multiple sclerosis, 142–143, 142f, 143f with congestive heart failure, 178f end-tidal CO2 analyzer in, 285f
with obesity, 358 with idiopathic pulmonary fibrosis, 305f due to enlarged tonsils and adenoids, 285f, 286f
due to opiates, 173f with leg channel activity, 288f, 289f hypopneas vs. apneas in, 283f
pathophysiology of, 41–42, 42f, 44f with leg movements, 179f vs. hypoventilation, 290f
period limb movements in, 196f due to nasal trauma, from fracture, 157–158, 157f, leg movement monitoring in, 287f, 288f
polysomnography of due to nasal fracture, 285f
with 5-minute epoch, 173f, 174f 158f, 285f nasal pressure monitors in, 283f, 284f
with 20-minute epoch, 173f from gunshot wound, 157, 157f due to obesity, 184f
with 30-second epoch, 173f, 175f polysomnography of, 285f with periodic limb movements, 294f
with Cheyne Stokes respirations, 174f sleep laboratory video on, 303 due to pharyngolaryngomalacia, 186f
with compressed 10-minute epochs, 172f due to neck abnormality(ies), 164 due to retrognathia, 286f, 287f
with compressed 30-minute epoch, 174f in Klippel-Feil syndrome, 164, 165f sleep stage recording in, 171f, 291f
in infant, 188f large collar size as, 164, 164f, 165f thermal sensors in, 283f, 284f
treatment-emergent, 176f due to obesity, 165, 165f postpartum, 356
relationship between obstructive and, 44f obstructive during pregnancy, 246
with retinitis pigmentosa, 358 with acromegaly, 289f sleep laboratory video(s) on, 355
risk factors for, 167–168 psychiatric consequences of, 260t
with seizures, 128f, 334f, 335f sleep laboratory video(s) on, 356 and pulmonary edema, 216, 217f, 359
sleep laboratory video(s) on, 358–359 and aortic dilatation, 216, 217f relationship between central and, 44f
idiopathic, 358 arousal threshold to noise in, 41f, 42f, 353 REM sleep behavior disorder with, 363
with obesity, 358 with awake obstructive apnea, 291f, 292f due to retrognathia, 286f, 287f
with retinitis pigmentosa, 358 cardiac arrhythmias and, 216, 217–219, 219f, 220f risk factors for, 167–168
sleep stage and, 170, 173f, 174f cardiovascular effects of, 216, 217f, 218f sinus arrest with, 219f
with cerebrovascular accidents, 144–145, 146, 146f sleep laboratory video(s) on, 353–354
complex, 303f, 304f in children with acromegaly, 356
COPD and, 199f, 200f in child, 299
and coronary artery disease, 316f due to craniofacial abnormalities, 184–187, in Down syndrome, 357
defined, 269 186f with heart failure, 359
due to dental abnormalities, 154, 154f with lack of arousal in response to noise, 353
in diabetes, 240 due to Down syndrome, 184–187, 187f due to nasal fracture, 303
due to enlarged tonsils, 184–187, 184f, 285f, 286f due to laryngomalacia, 184–187, 185f, 186f in obesity hypoventilation syndrome, 355
epidemiology of, 85 due to obesity, 184–187, 184f postpartum, 356
examination for, 149–166 due to pharyngolaryngomalacia, 184–187, 186f during pregnancy, 355
polysomnography of, 285f, 286f after uvulopalatopharyngoplasty, 354
of abdomen, 165, 165f sleep laboratory video(s) on, 299 with violent body movements, 354
of extremities, 166 due to tonsillar and adenoidal hypertrophy, sleep stage effect in, 171f, 291f
sleep studies of, 171f, 184f, 186f, 187f
with peripheral edema, 166, 166f 184–187, 184f, 285f, 286f and sudden cardiac death, 219
of facial and jaw, 149–155 in chronic kidney disease, 241 symptoms of, 168, 168b
coronary artery disease and, 219–220, 220f systemic hypertension and, 221, 221f
for bloodshot eyes, 150, 150f CPAP for, 190–192 due to thyroid mass lesions, 233f
for buck teeth, 154, 154f upper airway muscles and arousal threshold in,
in Down syndrome, 150, 150f adverse effects of, 192, 192f, 193f
for drooping eyelids, 150, 150f in children, 192, 195f 41f, 42f
for mandibular arch abnormalities, 154, 155f flow generators for, 190, 190f after uvulopalatopharyngoplasty, 354
for micrognathia, 154 titration of, 190–192, 191f, 192f vigorous movements in, 354
