Preface	6
	Contents	8
	Contributors	10
	Chapter 1: Normal Sleep	14
	Normal Sleep Stages and Architecture	14
	Breathing During Sleep: Ventilation and the Upper Airway	17
	Summary of Normal Breathing and Ventilation During Sleep	17
	Effect of Sleep on Control of Breathing	18
	Effect of Sleep on Upper-Airway Structure and Function	18
	Cardiovascular Function During Sleep	22
	Endocrine Function During Sleep	23
	Gastrointestinal Function During Sleep	23
	Summary of Keypoints	24
	References	25
	Chapter 2: Pharmacology of Sleep	29
	Introduction	29
	Sleep-Promoting Drugs	30
	Benzodiazepines	30
	Nonbenzodiazepine Receptor Agonists (NBRA)	32
	Barbiturates Derivatives	39
	Melatonin Receptor Agonists	39
	Ramelteon	39
	Tasimelteon	40
	Melatonin	43
	Antidepressants and Antipsychotics	43
	Trazodone	43
	Tricyclic Antidepressants (TCA)	44
	SSRI and SNRI	44
	Other Antidepressants	47
	Antipsychotic Agents	47
	Other Sedating Drugs	47
	Newer Sedatives Under Development	48
	Almorexant	48
	Agomelatine	48
	Stimulants/Wake-Promoting Drugs	49
	Amphetamine-Like Substances	49
	Modafinil	49
	Armodafinil	53
	Sodium Oxybate	54
	Drugs of Abuse	55
	New Drugs Under Development	57
	Summary of Keypoints	57
	References	58
	Chapter 3: Obstructive Sleep Apnea: Diagnosis with Polysomnography and Portable Monitors	67
	Introduction	67
	Prevalence and Epidemiology	68
	Risk Factor	68
	Clinical History	69
	Physical Exam	72
	Diagnosis of OSA	72
	Overnight Polysomnography (PSG)	72
	Split Night Study (Diagnosis Combined with Titration)	75
	Portable Monitoring (PM)	76
	Types of PMs (Type II–IV)	76
	When Should PM Be Considered for Diagnosis of OSA?	77
	Current Roles of Autotitrating Positive Airway Pressure (APAP)	78
	Cost Effectiveness of PSG vs. PM	79
	Utilities of Multiple Sleep Latency Test (MSLT) in OSA	79
	Future Outlook	80
	Summary Outline	80
	References	81
	Chapter 4: Approach to Hypersomnia	85
	Introduction	85
	Determinants of Daytime Sleepiness	86
	Sleep Factors	86
	Quantity of Sleep	86
	Quality of Sleep	86
	Circadian Rhythm	87
	Medications	87
	Demographic Factors	88
	Age	88
	Gender	88
	Race	88
	Obesity	88
	Pathology of the Central Nervous System	89
	Measurement of Daytime Sleepiness	89
	Multiple Sleep Latency Test (MSLT)	89
	Maintenance of Wakefulness Test (MWT)	90
	Epworth Sleepiness Scale (ESS)	91
	Summary of Measurements of Excessive Daytime Sleepiness	93
	Differential Diagnosis	93
	Approach to the Sleepy Patient	95
	Summary of Keypoints	97
	References	97
	Chapter 5: Obstructive Sleep Apnea: Epidemiology of Sleep Apnea	102
	Introduction	102
	Clinical Definitions of Obstructive Sleep Apnea	103
	Prevalence	106
	North America	109
	Europe	109
	Asia	110
	South America	110
	Australasia	111
	Disease Progression	111
	Risk Factors	112
	Obesity	112
	Age	114
	Gender, Menopause, and Pregnancy	114
	Craniofacial Features	115
	Ethnicity	116
	Alcohol and Cigarette Consumption	117
	Familial/Genetic Factors	118
	Summary of Keypoints	118
	References	119
	Chapter 6: Obstructive Sleep Apnea: Clinical Features and Adverse Consequences	125
	Introduction	125
	Risk Factors for OSA	127
	Obesity	127
	Age	128
	Sex	128
	Ethnicity	128
	Bony Structures	129
	Diseases Associated with Edematous States	129
	Positive Family History	129
	Hypothyroidism	130
	Presence of Co-Morbid Conditions	130
	Clinical Symptoms	130
	Physical Signs	131
	Adverse Consequences of OSA	133
	Consequences Directly Linked to Symptoms	133
	Cardiovascular and Metabolic Consequences	133
	Hypertension	134
	Coronary Artery Disease	135
	Stroke	135
	Arrhythmias	136
	Diabetes and Metabolic Syndrome	136
	Conclusion	137
	Summary of Keypoints	137
	Chapter 7: Assessments of Driving Risk in Sleep Apnea	139
