371.4 📋 章末速蚘 Summary

371.4.1 🔑 䞀句話瞜結

Sleep = NREM (N1 light, N2 spindles/K-complexes ~ 50%, N3 slow wave deep) + REM (dreaming, atonia, rapid eye movements) cycles ~ 90 min, 4-6 per night; adults need 7-9 hr; ICSD-3 categories — (1) insomnia (chronic difficulty ≥ 3 nights/wk for ≥ 3 mo with daytime consequences); (2) sleep-disordered breathing — OSA most common (recurrent partial/complete airway collapse, AHI ≥ 5 + symptoms or AHI ≥ 15 = diagnosis, mild 5-15/moderate 15-30/severe ≥ 30, risk factors obesity BMI > 30 + neck > 17 men/16 women + male + age + anatomic + acromegaly/hypothyroid, symptoms loud snoring + witnessed apneas + Epworth ≥ 10, consequences CV HTN/AF/CAD/stroke/HF/sudden death + metabolic + cognitive + MVA, diagnosis PSG gold standard or HSAT high pretest, CPAP first-line + APAP + BPAP + MAD mild-moderate + hypoglossal nerve stimulation Inspire moderate-severe with PAP intolerance BMI < 32 + UPPP/maxillomandibular advancement + tirzepatide GLP-1/GIP FDA 2024 OSA+obesity SURMOUNT-OSA) + CSA (HF Cheyne-Stokes, opioids, stroke — ASV contraindicated HFrEF EF < 45% SERVE-HF); **(3) hypersomnias — narcolepsy type 1 with cataplexy ↓ orexin/hypocretin autoimmune destruction HLA-DQB1*06:02 + sleep paralysis + hypnagogic hallucinations + EDS, PSG + MSLT (latency < 8 min, ≥ 2 SOREMPs); narcolepsy type 2 normal orexin; idiopathic hypersomnia (long sleep + sleep drunkenness); Kleine-Levin syndrome (recurrent hypersomnia + hyperphagia + hypersexuality, adolescents); (4) circadian rhythm disorders — DSPD adolescents/ASPD elderly/shift work/jet lag/irregular/non-24 in blind tasimelteon (Hetlioz); (5) parasomnias — NREM (slow-wave sleep, early in night — sleepwalking, sleep terrors, confusional arousal, children > adults); REM behavior disorder (RBD) — loss of REM atonia + acting out dreams + older men + clonazepam or melatonin + PROD of synucleinopathy PD/DLB/MSA 80%+ within 15 years; (6) sleep-related movement disorders — RLS see Ch369 + PLMD + bruxism; narcolepsy treatment — modafinil/armodafinil first-line for EDS + methylphenidate/amphetamines stimulants + solriamfetol (Sunosi) DNRI FDA 2019 + pitolisant (Wakix) H3 antagonist FDA 2019 + sodium oxybate / mixed-salt oxybate (Xywav lower sodium) Xyrem for EDS + CATAPLEXY; insomnia treatment — CBT-I first-line + DORAs (dual orexin receptor antagonists) — suvorexant (Belsomra), lemborexant (Dayvigo), daridorexant (Quviviq) FDA 2022 + Z-drugs short-term (zolpidem, eszopiclone, zaleplon) + benzodiazepines (avoid chronic + fall risk elderly) + melatonin agonists (ramelteon, tasimelteon) + low-dose doxepin (Silenor 3-6 mg)** + trazodone off-label。

