alexa A Prominent Increase in Slow Wave Sleep after PAP Therapy | Open Access Journals
ISSN: 2161-105X
Journal of Pulmonary & Respiratory Medicine
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

A Prominent Increase in Slow Wave Sleep after PAP Therapy

Muhammad Riaz1* and Gaurav Nigam1

1Twin Cities Community Hospital, 1100 Las Tablas Road, Templeton, CA 93465, USA

2Clay County Hospital, Flora, IL 62839, USA

*Corresponding Author:
Muhammad Riaz
Twin Cities Community Hospital
1100 Las Tablas Road, Templeton
CA 93465, USA
Tel: 8054343500
E-mail:
[email protected]

Received date: March 28, 2016; Accepted date: May 05, 2016; Published date: May 07, 2016

Citation: Riaz M, Nigam G (2016) A Prominent Increase in Slow Wave Sleep after PAP Therapy. J Pulm Respir Med 6: 342. doi:10.4172/2161-105X.1000342

Copyright: © 2016 Riaz M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Pulmonary & Respiratory Medicine

Abstract

Sleep disturbances are common in patients with chronic pain syndrome, and coexistent obstructive sleep apnea (OSA) in such patients could further compromise the quality of sleep and increase sleep fragmentation. Here we present an unusual case of profound increase in slow wave sleep as noted during the sleep study and discuss the potential causes for this observed polysomnograhic phenomenon.

Keywords

Obstructive sleep apnea; CPAP titration; Increase delta sleep; Sleep deprivation; Gabapentin; Slow wave sleep

Case Vignette

A 43-year-old female with past medical history of attention deficit hyperactivity disorder of inattentive type, depression, chronic pain syndrome, and diabetes mellitus presented to sleep disorder center for evaluation of excessive daytime sleepiness (EDS). She denied consumption of cigarettes, alcohol or recreational drugs. Her home medications included Metformin, Gabapentin, Bupropion, Venlafaxine, Buspirone and Methylphenidate. General physical exam was consistent with crowded oropharynx, (Mallampati class 3 with grade 1 tonsils), but a normal cardiovascular as well as neurologic exam. She underwent attended diagnostic in laboratory polysomnogram (PSG) which revealed OSA with an apnea hypopnea index (AHI) of 9.3 events/hour, and oxygen nadir of 90% (Table 1). Her percentage of total sleep time (TST) in non-rapid eye movement sleep in stage 3 (N3) increased from 15.3% in diagnostic PSG (Figures 1 and 2) to 58.1% (Figures 3 and 4) in titration study and up to 86.3% in re-titration study (Figures 5 and 6). Her titration study was done two weeks following diagnostic PSG and a continuous positive airway pressure (CPAP) setting of 6 cm of water was recommended. She had a re-titration study 9 months later due to CPAP intolerance and lack of significant improvement in OSA symptoms. This re-titration study recommended a bi-level positive airway pressure (BiPAP) of 12/7 cm of water. The patient was started on Gabapentin 900 mg daily 2-3 months prior to her re-titration study. Other than initiation of Gabapentin, no changes occurred in terms of her body weight, clinical comorbidities or use of prescription/nonprescription medications between subsequent sleep studies.

Sleep Variables Diagnostic PSG PAP Titration PAP Re-titration
AHI (events/hr) 9.3 9.3 4.9
SPO2 nadir (%) 90 93 96
Sleep latency (min) 33 60 1.5
Total sleep time (TST) in stage N1 (%) 7.7 0.9 2.2
Total sleep time (TST) in stage N2 (%) 77 41 11.4
Total sleep time (TST) in stage N3 (%) 15.3 58 86.3
Total sleep time (TST) in stage REM (%) 0 0 0

Table 1: Polysomnogram results. REM: Rapid eye movement sleep; N1, N2, N3: Stage 1, 2, 3 of non rapid eye movement sleep; AHI: Apnea hypopnea index; SPO2: Lowest oxygen saturation.

pulmonary-respiratory-medicine-Baseline-polysomnogram-hypnogram

Figure 1: Baseline polysomnogram hypnogram (Yellow N1, Green N2, and Dark Green N3).

pulmonary-respiratory-medicine-epoch-diagnostic-polysomnogram

Figure 2: An epoch of diagnostic polysomnogram showing delta sleep.

pulmonary-respiratory-medicine-Titration-polysomnogram-hypnogram

Figure 3: Titration polysomnogram hypnogram (Yellow N1, Green N2, and Dark Green N3).

pulmonary-respiratory-medicine-epoch-titration-polysomnogram

Figure 4: An epoch of titration polysomnogram showing delta sleep.

pulmonary-respiratory-medicine-Re-titration-polysomnogram-hypnogram

Figure 5: Re-titration polysomnogram hypnogram (Yellow N1, Green N2, and Dark Green N3).

pulmonary-respiratory-medicine-epoch-re-titration-polysomnogram

Figure 6: An epoch of re-titration polysomnogram showing delta sleep.