	Scope of the Problem	139
	Factors in Driving Risk	141
	The Interactive Responsibilities of a Driving Assessment	143
	Potential for Liability Risk for Pulmonary Physicians	144
	Societal Implications	146
	Lessons from the Alcohol Literature	146
	Principles in Assessment of Risk by the Pulmonary Physician	149
	Summary of Keypoints	150
	References	150
	Chapter 8: Nasal Continuous Positive Airway Pressure (CPAP) Treatment	153
	Mechanisms	153
	Beneficial Effects	154
	Excessive Daytime Sleepiness	154
	Blood Pressure	154
	Pulmonary Hypertension	155
	Heart Failure	155
	Cardiac Arrhythmias	155
	Neurocognitive Function	156
	Glucose Metabolism	156
	Motor Vehicle Accidents	157
	Adverse Effects	157
	Setting Up CPAP	157
	Titration	158
	Auto Titration	158
	Predictive Equations and Bedpartner Titration	159
	CPAP Modifications	159
	Adherence	160
	Conclusion	160
	Summary of Keypoints	161
	References	161
	Chapter 9: Obstructive Sleep Apnea: Oral Appliances	164
	Introduction	164
	Types of Appliances	165
	Mechanism of Action	166
	Efficacy and Effectiveness in the Treatment of OSA	167
	Impact on Polysomnographic Outcomes	167
	Impact on Health Outcomes	168
	Long-Term Efficacy	169
	Effectiveness Compared with Other Treatments	169
	Patient Selection and Prediction of Treatment Outcome	171
	Indications for Treatment	171
	Oral Considerations	171
	Indicators of Treatment Success	171
	Techniques for Predicting Outcome	172
	Contraindications	175
	Appliance Titration Protocols	175
	Adverse Effects	176
	Treatment Adherence	177
	Interdisciplinary Care Model	178
	Future Research	178
	Conclusion	179
	Summary of Keypoints	179
	References	180
	Chapter 10: Obstructive Sleep Apnea: Surgery	184
	Introduction	184
	Clinical Evaluation	185
	Background and Clinical Context of Surgical Therapy	185
	Role of Surgical Therapy	186
	Patient Evaluation	187
	Snoring	188
	Nasal Surgery	189
	Anatomy and Physiology	189
	Allergic Rhinitis and Sleep	190
	Pathophysiology of Nasal Obstruction and Sleep Disturbance	192
	Nasal Obstruction and Sleep-Disordered Breathing	193
	Surgical Treatment of Nasal Obstruction	193
	Nasal Surgery and Improved Effectiveness of Medical Therapy for OSA	194
	Oropharyngeal Surgery	195
	History	195
	A Paradigm Shift	196
	The Importance of Uvular Preservation	197
	Palatal Anatomy and Examination	197
	Surgical Techniques	199
	Expansion Sphincter Pharyngoplasty	199
	Transpalatal Advancement	200
	Hypopharyngeal Surgery	201
	Background	201
	Anatomy	202
	Hypopharyngeal Surgical Techniques	204
	Maxillomandibular Advancement Surgery	205
	Conclusion	206
	Summary of Keypoints	206
	References	207
	Chapter 11: Sleep and Lung Disease	211
	Introduction	211
	Sleep and COPD	211
	Hypoventilation	212
	Measurement of Hypoventilation and Respiratory Dysfunction	213
	Clinical Consequences of Sleep Hypoxemia in COPD	213
	Diagnosis of Nocturnal Hypoxemia in COPD	214
	Treatment of Nocturnal Hypoxemia	214
	Medications	215
	Noninvasive Positive Pressure Ventilation	216
	COPD and Obstructive Sleep Apnea: The Overlap Syndrome	216
	Sleep and Asthma	216
	Sleep Disturbances in Nocturnal Asthma	217
	Diagnosis	217
	Sleep and Restrictive Lung Disorders	217
	Chest Wall Disorders	218
	Pathophysiology of Hypoxemia	218
	Diagnosis	219
	Therapy	219
	Interstitial Lung Disease	219
	Diagnosis	219
	Treatment	220
	Sleep and Obesity: Hypoventilation Disorders	220
	Pathogenesis	220
	Clinical Features	221
	Diagnosis	221
	Therapy	221
	Weight Loss	222
	Summary of Keypoints	222
	References	223
	Chapter 12: Central Sleep Apnea	226
	Determinants of Central Apnea During NREM Sleep	226
	Hypocapnia	226
	Short-Term Potentiation	227
	Duration of Hyperpnea	227
