SLEEP IN THE ICU

CONTENTS

Preface
Nancy A. Collop
Erratum

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xiii

Normal Sleep and Circadian Processes

Nancy A. Collop, Rachel E. Salas, Michael Delayo,
and Charlene Gamaldo

449

The onset of sleep is associated with a variety of changes in both

behavioral and physiologic states. Sleep is not a uniform state
either: it has different stages that affect different areas of the brain
and body. Nonrapid eye movement sleep stages are as different
from rapid eye movement sleep as is wakefulness. Circadian
rhythms of physiologic systems also impact wake, sleep, sleepiness, and alertness. There are characteristic changes in both sleep
patterns and circadian rhythm that occur with aging. The
cardiovascular, respiratory, endocrine and gastrointestinal systems
also undergo changes with sleep onset. This article reviews the
aspects of normal sleep, physiologic changes that occur in the
human body with sleep, and how sleep changes over the lifespan.

Adverse Effects of Sleep Deprivation in the ICU

Rachel E. Salas and Charlene E. Gamaldo

461

The hospital is not conducive to sleep. Patients in the ICU are

particularly susceptible to sleep disruption secondary to environmental and medical issues. Despite the frequency of sleep
disruption in the ICU, the quality of critically ill patients sleep is
often overlooked. This article discusses the following issues
essential to understanding the factors associated with sleep loss
in the ICU: (1) core elements to consider from the baseline sleep

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history, (2) impact of the ICU environment on the ICU patients

sleep pattern, and (3) overall systematic impact of sleep deprivation on the ICU patient.

Pharmacology I: Effects of Sleep of Commonly Used ICU

Medications
Gerald L. Weinhouse

477

Critically ill patients are almost universally administered

medications to treat their acute illnesses and to maximize their
comfort. The effects of many of these medications on their sleep,
however, may be important. It is known that critically ill patients
have severely disrupted sleep and that this disrupted sleep has a
negative impact on ICU outcomes. This article reviews how
some commonly used ICU medications may affect patients
sleep.

Effects of Common Medications Used for Sleep Disorders

Qanta A. Ahmed

493

Sleep disorders are common and their diagnosis is becoming more

widespread with improved awareness among clinicians and
patients. The armamentarium for the pharmacologic treatment of
sleep disorders is rapidly growing, demanding that clinicians be
aware of their indications, adverse effects, and interactions. As
disorders, such as narcolepsy, shift-work sleep disorder, and RLS
are more readily identified, pharmacologic treatments for these
conditions will also become more common.

Sleep and Mechanical Ventilation

Aylin Ozsancak, Carolyn DAmbrosio, Erik Garpestad,
Greg Schumaker, and Nicholas S. Hill

517

Critically ill patients have severe sleep disruption and typically

encounter loss of circadian sleep pattern, steep fragmentation,
increasing proportions of transitional stages of sleep, and loss of
slow wave and rapid eye movement sleep. Mechanical ventilation
is associated with these same sleep abnormalities, but what is
attributable to the intensive care unit environment versus
mechanical ventilation itself may be difficult to discern. Recent
studies have shown that the ventilator mode and inappropriate
settings can contribute to sleep fragmentation, and it is important
to avoid overventilation that can induce central apneas when using
spontaneous breathing modes. Noninvasive ventilation in the
acute setting seems to be associated with the same sleep
abnormalities as invasive ventilation. Long-term noninvasive
positive pressure ventilation assists ventilation nocturnally and

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improves for patients with chronic respiratory failure caused by

restrictive thoracic disorders.

Diagnosis and Management of Obesity Hypoventilation

Syndrome in the ICU
Won Y. Lee and Babak Mokhlesi

533

Obesity hypoventilation syndrome (OHS) is characterized by

obesity, daytime hypercapnia, and sleep-disordered breathing in
the absence of other known causes of hypercapnia. Because of the
global obesity epidemic and the high prevalence of obstructive
sleep apnea in the general population, critical care physicians are
likely to encounter patients who have acute-on-chronic respiratory
failure attributable to OHS in their clinical practice. In this article,
we define the clinical characteristics of OHS, review its pathophysiology, and discuss the morbidity and mortality associated
with OHS. Finally, we offer treatment strategies during ICU
management using noninvasive positive pressure ventilation that
may guide the physician in the care of these challenging patients.

The Overlap Syndrome: Chronic Obstructive Pulmonary

Disease and Obstructive Sleep Apnea
David Hiestand and Barbara Phillips

551

The overlap syndrome defines the relationship between obstructive

sleep apnea (OSA) and chronic obstructive pulmonary disease
(COPD), and is a commonly noted but poorly studied disorder.
Individuals who have the overlap syndrome have been recognized
to have greater risk for pulmonary hypertension, right heart
failure, and hypercapnia than patients who have either disorder
alone. In patients who have advanced-stage COPD, concomitant
OSA likely has significant adverse consequences. The interaction
between these two diseases is unclear, however. Further clinical
trials of the overlap syndrome are urgently needed.

Common Sleep Problems in ICU: Heart Failure

and Sleep-Disordered Breathing Syndromes
Matthew T. Naughton

565

Ventilation during sleep is under tight metabolic control, and can

be destabilized by upper airway obstruction leading to snoring or
obstructive apneas, inadequate respiratory pump muscle activity
leading to hypoventilation, and central control instability leading
to changes in metabolic feedback and loop gain. These three
physiologic disturbances can lead to obstructive sleep apnea
hypopnea syndrome (OSAHS), hypoventilation syndromes, and
periodic breathing. OSAHS places a strain on the cardiac output by

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virtue of hypoxemia, large negative intrathoracic pressures, and

high swings in systemic blood pressure. Periodic breathing, also
known as central sleep apnea with Cheyne-Stokes pattern of
respiration, is likely to be a product of advanced heart failure.

Nonrespiratory Sleep Disorders Found in ICU Patients

Lee K. Brown and Madhu Arora

589

Intensive care subjects the critically ill patient to a multitude of

stressors caused by the severity of illness and the use of invasive
treatment modalities and medications. The ICU environment
contributes significant stress of its own related to noise, light,
24-hour patient care, and other factors that disturb sleep.
Consequently, various sleep pathologies may emerge or worsen
in the ICU patient. Some sleep disorder symptomatology may be
confused with serious neurologic complications of critical illness
and lead to inappropriate testing or treatment, particularly in the
patient who has narcolepsy. Given the high prevalence of sleep
disorders in the general population, it is essential that the ICU
practitioner attain an adequate knowledge of sleep and its
disorders.

The Sleep-Friendly ICU

Aharon E. Sareli and Richard J. Schwab

613

Achieving restorative sleep in the ICU remains a challenge for most

patients. Various environmental and nonenvironmental factors
affect sleep patterns in the ICU. This article discusses the effects
and relative importance of these factors on sleep patterns in the
critical care setting. In addition, the implications of sleep pattern
alteration on human physiology and homeostatic mechanisms are
considered.

Index

viii

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