Discussion

The cause of infrequent large increase in slow wave sleep in this case appears to be multifactorial.

First

Acute sleep deprivation and sleep fragmentation can present concurrently in patients with OSA and the treatment of OSA not only improves sleep fragmentation but also enhances the overall quality of sleep. It has been well reported that stage REM and N3 are the two most common sleep stages which increase after first night of CPAP, and stage N3 usually takes precedence over Stage REM after a night of sleep deprivation [1]. Given her history of untreated OSA, our patient has chronic partial sleep deprivation. Added to this; she reported sleeping only 1-2 hours prior to her re-titration study which could possibly explain increased slow wave sleep (N3 lasting 86% of total sleep time) during the re-titration study. A short sleep latency of 3 minutes on this study further supports acute sleep deprivation (compared to her sleep latency of 33 minutes on the baseline study). Given that her stage N3 was also increased between the baseline study and the first titration study (N3 lasting 58% of total sleep time), this incremental escalation during re-titration argues against presence of sleep deprivation as the only etiology for increase in the proportion of slow wave sleep. As first night of CPAP titration improves sleep architecture and increases slow wave sleep, increase in N3 on titration study likely a result of CPAP titration [1,2].

Second

Gabapentin is one of the commonly used medications for neuropathic pain. This medication has been reported to increase slow wave sleep with one study reporting a 5 percent increase from baseline and another study reporting 12 minutes of increase from the baseline duration respectively [3,4]. Our patient was started on Gabapentin 900 mg daily for chronic pain syndrome 2-3 months before her re-titration study and she denied taking this medication at the time of her baseline and titration sleep studies. As previous studies have established that both Pregabalin and Gabapentin can cause increased slow wave sleep, this N3 surge in re-titration could partially be attributed to Gabapentin. Nevertheless, this percentage increase in N3 sleep appears out of proportion to what has been reported in the literature. Our patient was also taking Bupropion (minimal effect on sleep architecture) [5], Venlafaxine (suppresses REM sleep and minimal effect on delta sleep) [6], Buspirone (decreases delta sleep) [7], and Methylphenidate (minimal effect on sleep architecture) [8] which are not known to increase stage N3 sleep.

Third

As reported in the literature, OSA patients can have increased slow wave sleep on their first night of CPAP titration. This was our first impression after looking at this patient’s titration study where stage N3 sleep was increased to 58% from baseline of 15%. When compared with re-titration, which has significant prolongation in proportion of stage N3 sleep, it is apparent that the etiology of this large increase in slow wave sleep is multifactorial. Increase N3 on first night of CPAP was likely due to treatment of OSA. Prolongation of N3 to 86% on re-titration was most likely a combination of acute sleep deprivation, Gabapentin and treatment of OSA.

At least 100 million Americans are suffering from chronic pain and associated healthcare cost is considered higher than heart disease, diabetes and malignancy [9,10]. A large number of chronic pain patients (41%) demonstrate poor sleep quality and as much as 60% patients with chronic neuropathic pain suffer from sleep disturbances [11,12]. CPAP not only alleviate cardiovascular complications associated with OSA but also improves quality of life by decreasing daytime sleepiness [13]. There is also a possible analgesic role of CPAP in improving pain tolerance in chronic pain patients [14]. Of note, obesity is another growing major health problem in United States with estimated prevalence of 35% [15]. Obesity and chronic pain do have interplay between each other [16], and obesity is the strongest risk factor for OSA [17]. Therefore screening for OSA can be very helpful in this demographic especially with coexistent obesity. As chronic neuropathic patients are often taking medications like Gabapentin for their neuropathic pain and PAP treatment of OSA in such patients with their concomitant use of Gabapentin could have a synergistic effect on their sleep quality.

Conclusion

Recognition of sleep disordered breathing in chronic pain patients can be of utmost importance as CPAP can not only improve sleep quality but also could have analgesic effect. Chronic pain patients who are taking medications like Gabapentin could have synergistic effect on sleep quality when combined with PAP therapy. Future research is needed to further investigate the effect of increase slow wave sleep on chronic pain, obesity, and Non-REM parasomnias.

Acknowledgement

The institution where the work was primarily performed is Sleep Disorders Center, University of Michigan, Ann Arbor, MI 48109, USA.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Recommended Conferences

Article Usage

  • Total views: 8177
  • [From(publication date):
    June-2016 - Aug 24, 2017]
  • Breakdown by view type
  • HTML page views : 8126
  • PDF downloads :51
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri, Food, Aqua and Veterinary Science Journals

Dr. Krish

[email protected]

1-702-714-7001 Extn: 9040

Clinical and Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

[email protected]

1-702-714-7001Extn: 9042

Chemical Engineering and Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001 Extn: 9040

Earth & Environmental Sciences

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

General Science and Health care Journals

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics and Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001 Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Informatics Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Material Sciences Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Mathematics and Physics Journals

Jim Willison

[email protected]

1-702-714-7001 Extn: 9042

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001 Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

John Behannon

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001 Extn: 9042

 
© 2008-2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords