Girona Clinic Sleep Unit: Reclaim your rest, improve your life
Contact
- Second floor / MODULE C
- 972 487 092
- unitatson@clinicagirona.cat
- From 09:00 to 21:00.
The Sleep Unit at Clínica Girona, under the direction of Doctors Inés Galofré and Pilar Santacana, is a reference centre in the field of sleep disorders. The Sleep Unit has been operating since 1997. Our main objective is to provide you with good quality sleep.
The Sleep Unit at Clínica Girona has been accredited by the Spanish Sleep Medicine Committee as Multidisciplinary Centre for Sleep Medicine, CMS. It has the backing of the Spanish Sleep Society, SES; la Spanish Society of Neurology, SEN; la Spanish Society of Pulmonology, SEPAR; la Spanish Paediatric Association, AEP; and the Spanish Society of Psychiatry, SEP.
Sleep disturbances are not merely an annoyance; in the long term, they can have significant repercussions on your health, increasing the risk of cardiovascular, metabolic, cognitive, and mood problems. Identifying and treating these disorders is a crucial step to improve their quality of life and general well-being.
We offer a comprehensive assessment for various sleep disturbances, in both adults and adolescents. Our aim is to understand the underlying causes of your sleep problems and Design a personalised and effective treatment plan.
What are we dealing with?
The Sleep Unit at Clínica Girona studies, diagnoses, and treats all sleep disorders. Sleep pathology includes all those alterations that occur during the night. Sleep problems affect approximately el 35% de la població.
Diagnosis and treatment
The space where the tests are conducted is designed to achieve the Optimal conditions of comfort and tranquility, while allowing the night technician to monitor the log's development throughout the night period.
The Sleep Unit consists of two interconnected rooms: the medical office, which serves as the sleep laboratory at night, and the room where the patient sleeps. The Clínica Girona Sleep Unit has three independent rooms, equipped and prepared for overnight recordings, therefore studies can be carried out on three people simultaneously.
is it possible to carry out, in certain cases, the ambulatory registration at the patient's home.
When do we finish the tests?
The Sleep Unit at Clínica Girona offers a diagnostic and treatment service for all sleep disorders. With this objective, the following tests are carried out:
- Visit from the sleep disorder specialist doctor.
- Overnight polysomnography.
- Nocturnal polysomnography with CPAP device.
- S.L.T. (Speech Lateralisation Test).
- Split sleep.
- Outpatient register.
How do we work?
The Sleep Unit at Clínica Girona offers a diagnostic and treatment service for all sleep disorders. The operation is as follows:
- The patient with a sleep disorder is referred to our unit by their primary care physician, specialist (ENT, pulmonologist, neurologist...), or attends of their own accord.
- A sleep pathology specialist conducts the initial consultation, based on which it is assessed whether the patient is a candidate for a sleep study, polysomnography (PSG), or is scheduled for successive appointments.
- If the answer is yes, the patient is informed about the type of test to be performed and a night is scheduled for them to sleep at the Sleep Unit.
- The patient is admitted to the Sleep Unit. The PSG lasts approximately 7–8 hours and is monitored throughout the night by a technician. Sleep studies are performed from Monday to Sunday.
- Sleep recordings, or PSG, are analysed and interpreted by sleep specialists, who will issue a diagnosis, based on which treatment will commence.
- The time between the completion of the PSG and the delivery of the results is approximately 15 days.
- In patients starting CPAP treatment, an annual follow-up check is recommended. This check allows us to assess whether the patient is adapting well to the CPAP, if they are using the device, and if the CPAP pressure remains optimal.
Proof that these are carried out
Overnight polysomnography
A polysomnography night register follows a standard protocol:
- The patient arrives at the Sleep Unit approximately one hour before going to sleep, between 10 pm and 11 pm.
- The night technician gives them questionnaires, attaches electrodes and sensors, following the Rechtschaffen and Kales criteria. These criteria allow for the recording of both wakefulness and the different stages of sleep. A Full respiratory examination and a pulse oximetry.
- The recording is made uninterruptedly for a minimum of 7 hours of sleep.
- The PSG can be performed with admission to the Clinic (optimal condition), being supervised by night technical staff, or it can be performed at home.
In a Polysomnography the following parameters are registered simultaneously:
- Electroencephalogram Brain activity is studied using surface electrodes placed in both Rolandic and occipital areas in a monopolar derivation. It allows for the assessment of different sleep states, as well as the structure and quality of sleep.
