Spontaneous baroreflex analysis in non-apneic snoring individuals during NREM sleep.

The primary purpose of this study was to measure baroreceptor sensitivity (BS) during wakefulness and non-rapid eye movement (NREM) sleep in non-apneic snoring individuals. To achieve this purpose continuous and simultaneous measurements of snoring, oxygen saturation, sleep stages, arterial blood pressure and heart rate were obtained from seven non-apneic snoring subjects. After obtaining these measures, a computer program was employed to detect concomitant increases or decreases in systolic blood pressure and R-R interval duration during sequences of three or more consecutive beats that occurred during stage II and slow wave sleep (SWS). The values recorded from a given sequence were plotted and the slope of the regression line fit to the data was used as a measure of BS. The results showed that mean arterial pressure and heart rate during stage II and SWS of NREM sleep were not significantly different from wakefulness. In contrast, the BS measured during NREM sleep was significantly lower than values recorded during wakefulness. In addition, linear regression analysis showed that an inverse and significant correlation existed between snoring frequency and the decrease in BS during sleep. We conclude that the decrease in blood pressure and heart rate normally observed during NREM sleep in healthy non-snoring individuals is attenuated or abolished in non-apneic snoring individuals and that these cardiovascular alterations may be partially mediated by a decrease in BS.

Successful treatment of the idiopathic restless legs syndrome in a randomized double-blind trial of oxycodone versus placebo.

In a double-blind randomized crossover trial, oxycodone or placebo was given in divided night-time doses to 11 patients with idiopathic restless legs syndrome (RLS) for 2 weeks prior to appropriate polysomnographic studies. Under double-blinded conditions, patients were asked to do daily ratings of their leg sensations, motor restlessness and daytime alertness on a 1-4 scale for the 2 weeks prior to the polysomnographic studies and for the nights of the polysomnographic studies as well. Leg sensations (p < 0.009), motor restlessness (p < 0.006) and daytime alertness (p < 0.03) were significantly improved on oxycodone as compared to baseline or placebo. Patients were studied polysomnographically under double-blinded conditions for 2 nights in each phase of the protocol. On an average dose of 15.9 mg oxycodone (equivalent to approximately three 5-mg tablets of commercial preparation), there was a statistically significant reduction in the number of periodic limb movements in sleep [(PLMS)/hour sleep (p < 0.004)] and in the number of arousals/hour sleep (p < 0.009) on drugs as compared to baseline or placebo. A statistically significant improvement was also noted in sleep efficiency (p < 0.006) and 10 of the 11 patients preferred oxycodone over placebo. We conclude that oxycodone is an effective treatment for RLS and PLMS.

Somnambulism in adults.

We evaluated with clinical interviews and polysomnographic examinations 10 adults with the complaint of sleepwalking, often accompanied by violent behavior or self-injury. During the polysomnographic studies, 8 patients had 47 distinct somnambulistic episodes. All episodes occurred in non-REM sleep, with 91% occurring in slow-wave sleep. Contrary to previous reports, episodes were not confined to the 1st 3rd of the night. Clinical EEGs were normal in 5 of 6 patients. In the 7 patients tried on 1 or more treatment regimens, clonazepam effectively suppressed the somnambulism in 5 of 6 patients in whom it was tried, carbamazepine in 1 of 3, flurazepam in 2 of 2, and a combination of clonazepam and phenytoin in one.

Postsurgical evaluation of uvulopalatopharyngoplasty: two case reports.

Uvulopalatopharyngoplasty (UPPP) has become a widely practiced procedure for the treatment of snoring and obstructive sleep apnea. Surgical outcome with UPPP has heretofore been assessed by investigators using the number of apneas per hour of sleep (apnea index) as the sole or primary criterion. We present two cases in which UPPP outcome was inadequately represented by the apnea index. It is suggested that the apnea/hypopnea index, extent of oxygen desaturations, degree of sleep fragmentation, level of daytime somnolence, interaction between respiratory function and sleep position and stages, and degree of respiratory strain be considered in the postsurgical evaluation.

