A. Consider Causes Other Than COPD for Insomnia - For classification of insomnia, refer to International Classification of Sleep Disorders. Polysomnography is rarely indicated.

Institute sleep hygiene measures (Zarcone 1994):

1. Homeostatic Drive for Sleep

a. Avoid naps.

b. Too much time in bed can decrease quality on subsequent night.

c. Get regular exercise each day. It is best to finish exercise at least 6 hours before bedtime.

d. Take a hot bath for 30 minutes within 2 hours before bedtime. A hot drink may help you relax as well as warm you.



2. Circadian Factors
 
a. Keep a regular time out-of-bed 7 days a week.

b. Do not expose yourself to bright light if you have to get up at night.

c. Get at least one-half hour of sunlight within 30 minutes of your out-of-bed time.



3. Drug Effects
 
a. Cigarette smoking should be stopped.

b. Avoid caffeine entirely for a 4-week trial period; limit caffeine use to no more than three cups no later than 10 a.m. if caffeine cannot be stopped.

c. Avoid alcoholic beverages before bedtime.



4. Arousal in Sleep Setting
 
a. Keep clock face turned away, and do not find out what time it is when you wake up at night.

b. Avoid strenuous exercise after 6 p.m.

c. Do not eat or drink heavily for 3 hours before bedtime. A light bedtime snack may help.

d. If you have trouble with regurgitation, be especially careful to avoid heavy meals and spices in the evening. Do not retire too hungry or too full. Head of bed may need to be raised.

e. Keep your room dark, quiet, well ventilated, and at a comfortable temperature throughout the night. Ear plugs and eye shades are OK.

f. Use a nonstressful bedtime ritual.

g. Set aside a worry time, other than bedtime.

h. Do not try too hard to sleep; instead, concentrate on the pleasant feeling of relaxation.

i. Use stress management in the daytime.

j. Avoid unfamiliar sleep environments.

k. Be sure mattress is not too soft or too firm, pillow is right height and firmness.

l. An occasional sleeping pill is probably acceptable.

m. Use bedroom only for sleep or sex; do not work or do other activities that lead to prolonged arousal.

Hypnotics should be used after other measures have been implemented (see Annotation A) and used sparingly with close attention to the possibility of abuse and untoward side effects. If general measures and occasional hypnotics are unsuccessful, referral to a psychiatrist or sleep specialist is indicated. If used, hypnotics and sedatives may have an adverse effect in patients with FEV₁ < 50 percent. Zolpidem has the most data indicating safety on multiple dose use in patients with FEV₁ < 50 percent and should be first choice. Triazolam has no obvious effect on respiration when used in single doses in patients with SaO₂ > 90 percent supine and may be considered a second choice to zolpidem in such patients. If patient has supine SaO₂ < 90 percent, zolpidem is clearly the first choice; triazolam and other benzodiazepines must be used with extreme caution. If patient snores habitually, all hypnotics must be used with great caution as they may induce or exaggerate sleep apnea and hypopnea even in asymptomatic patients.

C. Follow-Up With Routine Care - Refer back to main algorithm as necessary. Refer to respiratory specialist if symptoms do not resolve as expected, if there are complications limiting therapy or if recommendations do not readily apply to client.

D. If SaO₂ Supine is > 90 Percent, Use Benzodiazepines Cautiously - If decision is made to use hypnotic in COPD patients with FEV₁ 50 percent, benzodiazepines are first choice in patients with SaO₂ 90 percent. Otherwise zolpidem should be used.

As stated in Annotation B, except benzodiazepines hypnotics are not usually affected by presence of COPD of this degree unless there is supine SaO₂ < 90 percent and can be used as first choice in patients with FEV₁ > 50 percent. Zolpidem is first choice if SaO₂ supine < 90 percent.