- Electrooculogram Eye movements are explored using 2 electrodes placed at the upper corner of the left eye and the lower corner of the right eye. It helps to identify the REM sleep phase.
- Chin EMG Electromyographic activity is obtained by applying contact electrodes to the submental region. It allows for the assessment of muscle tone in different sleep states.
- Periodic leg movements register: It is obtained using a sensor placed at heel level. It is necessary to diagnose periodic limb movement disorder (PLMD) and restless legs syndrome (RLS).
- Electrocardiogram A recording is made using disposable adhesive ECG electrodes. It allows the assessment of heart rhythm abnormalities, sometimes caused by apnoeas.
- Hoarse microphone Miniature microphone placed at the level of the Adam's apple that detects the vibrations produced by snoring.
- Position sensor Record the changes in position that occurred during the night.
- Air-nasal-buccal flow Respiratory flow is achieved using a naso-buccal thermo-coupler located in the moustache. It allows for the assessment of apnoeas and their obstructive nature, as well as respiratory rate.
- Thoracic and abdominal breathing movements Respiratory effort is recorded using mercury-strain gauge bands fitted as a thoracic and abdominal belt with Velcro. It allows obstructive apneas to be distinguished from central apneas.
- Pulse oximetry Photometric sensor that is placed on a fingertip and measures blood oxygen saturation and pulse.
The data obtained is interpreted by the medical staff following the criteria of Manual of standardised terminology, techniques and scoring system for sleep stages in human subjects, The Righteous & Kale. The 7-8 hours of registration yield the following information:
- Study and evaluation of the EEG: Structure and percentage of different sleep states, histogram and statistics.
- Respiratory study: name, type and duration of respiratory pauses, Apnea-Hypopnea Index (AHI) calculation.
- Nocturnal oxygenation: number of desaturations, mean SaO2, minimum SaO2, relationship with respiratory flow alterations.
- Heart rhythm disturbances.
- Frequency, intensity and postural character of snoring.
- Study of nocturnal myoclonus of the lower extremities to assess the existence of RLS.
Nocturnal polysomnography with CPAP device
In the event that the patient is diagnosed with Sleep Apnoea-Hypopnoea Syndrome (SAHOS), a second night is scheduled to carry out a polysomnographic recording.
In this polysomnography study, the same parameters are recorded as in a conventional recording, incorporating a CPAP machine Continuous Positive Airway Pressure.
Throughout the night, the sleep technician regulates the pressure needed to eliminate snoring and apnoeas. The optimal pressure will be that which, without causing awakenings in the patient, manages to normalise breathing and oxygenation. improving the quality and structure of sleep.
The definitive diagnosis is made by the sleep specialist doctor once they have interpreted the polysomnography recording.
MSLT Multiple Sleep Latency Test
The M.S.L.T. is a test that allows for the assessment of daytime sleepiness. It is carried out if pathological hypersomnolence (narcolepsy, idiopathic hypersomnia, etc.) not related to OSA is suspected.
The night before performing the MSLT, the patient is admitted to the Sleep Unit, where a polysomnography is carried out. The following morning the patient is studied every 2 hours following a standard recording protocol.
The technician performs a total of 5 consecutive tests, starting the first test 2 hours after the patient wakes up. Every 2 hours the patient goes to bed and tries to sleep. A simultaneous EEG, EOG, and EMG recording is performed, which will last a maximum of 20 minutes from the onset of sleep.
Sleep latency and the presence or absence of REM sleep are valued. For the proper functioning of the test, silence and quiet conditions are required, which is why it is carried out in weekend.
Split - night
This is a test in which conventional polysomnography is performed for the first half of the night, followed by CPAP titration polysomnography for the second half. This way, the diagnosis and titration of CPAP pressure are performed in a single sleep study. It is indicated in severe patients where the clinical presentation is highly suggestive of Sleep Apnoea Syndrome.
Outpatient register
A nocturnal polysomnography is carried out at the patient's home. Indicated for those patients who have significant difficulty falling asleep at the Unit. The main advantage is that it is carried out at the patient's home. As a disadvantage, it should be noted that it is not a test supervised by the sleep technician.
