- Email: [email protected]
Sleepwalking Precipitated by Treatment of Sleep Apnea with Nasal CPAP*
Sleepwalking Precipitated by Treatment of Sleep Apnea with Nasal CPAP*
CASE REPORT
Richard P. MiIlllum, M.D., FC.C.P.;t GerardJ Ki/I/I, R. Psg. I:t and Mary A. Carskat/lln, Ph.D.t
A 33-year-old man with a long history of snoring, observed apneic episodes, and excessive daytime sleepiness, underwent all-night polysomnography, which demonstrated severe obstructive sleep apnea. During the nasal CPAP trial, two episodes of sleepwalking were observed during a period of delta sleep rebound. (Chest 1991; 99:750-51)
N
asal ('~lIItinuous positive airway pressure has hecome a standard form of therapy for patients with obstructive sleep apnea. I 4 In the first hours of use. nasal CPAP induces profound chan~es in sleep architecture includin~ falls in sta~es 1-2 and increases in sta~es 3-4 slow wave sleep.'''' as well as increases in REM sleep." A 33-year-old man experienced two episodes of sleepwalkin~ durin~ a rehound in slow wave sleep when first placed on nasal CPAP in the lahoratory, ·Fmm the tDf'partment of Medidnf'. Rhode Island Hospital and the tDepartment of Psyehiatry and lIuman Behavior. Bradley lIospital and Bmwn University. Pmvidenee, RI. Reprin/ n'qU('.~/s: Dr. Millman, Fblmonary DivLrion, Rhode Islarul
Hlls/Ii/ll/, Providencl' 0290.3
A 33-yf'ar-old ohese white man underw..nt all-night polysomnographic e"alnation f(.r a pr..snmed diagnosis of OSA. He had a 14year history of very loud snoring and a three-year history ofohserved apneas aecompanied hy the l"mplaint of exeessive daytime sleepiness. lie d..ni..d any past history of sleepwalking or night terrors. In the first 2..'5 hours of the stndy, th.. patient experieneed 266 episod..s of ohstructive apnea ranging fmm 2() to 30 sel,mds in NREM sleep and 30 to 60 st'<.'lIlds in REM slet·p. The apne:l index was 106 episodes per hour and the p:ltient was apneic .'57 pereent of the time. Severe oxygen des:lturations fmm :l haseline of 95 pereent to a nadir of 76 pereent in NREM sleep and 61 pereent in REM sleep were ohserved. During this period, sleep W:lS primarily NREM stages I and 2, with a very hrief (1..'5 minute) episode of REM sleep; no slow W:lve sleep was s..en (Fig 1). Becanse of the severity of the OSA, a trial of nasal CPAP was initi:lted while the patient was in the lahoratory rather than hring him haek a sel,md night. The patient was fitted to a medium m:lSk. and .'5 em 11,0 pressure was applied using a CPAP unit. The pressure was quickly inereased to 12..'5 em 11,0 which ohliterated the apne:lS and resn!tt·d in improved sleep t,msolidation indnding the appearanee of signifieant amounts of slow wave :lnd REM sleep (Fig 1). While on nasal CPAp, the patient ahruptly sat up and hegan to walk aeross the mom. He was ohserved to he in stage 4 sleep during this episode (Fig 2), and he was directed hack to I>t'd hy the technologist. A similar episode of sleepwalking oceurred during stage 3 sleep, The patient W:lS preserilJed n:lSal CPAP at 1.'5 em H,O pressure to use at homf'. On nasal CPAP, his excessive daytime sleepiness
Mvml Wake
S1 S2
S3 S4 FQ1 Apnea flypopnN
1_-
_.1
I'
1.1.111111111.1
5mmH20 10mmH20 12.5 mmH20
22
23
24
• •
, ...._--2
3
4
SleepWalk.
