© Borgis - Postępy Nauk Medycznych 1/2015, s. 64-68
Monika Kuźmińska1, 2, Magdalena Walicka1, Wojciech Kukwa2, *Ewa Marcinowska-Suchowierska1
Ocena polisomnograficzna zmian struktury snu u pacjentów z podejrzeniem zespołu zaburzeń oddychania w czasie snu o charakterze bezdechu obturacyjnego
Polysomnographic evaluation of sleep structure changes in patients with suspected OSA**
1Department of Family Medicine, Internal Medicine and Metabolic Bone Diseases, Medical Center for Postgraduate Education, Warszawa
Head of Department: Marek Tałałaj, MD, PhD, Associate Professor
2Department of Otolaryngology, Faculty of Medicine and Dentistry, Medical University of Warsaw
Head of Department: prof. Antoni Krzeski, MD, PhD
Streszczenie
Wstęp. Wyniki polisomnografii (PSG) pokazują zmiany struktury snu u chorych z zaburzeniami oddychania w czasie snu o charakterze bezdechu obturacyjnego (OSA): dłuższy sen płytki, krótszy sen głęboki i REM lub ich brak.
Cel pracy. Celem badania była analiza korelacji pomiędzy strukturą snu a zaburzeniami oddychania.
Materiał i metody. Przeanalizowaliśmy 907 PSG pacjentów z podejrzeniem OSA podzielonych na dwie grupy według AHI (ang. Apnea Hypopnea Index): bez OSA (AHI < 5) i z OSA (AHI ≥ 5). Pacjentów z OSA podzielono na stadia: łagodne (5 ≤ AHI < 15), umiarkowane (15 ≤ AHI ≤ 30) i ciężkie (AHI > 30). Analizowano czas trwania poszczególnych stadiów snu za pomocą Statistica 6.1.
Wyniki. Występowały statystycznie istotne różnice pomiędzy grupami z OSA vs bez OSA w procentowym występowaniu snu płytkiego – 76,7 vs 86,45%; głębokiego – 17,53 vs 14,35% (dla obu p < 0,0001) oraz REM – 5,87 vs 5,77% (p < 0,05 ). W grupie z OSA strukturę snu oceniono w stadiach: łagodnym (sen płytki – 79,87%; głęboki – 14,35%; REM – 5,77%); umiarkowanym (sen płytki – 82,73%; głęboki – 12,64%; REM – 4,63%) oraz ciężkim (sen płytki – 86,45%; głęboki – 9,54%; REM – 4,01%).
Wnioski. Stwierdzono dłuższy sen płytki, krótszy głęboki i REM w grupie z OSA, a w grupie bez OSA krótszy sen głęboki i REM w porównaniu do wartości fizjologicznych, czego przyczyną mogą być gorsze i niefizjologiczne warunki snu w pracowni polisomnograficznej ograniczające badanie.
Summary
Introduction. Recent polysomnography (PSG) studies show the same sleep structure changes in OSA patients: longer the light sleep, shorter or lack of the deep sleep and REM.
Aim. The aim of the study was to analyze correlation between sleep structure and breathing sleep disturbances.
Material and methods. We analyzed 907 polysomnograms of patients with suspected OSA, they were divided into 2 groups based of AHI: non-OSA (AHI < 5) and OSA (AHI ≥ 5). According to AHI OSA group was divided into: mild (5 ≤ AHI < 15), moderate (15 ≤ AHI ≤ 30), and severe (AHI > 30). We analyzed duration of sleep stages: light, deep sleep and REM using Statistica 6.1.
Results. We found the statistically significant differences of sleep structure between non-OSA and OSA population in light sleep 76.7 vs 86.45% (p < 0.0001); deep sleep 17.53 vs 14.35% (p < 0.0001); REM 5.87 vs 5.77% (p < 0.05). In OSA group sleep structure was classified in AHI dependent groups: mild (light sleep – 79.87%; deep sleep – 14.35%; REM – 5.77%); moderate (light sleep – 82.73%; deep sleep – 12.64%; REM – 4.63%); severe (light sleep – 86.45%; deep sleep – 9.54%; REM – 4.01%).
Conclusions. We found longer the light sleep, shorter deep and REM sleep in OSA, and also in non-OSA shorter deep sleep and REM comparing to physiological sleep what may be due to worse sleep laboratory conditions compared with home and may be limiting for PSG.
Introduction
Normal sleep architecture is responsible for effective rest. It is well known that deep sleep of NREM stage and REM sleep are responsible for the proper functioning of the body. The physiology of sleep stages percentage composition is the following for NREM sleep: light sleep consists of stage 1 – 5-10% and stage 2 – 45-55%, deep sleep consists of stages 3 + 4 (in new classification the 4th stage of NREM sleep has been included within stage 3; this stage is also called slow wave sleep [SWS]) (1) and takes 10-20% of total sleep time.
REM sleep is estimated in physiology to take approximately 20% of total sleep time. Excessive daytime sleepiness is a symptom common to patients with OSA and it results in many psychological consequences such as: worse quality of life, worse concentration, increased risk of motor incidence, decreased work capacity. Previous studies have shown that daytime sleepiness is more related to sleep fragmentation and to intermittent hypoxemia in OSA (2).
