hi everybody and welcome to this new presentation of the master of in sleep and consciousness my name is Maronei i'm a professor of neurology in burn university and in Lugano University i'm also the head of the sleep lab in Lugano so during my presentation I would like to to I mean I would try to give you an overview uh on a complicated subject actually a large a large subject which is the international classification of sleep disorders of course I will not be able to go into the detail of all disorders because the classification include more than 80 different disorders but I would like to give an overview on the main concept behind the classification so we can start with the first slide which actually uh tell you something about the generals of a classification this is regardless to sleep disorder but in general a classification is a guide that help usually physician in recognize a specific disease so uh in other words classification usually contain the diagnostic criteria for to recognize a identified specific disease another secondary him of classification is usually to provide some insights on epidemiology pathophysiology and also course of each specific disease also it is important to set up a classification just to define the borders of the discipline especially in the case of uh uh sleep medicine because actually sleep medicine is a very young discipline and so the classification is very helpful to define the borders of the field in comparison with the other uh specialtity also in in a classification usually is useful to identify possible knowledge gaps to be filled in the future by writing a research agenda so indeed usually the hedel is to base a classification on top into I mean on pathophysiological uh knowledge but indeed because sometimes the pathophysiology is not well known for specific disease classification might be based on the clinical phenotype and this is also the case as I will show you uh for the international classification of sleep disorders so as I told you before sleep medicine is a is a very young discipline at the beginning it was considering a multid-disiplinary uh speciality but now is a a single specialtity independent speciality from the others but in uh any case we are talking about a very young discipline so the sleep medicine actually uh born in the second half of the 20th century after important discovering coming from the sleep physiology so I just collect in this light the most important discoveries uh coming from the field of uh sleep physiology like the discovery of REM sleep in 1953 and then in 1958 the discovery of melatonin and then later on discovery of the main uh brain center uh producing sleep and all of this discovery in the first part of the 23 secondary uh I mean increase the knowledge around the sleep and in the second part of the 20th century actually uh around 1960 1980 the sleep medicine develop and to I mean to arrive to the first uh attempt to set up a classification of sleep disorder we need to wait until 1979 when a new journal which was called sleep that even now is the reference journal for sleep specialist actually included a single issue dedicated to the first classification of sleep disorders these were 137 pages actually which tried to classify all sleep disorder new at that time so in uh this first classification actually they try to classify or subclassify all sleep disorder in four different chapters uh one dedicated to insomnia the second one dedicated to hyperomnia the third to the circadian disorder and the last one dedicated to parasomnia actually this uh this actually was not the official but in any case the first uh classification coming from the American society then for the real official international classification of sleep disorder we need to wait until 1990 when uh four different society the American the European the Japanese and the Latin American sleep society they decide to sit together uh in order to produce the first international documents uh which collects all sleep disorder known at that time actually in this first edition were collected 84 sleep disorders and they were classified in four different chapters so the first chapter uh was named disomnia and include several sleep disorders then we have a second chapter dedicated to parasomnia which are usually uh um I mean uh behavior strange behavior occurring during sleep and then a third uh chapter dedicated to medical and psychiatric disorder associated with sleep actually the idea behind this first chapter that was named insomnia was that the overlap between insomnia and sulence actually daytime sulence often is too large to be distinguish clearly distinguish and manual sleep disorder may contain inside both symptom insomnia and uh hyperomnia so let's say for example sleep apnnea patient affected by sleep apnnea may have insomnia because the sleep may be interrupted by by the apnea events but at the same times he may also have sulence during the day so and that's the reason because they decided to put many disorders together inside uh I mean under the name of the sonia so this is valid also for other kinds of disorders for example narcolepsy I mean the main feature on narcology of course is the daytime somnolence but narcology may also suffer of insomnia so that's the reason because they decide to create one single chapter that contain several several different sleep disorders and then the the general architecture of the classification actually was uh was uh changed in 2005 when came out the second edition of the international classification of the disorders i mean during these 15 years several new pieces of knowledge have been collected and so the sleep expert thought that now might be the time to disentangle between insomnia and hypersonia and to create two different chapters so the high C uh second version of 2010 then was uh actually um is is the the architecture of this classification is the one that resist now in the last version and actually used to uh classified all sleep disorder in uh uh eight different chapters one dedicated to insomnia the second large chapter dedicated to breathing disorders and then one chapter only for hyperomnia and then one for the circadian ripped sleep disorders one for paromnia and then a last one uh which is focus on sleepreated movement disorders actually there are other two small chapter one for emissionia and the other for isolated symptoms outside of specific disease should be noted that one year later actually came out also another uh pocket version of the international classification of deep disorders so this is still the second version but the is pockets i mean uh ideally this should be at the beginning a kind of summary of the international classification of sleep disorder but indeed if you look inside of this pocket version the the the organization of the classification changed a little bit especially because they included a new chapter in the classification which was dedicated to the pediatric sleep medicine actually pediatric sleep medicine was almost neglected in the previous classification and so this is an important new entry then in 2011 the American Academy