Fall/Winter 2016 Sleep Section Bulletin

Fall/Winter 2016 Sleep Section Bulletin

Marilyn Woodard Barclay, RCBS, RRT, CPFT, RPSGT retired
Corvallis, OR
In this issue:

Sleep Paralysis

Marilyn Woodard Barclay, RTBS, RRT, CPFT, RPSGT

Barkoukis’s Therapy in Sleep Medicine defines sleep paralysis (SP) as “the inability to move any voluntary muscles at awakening or when falling asleep while being subjectively awake and conscious.”1 Attacks presumably last up to several minutes. SP is common in narcolepsy. When SP occurs without narcolepsy it is called isolated sleep paralysis.

In a study of more than 36,000 people, 7.6% of the general population, 28.3% of students, and 31.9% of psychiatric patients reported having experienced at least one episode of SP. Racial minorities experienced more events than Caucasians.2 SP has affected humans for millennia. The first known written account was by the Persian scholar Rhazes (865-925 AD), who wrote in Liber Continens, “and Kabus (sleep paralysis) could occur in individuals following alcohol consumption.”3

SP has so impacted peoples’ lives that it has been the topic of art, including a 1781 painting by Henry Fuseli called The Nightmare, an 1894 sculpture by Eugene Thivier called Le Cauchemar (The Nightmare), and a 1915 painting by Fritz Schwimbeck entitled My Dream, My Bad Dream. It is believed that Guy de Maupassant (1851-1893) was describing episodes of SP in the story “The Horla.” SP has also been the subject of cinema, as in the Swedish film Marianne, and The Nightmare, a 2015 documentary that was applauded at the Sundance Film Festival.

Sleep paralysis crosses culture boundaries as well, with cultural expectations impacting hypnogogic and hypnopompic hallucinations associated with SP. These hallucinations generally take the form of a unformed humanoid figure and are often accompanied by feelings of menace.4 The form may be culturally suggestive of an alien being, a ghost, or in Scandinavian folklore, a creature known as “The Hag.” YouTube has an explanation of The Hag by Angry Grandpa. (Warning: this video may offend some people as the language is rather colorful — and Grandpa is in serious need of tobacco cessation!)

It has also been suggested that SP may be involved in perceived alien abduction and some childhood sexual abuse.5


The pathophysiology of sleep paralysis is not fully understood. SP is considered a parasomnia wherein rapid eye movement (REM) and wake stage overlap.6 Some studies have shown that people with SP have shorter REM sleep latencies and shortened non rapid eye movement (NREM) and REM cycles, along with REM fragmentation.7 These observations support the claim that disrupted sleep patterns may influence SP. Students frequently have poor sleep habits, and their high incidence of SP supports the theory that disrupted sleep influences SP.

Another theory holds that cholinergic sleep “on” neural populations are hyper-activated and the serotonegic sleep “off” neural populations are under-activated in SA. This might cause a delay in the signals causing arousal to overcome the signals causing sleep.8

Genetics seems to play a role in SP too. Twin studies have shown that if one twin of a monozygotic pair experiences SP, the other twin is very likely to experience it as well.9

True story

The following is a true event shared by Sleep Section member and past chair, Peter Allen —

MSLT, 50-year-old, 5 foot tall, 300 lb., very cheerful, female patient in lab for BIPAP night w/MSLT. Patient history of treated OSA, but still EDS.

Technologist on duty: P. Allen, RRT-NPS, RPSGT, etc., with new support staff “Kathleen” observing.

Night time study unremarkable using BPAP settings from home; no adjustments were needed.

Note: Study was run continuously all day.

NAP 1: Routine

NAP 2: Routine

NAP 3: Routine

NAP 4: P. Allen “OK, I will be right in.” Patient responded with a reply muffled by a full face mask.

Patient did not seem awake when technologist entered the room. Technologist started speaking while staying arms-reach away from the patient.

Patient’s eyes were open and she was saying something but her lips were not moving.

Technologist repeatedly attempted to rouse patient with voice and gently bouncing the mattress.

Patient was positioned on her left side breathing through her BIPAP, eyes open but not responding.