More frequent sleep disturbances
Snore
Approximately un 45 % de les persones adultes ronca ocasionalment i un 25% són roncadores habituals. Snoring is more common in men and overweight individuals, and it worsens with age. Snoring is the noise caused by an obstruction of airflow in the upper airway (UAW), creating air turbulence that causes the soft palate to vibrate.
People who snore have at least one of the following problems:
- Reduced muscle tone.
- Pharyngeal tissue, tonsils, adenoids enlargement.
- An excessive length of the soft palate and uvula.
- Nasal obstruction.
Snoring is a significant social problem. The snorer is criticised for disturbing those who live with them. Medication, it becomes a problem when it progresses to SAHOS (Sleep Apnoea Syndrome). It is important to note that bronchopathy by itself is not a disease, but when accompanied by daytime sleepiness and other symptoms common in SAHOS, one should attend a Sleep Unit.
Sleep Apnoea Syndrome (SAS)
Sleep Apnoea-Hypopnoea Syndrome (SAHS) affects between 2 and 15% of the general population. Its incidence is three times greater in men than in women. A patient has OSAHS when they present 10 or more apnoeas or hypopnoeas per hour of his.
Apnoeas occur due to the total or partial (hypopnoea) collapse of the upper airway, caused by anatomical and/or functional abnormalities of the oropharynx. Its duration must be greater than or equal to 10 seconds.
The appearance of repeated apnoeas during sleep prevents entry into deep sleep, which is necessary for restful sleep, leading to daytime sleepiness, difficulty concentrating, and fatigue during the day as the main symptoms.
Principal Symptoms of OSAHS:
SAHS Nocturnes:
- Rumbling of high intensity, interrupted by respiratory silences, apnoea.
- Cessation of breathing during sleep.
- Frequent awakenings during the night.
- Nocturia.
- Decreased libido.
- Sweating.
- Gastro-oesophageal reflux.
SAHS Diurnal
- Significant daytime sleepiness.
- Feeling of unrestful sleep.
- Morning headache.
- Dry mouth upon waking.
- Decreased concentration ability.
- Memory loss.
- Difficult-to-control high blood pressure.
- Changes in behaviour: irritability, low mood.
Consequences of SAHS:
Adults with OSA have a greatest risk of suffering heart disease, with myocardial infarction, arrhythmias, strokes and hypertension. They also have a higher risk of workplace and traffic accidents caused by daytime sleepiness due to unrefreshing sleep.
How is OSA diagnosed?
To diagnose OSAHS, the patient must be seen by a specialist in a Sleep Unit, where they will undergo polysomnography. PSG is the only way to reach a definitive diagnosis.
Com es tracta un pacient amb SAHS?
- In all cases, good is recommended Sleep hygieneControl and weight loss and abstinence from alcohol and sedatives and central nervous system depressants.
- If the OSAHS is mild, these measures may be sufficient.
- CPAP (Continuous Positive Airway Pressure): This is the treatment of choice for moderate to severe OSA. It requires annual control and monitoring. It is a mechanism that works by sending ambient air at a constant pressure that prevents airway obstruction through a nasal mask. The pressure must be determined by overnight polysomnography.
- Surgery: Pharyngeal surgery, uvulopalatopharyngoplasty or UPPP consists of excising, in cases of hypertrophy, part of the soft palate and uvula, thereby widening the airway. This technique is indicated for mild to moderate snorers and those with OSAHS.
- Mandibular advancement devices.
Insomnia
Insomnia is the most frequent sleep problem. Each year between 20 and 40% of adults complain of difficulty sleeping, sent un problema important per a un 17% d’ells. És més freqüent entre dones i augmenta amb l’edat.
Main symptoms:
Insomnia is not a specific illness, but rather a symptom attributable to a large number of pathological processes. The patient complains of fatigue, daytime sleepiness, irritability, and difficulty concentrating. A detailed clinical history will determine the cause to initiate treatment.
Sleep hygiene standards
- Regular sleeping hours.
- Not staying in bed without sleeping.
- Avoid napping.
- To expose yourself to sunlight upon waking.
- Exercise in the morning.
- Have a warm bath before going to sleep.
- Avoid carbohydrates at night.
- Avoid alcohol at the end of the day.
- Avoid stimulating drinks or caffeine from four in the afternoon.
- Comfortable ambience.
- Learn to relax.
Sleep hygiene standards are a useful tool in the treatment of insomnia and improve its quality.