of Sleep Medicine approved a revision of the ICST2 because they thought that I mean the new knowledge may be implemented in a new version of the ICST and so the they put together some sleep expert and for the first time in the task force was al were also included two pediatricians so this is because uh the pediatric sleep medicine started to be important and then they produced the first American draft of the of the classification and the draft then was uh circulated among the other international society for a second revision so and finally they publish in 2014 the third edition of the international classification of the disorders this is the the one that is still valid nowadays and this is the probably the most important book uh of reference for sleep specialist of course together with my presentation I will deliver it to you uh other two papers but uh of course for the students that would like to go much deeper in the subjects I mean I may suggest to buy uh this that is actually the international classification of sleep disorder which is the official book and is quite important because it collect the main clinical features and the diagnostic criteria of all sleep disorders so also in this case the architecture didn't change too much compared to the previous classification we still have one chapter dedicated to insomnia a second one even larger than before dedicated to breathing disorders then we have the chapter of hypersonia but they decided to change a little bit the name from hypersonia to central disorder of hypersonnalance this is to highlight that in this chapter we have all disorders uh that express themsel with hypersonia but they depend on primary disorder of the central nervous system then we still have the chapter of the circadian ripped sleepwake disorder the chapter of parasomnia that was present since the beginning and then still a chapter that focus on sleepreated movement disorders so um if you uh go through the pages of this book you can see that for each sleep disorder they have the similar they have a similar outline and so for each disorder they started giving you possible synonym synonymous or alternate names of the same disorders and then they always have a clear diagnostic criteria for for the diagnosis of each sleep disorders i mean diagnostic criteria should be based on evidence uh data but because sometimes we don't have a perfect knowledge of each disease sometimes the diagnostic criteria are based on expert consensus so then they will give you per each disease even some essential clinical features some assoc associated clinical features and then give you some insight on the clinical and pathophysiological subtypes of possible phenotype of the same disease then usually they give you some insights on the epidemiology about the prevalence and incidence of disease some possible triggering or precipitating factor some insight on the familiar pattern especially for those disease that are uh actually uh they have own um genetic background and so some insight on the course of disease and possible late onset complication of the disease some issue of the development uh problem so in this classification the chapter of pediatric disease was cancelled because in each disease they provide some insight on the pediatric uh on the pediatric uh age so usually in each chapter or in each description of disease you will find something about the mechanism of the pathophysiology and then objective findings that usually are based on the polyonography which is the main instrumental investigation used to perform the diagnosis of sleep disorders so before go a little bit deeper in the subjects let me also highlight that sleep disorder in general are not only included in the ICSD but of course they are also included in international classification of disease which is the ICD10 but also part of the DU are included in another important manual which is the diagnostic and statistical manual of mental disord disorder even call it DSM which arrive nowadays to the fifth edition but of course if you want to go deeper and going to to also treat the details of each sleep disorder the most detailed one remain the international classification of sleep disorder third edition so beside the the book that I show you before which is the international classification of sleep disorder there is also another important manual which is very useful to guide you through all sleep disorder which is this one always produced by the American Association of Sleep Medicine which actually is the manual for scoring sleep related events like uh uh I mean the rules to to stage sleep to recognize and to uh quantify some events like arousal cardiac events respiratory events or also motor events i mean in the ICSD you will find um all information concerning disease here in in this manual you find information and scoring rules for specific sleep events that usually can be uh recording in the context of video polyonography so I think that we can go uh inside the ICSD and try to give you uh an overview on the main uh six different chapters uh that I show you before so I would start with the first chapter which is the one dedicated to insomnia and uh insomnia actually can be uh recognized or identified uh by the satisfaction of at least three important criteria actually the general criteria for insomnia regardless the subtype of insomnia and even regardless the time frame of insomnia in term of acute or chronic in general if you uh wanted to define insomnia you needed to to to meet all of these three criteria so first of all so first of all the the first criteria is the the patient should report subjectly a sleep difficulty what does it mean sleep difficulty it means a difficulty in initiating maintain sleep or even complain a early morning awakening so this difficulty to to fall to to sleep actually should be associated with an adequate sleep opportunity so in other words I mean a patient affected by insomnia should have the opportunity to have a I mean uh a a good room to sleep which should be silent black and also with a medium low temperature in order to uh to let it possible to sleep and then the third criteria beside the sleep difficulty and another great sleep opportunity is the negative consequence in term of daytime symptoms of insomnia so in other word I mean even if you have some difficulty in initiating or maintaining sleep and you have adequate sleep opportunity you also need to be classified as an insomnia that the sleep difficulty will provoke some symptoms during the day or some negative consequence of insomnia without an impact of insomnia to the quality of life in your daytime time living you may you cannot be classified as insomnia and this is because in the general population there are also some subject even call it short sleeper uh that may may even sleep shorter like five or six hours and uh despite this they may have uh they may be good sleeper without any daytime symptoms so the second criteria to be important is the time criteria because insomnia can be distinguished in acute insomnia and in chronic insomnia the acute insomnia in the previous uh classification