for prognathia, 152 types of masks for, 190, 190f with violent body movements, 354
for retrognathia, 152–155, 153f due to craniofacial anomalies, 187f
for skeletal abnormalities, 150, 151f cycle of ventilatory instability in, 42f
of nasal airway, 156–158 defined, 41–42
in Down syndrome
in children, 184–187

378 Index

Sleep apnea (Continued) Sleep disorder(s) (Continued) Sleep stage recording, in obstructive sleep apnea,
in Parkinson’s syndrome, 134f, 324f rest-activity cycle in, 95f, 96t 171f, 291f
with REM sleep behavior disorder, 350 treatment for, 95, 96t
pathophysiology of, 41–43 Sleep staging, 61–62, 261–267
patient interview videos of, 347–348 Sleep drive, 22, 23f, 26f classification in, 263
with Arnold-Chiari malformation, 351 Sleep histogram, 64, 65f of stage N1, 263, 265f
with Becker muscular dystrophy, 351 Sleep homeostat, 22, 23f, 26f of stage N2, 265, 265f
in child, 347 Sleep hygiene of stage N3, 265, 266f
with Down syndrome, 347 of stage R, 266, 266f
in elderly, 347 for delayed sleep phase disorder, 91–92 of stage W, 263, 264f
with multiple sclerosis, 351 inadequate, 105t of waves, 263, 264t
with narcolepsy, 349 Sleep hygiene education, for insomnia, 106t historical background of, 261
with Parkinson’s disease and REM sleep behavior Sleep laboratory video(s), 00018#sc0020 recording in, 261–263, 262t
disorder, 350 on central apnea and Cheyne Stokes respirations, of EEG of brain activity, 261, 262f, 263f
periodic limb movements in sleep with, 362 of EMG for skeletal muscle tone, 263
with peripheral edema, 166, 166f 358–359 of eye movements, 261–263
presenting as restless sleep, 348 with heart failure, 359 smoothing rules in, 266–267
due to relationship between tongue and pharynx, idiopathic, 358
158–160 with obesity, 358 Sleep state, as facilitator of epilepsy, 125, 126f
Mallampati Class I, 158, 159f with retinitis pigmentosa, 358 Sleep study(ies)
Mallampati Class II, 158, 159f on neurologic and other disorder(s), 361–364
Mallampati Class III, 160, 160f delayed sleep phase as, 363 for narcolepsy, 112–114
Mallampati Class IV, 160, 160f periodic limb movements disorder as, 362 maintenance of wakefulness test as, 114
with restless legs syndrome, 362 REM behavior disorder as, 363 Multiple Sleep Latency Test as, 112–113, 113f
due to rosacea, 156, 156f restless legs syndrome as, 361, 362 nocturnal polysomnogram as, 112, 112f
scoring rules for, 269, 270f seizures as, 364
due to soft palate tumor, 163, 163f sleep paralysis as, 363 patient interview video on explaining results of, 348
teaching and CPAP mask fitting for, 348 on obstructive sleep apnea, 353–354 for sleep-disordered breathing, 168
in truck driver, 348 with acromegaly, 356
after uvulopalatopharyngoplasty, 163, 164f in child, 299 data obtained in, 168
in Down syndrome, 357 scoring interval(s) in, 178–182
Sleep Apnea Syndrome, 15 with lack of arousal in response to noise, 353
Sleep architecture, 64, 65f due to nasal fracture, 303 5-minute compressed epoch as, 174f, 178, 180f
in obesity hypoventilation syndrome, 355 10-minute compressed epoch as, 168f, 169f,
antiepileptic drugs and, 125, 125t postpartum, 356
changes across night in, 275, 275f, 276t during pregnancy, 355 172f, 178, 178f, 180f, 183f
Sleep behaviors, clinical evaluation of, 87–88, 88b after uvulopalatopharyngoplasty, 354 20-minute epoch as, 173f
Sleep breathing disorders. See Sleep-disordered with violent body movements, 354 30-second compressed epoch as, 174f, 178
on respiratory disease(s), 359–361 30-second epoch as, 169f, 173f, 175f, 178, 179f,
breathing (SDB). asthma as, 359
Sleep center health and family questionnaire, 279f COPD as, 359, 360 181f, 183f
Sleep center medication log, 277–280, 281f interstitial pulmonary fibrosis as, 361 choice of, 178, 181f, 182f
Sleep clinic screening questionnaire, 277–280, 277f overlap syndrome as, 360, 361 compression of, 178, 180f
