Introduction: Sleep-disordered breathing (SDB) in patients with chronic respiratory failure (CRF) due to pulmonary disease remains an underrated and undiagnosed entity. Materials and methods: A prospective descriptive study in patients with CRF with history suggestive of SDB was carried out using polysomnography (PSG) over a period of 12 months. Results: Thirty patients with the Epworth sleepiness scale greater than 11 and CRF underwent PSG. Ninety percent patients had obstructive sleep apnea (OSA) syndrome using the respiratory disturbance index (RDI) of 5 as cut-off. Mean RDI was 13.4 and mean apnea-hypopnea Index (AHI) was 10.5. Besides, the patients had a poor sleep quality; sleep efficiency was 69.38 ± 14.44%, sleep onset time was 30.35 ± 24.31 minutes. Wake after sleep onset (WASO) was 107.25 ± 57.71 minutes. Rapid-eye-movement (REM) sleep latency was 126.08 ± 66.61 minutes. N1 was 23.75 ± 14.89, N2 was 45.22 ± 12.69, N3 was 20.02 ± 12.57, and REM sleep period was 11.33 ± 8 minutes. The body mass index (BMI) and Epworth sleepiness score (ESS) had a significant correlation with AHI with p value < 0.005. Conclusion: Sleep-disordered breathing is an important comorbidity in patients with CRF leading to increased morbidity and mortality. A high of suspicion must be kept for the same especially in patients with higher BMI and high ESS. Such patients have a poor quality of sleep besides increased incidence of sleep apnea.

We are reporting the third largest Indian narcolepsy case series. Among 250 consecutive patients referred to our sleep center for polysomnography (PSG), 3 of them were diagnosed to have narcolepsy with cataplexy (NC). They had history of excessive daytime sleepiness (EDS) and sudden loss of muscle power leading to fall without alteration in consciousness. Their polysomnographies did not have obstructive sleep apnea (OSA). All of them had multiple sleep latency test (MSLT) showing sleep latency of less than 8 minutes and two sleep-onset rapid eye movement period (SOREMP). Since narcolepsy patients commonly have restless leg syndrome (RLS), RLS was studied in detail in them. All our patients with NC had RLS. The patients from Western countries with NC and RLS have normal or high iron level. But the serum iron level was low in two patients and normal in one patient. The management of RLS secondary to iron deficiency is thus an important component of NC in Indian patients. Key messages: • Clinical history is very important for suspicion of narcolepsy. • Multiple sleep latency test is diagnostic of narcolepsy in the current clinical context. • Restless leg syndrome is diagnosed on history alone. Since it occurs commonly with narcolepsy, history of RLS in important in narcolepsy patients. • Iron deficiency can also be causative factor for RLS in narcolepsy in Indian patients though it is reported to be due to narcolepsy itself in Western counterparts. • Modafinil alone is not useful in the treatment of narcolepsy; a tailor-made pharmacological and supportive non-pharmacological approach is essential.

Obesity hypoventilation syndrome (OHS) is a syndrome characterized by a constellation of obesity [body mass index (BMI) ≥ 30 kg/m²], daytime hypercapnia (arterial carbon dioxide tension ≥ 45 mm Hg), and sleep-disordered breathing (SDB), provided other conditions leading to alveolar hypoventilation have been objectively ruled out. Delayed diagnosis can precipitate significant cardiorespiratory morbidity in the form of pulmonary hypertension, heart failure, and coronary disease. Sleep fragmentation, oxidative stress, and obesity-related deconditioning are the predominant mechanisms of the clinical predicament and the poor quality of life. The diagnosis requires a due awareness about its presence and a prone index of suspicion in the suitable clinical context. The diagnosis is conclusively established on basis of a sleep study and arterial blood gases (ABGs). Management requires a holistic approach focusing on weight reduction, lifestyle modification, treatment of comorbidities, and control of the SDB by means of continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) and pulmonary rehabilitation. Opportune therapy facilitates an optimistic prognosis and improves the quality of life.

Background: Sleep disturbances in bipolar disorder exert negative impact. Here we report a case of bipolar disorder, who had manic relapse due to decreased sleep because of waking up early during religious festivities. Case description: Mrs S is a 50-year-old married Muslim lady was diagnosed to have bipolar affective disorder (BPAD) for the past 25 years. Till now, she had about 8 to 10 manic episodes. From December 2017, she has remained euthymic, being compliant on tab. lithium 1200 μg/day (serum lithium level: 0.79 mmol/L). During her scheduled follow-up (May 25, 2019), she reported decreased need for sleep, grandiose ideas, increased psychomotor activity and energy from the start of Ramadan, about 20 days ago. During these 20 days, she woke up about 2 hours earlier to prepare food for family. She was compliant on lithium. Her Young Mania Rating Scale (YMRS) score on the first day was 19, showing manic levels and the Pittsburgh Sleep Quality Index (PSQI) was 12, showing poor sleep. Tab. olanzapine 30 μg/day was added to lithium 1200 μg/day. She showed gradual improvement in quality and quantity of sleep and was discharged after 2 weeks (June 09, 2019), with tab. lithium 1200 μg/day and tab. olanzapine 10 μg/day. The patient and her family were psychoeducated regarding the importance of sleep and compliance. During the next follow-up after 5 days, she showed improvements. Conclusion: Sleep architecture changes in rapid eye movement (REM) sleep like shortened latency and increased density may contribute toward hypomanic/manic symptoms. In bipolar disorder, sleep disturbances even on one previous night may subsequently change the mood toward mania, in spite of having adequate serum lithium levels. Clinical significance: Psychiatrists need to be vigilant regarding this and provide psychoeducation on sleep hygiene especially with sleep deprivation.