	Role of Upper Airway Reflexes	227
	Mechanisms Perpetuating Breathing Instability	228
	Pathophysiologic Classification of Central Sleep Apnea	228
	Central Sleep Apnea Secondary to Hypoventilation	229
	Central Apnea Secondary to Hyperventilation	230
	Central Apnea Risk Factors	230
	Sleep State	230
	Age and Gender	231
	Medical Conditions	231
	Clinical Features and Diagnosis	232
	Management	233
	Positive Pressure Therapy	233
	Pharmacological Therapy	234
	Supplemental O 2 and CO 2	235
	Approach in Selected Clinical Syndromes	235
	Summary	235
	Summary of Keypoints	236
	References	236
	Chapter 13: Insomnia: Etiology, Clinical Manifestations, and Morbidity	240
	Introduction	240
	DSM – IV	243
	ICSD – II	243
	Prevalence and Risk Factors of Insomnia	245
	Pathophysiology of Insomnia	246
	Clinical Assessment	248
	Sleep History	248
	Medical History	249
	Psychiatric History	249
	Family History	249
	Medication History	249
	Functional Outcomes Associated with Insomnia	251
	Conclusion	251
	Summary of Keypoints	252
	References	252
	Chapter 14: Management of Insomnia	256
	Introduction	256
	Control of Breathing During Sleep	258
	Pulmonary Disorders and Sleep	260
	Bronchospastic Airway Disorders	260
	Interstitial Lung Diseases and Sleep	260
	Kyphoscoliosis, Restrictive Thoracic Cage Disorders, and Sleep	262
	High Altitude Sickness and Insomnia	264
	Carbonic Anhydrase Inhibitors: Acetazolamide	265
	Benzodiazepines	265
	Non-benzodiazepine Benzodiazepine Receptor Agonists	266
	Oral Steroids	267
	Other Medication Used to Treat Insomnia at High Altitude	267
	Medications Used to Treat Insomnia	267
	Efficacy of Hypnotics	268
	Safety of Medications Commonly Used in Insomnia	272
	Sedating Antidepressants	275
	Cognitive-Behavioral Therapy of Insomnia	276
	Other Medications	276
	Summary of Keypoints	277
	References	278
	Chapter 15: Circadian Disorders	284
	Circadian Biology	284
	Circadian Rhythm Sleep Disorders	286
	Delayed Sleep Phase Disorder	286
	Diagnosis of Delayed Sleep Phase Disorder	287
	Treatment of Delayed Sleep Phase Disorder	287
	Advanced Sleep Phase Disorder	289
	Diagnosis of Advanced Sleep Phase Disorder	289
	Treatment of Advanced Sleep Phase Disorder	290
	Free-Running Type	290
	Diagnosis of Free-Running Type	290
	Treatment of Free-Running Type	291
	Irregular Sleep–Wake Rhythm	291
	Diagnosis of Irregular Sleep–Wake Rhythm	291
	Treatment of Irregular Sleep–Wake Rhythm	292
	Shift Work Disorder	292
	Diagnosis of Shift Work Disorder	293
	Treatment of Shift Work Disorder	293
	Jet Lag	295
	Diagnosis of Jet Lag	295
	Treatment of Jet Lag	295
	Summary	296
	Summary of Keypoints	297
	References	297
	Chapter 16: Narcolepsy and Idiopathic Hypersomnia	304
	Introduction	304
	Clinical Features	305
	Narcolepsy	305
	Idiopathic Hypersomnia	307
	Epidemiology	308
	Narcolepsy	308
	Idiopathic Hypersomnia	308
	Pathophysiology	309
	Narcolepsy	309
	Idiopathic Hypersomnia	310
	Diagnosis	310
	Narcolepsy	310
	Idiopathic Hypersomnia	312
	Differential Diagnosis	313
	Head Trauma and Excessive Sleepiness	314
	Treatment	314
	Nonpharmacologic Management	315
	Pharmacologic Management of Symptoms Common to Both Narcolepsy and Idiopathic Hypersomnia	315
	Pharmacologic Management of Symptoms Specific to Narcolepsy	316
	Cataplexy	316
	Fragmented Nocturnal Sleep	317
	Conclusion	317
	Summary of Keypoints	317
	References	318
	Chapter 17: Parasomnias	322
	Introduction	322
	NREM Parasomnias or Disorders of Arousal	322
	Confusional Arousal	322
	Definition	322
	Clinical Symptomatology	323
	Etiology	323
	Pathophysiology	323
	Epidemiology	323
	Diagnostic Workup	323
	Treatment	324
	Sleepwalking or Somnambulism	324
	Definition	324
	Clinical Symptomatology	324