Sleep continuity, with depression, 255t on upper airway resistance syndrome, 357–358 split screen for, 178, 181f, 182f, 183f
Sleep deprivation with quiet snoring, 357 Sleep symptom checklist, 277–280, 277f, 278f
with variable snoring, 357, 358 Sleep terrors, 206t, 208f
in adolescents, 85, 86b Sleep maintenance insomnia, 99f vs. nocturnal seizures, 212b
and driving, 85, 85b Sleep mechanisms, 20–25 Sleep-disordered breathing (SDB), 149–205
and leptin and ghrelin, 58–60, 59f Sleep medicine, history of, 8–19 classification of, 167, 167b
and psychomotor vigilance task, 28f, 68, 68f Sleep of Reason Produces Monsters, The, 6, 6f clinical evaluation of, 86, 87b, 168
and reaction time performance, 28, 28f Sleep onset insomnia, 99f exam in, 168
time-on-task effects of, 28, 28f with heart failure, 305f symptoms in, 168, 168b
Sleep diaries, 89, 89f sleep laboratory video on, 363 defined, 167
Sleep disorder(s) Sleep organization, antiepileptic drugs and, 125, 125t diagnostic assessment methods for, 269–270
adjustment, 105t Sleep paralysis definitions and scoring rules for, 269–270
circadian rhythm (See Circadian rhythm sleep defined, 87, 108 for hypopnea, 269–270, 271f
in narcolepsy, 107–108, 107b for respiratory effort related arousals, 270
disorder[s] [CRSDs]) sleep laboratory video on, 363 for sleep apnea, 269, 270f
diagnosis of polysomnography of, 332f recording technique in, 267t, 269
during pregnancy, 246 due to growth hormone hypersecretion, 233–234,
clinical evaluation in, 86–88 treatment for, 114, 114b
of excessive sleepiness, 87, 87b Sleep problems checklist, 277–280, 278f 235f
family history in, 88 Sleep promoting systems, 22, 22f hypnogram for, 178, 181f
history of present illness in, 86 Sleep regulation patient interview videos of, 347–348
impact on patient in, 88 brain in, 20–25
of insomnia, 87, 87b circadian rhythms in, 25–27 with Arnold-Chiari malformation, 351
medical history in, 88, 88b endocrine system in, 56–60 with Becker muscular dystrophy, 351
medication history in, 88 interactive regulation of feeding and, 53–56 with cardiovascular comorbidities, 347
patient complaints in, 86, 86b localized and use-dependent, 27–29, 27f, 28f in child, 347
sleep behaviors in, 87–88, 88b physiologic, 29–34, 33f with Down syndrome, 347
of sleep-disordered breathing, 86, 87b Sleep restriction in elderly, 347
social history in, 88 historical background of, 19 explaining results to patient with, 348
for insomnia, 106t with multiple sclerosis, 351
physical exam in, 88, 88b, 89b Sleep schedule, questionnaire on, 277f with narcolepsy, 349
self-administered instruments in, 89–90 Sleep spindle(s), 264t, 267t with Parkinson’s disease and REM sleep behavior
in fibromyalgia, 252, 252f
Berlin Apnea Questionnaire as, 90, 90f Sleep stage(s), 64t disorder, 350
Epworth Sleepiness Scale as, 90, 90f with aging, 67f, 275 presenting as restless sleep, 348
sleep diaries as, 89, 89f in art, 1, 1f teaching and CPAP mask fitting for, 348
impact of, 85 changes across night in, 275, 275f, 276t in truck driver, 348
on adolescents, 85, 86b parameters for evaluating, 276t pediatric, 184–189
in clinical evaluation, 88 proportion of night spent in, 64, 64f central, 184–187, 188f
on disasters, 85, 85f and sleep-disordered breathing, 170, 171f
on driving, 85, 85b stage N1, 62f due to neuromuscular disorders, 184–187, 188f
on workplace productivity, 85, 85b stage N2, 63f obstructive
jet lag, 95–96 stage N3, 63f
clinical presentation of, 95, 96t stage R, 64f due to craniofacial abnormalities, 184–187,
rest-activity cycle in, 96f, 96t stage W, 62f 186f
treatment for, 95, 96t
magnitude and significance of, 86, 86f due to Down syndrome, 184–187, 187f
shift work, 95 due to laryngomalacia, 184–187, 185f, 186f
clinical presentation of, 95, 96t due to obesity, 184–187, 184f
epidemiology of, 95 due to pharyngolaryngomalacia, 184–187,

186f