the version the second edition was also called adjustment insomnia while the chronic one remain with the same name actually the criteria to classify between chronic and adjustment or acute uh are the one listed in the right part of the slides so as you can see here first of all the acute insomnia that was named adjustment insomnia in the second ed edition now in the third edition is named shortterm insomnia but the meaning more or less is always the same so when a sleep complain or insomnia is longer has been longer than 3 months we can classify this insomnia as a chronic while for a shorter period we have to classify the insomnia as a shortterm uh insomnia also there is a minimum uh threshold or frequency to classify a patient as insomnia and the minimum frequency of insomnia episode should be higher than three times uh per week beside the classification of chronic and short-term insomnia we have also some isolated symptoms which the one is the excessive time in bed which is the equivalent of what we call it in the past insomnia due to bad sleep hygiene and also short sleeper for those subject that used to sleep less than six hour even without daytime consequence of they their sleep because they are probably genetically determined short short sleepers so also the main change between the second edition and the third edition of the classification concerning the definition of insomnia consist in the identification of the possible subtype of insomnia so in the second edition insomnia was a subclassified in several different subtype of insomnia like psychophysiological paradoxical ideopathic associated with mental disorder sleep hygiene behavioral in child due to drug or substance or medical condition or even some other unspecified so now in the third edition they uh put all the subties in in inside the same group which is called a chronic insomnia without uh a clear uh subclassification in different phenotypes so they still mention in the same phenotype but in the third edition we you will not find a clear diagnostic criteria for each of the subtype while you will find this if you go back to the second edition and the reason because they decided to cancel um this subclassification in different insomnia phenotype is due to the large overlap that may exist between this phenotype and also we have no real let's say evidencebased knowledge to classify it differently all these subtype but they still may be important because they may refer refer a little bit to the mechanism behind insomnia and so might be still important to mention and to know what is the main clinical feature of the of each of these subtype so I'm not going into the detail of the diagnostic criteria but uh the criteria for insomnia should be at least mention it as I told you before we need at least three criteria to perform the dynasty of insomnia the first one is uh something to do with the difficulty to sleep that may be expressing in difficulty in initiating maintain sleep or wake up too early in the morning and also the difficulty in sleep might be reported not only by the single patient but also might be reported by parents in case of kids and also by caregiver in in in case that the patient is not able to report or to complain the symptoms the criteria B as I told you before is mandatory so this difficulty in uh to sleep should be accompaned by daytime symptoms and here you see a list of several possible different uh daytime in symptoms that can be uh let's say induced by a chronic bad sleep or chronic sleep deprivation in a context of insomnia also as I told you before this should occur together with uh a good opportunity uh to sleep at a great opportunity to to sleep and also we have two possials actually the one of frequency so the episode of insomnia should be at least three times per week and with a duration longer than three months to be classified as a as a chronic otherwise should be classified as acute or let's say short-term insomnia so now we go directly to the second chapter which is actually as I told you the largest one in term of number of different sleep disorder that are collected within the this chapter and uh also maybe the most complicated one because most of the diagnosis uh need a specific knowledge for scoring events breathing event as I will show you before and then we also need to move to the other manual that I show you before which is the manual for scoring sleep events in particular breathing event in this case so this chapter would like to collect all possible uh breathing disorder occurring during sleep and uh is uh um subclassified in four different sub chapters one dedicated to obstructive breathing disorders the second one for central sleep disorders then one new chapter that was not present before in the second edition completely dedicated to hypoventilation during sleep and the other one which is the last one uh which collect disorders provoking hypoxia during during sleep so the rational behind the classification is mainly due to the type of events uh that you can score in the polyonography of these patients and uh looking to the next slides actually and moving to the manual uh from the classification to the manual i mean the type of events the breathing event that you can score are fundamentally three one are apnea the second is called hypoappa and the third one is the respiratory effort arousal even call it rare so let's start giving some very very brief insights concerning the apnea so an apnea can be defined as a drop in the amplitude of the aonazal flow which is usually recorded or by using the mister or by using a pressure naso canula so uh is a drop of the amplitude of oronas or flow higher than 90% with a duration longer than 10 seconds then we should be able to classify the apnea as a central or obstructive depending on the occurrence of toriccoal movements so if during the apnea your torico abdominal apparatus continues to move then the apnea should be classified as obstructive while if during your apnea you also have a stop of toric abdominal movements this apnea should be classified as a central you may also have a mixed apnea in case you have both the first part without any toic abdominal movement and the second part with some movements inside the general apnea so when the drop of the amplitude of the oronas flow is lower than 90% but is higher than 30% then the event if it last longer than 10 second can be classified as hypoapplia but uh to be classified as hypoapplia uh also you need other two important criteria so the hypoappa which is a drop of the oronazal flow amplitude lower than 30% for a duration of 10 seconds should be accompanied also or by a cortical arousal at the end or by a desaturation in oxygen desaturation higher than 3% so another even milder uh breathing event is the so-called rare or respiratory related arousals so herein you have no clear drop of the amplitude of the auronasal flow but you have just a flattering of the wave form of the oronazal flow which is accompaned by a final arousals so this is a a mild event but that can be enough to provoke an arousal and so to provoke a sleep disruptions so while