Technologist gave her a little shake on the elbow; no response.

The technologist returned to the control room where Kathleen was preparing to call a rapid response.

The patient’s vital signs were stable and bilateral EEG indicated REM with no irregularities. Technologist felt a rapid response was not indicated and proceeded to attempt to rouse the patient.

Approximately seven minutes elapsed. The technician removed the mask, bounced the bed, and spoke to the patient with a loud voice.

The patient awakened, sat up, and started to roll off the bed. The technician safely repositioned her.

At that point the light dawned that this was an episode of sleep paralysis. The technologist had more than 25 years of experience but had not previously witnessed it.

The patient told the technologist that she was aware the entire time and her normal pattern was to wake up and then take a few minutes to recover from the sleep paralysis. Although the technologist was aware that the patient had a history of cataplexy, there was no chart note indicating a history of SP.

The patient shared that when she’d been in the hospital she’d had codes called on several occasions. She was aware and got to watch people try and figure out what was going on.

The technologist texted the medical director to see if four NAPs w/REM, one of them w/SP, was enough, but of course the text came back, “Run the 5th NAP, see what happens.”

Fifth NAP, she did it again, but this time the technologist sat next to the bed speaking about how the test was done. After a few minutes she came around, thanked the technologist for understanding, reviewed the conversation, and wrapped up her day at the lab.

Thanks to Peter Allen for sharing this true story. Be sure to ask him to tell it next time you see him, as his version is pretty funny.


Because altered sleep patterns and sleep deprivation appear to influence the frequency of SP, the most effective treatment is good sleep hygiene. The Sleep Paralysis Project suggests the following:

  • Some people find it helpful to disassociate themselves from the attack. Rather than allowing themselves to become immersed in the attack, they adopt a third person stance, observing their body and perceived environment as objectively as possible. Focusing on noticing and analyzing details of the attack can make the experience less overwhelming and immersive.
  • Many people find that if they can avoid sleeping on their back, the chance of an attack is much reduced.
  • Many people find that staying calm is the most important thing to remember during a sleep paralysis attack. It has been suggested that remembering and understanding what is happening and — as much as possible — trying to relax and breathe normally can reduce the length and intensity of an attack.
  • Some people are able to control their breathing or make small noises during an attack and can use this to break it either by alerting a partner, fully waking themselves, holding their breath for a short period, or intentionally breathing with increasing speed and heaviness, making firm noises until the paralysis is broken.
  • Concentrating intensely on moving one small muscle, such as a finger, can lead to a tiny movement which can break the paralysis and end the attack.10

 SP is a common parasomnia that can be quite debilitating for some patients. As providers it is important that we are aware and prepared to respond correctly when patients present with symptoms of SP.


  1. Barkoukis TJ. Therapy in sleep medicine. Philadelphia, PA: Elsevier/Saunders; 2012.
  2. Sharpless B A, Barber JP. Lifetime prevalence rates of sleep paralysis: A systematic review. Sleep Med Rev 2011;15(5):311-315.
  3. Golzari SE, Ghabili K. Alcohol-mediated sleep paralysis: The earliest known description. Sleep Med 2013;14(3):298.
  4. Jalal B, Ramachandran VS. Sleep paralysis and “the bedroom intruder”: The role of the right superior parietal, phantom pain and body image projection. Med Hypotheses 2014;83(6):755-757.
  5. Mcnally RJ. Sleep paralysis, sexual abuse, and space alien abduction. Transcult Psychiatry 2005;42(1):113-122.
  6. Goldstein K. Parasomnias. Dis Mon 2011;57(7):364-388.
  7. Walther B, Schulz H. Recurrent isolated sleep paralysis: polysomnographic and clinical findings. Somnologie 2004;8(2):53-60.
  8. Cheyne J, Rueffer S, Newby-Clark I. Hypnagogic and hypnopompic hallucinations during sleep paralysis: neurological and cultural construction of the night-mare. Conscious Cogn 1999;8(3):319-337.
  9. Sehgal A, Mignot E. Genetics of sleep and sleep disorders. Cell 2011;146(2):194-207.
  10. Treatment. The Sleep Paralysis Project. http://thesleepparalysisproject.org/about-sleep-paralysis/treatment/.