due to tonsillar and adenoidal hypertrophy,

184–187, 184f, 285f, 286f
patient interview video of, 347
periodic respirations as, 184–187, 189f
treatment of, 192, 194f, 195f

Index 379

Sleep-disordered breathing (SDB) (Continued) Sleep-promoting agent(s) (Continued) Stroke (Continued)
and periodic limb movements, 195, 196f zolpidem as, 69t, 72 sleep disorder(s) and, 144–146
during pregnancy, 246, 246t binding site of, 72f breathing disturbances and, 144–145, 145f, 145t
respiratory event(s) in, 168–182 modified-release (extended-release), 72, 72f, 73f central sleep apnea as, 144–145, 144f
apneas as, 168–170, 169f plasma concentration of, 72f polysomnography of, 329f, 330f, 331f
central, 170, 172f, 173f, 174f structure of, 72f excessive daytime sleepiness as, 329f, 330f
mixed, 170, 176f, 178f, 179f zopiclone as, 69t insomnia as, 329f
Cheyne Stokes respirations as, 170, 174f obstructive sleep apnea as, 144–145, 146, 146f
hypopnea as, 168–170, 168f, 169f, 179f Sleep-related breathing disorders. See Sleep-disordered
nonapneic, 183, 183f breathing (SDB). Stylopharyngeus muscle, during sleep, 40f
respiratory effort as, 170, 175f Sublaterodorsal (SLD) nucleus, in REM sleep, 23f
respiratory effort–related arousal as, 168–170, Sleep-related eating disorder, 207, 207b, 208f Substance
170f Sleep-wake behavior, brain in, 20, 20f
risk factors for, 167–168 Sleep-wake cycle hypersomnia due to, 110
sleep stage effect on, 170, 171f hypersomnia not due to, 110
sleep study for, 168 cerebral blood flow during, 49, 49f Sudden cardiac death, obstructive sleep apnea and, 219
data obtained in, 168 control of, 24f, 25–27 Sullivan, Colin, 15, 16f
scoring interval(s) in, 178–182 Sleepwalking, 206t, 207b Sundowning syndrome, 141–142, 141f
5-minute compressed epoch as, 174f, 178, 180f historical background of, 8 Supplementary sensorimotor seizures, 129
10-minute compressed epoch as, 168f, 169f, Slow eye movements (SEM), 264t Suprachiasmatic nucleus (SCN)
172f, 178, 178f, 180f, 183f Slow wave sleep in Alzheimer’s disease, 140
20-minute epoch as, 173f age differences in, 64, 65f in circadian rhythms, 25, 26f
30-second compressed epoch as, 174f, 178 epilepsy with continuous spike waves during, 131 in control of timing of sleep, 24f, 25, 26f
30-second epoch as, 169f, 173f, 175f, 178, 179f, waveforms in, 264t, 267t historical background of, 14
181f, 183f Smoking, COPD due to, 198f Sweat artifact, in hyperthyroidism, 230f
choice of, 178, 181f, 182f Snoring Sympathetic activity, during sleep, 45, 46f
compression of, 178, 180f in COPD, 197, 198f Synucleinopathies, REM sleep behavior disorder in,
split screen for, 178, 181f, 182f, 183f in diagnostic assessment, 262t
spectrum of, 167, 167b during pregnancy, 246 135–136, 136f
treatment of, 190–194 Syringomyelia, 351
CPAP for, 190–192 and preeclampsia, 246, 246t Systemic hypertension, due to obstructive sleep apnea,
adverse effects of, 192, 192f, 193f and stroke, 144–145
in children, 192, 195f trauma (redness) of tonsils due to, 163, 163f 221, 221f
flow generators for, 190, 190f in upper airway resistance syndrome Systolic heart failure, 221–223
patient interview video of, 348
titration of, 190–192, 191f, 192f quiet, 357 and central sleep apnea
types of masks for, 190, 190f variable, 357, 358 Cheyne Stokes respirations in, 223–224, 223f,
oral appliance or dental device for, 192, 193f, 194f after uvulopalatopharyngoplasty, 354 224f
rapid maxillary expansion for, 192, 194f SNRIs (serotonin and norepinephrine reuptake clinical features of, 222–223, 222f, 223f
consequences of, 223–224, 224f
Sleep-Eze (diphenhydramine), for sleep promotion, 74, 75t inhibitors), REM suppression due to, 257t epidemiology of, 221–223, 222f
Sleepiness, daytime Social history, 88 vs. obstructive sleep apnea, 223–224
Sodium oxybate, to promote wakefulness, 76t, 78 treatment of, 225–226, 225f, 226f
and catastrophic disasters, 85, 85f Soft palate tumor, 163, 163f