	Etiology	325
	Pathophysiology	325
	Epidemiology	326
	Diagnostic Workup	326
	Treatment	326
	Sleep Terror or Pavor Nocturnus	327
	Definition	327
	Clinical Symptomatology	327
	Etiology	328
	Pathophysiology	328
	Epidemiology	328
	Diagnostic Workup	328
	Treatment	328
	REM Parasomnias	329
	REM Sleep Behavior Disorder	329
	Definition	329
	Clinical Symptomatology	329
	Etiology	330
	Pathophysiology	330
	Epidemiology	330
	Diagnostic Workup	330
	Treatment	330
	Parasomnia Overlap Syndrome/Status Dissociates	332
	Isolated Recurrent Sleep Paralysis	333
	Definition	333
	Clinical Symptomatology	333
	Etiology	333
	Pathophysiology	333
	Epidemiology	333
	Diagnostic Workup	334
	Treatment	334
	Nightmares	334
	Definition	334
	Clinical Symptomatology	334
	Etiology	335
	Pathophysiology	335
	Epidemiology	335
	Diagnostic Workup	335
	Treatment	335
	Other Parasomnias	336
	Sleep-Related Dissociative Disorder	336
	Treatment	337
	Sleep Enuresis	337
	Definition	337
	Clinical Symptomatology	337
	Etiology	338
	Pathophysiology	338
	Epidemiology	338
	Diagnostic Workup	338
	Treatment	339
	Sleep-Related Eating Disorder	341
	Definition	341
	Etiology	341
	Pathophysiology	341
	Clinical Symptomatology	341
	Epidemiology	342
	Diagnostic Workup	342
	Treatment	342
	Exploding Head Syndrome	343
	Treatment	343
	Catathrenia	343
	Treatment	343
	Sleep-Related Hallucinations	344
	Treatment	344
	Future Directions	345
	Conclusion	345
	Summary of Keypoints	345
	References	346
	Chapter 18: Movement Disorders	356
	Introduction	356
	Restless Legs Syndrome	357
	Demographics	357
	Diagnosis	357
	Associated Features	358
	Differential Diagnosis	359
	Primary vs. Secondary Factors	359
	Management	360
	Periodic Limb Movement Disorder	362
	Demographics	362
	Diagnosis	362
	Associated Features	363
	Differential Diagnosis	363
	Management	363
	Sleep-Related Leg Cramps	364
	Diagnosis	364
	Demographics	364
	Differential Diagnosis	365
	Associated Features	365
	Treatment	365
	Sleep-Related Bruxism	367
	Demographics	367
	Diagnosis	367
	Differential Diagnosis	367
	Associated Features	368
	Management	368
	Sleep-Related Rhythmic Movement Disorder	369
	Demographics	369
	Diagnosis	369
	Associated Features	370
	Differential Diagnosis	370
	Treatment	371
	Conclusion	371
	Summary of Keypoints	371
	References	372
	Chapter 19: Perioperative Care of Patients with Obstructive Sleep Apnea Syndrome	377
	Introduction	377
	Preoperative Risk Assessment and OSA Screening Protocols	378
	Factors Contributing to Increased Risk of Complications in Surgical Patients	378
	Morbid Obesity and OSA	379
	Preoperative Evaluation	379
	Preoperative Screening for Suspected OSA	379
	The Berlin Questionnaire	380
	The American Society of Anesthesiologists’ Checklist	380
	The STOP Questionnaire	380
	The STOP-Bang Model	381
	Sleep Apnea Clinical Score	381
	Preoperative Evaluation of Known OSA	383
	Preoperative OSA Optimization	384
	Intraoperative OSA Management	384
	Choice of Anesthetics/Anesthetic Technique	384
	Increased Risk of Difficulty with Tracheal Intubation	385
	Postoperative OSA Management	386
	Postoperative Pain Control	386
	Postoperative Monitoring	387
	Oximetry	387
	Capnography	388
	Management Algorithms	388
	PACU	388
	Intervention Protocols	392
	General Surgery	392
	Intervention Protocols in Orthopedic Surgery	392
	Intervention Protocols in Gastric Bypass Surgery Patients	393
	Conclusion	394
	Summary of Keypoints	394
	References	395
	Chapter 20: Sleep and Critical Illness	400
	Introduction	400
	Why Care?	401
	Measurement of Sleep During Critical Illness	402
	Nature and Extent of Sleep Disturbances	403
	Causes and Cures	404
	Conclusion	407
	Summary of Keypoints	407
	References	408
	Index	411