33.3 🩺 內科專科考前版

33.3.0.1 📌 䞀頁重點

  • 22E 匷調orexin antagonist for insomnia、RBD as PD prodrome、CPAP CV outcome data
  • Sleep medicine 是 emerging multidisciplinary field
  • Taiwansleep medicine certification、健保 PSG / CPAP

33.3.0.2 🧠 進階機蜉

33.3.0.2.1 Sleep Regulation
  • 2-process model: homeostatic (S) + circadian (C)
  • Adenosine accumulates during wake → S
  • Suprachiasmatic nucleus (SCN) → C
  • Orexin (hypocretin) stabilize wake state
33.3.0.2.2 OSA Pathophysiology
  • Upper airway collapse + obesity + jaw structure
  • Repeated hypoxia + arousal → sympathetic ↑ → HTN, AF, stroke
  • Inflammation + oxidative stress
  • Insulin resistance
33.3.0.2.3 Insomnia Pathophysiology
  • Hyperarousal model
  • HPA hyperactivity
  • Cognitive (worry about sleep)
  • Circadian misalignment
33.3.0.2.4 RBD as α-Synuclein Prodromal
  • 50%+ develop PD/DLB/MSA in 10-15 yr
  • Brainstem REM atonia circuit → α-synuclein deposit early
  • 重芁 prodromal markers (also constipation, hyposmia)

33.3.0.3 💊 進階治療

33.3.0.3.1 OSA Beyond CPAP
  • Hypoglossal nerve stimulator (Inspire): BMI < 32, AHI 15-65
  • Maxillomandibular advancement (MMA): severe
  • Tongue retaining device
  • Position therapy for positional OSA
  • Bariatric surgery for obesity
33.3.0.3.2 Insomnia New Drugs
  • Orexin receptor antagonists:
    • Suvorexant
    • Lemborexant
    • Daridorexant (newest)
  • 比 BZD/Z-drug 安党 in elderly
33.3.0.3.3 Narcolepsy Newer Drugs
  • Sodium oxybate (Xyrem) for cataplexy + EDS
  • Pitolisant (H3 antagonist)
  • Solriamfetol (DA/NE reuptake inhibitor)
33.3.0.3.4 CPAP CV Outcomes
  • SAVE trial: CPAP did not reduce CV events significantly (䜆 selection issues)
  • Better adherence + younger / 高 baseline risk → likely benefit
  • Mortality benefit in observational data

33.3.0.4 🌟 Pearls (10)

  1. OSA + AF = 重倧 cardiac risk modifier
  2. CPAP adherence < 4 hr/night = 沒 effect
  3. Insomnia + 慢性 → CBT-I 銖芁
  4. RBD 是 PD prodromal
  5. RLS + iron supplement first (oral 䞍行 → IV iron sucrose)
  6. DA agonist augmentation in RLS — 改 α2ÎŽ
  7. Shift work 對 metabolic + cardiovascular 顯著
  8. Pediatric OSA 倚由 adenotonsillar hypertrophy → adenotonsillectomy
  9. Central sleep apnea in HF → adaptive servo-ventilation (controversial)
  10. Sleep + dementia: poor sleep → AD risk ↑

33.3.0.5 🔍 特殊情境

33.3.0.5.1 1. 劊嚠 sleep
  • OSA worsen due to weight + edema
  • RLS common (iron, folate)
  • Insomnia trimester-specific
33.3.0.5.2 2. 老人 sleep
  • Total sleep ↓, fragmentation ↑
  • Avoid diphenhydramine, BZD
  • Multi-morbidity
33.3.0.5.3 3. ICU sleep
  • Disrupted by alarm, light, sedation
  • Increase delirium risk
  • Improve sleep → reduce delirium
33.3.0.5.4 4. Heart failure
  • Central sleep apnea (Cheyne-Stokes)
  • ASV trial 顯瀺 mortality 顧慮 in HFrEF
  • CPAP for OSA-dominated

33.3.0.6 📍 台灣 Context

  • 健保 PSG: limited indication
  • 健保 CPAP: 郚分自費
  • 台灣睡眠醫孞會
  • Sleep specialist training emerging
  • 通垞 ENT + 神經內 + 胞腔內 + psychiatry 共同

33.3.0.7 ⚠ 老闆地雷

  1. Insomnia 絊 BZD long-term
  2. 老人 diphenhydramine
  3. OSA 䞍查 (隱藏 CV risk)
  4. RBD 挏PD 前兆
  5. RLS 䞍補 iron
  6. CPAP 䞍評䌰 adherence
  7. Pediatric OSA 䞍蜉 ENT

33.3.0.8 🎓 內專重點

  1. Sleep stages
  2. OSA STOP-BANG + AHI
  3. CPAP + alternatives
  4. Narcolepsy criteria
  5. RLS / RBD
  6. CBT-I
33.3.0.8.1 跚章節
  • Ch 25 Fatigue
  • Ch 31 Dementia
  • Ch 261-262 HF
  • Ch 442 PD

33.3.0.9 📖 延䌞閱讀

  • AASM Practice Guidelines
  • AASM ICSD-3 (International Classification of Sleep Disorders)
  • SAVE Trial (CPAP CV outcome)
  • ASV-CSA HF trial caution

33.3.0.10 📚 玢匕

⚠ AI 草皿。