371.4.2 💊 治療粟芁

  • OSACPAP first-line (titrate to eliminate apneas/hypopneas; APAP auto-adjusting; BPAP if high pressures or hypoventilation); mandibular advancement device (MAD) mild-moderate; hypoglossal nerve stimulation (Inspire) moderate-severe with PAP intolerance + BMI < 32 + no concentric collapse on DISE; tirzepatide FDA 2024 for OSA + obesity (SURMOUNT-OSA, significant AHI reduction); weight loss + positional therapy + alcohol/sedative avoidance; modafinil/armodafinil + solriamfetol + pitolisant for residual sleepiness
  • CSAtreat underlying (HF optimization); ASV for non-HFrEF CSA; AVOID ASV in HFrEF EF < 45% (SERVE-HF mortality signal); CPAP + supplemental O2 + acetazolamide options
  • narcolepsy EDSmodafinil 100-400 mg/d or armodafinil 150-250 mg first-line + methylphenidate + amphetamines + solriamfetol (Sunosi) 75-150 mg/d + pitolisant (Wakix) 17.8-35.6 mg/d + sodium oxybate (Xyrem) or mixed-salt oxybate (Xywav lower Na) 4.5-9 g nightly divided into 2 doses
  • cataplexysodium/mixed-salt oxybate first-line + pitolisant + SNRIs (venlafaxine) + SSRIs
  • REM behavior disorder (RBD)safety measures + clonazepam 0.25-1 mg HS or melatonin 3-12 mg HS (less side effects); counsel about synucleinopathy risk + neurological follow-up
  • insomniaCBT-I (Cognitive Behavioral Therapy for Insomnia) first-line + sleep hygiene + stimulus control + sleep restriction; pharmacologic short-term DORAs (suvorexant 10-20 mg, lemborexant 5-10 mg, daridorexant 25-50 mg FDA 2022) + Z-drugs (zolpidem 5-10 mg, eszopiclone 1-3 mg) + low-dose doxepin (Silenor 3-6 mg) + ramelteon 8 mg + trazodone
  • circadian rhythm disordersDSPD melatonin 0.5-5 mg 5-7 hr before desired bedtime + morning bright light; ASPD evening light + afternoon melatonin; shift work scheduled bright light + modafinil + melatonin off-shift; jet lag melatonin + light timing; non-24 in blind tasimelteon (Hetlioz) 20 mg
  • NREM parasomniassafety + sleep hygiene + treat triggers (sleep deprivation, fever, stress) + clonazepam selected severe

371.4.3 🎯 盧醫垫的考前提醒

  1. Normal sleep architecture: NREM N1 (light) + N2 (spindles/K-complexes 50%) + N3 (slow wave deep) + REM (dreaming, atonia) cycles ~ 90 min; adults need 7-9 hr; REM ↑ in latter half of night
  2. OSA diagnosis: AHI ≥ 5 + symptoms OR AHI ≥ 15 = OSA; mild 5-15, moderate 15-30, severe ≥ 30; PSG gold standard, HSAT for high pretest probability without comorbidities; Epworth Sleepiness Scale ≥ 10 = excessive
  3. OSA risk factors + consequences: obesity (BMI > 30, neck > 17 men/16 women) + male + age + anatomic + acromegaly + hypothyroid; CV consequences HTN + AF + CAD + stroke + HF + sudden death + metabolic + cognitive + MVA → CPAP first-line; tirzepatide FDA 2024 for OSA + obesity (SURMOUNT-OSA)
  4. Hypoglossal nerve stimulation (Inspire) criteria: moderate-severe OSA + PAP intolerance + BMI < 32 + no concentric collapse on DISE (drug-induced sleep endoscopy)
  5. CSA + HFrEF: AVOID ASV if EF < 45% (SERVE-HF 2015 mortality signal); CPAP + O2 + acetazolamide alternatives; treat underlying HF aggressively
  6. Narcolepsy type 1: **↓ orexin/hypocretin (autoimmune) + HLA-DQB1*06:02 + cataplexy (sudden brief loss of muscle tone with strong emotion) + sleep paralysis + hypnagogic hallucinations + EDS → MSLT (latency < 8 min, ≥ 2 SOREMPs); modafinil/armodafinil first-line + oxybate for EDS + cataplexy + pitolisant (H3 antagonist) + solriamfetol (DNRI)**
  7. REM behavior disorder (RBD) EXTREMELY IMPORTANT: loss of REM atonia + acting out dreams (often violent) + older men → prodrome of synucleinopathy (PD, DLB, MSA) — 80%+ develop within 15 years! → counsel + neurological follow-up + clonazepam 0.25-1 mg HS or melatonin 3-12 mg HS (melatonin less side effects)
  8. Insomnia first-line CBT-I (Cognitive Behavioral Therapy for Insomnia) — sleep hygiene + stimulus control + sleep restriction + relaxation; pharmacologic DORAs (suvorexant, lemborexant, daridorexant Quviviq FDA 2022) + Z-drugs short-term + low-dose doxepin + ramelteon + trazodone
  9. NREM parasomnias (sleepwalking, sleep terrors, confusional arousal): out of slow-wave sleep + early in night + children > adults + genetic + triggers (sleep deprivation, fever, stress) → safety + sleep hygiene + treat triggers + clonazepam selected; REM parasomnias different (RBD, nightmares, sleep paralysis)
  10. Circadian rhythm disorders treatment: DSPD (delayed) — melatonin evening + morning light; ASPD (advanced) — evening light + afternoon melatonin; shift work — scheduled bright light + modafinil + melatonin; non-24 in blind — tasimelteon (Hetlioz)