Subjecl's age: 33.9452 years
v •
Lights Out
Recording dale: 5/4/89
Subjecl's gender: Male
A
End of Night
Experiment: Apnea CPAP Trial
Total sleep time: 390.61 minutes
•
FICI'HE 1. lIistogram shows movement time (MlllIIl), wakefulness (wllk£'!. and sleep stages (.'VREM SI, S2, S3, S-I, and Rf:M) ahove indic:ltnrs of apneas, hypopneas, nasal CPAP le"el (.'5, 10, or 12.5), and two episod..s of slt'epwalking ;LS a I1l1ll'lion of time of night. Not.. that sleep onset is rapid, hut sl('ep is "ery disrnpkd and apneaslhypop,was fre'lnt'nt hef(,re midnight wllt'll CPAP was iuitiatt'd. At uasal CPAP of 12..'5 l'1I1 11,0, sleep resumed and first sleepwalking· 'K·l'urn·d after five minutes of stagi' -to Sel~)Ild slt·epwalkiug· CK'l'llrred approximately 30 minntes later from stagt' 3.
750
Sleep Walking Precipilated by Treatment for Sleep Apnea (Millman. Kipp, CarskadonJ
.... )
I. ,.I r
('
Submental EMG EEG
. "\ . EKG
'.J
I
-,j' ) ' "" "., '~I",jt-,j,'~J' I
i
0
I
.'JJ'
I I.
0
,.1 I'· ' ,"\ '...,)',.)"J) I
i I 0
'.j '1, •• .',1 . I '...J ·'J:JWJ>1JII.I1J" 0 I I i ' , Ii'
,} Jit,oIJI'
f'lIa5lal THR
oj.
I
0
I \ I
'Jot i
:l~"'"
,
,
'" .\,'I ,
I
'"
Oral
THR-" -.-.. ----. -.-----'- --'--'---'-- ..,-'--- - - - -' ._'- FIGURE
2. Polysomno~raphic
electroencephaIo~ram
electrocardio~ram
.
recording during the episode of sleepwalking in slow wave sleep. EEG. (C3-A2); EOG. ele<:trooculogram; EAlG. electromyogram; Thr, thermistors; f:KG.
and the observed apneas have resolved. No further episodes of sleepwaIkin~ have been reported. DISCUSSION
This patient with severe obstructive sleep apnea experienced two episodes of sleepwalking when first placed on nasal CPAP in the laboratory. He had no previous history of NREM sleep parasomnias. The two episodes of sleepwalking were apparently tri~ered by a slow wave sleep "rehound." It is probable that the severe OSA had prof(lIIndly disrupted the patient's sleep patterns for a numher of years and that this disruption included suppression of slow wave sleep, and possibly a reduction of RE M sleep as well. It has long been known that reduction of slow wave sleep hy total sleep deprivation or by arousals that interrupt slow wave sleep is followed by a recovery rebound of slow wave sleep when undisturbed sleep is permitted. 7 ,. The case reported here demonstrates such a suppression/recovery process, with the OSA-associated arousals aborting attempts to enter slow wave sleep and the elimination ofapneas by nasal CPAP providing an undisturbed "recovery" period. The association in children of parasomnias - such as sleeptalking, sleepwalking, and night terrors-with slow wave sleep. particularly stage 4, has been known for many years." It has also been suggested that such disturbances are potentiated after sleep has been disturbed and during rebound recovery, which is associated with relatively high arousal threshold, III A similar process may be present in our patient, in whom a slow wave sleep rebound and presumed associated increase in arousal threshold accompanied the initiation of nasal CPAP. There are no clues to su~est why this particular patient experienced sleepwalking. other than a that he is relatively young (33 years), which su~('sts