the first event that I show you which was the apnea can be classified in central and obstructive the rarer event of course are always obstructive event and never central concerning the second event which is the hypoapnia even the hypoapna like the apnea one can be distinguished in central or obstructive events so these are the simple rules that uh let you able to distinguish between central and obstructive hypoappa so every time that you have an hypoappa together with one of these three features you can score the hypoapna as obstructive the first one is snoring the second one is oronazal flattering the same that you see in the rera events and the other one is paradoxical respiration between torico abdominal movement if at least one of the three are met in your scoring then the event should be classified as obstructive if none of these features are met you can classify the hypoapnia as a central hypoia so then after your definition of each events or breathing event in your polyonography polyonography actually during the night then in your final report you can even decide which is the severity of the disease basing on some important index the hypoapa index is the number of apnea per hour of sleep the AHI is the apnea and hypoappa index concern the number of apnea and hypopnia per hour of sleep and then this is the most important one because this is the base to classify the severity of the disease you have the so-called RDI which is the respiratory disturbant index which is actually the number of hypopnia apneas and rare so all the events that you can recognize in your psg so the number of apnea hipopnas and rasp per hour sleep give you the is important to classify the severity of your breathe sleep related breathing disorder when thei is lower than five the breathing pattern can be judged as normal if the RDI ranges between five and 15 the breathing disorder should be judged as mild then it become moderate when the DRD the RDI ranges between 15 and 30 and should be judged as severe when the RDR is higher than 30 as you can see in the right part of the of the slides we have different criteria for children and that's the reason because the first sub chapters which is the subchapter of obstructive sleep syndrome is divided itself in another two section obstructive sleep apnea of adults and obstructive sleep apnnea of um pediatric age i mean here the cutff the age cutff between the two is still not clear in some laboratory they use 18 which is the legal let's say definition of adult but in most of the laboratory even in my lab actually we use the cutff of 12 years so for even uh not adult uh patient older than 12 year but younger than 18 we already use the adult criteria to score and even for severity and this is the what is also suggested by the most of the um sleep expert even in uh in the ICSD third version so as before for for insomnia I'm not going into the detail of a single criteria because these are too much for this simple overview but in this slide in any case you can see what are the diagnostic criteria for the dy of sleep apnea disorder in adults so what is might be important to highlight is that as I told you before you need at least five breathing event per hour of sleep to be classified at least as a mild disorders but to be classified we may have a difference between disorder and syndrome or disease so every time that you have more than five breathing event per hour you uh to be classified as affected by sleep apnnea in term of disease or syndrome you also need at least one of these daytime symptoms or comorbidity cardiovascular coorbidity while if you are moderate so that means that you have more than 15 breathing event per hour you don't need any other uh aon pain coorbidity or daytime symptoms to be classified as affected by sleep apopia so just to summarize or you have more than 15 breathing events and then you might be classified as affected by sleep apnea or if you have more than five but less than 15 you also need to be affected by sleep apnea some other clinical features that are collected here like sleepiness for example or chalking or gasping or also some other cardiovascular uh coorbidity like diabetes hypertension or for example atrial fibrillation so the second sub chapter of the sleep relating breathing disorder concern and collect together all the breathing disorder basic on central impairment that are not obstructive as you can see here you will find the most frequent one which is the periodic breathing pattern even called a chain stock uh disorder then you may have some central Z uh syndrome uh due to medical disorder or to high altitude for example or to substance or drugs and then you have also some primary central sleep apnea usually present uh in infancy or even congenital so a general criteria for central path breathing is that this patient actually should have more than five central events for central event as I told you before maybe central apnea or central hypoas and so they should have at least five central events per hour of sleep and also in the global amount of the breathing event at least 50% of them should be central otherwise the disorder should be classified as obstructive and not as a central one uh I mean the most frequent central breathing disorders as I told you is a chain stock breathing and actually the chain stock brley is characterized by at least three at least three consecutive central aer that are separate separated by a crescendo and the crescendo change in breathing amplitude with a cycle length which usually should be longer than 40 40 seconds as you can see in this slide this is the typical chain stock breathing which is also called periodic breathing and as you can see here this is the event in this case is an apnea and at the end of the apnea you find a crescendo and the crescendo amplitude of breathing part and then a new app if you have at least five of them and in general at least 50% of the events looks like this one you are facing a patient with the chain stock breathing if you want also to calculate the length that should be longer than 40 seconds this is the rule to calculate the length of a chain st so the the cycle start at the beginning of the apnea and go forward until the beginning of the next hapna so the duration of uh uh of this period is uh coincides with the with the length with the with the cycle length of the chain stock breathing this might be important because longer is the length of the cycle and usually more severe are the patients as you probably already know this brain this chain stock breathing is usually associated with the cardiovascular and earth failure so I'm not describing all the other central pattern but let me just stress briefly another entity which is called the treatment emergent central sleepapia the reason because I would like to highlight briefly this disorder is because this in a new entry actually and it is a specific disorder that previously was even called the complex sleepopia so here we are dealing with patient affected by regular obstructive sleep but that are successfully treated by ventilation so they are patient treated by CPAP but