clinical evaluation of, 87, 87b Sominex (diphenhydramine), for sleep promotion, 74, clinical features of, 221
with depression, 254 epidemiology of, 221–223
in epilepsy patients, 130f, 131 75t and obstructive sleep apnea, 221–223
medications for, 76t Somnogen, endogenous, 23f
in multiple sclerosis, 338f, 339f SOREMP (sleep-onset REM period), in narcolepsy, vs. central sleep apnea, 223–224
in narcolepsy, 107–108, 107b clinical features of, 221, 222–223
in older patients, 99f 112, 112f, 113f epidemiology of, 221–223, 222f, 222t
in Parkinson’s disease, 132, 132f Spinal cord blood flow, during sleep, 50, 50f treatment of, 226–227, 226f
during pregnancy, 245–246 Spinal cord diseases, sleep disorders with, 146
with stroke, 329f, 330f Spinal cord injury (SCI), sleep disorders with, 146 T
treatment for, 114 Spinal muscular atrophy, sleep-disordered breathing in,
Sleepiness Scale, 90, 90f Tachycardia
Sleeping Apollo, 2, 2f 188f with heart failure and Cheyne Stokes respirations,
Sleeping pills. See Sleep-promoting agent(s). Spitz, Annie, 12 322f
Sleeping Venus, 2, 2f SSRIs (selective serotonin reuptake inhibitors), REM with sleep apnea and movement disorder, 323f
Sleep-onset REM period (SOREMP), in narcolepsy, ventricular, 321f, 322f, 323f
suppression due to, 257t with obstructive sleep apnea, 220f
112, 112f, 113f ST depression, due to obstructive sleep apnea, 219
Sleep-promoting agent(s), 69–76, 69t Stage N1, 62f, 263, 265f, 267t Tachypnea, thermal, during sleep, 30f
Stage N2, 63f, 265, 265f, 267t Takahashi, J. S., 18
barbiturates as, 69t Stage N3, 63f, 265, 266f, 267t TC (thalamo-cortical) system, in sleep regulation, 22f
benzodiazepines as, 69, 69t, 72f Stage R, 64f, 266, 266f, 267t TCAs (tricyclic antidepressants), REM suppression due
chloral hydrate/betaine as, 69t Stage W, 62f, 263, 264f, 267t
chlormethiazole as, 69t Steen, Jan, 4, 4f to, 257t
diphenhydramine as, 74, 75t Stefansson, H., 19 Teeth
eszopiclone as, 74f Stephan, Frederick, 14
Sternbach, Leo, 13 “buck,”, 154, 154f
pharmacokinetics of, 73f Stimulant(s), 76–78, 76t crowded, 152, 152f
structure of, 73f Teeth clenching and teeth grinding, 211–213
ethanol as, 76 amphetamines and related compounds as, 76t, 77 clinical presentation of, 211–212, 213f
structure of, 76f mechanism of action of, 77f consequences of, 211–212, 213f
GABA-A receptor complex and, 69f, 70–71, 70f polysomnogram of, 212, 213f, 214f
over-the-counter, 75t caffeine as, 78, 79f treatment of, 212–213
promethazine as, 69t for cataplexy, 76t Temazepam, for sleep promotion, 69t
ramelteon as, 74, 75f clinical characteristics of, 77t Temperature regulation
structure of, 74f for excessive daytime sleepiness/irresistible episodes during menopause, 248–250, 249f
sedating antidepressants (trazodone) as, 74–75, 75f in sleep, 29, 29t
characteristics of, 75b of sleep, 76t
structure of, 75f mechanism of action of, 77f and chest sweating, 31f
site of action of, 71, 71f modafinil as, 76t, 77 and metabolic rate, 30f
triazolam as, 71, 71t and shivering, 30f
site of action of, 71f efficacy of, 78f and tachypnea, 30f
structure of, 72f mechanism of action of, 77f, 78f Temporal lobe epilepsy, 126, 127–129, 129f
zaleplon as, 69t, 74f pharmacokinetics of, 78t polysomnography of, 335f, 336f
binding site of, 72f for poor sleep, 76t Tender points, in fibromyalgia, 251, 251f
structure of, 74f to promote wakefulness, 76t, 79f Tensor palatini muscle, during sleep, 40f
relative efficacy of, 79f Thalamo-cortical (TC) system, in sleep regulation, 22f
sodium oxybate as, 76t, 78 Thermal sensors, in obstructive sleep apnea, 283f,
Stimulus control, for insomnia, 106t
Stress, post-traumatic, 259, 269b 284f
Stroke Thermal tachypnea, during sleep, 30f
polysomnography of Thermoregulation
with excessive daytime sleepiness, 329f
with insomnia, 329f during menopause, 248–250, 249f
with sleep apnea, 330f, 331f in sleep, 29, 29t