Sleep-related laryngeal obstruction presenting as snoring or sleep apnea.

The difference between snoring (with or without sleep apnea) and laryngeal stridor resulting from laryngeal dysfunction may not be readily apparent. Two cases of Shy-Drager syndrome and one undiagnosed case in which laryngeal dysfunction was exacerbated by sleep are reported. Such dysfunction might create life-threatening situations for which emergency tracheostomy should be considered. The importance of differentiating stridor from snoring is discussed.

A double-blind randomized crossover trial of bromocriptine and placebo in restless legs syndrome.

A double-blind randomized crossover study of 7.5 mg bromocriptine at bedtime versus placebo was conducted in 30-day phases (with a 2-week washout period between phases) in 6 patients with idiopathic restless legs syndrome. Five patients experienced partial subjective improvement in restlessness and paresthesias on bromocriptine as opposed to placebo and expressed a desire to continue on the medication. On bromocriptine, the patients showed polysomnographically a mean decrease of 43% from control and a mean decrease of 57% from placebo in the number of periodic movements of sleep per hour of sleep (p less than 0.025). Two of 3 patients with abnormally decreased total sleep time and sleep efficiency showed an improvement in these measures on therapy. The dopamine agonist bromocriptine may be a useful therapy in some patients with restless legs syndrome.

Opioid treatment of periodic movements in sleep in patients without restless legs.

Opioids may be a useful treatment for some patients with Periodic Movements of Sleep (PMS) and sleep disturbances. Four patients who had only idiopathic PMS and sleep disturbances but not Restless Legs Syndrome (RLS) were treated with various opioids. Two of the patients responded with a more than 98% decrease in the number of PMS per night of sleep and a doubling of the percentage of sleep period time spent in deep (Stages 3 and 4) sleep.

Dyskinesias while awake and periodic movements in sleep in restless legs syndrome: treatment with opioids.

In five unrelated patients with the restless legs syndrome, opioid drugs relieved restlessness, dysesthesias, dyskinesias while awake, periodic movements of sleep, and sleep disturbances. When naloxone was given parenterally to two treated patients, the signs and symptoms of the restless legs syndrome reappeared. Naloxone placebo had no effect. Opioid medications may offer a useful therapy for the restless legs syndrome. The endogenous opiate system may be involved in the pathogenesis of the syndrome.

Sleeping position and sleep apnea syndrome.

Four patients who were evaluated for hypersomnia-sleep apnea syndrome were found in all-night sleep studies to have obstructive or mixed apneas related to their sleeping positions. All four were available for comprehensive follow-up and were subsequently restudied while avoiding the supine position. Supine, prone, and lateral decubitus apnea indices were calculated for each patient for each night. The supine sleeping position was associated with significantly more apneas than the non-supine positions. Keeping these patients off their backs when they slept was effective treatment. Additionally, when results of surgical or pharmacologic treatments of apnea are evaluated, positional apnea indices should be considered.

Flurazepam and the sleep of herniorrhaphy patients.

The effects of flurazepam on the nocturnal sleep patterns of 20 pre- and postoperative herniorrhaphy patients were studied polygraphically, in double-blind fashion, in the clinical setting. Compared to patients who received no hypnotic, patients treated with flurazepam had, preoperatively, significantly more Stage 2 and less REM and, postoperatively, significantly greater total sleep time, fewer awakenings, and less total awake time. The flurazepam group also initially had more delta sleep, but then showed a steady decrease of delta sleep over the hospitalization.

Sleep in herniorrhaphy patients.

The nocturnal sleep patterns of 10 elective herniorrhaphy patients were documented by continuous, 8 hour polygraphic recordings from night 1 of hospitalization until discharge on day 4 or 5. Subjects showed a dramatic loss of REM sleep and stages III and IV and major increases in time awake and drowsy for the first 2 postoperative nights, with a gradual return toward normal sleep over the hospitalization period. The significance for healing of the loss of stages REM, III, and IV is discussed, especially with regard to hospital procedures and the use of medications.