in this patient what's happened is that after disappearance of obstructive sleep events I mean the CPAP provoke the occurrence of new central event and that's the reason because it's called treatment treatment emergent central sleep apnnea this is a particular subtype of central events that usually are due to too high pressure or ventilation then the other sub chapter is the so-called asleep related hypoventilation disorder here in you don't need uh regular briefing events like apnea or hypoappa but you just need hypoventilation and hypoventilation should be always measured by the capnography which tell you the level of CO2 in the blood actually this regardless to the subtype type of inilation that can be associated with obesity or might be on the genetic base or even provoked by other substance or drug but regardless of the subtypes the general criteria is hypoventilation that can occur with or without the apnea or the hypoapa herein I give you the general criteria for hypoventilation that should should occur during sleep for all of these entity except for obesity hypoventilation syndrome where we need hypoventilation also during daytime for all the other is enough to demonstrate hypoventilation during the night but what is hypoventilation for the general criteria to establish hypoventilation as I told you you need to measure the CO2 and the CO2 should increase during sleep up to a value of at least 55 mm for at least 10 minutes or you may even satisfy the second criteria which is an increase in the level of uh CO2 during sleep of at least an interval of 10 mm comparing to the basil the basel value before fall asleep if you have one of these two criteria and these criteria are in the manual actually then you can classify your patient as affected by hypoventilation regardless of the number of breathing event like apnea or hypoapna as I told you before the only one exception is for the obesity hypoventilation syndrome which need an hypercapnea also during the daytime then the last sub chapter is dedicated to hypoxmia and these are for patient actually who present a desaturation a tonic desaturation uh during sleep also in this case the hypoxia might be associated or not to breathing events apnea air hypoapna but should not provoked mainly by the breathing event but from other condition the second important uh uh thing is that in this case if you want to make the diagnosis of slipperate hypoxia you need to exclude hypoventilation because if you have an hypercapnea so if you have an hypoventilation in this patient which contains hypoxia then this patient should be classified in the chapter of hypoventilation and no more in the hypoxia so in other words to be classified as hypoxmic patient you need a saturation during sleep lower than 88% in adult or 90% in children for more than 5 minutes together with this the hypoxia should be isolated so not accompaned by hypercapnea or hypoventilation but might be accompaned by apnea or hypo apnea but in this case the hypoxia should not be provoked by apnea and hypoapnia which are simply a complaining symptom but not provoking symptom so at the end of the breathing disorder chapters you have also some a couple of so-called isolated symptom one is snoring which is a very frequent uh um clinical feature especially in adult male I mean almost 40% of adult male may suffer on snoring that can be accompontained or not by by daytime symptoms when snoring is a contained by daytime symptoms like snolins for example then you are dealing with what we used to call previously wars which is the acronym for upper eyeway resistant syndromes the other one which actually is a new entry in the third edition is the soalled nocturnal growing even called it in Latin catrrenia the catrrenia is an isolating breathing disorder which indeed is a little bit in between breathing disorder and parasomnia and this is a clear example video poly sonographic example of a patient affected by no actually this is very different comparing to snoring is a kind of gloomy sounds produced during the expiratory phases and actually usually is not dangerous and we don't use to treat these patients let me uh let me show again a little bit the sounds so you can remember the kind of So it's a kind of uh gloomy complaint by by the patients why might be important to recognize this particular isolated symptom because if you look at the right side of the slides the breathing pattern can very much be similar to central aa these indeed are not central a you don't have any desaturation together with these events but these are in fact nocturnal growing event or catatronia events so the other chapters is the one dedicated to hyperomnia or even calling the new addition as a central disorder of hyper somnolins so this include six different subchapter or six different disease which are narcolepsy type one and type two hydopathic hypersonia clane levine syndrome which is actually a periodic hyperomnia or recurrent hypersonia and then hypersonnia due to medical psychiatric disorder or the use of substance hands or drugs the last one is a very important chapter because we are seeing a lot of patient right now with this uh syndrome which is the insufficient sleep syndrome which is also called it as a chronic sleep deprivation so in this case the daytime sunless is provoked by a short duration which is usually due to behavioral bad rules actually so herein is very important to stress that to subclassify between these different hypersonic disorder you need for sure is mandatory to to perform an instrumental investigation so in particular is very important the vigilant test called multiple sleep latency test which is a vigilance test test performed during daytime in which the the patient is undergo to four or five different tests during the day to see if he fall asleep or not so if the me mean latency to fall asleep between these four or five episode is shorter than 8 minutes then the the patient is affected by a pathological daytime somnance another important concept is the so-called occurrence of sormp the sor is the acronomy for sleep onset REAM period and actually is the latency of a first REAM phase after falling asleep usually we need around 80 90 minutes to to do the first REM sleep after fall asleep but some patient in particular those affected by narcopsy they use to enter in the ram phase even before with a latency that if is shorten than 15 minutes then can be classified as a sor ramp or sleep onet period another important clinical feature is catapixi and also nowadays also the level of orexin in the CSF so especially for the dynasties of narcopsy type one and two we need all of this information or part of this information so for both type one and type two of narcopsy you always need the presence of sleep attacks during the past three months for the type one but also as you can see here for the for the type two narcoy so the main feature is some associated with irresistible uh uh sleep attacks during the day also to in in common between the type one and type two you have the results of the MSLT for the MSLT you need a pathological mean value lower than 8 minus