Medical Image of the Week: REM without Atonia

Figure 1. Polysomnogram with thirty-second epoch showing leg movements and relative increase in chin tone during REM sleep.

Figure 2. Polysomnogram with thirty-second epoch demonstrating similar interval of REM without atonia with the addition of sleep-talking.

A 78 year-old man with a past medical history of Parkinson’s disease (PD) presented to the sleep medicine clinic for evaluation of obstructive sleep apnea (OSA). An overnight polysomnogram (PSG) study was consistent with sleep apnea and revealed frequent leg and arm movements and sleep-talking during rapid eye movement (REM) sleep.

REM sleep behavior disorder (RBD) is a parasomnia characterized by repeated episodes of abnormal behavior occurring during REM sleep (1,2). On PSG, REM sleep without atonia is seen while features of “normal REM” such as number of REM periods and REM cycling remain intact (2). RBD emerges most often in the context of alpha-synucleinopathies, and occurs in up to 60% of PD patients (3). The presence of RBD may be an important preclinical symptom prior to the onset of PD. Cases of PD with RBD are associated with a unique phenotype with an older age of onset, longer disease duration, more profound motor disability, and greater degrees of hallucinations and cognitive dysfunction (3). Establishing a safe sleep environment can be of primary importance in patients with RBD as REM without atonia is associated with injurious behavior. Melatonin is effective as a first-line agent in patients with dementia. In non-demented patients without OSA, low-dose clonazepam is the first line intervention and is rarely associated with withdrawal or need for dose escalation (1). Treating concomitant OSA is important adjunctive therapy.

Jared Bartell, Safal Shetty MD, and Kenneth S. Knox MD

University of Arizona Medical Center

Tucson, AZ

References

1. Aurora RN, Zak RS, Maganti RK, Auerbach SH, Casey KR, Chowdhuri S, Karippot A, Ramar K, Kristo DA, Morgenthaler TI; Standards of Practice Committee; American Academy of Sleep Medicine. Best practice guide for the treatment of REM sleep behavior disorder (RBD). J Clin Sleep Med. 2010;6(1):85-95. [PubMed]
2. Schenck CH, Mahowald MW. REM sleep behavior disorder: clinical, developmental, and neuroscience perspectives 16 years after its formal identification in SLEEP. Sleep. 2002;25(2):120-38. [PubMed]
3. Kim YE, Jeon BS. Clinical implication of REM sleep behavior disorder in Parkinson's disease. Parkinsons Dis. 2014;4(2):237-44. [CrossRef] [PubMed]

Reference as: Bartell J, Shetty S, Knox KS. Medical image of the week: REM without atonia. Southwest J Pulm Crit Care. 2015;10(3):147-8. doi: http://dx.doi.org/10.13175/swjpcc022-15 PDF

Medical Image of the Week: Cheyne-Stokes Respiration

Figure 1. Cheyne-Stokes Breathing pattern seen. The red arrow indicates the cycle time which is defined as the duration of the central apnea (or hypopnea) + the duration of a respiratory phase.

A 62 year-old male with a past medical history congestive heart failure, chronic obstructive pulmonary disease, and obesity with a body mass index of 38.02 kg/m² underwent an overnight polysomnogram for clinical suspicion for obstructive sleep apnea. He was found to have a periodic breathing as seen in the image above.

Cheyne-stokes respiration (CSR) is a type of periodic breathing characterized by crescendo-decrescendo pattern of respiration separated by central sleep apneas (CSA) or hypopneas (1). CSR-CSA may be seen in up to 15-37% of systolic heart failure patients (2,3). A longer cycle length, usually between 45-90 seconds, as well as the waxing and waning breathing pattern differentiate CSR from other forms of cyclic central apnea. CSA leads to chronically increased sympathetic activity and exerts multiple deleterious effects on the failing heart (2). The presence of CSR has been associated with higher mortality and rapid deterioration in cardiac function (4).

Jared Bartell and Safal Shetty, MD

University of Arizona Medical Center

Tucson, AZ

References

1. Berry RB, Budhiraja R, Gottlieb DJ, Gozal D, Iber C, Kapur VK, Marcus CL, Mehra R, Parthasarathy S, Quan SF, Redline S, Strohl KP, Davidson Ward SL, Tangredi MM; American Academy of Sleep Medicine. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med. 2012;8(5):597-619. [CrossRef]  [PubMed]
2. Yumino D, Bradley TD. Central sleep apnea and Cheyne-Stokes respiration. Proc Am Thorac Soc. 2008;5(2):226-36. [CrossRef] [PubMed]
3. Garcia-Touchard A, Somers VK, Olson LJ, Caples SM. Central sleep apnea: implications for congestive heart failure. Chest. 2008;133(6):1495-504. [CrossRef] [PubMed]
4. Hanly PJ, Zuberi-Khokhar NS. Increased mortality associated with Cheyne-Stokes respiration in patients with congestive heart failure. Am J Respir Crit Care Med. 1996;153(1):272-6. [CrossRef] [PubMed] 

Reference as: Bartell J, Shetty S. Medical image of the week: Cheyne-Stokes respiration. Southwest J Pulm Crit Care. 2015;10(3):145-6. doi: http://dx.doi.org/10.13175/swjpcc017-15 PDF