PAP Therapy: Current Understanding of Adherence and Future Opportunities  

Abdullah Alismail, MS, RRT-NPS, RRT-SDS
Loma Linda University, Loma Linda, CA

Positive airway pressure (PAP) adherence has been one of the most discussed topics in the literature of sleep medicine. To achieve a high level of PAP adherence, different modalities and interfaces of PAP delivery have been developed and studied for therapy effectiveness. Examples range all the way from nasal only devices to full masks.

Studies run the gamut

In a recent study that evaluated different nasal masks for CPAP patients, Neuzeret and Morin found that the initial mask selection makes a difference on patient adherence.1 Another study reviewed the reevaluation of patients who were noncompliant with their PAP therapy. Russell et al., reported in their retrospective study that patients who failed to tolerate PAP weren’t referred again to their health care provider or clinician for follow up.2 This finding should be evaluated closely as it can play a major role in increasing the number of OSA patients who might suffer from a disease side effect if not followed up with.

As we all know, several factors affect PAP adherence. In a recent study, researchers in Thailand concluded that adding humidity to CPAP therapy increased adherence.3 Furthermore, in a retrospective study, Krakow et al., investigated the understanding of “adherence” versus “use.”4 From their findings, the authors suggested it might be better to focus on the word “usage” rather than “adherence,” as it offers much greater advantage when interpreting patient benefit.

How insurance companies are interpreting patient usage of PAP therapy also comes into play, as they have a certain percentage the patient must achieve. The authors brought up a great point when they compared PAP usage in OSA patients to therapy usage in a diabetic patient. In other words, what if there was an “adherence” concept with diabetic patients? If they don’t achieve the threshold, they don’t get coverage! This example should make us all think about how we approach our patients as health care professionals. It is all part of an interdisciplinary approach (including insurance companies).

Durable medical equipment (DME) providers play a major role in an interprofessional/interdisciplinary approach as well. Being involved, focusing on the patient, and completing the circuit with the prescribing physician is critical. To my knowledge, there aren’t many studies that have evaluated the interprofessional relationship between the DME provider, prescribing physician, and patient.

Could technology be the answer?

A recent technology that has been getting attention is the micro-CPAP technology by Airing.5 This technology uses the concept of “micro-blowers,” which are incredibly small compared to current PAP devices. While this device has yet to receive FDA approval, the advancement of this and other technology should make us stop and ask, “Could new technology increase PAP adherence?”

Regardless of the technology we use, a high evidence-based approach will likely be needed to increase the level of PAP adherence, or usage, with our patients. This approach might be achieved by conducting high evidence-based studies. Most reported studies are considered low evidence, according to Krakow et al.4 Respiratory therapists who are specializing in the area of sleep medicine should consider leading this avenue of research with their clinical expertise in this area.


  1. Neuzeret PC, Morin L. Impact of different nasal masks on CPAP therapy for obstructive sleep apnea: a randomized comparative trial. Clin Respir J 2016;Jan 18, Epub ahead of print.
  2. Russell JO, Gales J, Bae C, Kominsky A. Referral patterns and positive airway pressure adherence upon diagnosis of obstructive sleep apnea. Otolaryngol Head Neck Surg 2015 Nov;153(5):881-887.
  3. Soudorn C, Muntham D, Reutrakul S, Chirakalwasan N. Effect of heated humidification on CPAP therapy adherence in subjects with obstructive sleep apnea with nasopharyngeal symptoms. Respir Care 2016 Sep;61(9):1151-1159.
  4. Krakow B, Ulibarri VA, Foley-Shea MR, Tidler A, McIver ND. Adherence and subthreshold adherence in sleep apnea subjects receiving positive airway pressure therapy: a retrospective study evaluating differences in adherence versus use. Respir Care 2016 Aug;61(8):1023-32.
  5. The world’s first maskless, hoseless, cordless micro-CPAP device. www.fundairing.com/#first-ever-micro-CPAP

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Next Bulletin Deadline: March 1