possible developmental factor. Although this phenomenon is rare, it is important that sleep physicians and polysomnographic tpchnologists are aware that patients may experience such events wllt'n nasal CPAP is initiated. The tecllllologist must be prepared to provide prompt attention to prevpnt injury. REFEHENCES
2
3 -t .'5
6
7
Ii
9 10
SlIlIivan CEo Bt'rtllOn-Jont·s ~I. Issa FC. Eves L. Ill-versal of ohstnl<:tive slet'p apnt'a hy t'mtinllolls positive airway preSSllrl' applied throllgh the nares. L;1II"l'! IHHI; 1:1#)2-6.'5 Hapoport OM. Sorkin B. Garay SM. Coldrinl-( HM. H,·,.....salof the "Pid(widan syndrolll"" hy lonl-(-tenll liS" of no<:tllrnalnasalairway pressllre. N Enl-(l J Med 19H2: 307:fJ:31-:3.'3 Sanders NH, MIHlrt· SE. En'slal-(t' J. CPAP ,'ia nasal mask: a tn'atment for ol'dllsiH' sl,·,'p apnea. Cltest 19S:3; H:3: 1-t-t--t5 Sanders MII. Nasal CPAP l'ff,·<:t "II patterns of sleep apnea. Chest 19&1; 1l6:S:39--t-t Hajagopal KH. B"lIIlt'tt LL. Dillard TA. Tellis q. T"nholder t-IE. Overnighlnasal CPAP impro",'s hYP"rsomnoll'nl'" in sleep apm·a. Chest l!-}Rfi; !Xl: 172-76 Issa FG. SlIllh'an CEo The imlllt'diah' ,·Il"l"ls of nasal l'mtinllons p..sitin· airway pressllre treatment on sleep patlt-rns ill patient with ohstrul"lh'e sleep apnea S\'ndronlt·. Elel"lroenl't'pltal"l-(r Clin Nenrophysiol WIlfi; 63: 10-17 Naitoh P, Kales A, Kollar EJ. Smith JC. Ja,,,hson A. Elel"ln>t'nl'ephalol-(raphi<: al"li,'ity after prolonl-("d sl,'t'p loss. EI,'clro..ncl'phalogr CI Neurophysiol 1009; 27:2-1 I D..ment \"C. Greenherg S. Cluml-(l's in total amount of stage fi.llr sleep as a fnnction of partial sleep depri"ation. EI,·l"lr....nc..phalol-(r CI Neurophysiol 1966; 20:.'523-20 Bronghton HJ. SIt'"p disorders: disorders of arollsalt Sd"lIc,' 19fi1l; 1.'59:1070-7H Ft'rher R. Solve your child's sle,'p proltk'ms. New )in-k: Simon and Scltnster. IfJH.'5 CHEST I 99 I 3 I MARCH, 1991
751
CASE REPORT
Richard P. MiIlllum, M.D., FC.C.P.;t GerardJ Ki/I/I, R. Psg. I:t and Mary A. Carskat/lln, Ph.D.t
A 33-year-old man with a long history of snoring, observed apneic episodes, and excessive daytime sleepiness, underwent all-night polysomnography, which demonstrated severe obstructive sleep apnea. During the nasal CPAP trial, two episodes of sleepwalking were observed during a period of delta sleep rebound. (Chest 1991; 99:750-51)
N
asal ('~lIItinuous positive airway pressure has hecome a standard form of therapy for patients with obstructive sleep apnea. I 4 In the first hours of use. nasal CPAP induces profound chan~es in sleep architecture includin~ falls in sta~es 1-2 and increases in sta~es 3-4 slow wave sleep.'''' as well as increases in REM sleep." A 33-year-old man experienced two episodes of sleepwalkin~ durin~ a rehound in slow wave sleep when first placed on nasal CPAP in the lahoratory, ·Fmm the tDf'partment of Medidnf'. Rhode Island Hospital and the tDepartment of Psyehiatry and lIuman Behavior. Bradley lIospital and Bmwn University. Pmvidenee, RI. Reprin/ n'qU('.~/s: Dr. Millman, Fblmonary DivLrion, Rhode Islarul
Hlls/Ii/ll/, Providencl' 0290.3