Types of insomnia
Insomnia can be classified according to the time of its occurrence during the night:
- Sleep-onset insomnia: Difficulty falling asleep for more than 30 minutes.
- Maintenance insomnia: Night-time awakenings with difficulty returning to sleep.
- Early-onset insomnia: Premature morning awakening.
Depending on the duration:
- Transient insomnia: Duration less than 1 week.
- Short-term insomnia: Lasting between 1-3 weeks.
- Chronic insomnia: Duration over 4 weeks.
- Childhood insomnia due to incorrect habits
Childhood insomnia due to incorrect habits
Sleep is the activity in which a child invests the most time. There is a close relationship between nighttime problems and daytime behavioural disturbances. A child's sleep disturbances cause family stress and school dysfunction.
It is the most frequent sleep disorder in childhood. It can affect children between 6 months and 5 years old. They are physically and mentally normal children. It is characterised by difficulty falling asleep and frequent awakenings during the night (3-15), with difficulty returning to sleep.
The drugs have little effect. There is poor habituation to sleep: the child has not learned to fall asleep independently. They have created incorrect sleep associations (arms, bottle, parents' bed…). The child has a very alert disposition and is very aware of their surroundings.
As age increases, demands grow and the problem worsens. Sleep structure disorders occur: it is superficial and fragmented, hypervigilance. Thehours of sleep is insufficient and s’Observe changes in the child's character, as they are more irritable, restless and show increased dependence on parents.
Childhood insomnia destabilises marital harmony. The child’s bedtime is delayed without success. It creates a feeling of paternal guilt and insecurity regarding the problem and, in extreme cases, leads to paternal rejection of the child.
The course of action to take is as follows:
- Establish regular bedtimes, as well as games and routines before going to sleep.
- Leave the child to fall asleep on their own; it is important that the conditions at the start of sleep are maintained throughout the night.
- A cuddly toy will help the child fall asleep.
- It's important to respect the light/dark cycle and create optimal conditions for sleep.
Wakefulness-Sleep Cycle Disorders
Delayed sleep phase syndrome
It is characterised by chronically maintaining a sleep schedule delayed in relation to the desired one. Specifically, it is a difficulty in falling asleep and waking up at conventional times, with sleep onset occurring between one and six in the morning. Despite the difficulties in falling asleep, these patients have a normal sleep duration and quality. They maintain a stable sleep schedule within 24 hours, but with shifted timings.
Delayed Sleep Phase Syndrome (DSPS) is the most common circadian rhythm disorder and typically manifests in puberty. Without treatment, the progression is chronic, and patients seek medical consultation when the phase delay interferes with their academic, family, social, or professional life.
Main symptoms:
- Difficulty falling asleep and waking up in the morning.
- Daytime somnolence and tiredness during the first half of the day.
- During the holidays they sleep without any problem and do not experience daytime sleepiness.
Hypernymal or free-running syndrome
It is characterised by a lack of synchronisation of the endogenous circadian rhythm with external time cues. These patients present with a wake/sleep cycle exceeding 24 hours. They show a daily delay of one to two hours in bedtime and wake-up time per day, with sleep onset occurring at a variable time as days progress and periodic deterioration of wakefulness.
Representa un 12% dels trastorns del ritme biològic. En les persones amb percepció lluminosa normal és poc freqüent, la seva freqüència és del 50% entre els invidents.
Main symptoms:
- Inability to maintain a regular sleep schedule.
- Periods of insomnia alternating with daytime sleepiness, with periods of no problems.
Delayed sleep phase syndrome
It is characterised by chronically maintaining a sleep schedule that is delayed in relation to what is desired, difficulty falling asleep and waking up at conventional times, with sleep onset occurring between 1 am and 6 am. Despite the difficulties in falling asleep, these patients experience sleep of normal duration and quality. They maintain a stable sleep schedule within a 24-hour period, but with shifted timings.
Delayed Sleep Phase Syndrome (DSPS) is the most common circadian rhythm disorder and typically manifests in puberty. Without treatment, the progression is chronic, and patients seek medical consultation when the phase delay interferes with their academic, family, social, or professional life.
Main symptoms:
- Difficulty falling asleep and waking up in the morning.
- Daytime somnolence and tiredness during the first half of the day.
- During the holidays they sleep without any problem and do not experience daytime sleepiness.