this is valid for type two and type one and also you need at least two sorms so that means that at least two times the patients entering in RAM in RAM phase within 15 minutes in the course of the MSLT test or even in the pol in the the night before the MSLT test that is measured by polyonography so if you have two sorms and the mean latency lower than 8 minutes then you might be classified as a patient affected by narcolypse then to discriminate between type one and type two you have to look to clinical feature or to the level of orexin in your CSF so concerning the clinical feature what is important is cataplexy catapy should be present only in narcole narcolepsy type one and the other one is the level of orexin in CSF which is pathological only in narcolepsy type one and should be lower than 110 pico gram per milliller so in other in other word narcoys type one is the one associated with catablexy associated with the absence of orexin in the CSF if a patient uh have the criteria for type two so that means is not affected by cataplexi and also have normal value of hypocratin if this patient in the course of his disease will develop cataplexi or pathological value of hypocritin automatically this the dye should be changed from type two to type one then if you have a pathological somnness during daytime but you don't have any sor so by so that means that your MSLT is pathological because the latence is lower than 8 minutes but you have no sors or at least a number of sor lower than two then you might be classified as ideopathic hypersonnia and we are outside of the narcopsy In particular patient with ideopathic hypersonia need a pathological MSLT or they need to sleep at least 11 hours in within the 24hour this should be demonstrated by polyonography or even by actigraphy or by sleep log and then the last disorder of this chapter is the so-called insufficient sleep syndrome which is quite frequent frequent nowadays even called a chronic uh chronic sleep deprivation so the if you want to make the dynasty of this disorder you need all of these criteria to be satisfied so that means daytime somnance or sleep attack sleep time should be shorter than than the one expected for age and also these symptoms should be present for most of the day for a period longer than three months usually the end of the sleep the so-called light on in the morning is always determined by an alarm clock in this patient or by the help of another another person or a caregiver otherwise this patient usually sleep longer especially during the the weekend also very important that in this patient you don't need a particular pharmacological treatment but you just need to change the behavior to extend the time window of the bad time actually and this should result in recovery of the symptoms then the other important chapter is the one also called it circadian sleepwake disorders which collect actually six different disorder in the common feature of this disorder is that here in the patient usually is not affected by sleep distraction so the quality of sleep and even the duration of sleep is quite preserved what is really the core of this uh disorder is a kinds of misalignment between the internal clock and external environment so in other in other words this patient if are free to choose their sleep schedule they sleep well but they sleep in a wrong time compared to the social environment so when the sleep phase is shifted forward we used to call this as a delayed sleepwake phase syndrome when the sleep phase is shifted backward we call this patient as advances sleepwake phase uh syndrome then we may have also an irregular sleepwake rhythm disorder which is quite typical of patient affected by neurodeenerative disorder then we have also the so-cal non24hour sleepwake disorder which is typical of blind people and then we have a very important and frequent disorder which is the one associated with the shift to work i mean after of mean seven eight year of nocturnal shift work at least 80 90% of the s the subjects may develop specific sleep disorders and then you have the jet lag syndrome that is a very popular syndrome which is due to the change in time zone that usually should be longer than 3 4 hours but in any case the core feature is in a misalignment between the internal clock and the external environment the instrumental investigation that allow you the diagnosis of circadian sleep disorder is usually the arctigraphy which should be performed for at least a couple of week to uh in order to include at least two weekends in the in their recording so when I talk about internal clock I mean a specific a specific um central uh nucleus in the brain so the internal clock is a small nucleus also called the supraismatic nucleus which is located in the hypothalamus and this nucleus actually is the master clock which drive the occurrence of biological phenomena every 24 hour like the sleepwake cycles so this central communicate to all the organs to let them know that it's time to sleep actually so this is a kinds of synchronizer of the biological systems and the communication between the central and all the other organs is uh performed by melatonin so melatonin is delivered by the pineal gland usually around 8 900 p.m and actually is the hormone that synchronize all the organs and let them know that this is time to sleep the internal clock is also influenced by external environment there are many uh also called in German zber that may influence the internal clock but the most important one is the external light so light is able to suppress completely melatonin and then to influence uh this the internal clock so the general criteria for the wall group of circadian disorder are the following one listed in this line so the patient should be affected by a chronic or recurrent pattern of sleep wake disruption which should be primary due to alternation of the endogenous circadian uh circadium pacemaker which is the suplacmatic nucleus but also or or and associated with a ma misalignment between the internal clock and the external environment this patient they have to show negative consequence of this misalignment so they should present insomnia or daytime sleeping or both together or alternated insomnia or somdance and this should result also in negative consequent concerning occupational or educational activity during the day so this misalignment should provoke a clinical significant distress in the patients so once again a a misalignment between internal external uh internal clock and external environment at least insomnia or sleepiness or both together and also a clinical significant impact of the symptoms in the daily life in one of these dimension mental physical social occupational or education so the melatonin in the blood can be measured usually by those melatonin in the saliva and by measuring the level of melatonin we can also establish which is the chronotype of these patients and uh usually the what we measure in in the in the saliva is the so-called DMO which means dim light melatonin onset that usually in a normal chronoype is between 8 and 1000 p.m if a patient is affected by