A 33-yf'ar-old ohese white man underw..nt all-night polysomnographic e"alnation f(.r a pr..snmed diagnosis of OSA. He had a 14year history of very loud snoring and a three-year history ofohserved apneas aecompanied hy the l"mplaint of exeessive daytime sleepiness. lie d..ni..d any past history of sleepwalking or night terrors. In the first 2..'5 hours of the stndy, th.. patient experieneed 266 episod..s of ohstructive apnea ranging fmm 2() to 30 sel,mds in NREM sleep and 30 to 60 st'<.'lIlds in REM slet·p. The apne:l index was 106 episodes per hour and the p:ltient was apneic .'57 pereent of the time. Severe oxygen des:lturations fmm :l haseline of 95 pereent to a nadir of 76 pereent in NREM sleep and 61 pereent in REM sleep were ohserved. During this period, sleep W:lS primarily NREM stages I and 2, with a very hrief (1..'5 minute) episode of REM sleep; no slow W:lve sleep was s..en (Fig 1). Becanse of the severity of the OSA, a trial of nasal CPAP was initi:lted while the patient was in the lahoratory rather than hring him haek a sel,md night. The patient was fitted to a medium m:lSk. and .'5 em 11,0 pressure was applied using a CPAP unit. The pressure was quickly inereased to 12..'5 em 11,0 which ohliterated the apne:lS and resn!tt·d in improved sleep t,msolidation indnding the appearanee of signifieant amounts of slow wave :lnd REM sleep (Fig 1). While on nasal CPAp, the patient ahruptly sat up and hegan to walk aeross the mom. He was ohserved to he in stage 4 sleep during this episode (Fig 2), and he was directed hack to I>t'd hy the technologist. A similar episode of sleepwalking oceurred during stage 3 sleep, The patient W:lS preserilJed n:lSal CPAP at 1.'5 em H,O pressure to use at homf'. On nasal CPAP, his excessive daytime sleepiness
Mvml Wake
S1 S2
S3 S4 FQ1 Apnea flypopnN
1_-
_.1
I'
1.1.111111111.1
5mmH20 10mmH20 12.5 mmH20
22
23
24
• •
, ...._--2
3
4
SleepWalk.
Subjecl's age: 33.9452 years
v •
Lights Out
Recording dale: 5/4/89
Subjecl's gender: Male
A
End of Night
Experiment: Apnea CPAP Trial
Total sleep time: 390.61 minutes
•
FICI'HE 1. lIistogram shows movement time (MlllIIl), wakefulness (wllk£'!. and sleep stages (.'VREM SI, S2, S3, S-I, and Rf:M) ahove indic:ltnrs of apneas, hypopneas, nasal CPAP le"el (.'5, 10, or 12.5), and two episod..s of slt'epwalking ;LS a I1l1ll'lion of time of night. Not.. that sleep onset is rapid, hut sl('ep is "ery disrnpkd and apneaslhypop,was fre'lnt'nt hef(,re midnight wllt'll CPAP was iuitiatt'd. At uasal CPAP of 12..'5 l'1I1 11,0, sleep resumed and first sleepwalking· 'K·l'urn·d after five minutes of stagi' -to Sel~)Ild slt·epwalkiug· CK'l'llrred approximately 30 minntes later from stagt' 3.
750
Sleep Walking Precipilated by Treatment for Sleep Apnea (Millman. Kipp, CarskadonJ
.... )
I. ,.I r
('
Submental EMG EEG
. "\ . EKG
'.J
I
-,j' ) ' "" "., '~I",jt-,j,'~J' I
i
0
I
.'JJ'
I I.
0
,.1 I'· ' ,"\ '...,)',.)"J) I
i I 0
'.j '1, •• .',1 . I '...J ·'J:JWJ>1JII.I1J" 0 I I i ' , Ii'
,} Jit,oIJI'
f'lIa5lal THR
oj.
I
0
I \ I
'Jot i
:l~"'"
,
,
'" .\,'I ,
I
'"
Oral
THR-" -.-.. ----. -.-----'- --'--'---'-- ..,-'--- - - - -' ._'- FIGURE
2. Polysomno~raphic
electroencephaIo~ram
electrocardio~ram
.
recording during the episode of sleepwalking in slow wave sleep. EEG. (C3-A2); EOG. ele<:trooculogram; EAlG. electromyogram; Thr, thermistors; f:KG.
