B. Catathrenia
Discussion
Our patient’s PSG tracing demonstrated a dysrhythmic respiratory
pattern consisting of a protracted expiratory phase following
inspiration during stage 2 sleep and characterized by bradypnea (Figure
2). During each expiratory segment, the snore microphone captured an
extended groaning vocalization. This respiratory pattern was not
associated with hypoxemia or discernible speech production. The
apnea-hypopnea index (AHI) was 0.0 as the patient did not meet the ≥10
second criteria for scoring an apnea. The patient was initiated on
auto-mode positive airway pressure (PAP), which resulted in resolution
of his groaning and subjective improvement in his sleep quality.
Catathrenia is a rare form of sleep-disordered breathing that
consists of dysrhythmia, bradypnea and deep inspiration followed by a
prolonged expiratory phase and accompanied by vocalizations that are
often described as groaning [1,2]. Catathrenia’s polysomnographic
morphology mimics that of CSA due to absence of air flow on oronasal
thermal sensor coupled with absence of inspiratory effort; however, the
presence of vocalization as reflected in the snore channel argues
against a diagnosis of CSA [3]. While catathrenia is not associated with
hypoxemia [2,3], it may be associated with arousals that can disrupt
the sleep quality and lead to excessive daytime sleepiness [3,4].
Catathrenia may occur in either REM or non-REM (NREM) sleep; however, it
has a strong predilection (81%) for REM sleep [4]. Our patient’s events
were limited to NREM sleep and because they were also not associated
with abnormal motoric activities, RBD was considered to be less likely.
Our patient’s vocalizations were stereotypical in that they were
repetitive and of similar acoustic quality. They also lacked the
disorganized pattern of verbal and non-verbal speech that is
characteristic of somniloquy [5]. Furthermore, our patient’s groans
consistently occurred in the setting of prolonged expiration [2,3],
which supports the diagnosis of catathrenia over somniloquy. Expiratory
snoring, in contrast to the prolonged expiratory groans of catathrenia,
occurs at the peak of expiration and is not associated with bradypnea
[2]. PAP has been shown to be effective in treating catathrenia [4].
References
-
International Classification of Sleep Disorders. Diagnostic and Coding Manual. 2nd American Academy of Sleep Medicine; Westchester IL, USA: 2005.
-
Vetrugno R, Lugaresi E, Ferini-Strambi L, Montagna P. Catathrenia (nocturnal groaning): what is it? Sleep 2008;31(3):308-309.
-
Ramar K, Gay P. Catathrenia: getting the ‘cat’ out of the bag. Sleep Breath 2008;12:291-294.
-
Drakatos P, Higgins S, Duncan I, et al. Catathrenia as a REM predominant disorder of arousal. Sleep Med. 2017;32:222-226.
- Arnulf I, Uguccioni G, Gay F, et al. What does the sleeping brain
say? Syntax and semantics of sleep talking in healthy subjects and in
parasomnia patients. Sleep 2017;40:zsx159.