a delayed phase the DM shift forward uh later than usually midnight if a patient is affected by advanced phase syndrome then the rise in melatonin in the blood or in the saliva usually is anticipated and before 77 p.m so it's a really important melatonin and light as I told you before because light influence a lot circadian uh sleepwake rhythm and that's the reason because we use melatonin and light to treat this patient so every time that you want to shift forward the sleep phase you should give light at the evening like in this case light will suppress melatonin and then your sleep progressively shift forward in case you have a patient affected by delayed phase syndrome usually patient with delay phase syndrome are young while those affected by advanced phase syndrome are usually elderly but let's say that you have a patient affected by delayed phase syndrome if you wanted to shift backward the sleep phase you should give light in the morning and the melatonin a few hours before in the evening so this is a real patient as you can see this is an actigraphic example of a real patient affected by delay phase syndrome so this patient us to fall asleep around here so around 5 between 5 and 6 in the morning and usually wake up in the mid afternoon around 3 4 uh p.m so also if you see the dim light melatonin onset in this patient is around 4:00 in the morning so if you wanted to shift backward these patients you may administer light in the morning and give melatonic uh during the evening times this is what we usually do in our sleep lab and this treatment usually is effective and this is what's happened in this patient after few weeks of treatment as you can see here the sleep phase has been shifted backward and now the sleep pattern is pretty much normal you fall asleep around 11 p.m and wake up around 7 in the morning so the next chapter is the one dedicated to parasomnia this is quite eterogenous chapter that try to put together all abnormal behavior that may occur during sleep without the patient is aware of this strange behavior so the general criteria to distinguish the subtype of parasomnia is mainly the due to the sleep stage in which parasomnia occur so basing on this we may classify uh the chapter of panasonomia in three different subchapters the first one is the one of parasomia occurring only during nonREM sleep even called a non REM related parasomnia the second one collect all disorder occurring only during REM sleep even called a REM related parasomnia and then the last one in which you can classify those parasonia that may occur both during RAM or nonREAM sleep as isolated symptom you have also sleepalking which is not really a disease but is a very common phenomena especially in the young age so the first chapter is the one collecting all possible abnormal behavior occurring during norm sleep especially in the first one in the first or in the second sleep cycle and in particular during slowwave sleep even called it stage N3 so possible norm parasomnia are the following one confusual arousals sleep walking and sleep terrors so the first three actually might be even called disorder of arousal herein the main feature is a sleep state dissociation so the sleep the patient is sleeping during non RAM sleep but he may wake up with a confusion arousal so actually it he doesn't wake up really and but has an arousal and some confusional behavior it may be able to walk around and in this case we talk about sleep walking or they may also present sleep terrors so sleep terror should not be confounded with the nightmares because nightmare uh are actually bad dream which occur specifically during REM sleep here we are talking about sleep terror so in sleep there the patient wake up very abruptly is sweating with tachicardia and a very scared face but is not able to tell you any oneric content because it's not dreaming because is not is not occurring during REM sleep but during norm sleep then you have another disorders which doesn't belong to the arousal disorder which is fillating eating disorder in this case the patient wake up during the night and start together with walking also usually used to eat during the night but during this episode the patient is not really conscious so it might be possible that is he will eat also non-edible edible food and so these kinds of behavior might be even dangerous then we have the subchapter of RAM parasonia which as I told you collect together all disorders abnormal behavior occurring during RAM sleep so during dreaming actually the most popular one is for sure the RAM behavior disorders in this case a patient used to mimic the the dream that they are conducted actually and this occur uh may may occur together with some neurodeenerative disease herein there is a failure of the mechanism that usually physiological paralyze your muscles during during REM sleep then you may have also sleep paralysis sleep paralysis as you know is one of the typical feature of narcolepsy but in this case we are talking about isolated sleep paralysis because they occur without any sleep attack during the day and then you have you may have also nightmares nightmares are also disagreeable or bad dream which usually wake you up in the middle of the REM sleep and in this case you usually do not have any autonomic activation like you have usually in the night terrors which occur in in non-REAM sleep this is a video poly sonographic example of patient affected by rand behavioral disorder this patient of course is not aware of this behavior is simply dreaming but is mimicking is dreaming and also can talk move and sometimes this behavior might be even might be even better for the patient and also for the better part so these are all example of patient as you can see by the video they usually are elderly people and in at least half of the case after few years after six seven years in half of the case they develop some new like disease this patient is laughing actually Every time this patient they enter the RAM sleep you know that we usually do four or five sleep cycle during a single night that means four or five RAM period every time that they enter in this in this period they lost the physiological atonia and so they can move and mimic to dream so other parasomnia I'm not going into the detail just to mention them are the so-called exploding head syndrome which usually occur in the transition between wake and sleep sleepreated hallucination also in this case they are part of the clinical feature of the narcolepsy but also in this case like before sleep paralysis here in they occur isolated without any daytime son so outside of the clinical picture of narcopsy also sleep an enory is very frequent especially in kids and then other parsonia due to medical or drugs or other substance very typical for example is paronial or arousal disorder occur occurring in in elderly subject with zulpidm which is a non-benzoazipene hypnotic So then we have the last chapter of the high CSD tree which collect several disorders which in common they have uh like movement or motor symptoms as the main feature actually I would say that also this chapter is a