Hypernymal or free-running syndrome
It is characterised by a lack of synchronisation of the endogenous circadian rhythm with external time cues. These patients present with a sleep-wake cycle exceeding 24 hours. They exhibit a daily delay of one to two hours in bedtime and wake-up time per day, with sleep onset occurring at varying times as days progress and periodic deterioration of wakefulness.
Representa un 12% dels trastorns del ritme biològic. En les persones amb percepció lluminosa normal és poc freqüent, mentre la seva freqüència és del 50% entre els invidents.
Main symptoms:
- Inability to maintain a regular sleep schedule.
- Periods of insomnia with daytime sleepiness, alternating with periods without any problems.
Hypersomnias: Narcolepsy and Idiopathic Hypersomnia
Sleep disorders characterised by excessive daytime sleepiness.
Narcolepsy
It is a syndrome of excessive daytime sleepiness associated with abnormal manifestations of REM sleep. It is a little-studied disease. Its prevalence varies between 0.0002%–0.16%. The age of onset is in 60%% of cases between 15 and 20 years old, although its diagnosis is usually much later.
Main symptoms:
The main symptoms of narcolepsy are:
- Daytime somnolence: In the form of uncontrollable sleep attacks, more than one per day and of variable duration. The somnolence reduces activity and concentration.
- Cataplexy: Sudden loss of muscle tone without loss of consciousness, triggered by an emotional stimulus (laughter, crying, or anger). It can be total or partial.
- Hypnagogic hallucinations: Experiences perceived as dreams that occur at the onset of sleep. Primarily visual and auditory.
- Sleep paralysis: Brief episodes in which the individual is unable to move at the onset of sleep or upon waking. Very unpleasant experience.
The sleep of patients with narcolepsy is very different from that of normal patients. REM sleep appears shortly after the subject has fallen asleep. Narcoleptics show less deep sleep and more awakenings during the night, as well as an increase in superficial sleep, which produces the sensation of a fragmented night.
A family predisposition to narcolepsy has been demonstrated, along with the incidence of between 98% and 100% of HLA-DR2 HLA-DQwl antigens, indicating the presence of a specific genetic basis.
Com es diagnostica la narcolèpsia?
The sleep specialist conducts an interview with the subject and relatives. The sleep diary is a good tool. It is necessary to perform a nocturnal polysomnography (PSG) to rule out another sleep disorder, followed by a Multiple Sleep Latency Test and immuno-genetic studies.
Idiopathic hypersomnia
It begins in adolescence. It has a chronic evolution and is familial in nature. Night-time sleep is prolonged but not fragmented. The subject experiences significant difficulty waking in the morning and a feeling of sleep drunkenness. One or more long-duration sleep episodes occur during the day, but they are not restorative.
Kleine Levine Syndrome
It is a rare syndrome. It begins in adolescence, being more common in men. Its onset can be associated with a flu infection. There is no family history. Kleine-Levin syndrome is a recurrent hypersomnia, meaning it occurs in episodes, with intervals of more than a month and less than a year.
Main symptoms:
- Sleep attacks.
- Increase total sleep time and decrease REM sleep latency.
- Parasomnias, intense dream activity.
- Conduct disorder.
- Sexual disinhibition.
- Duration: Episodes between 12 hours and 4 weeks.
Other hypersomnias:
Poor sleep/wake cycle hygiene. Chronic reliance on medication and alcohol.
Hypersomnia associated with medical conditions
- Endocrines: diabetes, hypothyroidism.
- Neurological: Brain tumours.
- Infectious: epidemic encephalitis, trypanosomiasis…
- Psychiatric: Depression.
Parasomnias
Restless legs syndrome
It is a chronic neurological disorder characterised by unpleasant sensations in the legs and an uncontrollable urge to move them when at rest. It affects approximately 5-10% of the general population and over 80% goes undiagnosed. És més freqüent en les dones i la seva prevalença augmenta amb l’edat. Existeix una història familiar positiva en més del 50% dels pacients afectats.
Main symptoms:
- An unpleasant sensation in the legs, often difficult to describe (nerves, cramps, burning, ants crawling, itching, pain...).
- A need to move the legs, almost always during periods of rest.
- The symptoms worsen in the afternoon and at night.
- Difficulty falling asleep and frequent awakenings during the night. 90 % of patients suffer from insomnia.
- It is often associated with Periodic Limb Movement Disorder during sleep.
- Daytime sleepiness and tiredness.