and the observed apneas have resolved. No further episodes of sleepwaIkin~ have been reported. DISCUSSION
This patient with severe obstructive sleep apnea experienced two episodes of sleepwalking when first placed on nasal CPAP in the laboratory. He had no previous history of NREM sleep parasomnias. The two episodes of sleepwalking were apparently tri~ered by a slow wave sleep "rehound." It is probable that the severe OSA had prof(lIIndly disrupted the patient's sleep patterns for a numher of years and that this disruption included suppression of slow wave sleep, and possibly a reduction of RE M sleep as well. It has long been known that reduction of slow wave sleep hy total sleep deprivation or by arousals that interrupt slow wave sleep is followed by a recovery rebound of slow wave sleep when undisturbed sleep is permitted. 7 ,. The case reported here demonstrates such a suppression/recovery process, with the OSA-associated arousals aborting attempts to enter slow wave sleep and the elimination ofapneas by nasal CPAP providing an undisturbed "recovery" period. The association in children of parasomnias - such as sleeptalking, sleepwalking, and night terrors-with slow wave sleep. particularly stage 4, has been known for many years." It has also been suggested that such disturbances are potentiated after sleep has been disturbed and during rebound recovery, which is associated with relatively high arousal threshold, III A similar process may be present in our patient, in whom a slow wave sleep rebound and presumed associated increase in arousal threshold accompanied the initiation of nasal CPAP. There are no clues to su~est why this particular patient experienced sleepwalking. other than a that he is relatively young (33 years), which su~('sts
possible developmental factor. Although this phenomenon is rare, it is important that sleep physicians and polysomnographic tpchnologists are aware that patients may experience such events wllt'n nasal CPAP is initiated. The tecllllologist must be prepared to provide prompt attention to prevpnt injury. REFEHENCES
2
3 -t .'5
6
7
Ii
9 10
SlIlIivan CEo Bt'rtllOn-Jont·s ~I. Issa FC. Eves L. Ill-versal of ohstnl<:tive slet'p apnt'a hy t'mtinllolls positive airway preSSllrl' applied throllgh the nares. L;1II"l'! IHHI; 1:1#)2-6.'5 Hapoport OM. Sorkin B. Garay SM. Coldrinl-( HM. H,·,.....salof the "Pid(widan syndrolll"" hy lonl-(-tenll liS" of no<:tllrnalnasalairway pressllre. N Enl-(l J Med 19H2: 307:fJ:31-:3.'3 Sanders NH, MIHlrt· SE. En'slal-(t' J. CPAP ,'ia nasal mask: a tn'atment for ol'dllsiH' sl,·,'p apnea. Cltest 19S:3; H:3: 1-t-t--t5 Sanders MII. Nasal CPAP l'ff,·<:t "II patterns of sleep apnea. Chest 19&1; 1l6:S:39--t-t Hajagopal KH. B"lIIlt'tt LL. Dillard TA. Tellis q. T"nholder t-IE. Overnighlnasal CPAP impro",'s hYP"rsomnoll'nl'" in sleep apm·a. Chest l!-}Rfi; !Xl: 172-76 Issa FG. SlIllh'an CEo The imlllt'diah' ,·Il"l"ls of nasal l'mtinllons p..sitin· airway pressllre treatment on sleep patlt-rns ill patient with ohstrul"lh'e sleep apnea S\'ndronlt·. Elel"lroenl't'pltal"l-(r Clin Nenrophysiol WIlfi; 63: 10-17 Naitoh P, Kales A, Kollar EJ. Smith JC. Ja,,,hson A. Elel"ln>t'nl'ephalol-(raphi<: al"li,'ity after prolonl-("d sl,'t'p loss. EI,'clro..ncl'phalogr CI Neurophysiol 1009; 27:2-1 I D..ment \"C. Greenherg S. Cluml-(l's in total amount of stage fi.llr sleep as a fnnction of partial sleep depri"ation. EI,·l"lr....nc..phalol-(r CI Neurophysiol 1966; 20:.'523-20 Bronghton HJ. SIt'"p disorders: disorders of arollsalt Sd"lIc,' 19fi1l; 1.'59:1070-7H Ft'rher R. Solve your child's sle,'p proltk'ms. New )in-k: Simon and Scltnster. IfJH.'5 CHEST I 99 I 3 I MARCH, 1991
751