Hypersomnia and Periodic Respiration–Presentation of Two Cases* and Comment on the Physio-Pathogenesis of the Pickwickian Syndrome

Two patients with prominent hypersomnia during daytime and frequent, periodic apnea during sleep are reported. The 1st case was without obesity or hypercapnia during waking period. She had ankylosis of the jaw joints. The 2nd case was a typical of the Pickwickian syndrome with marked obesity and hypercapnia in the awake state. Both of the patients showed frequent, periodic apnea lasting 10–48 sec only during sleep. Duration of the apneic period was longest in the paradoxical phase of sleep with rapid eye movements. Return of respiration at the end of the apnea was always just preceded by arousal response in the EEG: K-complex with or without appearance of alpha rhythm. Thus, their nocturnal sleep was constantly fragmented due to the periodic apnea. Stable, deep sleep with high voltage slow waves was much reduced in the 1st case and it was completely absent in the 2nd case. The periodic apnea in the two patients was of obstructive type. Respiratory movement of the thorax accompanied by EMG activity in the inter-costal muscles persisted even during the apneic period. It was confirmed in the 1st case by radiological examination performed during sleep with the use of a television that the base of her tongue dropped down back into the hypopharynx obstructing this completely during apneic period. Tracheotomy and insertion of tracheal canule resulted disappearance of the periodic apnea during sleep and of hypersomnia during daytime. It is concluded from the above findings that hypersomnia in our patients is due to, and is compensating for the sleep disturbance in the night. Physio-pathogenesis of the Pickwickian syndrome are briefly discussed in the light of the present findings with reference to previous works.