little bit eterogeneous because put together several different type of of disorder but in most of the case the main feature concern a abnormal movement behavior or motor symptoms the most frequent and important one uh which actually is probably the most frequent sleep disorder is restless lack syndrome then we also have a periodic lily movement disorder nocturnal or sleepreated leg cramps we may have a brains during sleep may have a rhythmic movement disorders or even a new entry in the ISCD3 which is the benign sleep myioon in infancy and also another new entry also in this case this was not previously mentioned in the in the ICST2 which is the proposinal myioon at the sleep onset also here we are not going into details of each of the disorder let me just give you very few insight concerning restless legs and PLM which are the most frequent one another important uh issue is that all of the disorder like proposinal or rhythmic movement disorder lexa cramps brain and so on they may occur both in norm and REM sleep but most of them occur with a particularly high frequency during the transition between wake and sleep so as I told you the most frequent one is the restless lag syndrome that was actually described uh for the first time and during the the the half the mid half of the 20th century and affect more or less three from 3 to 5% of general population which is that means is that is very frequent and is more represented in women compared to men and concerning the diagnosis of restless leg syndrome this should be performed by using the diagnostic criteria that you can see in this slide which are the the the same that are reported in AICSD3 actually these are subjective complaint because we have no objective marker to perform the dus of rest slack syndrome and the patient with RLS should complain about sensory strange symptoms which might be uh let's say characterized by uncomfortable or unpleasant sometime even painful sensation usually located in the legs but also in the arms and these sensitive symptom need to be gone or worse during rest and need to be relieved or improved by movements and also the sensory symptoms has a typical circadian trend with a a worsening or appearance during the evening or night so if patient have these complaints and um satisfy all of these four criteria that means that the patient is affected by rest slack syndrome so patient affected by RLS together with the essential symptoms that I showed you before that are mandatory for the diastolex they also present may present even if even if are not mandatory for the diagnosis some so-called supportive or associated features so almost 90% of these patient also present periodic leave movement most of them they have a wonderful clinical response by using dopamine agonist uh in a high uh in a high percentage of these patients there is a familiar history because probably the genetic background is very important for restless syndrome and most of them also suffer of insomnia this is very important because part of this patient usually come to your attention complaining insomnia and not sensory symptom and you should be able to discriminate between RLS restless legs and primary insomnia so this is a typical example of a patient uh affected by restless legs and you can see as I told you before in 90% of the case this patient present also periodic limb movement during sleep usually more during norm sleep these are unvolutional motor events occur in the legs characterized by a dorsif flexion of the foot of the knee at some time of the hip the typical feature is the periodicity they usually occur every around 20 30 seconds during normal sleep however as is shown by this slide periodic limb movement are very sensitive for the dies of restless legs because as I told you 90% of patient with have periodic leg movement but they are not specific for restless legs because PLM may occur in several other diseases but may occur as you see here also isolated without any other symptoms and in this case are periodic leg movement without a particular uh impairment of sleep as you see below in a recent survi uh Abarubio and the group of Loausana actually found that around 28% of general population present a number of periodic brament per hour of sleep higher than than 50 so PLM may occur inside restless leg syndrome alone or together with other disease when PLM are not associated with RLS but are associated with insomnia or sleepiness and because they may uh disrupt sleep so in this case we can even perform the dus of periodic limb movement disorder without restless leg syndrome that as I show you before is the second disorder listed in this chapter so this is another example of a very frequent motor phenomenon which is the brais which is the thie grling occurring during norm sleep with this is the typical polyonographic pitch feature of brais which is a repetitive masticatory movement producing a strange sound as you can see in this patient thanks so this is the typical sound of a patient affected by Braxims and as you can see by the poly sonography picture if you wanted to record in the detailed phenomena and also to score the Braxims episode you you need to record also the mass muscles bilateral with two bipolar record so I'm not going to detail of the other movement disorder which are quite rare and I end my presentation just showing you the last chapter of the international classification of sleep disorder third edition which collect together a Michelania of so-called borderline disorders which are not cannot be well classified in one of the chapter that I show you before so these are eterogeneous disorder like for example the the first one which is the fatal familia insomnia which is a pryion severe uh a pryion severe very severe disease but likely is very rare the second one which is the sleep related epilepsy which is a chapter in which actually not a chapter but is a is a disorder in which are located the whole possible form of epilepsy occurring during sleep or male during sleep like for example frontal lobe epilepsy or even temporal lobe epilepsy then another one is the sleepreated headache this was even called it before hypnic headache and this typical headache occuring during sleep that wake up the patient almost every night usually the same time of the night then we have also slipperated lingo spasm which is indeed a breathing disorders also called the stringor which is also typical of patient affected by particular neurodeenerative disorder so then we have also sleepreated gastro esophageal reflux which as you know may accommain patient affected by obstructive sleep apnea and then sleepreated myocardia so I finish my overview of sleep disorder try to give you some insight of the main most frequent sleep disorders as I can as I show you these are uh classified in eight different chapters and more or less they are represented by 83 84 different sleep disorders so if you want to go deep in the subjects I told you before it would be good to buy one of these two books that represent the main reference book for sleep specialist so I thank you for your attention and I wish you a good study