Sleep deprivation has also other consequences, current data suggest the relationship between sleep restriction and alterations in glucose metabolism, disregulation of appetite, decreased energy expenditure (3).
The results of many studies show that sleep disturbances are observed in patients presenting sleep-disordered breathing (SBD) primarily of obstructive sleep apnea syndrome (OSA). Usually it is sleep fragmentation and extension of light sleep and reduced deep sleep and REM. Many studies show that hypnogram of OSA patients usually presents absence of slow wave sleep and REM (2, 4). Consequences of sleep structure disturbances may underlie many clinical complications of OSA.
Aim
The aim of the study was to analyze a correlation between sleep structure and breathing sleep disturbances and to score the change in the length of sleep stages depending on the severity of the disease based on AHI. We also wanted to see the correlation between AHI and the percentage occurrence of various stages of sleep.
Material and methods
Patients
We examined retrospectively 907 (n = 907) polysomnograms recruited from patients (both sexes) referred to a sleep laboratory for suspected sleep apnea. We included patients with clinical suspicion of OSA, obese patients before bariatric surgery, patients before laryngological procedures, and patients who snored regularly. Patients were referred to the sleep laboratory by physicians of many specialties: family doctors, surgeons, internists, otolaryngologists.
The reasons for referring patients to clinical polysomnography were as follows:
– snoring,
– snoring with apnea observed bypersons sleeping in one room with the patient,
– abnormal nasal patency, and throat – before any surgery,
– excessive daytime sleepiness,
– insomnia,
– heart problems, such as hypertension resistant to treatment,
– obesity,
– prior to the surgery of obesity (bariatric surgery).
Anthropometric characteristics of the group are listed in table 1.
Table 1. Anthropometric characteristics of the group.
| Mean values | Women
n = 271 | Men
n = 636 | Total
n = 907 |
| Mean age (SD)* | 51.9 (14.7) | 51.9 (13.1) | 51.9 (13.6) |
| Mean BMI kg/m2 (SD) | 35.2 (10.5) | 31.3 (7.3) | 32.5 (8.6) |
*Standard deviation
Polysomnographic studies were performed and evaluated in accordance with current international standards (5-7).
PSG included the following variables: electroencephalograms, electrooculograms, electromyelograms of submental muscules, electrocardiogram, airflow (nasal and oral), chest and abdominal efforts, snoring (microphone) and arterial oxyhemoglobin saturation and pulse (finger probe).
Polysomnographic recordings were evaluated with respect to:
– amount of disordered breathing during sleep,
– type of a disorder: obstructive sleep apnea, mixed, central, hypopnea,
– AHI (Apnea Hypopnea Index),
– disease severity based on AHI: (mild form of 5 ≤ AHI < 15, moderate 15 ≤ AHI ≤ 30; severe AHI > 30),
– the number of desaturations,
– the average oxygen saturation (Sa av),
– minimum oxygen saturation (Sa min),
– heart rate (HR),
– the length of non REM (non-rapid eye movement) sleep composed of light sleep stages 1 and 2 (1 + 2), and composed of deep sleep stages 3 and 4 (3 + 4),
– the length of REM sleep (rapid eye movement).
Criteria and definitions used in polysomnography
Characteristic of sleep stages
Stage 1 sleep – EOG-slow rolling eye movements. EEG-low voltage, mixed frequency; may be ? rhythm 2-7 Hz, up to 50-75 uV range; vertex sharp waves (200 uV). ? waves 4-7 Hz; low voltage, mixed frequency backgrounds; often appear as sharp vertex waves; EMG tonic activity, slight decrease compared with waking.
Stage 2 sleep – EOG slow rolling eye movement occasionally near sleep onset. EEG-low voltage, mixed frequency. Sleep spindles-bursts of 12-14 Hz activity, ≥ 0.5 s long, no amplitude requirement. K complexes sharp negative wave followed by positive component, ≥ 0.5 s long, no amplitude requirement. EMG-low level tonic activity.
Stage 3 sleep – EOG-reflects EEG. EEG – δ rhythm takes 20-50% of epoch (30 sec of sleep), high amplitude waves (higher than 75 uV) with low frequency (≤ 2 Hz). EMG-tonic activity, low level).
Stage 4 sleep – usually described as a part of stage 3, the difference is related to amount of δ rhythm (more than 50%).
REM sleep – EOG-phasic REMs. EEG-low voltage, mixed frequency, sawtooth waves, ? activity, slow α activity. EMG-tonic suppression, phasic twitches (8).
Characteristic of respiratory events
AHI (Apnea Hypopnea Index) was used as the main criterion for the OSA diagnosis. AHI was defined as the number of apneas and hypopneas per hour of sleep. We used to identify OSA AHI ≥ 5.
Using AHI criteria we divided the AHI ≥ 5 group into three severity stages:
– mild OSA 5 ≤ AHI < 15,
– moderate OSA 15 ≤ AHI ≤ 30,
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