Table 10.

Respiratory and sleep

Symptom	Treatment approach
Stridor and other respiratory issues	Referral to ENT for laryngoscopy in the first instance to exclude mechanical lesions or other secondary causes of vocal cord dysfunction. Urgent referral for patients reporting laryngospasm. Drug-induced sleep endoscopy or video polysomnography if awake investigations show no cause.50 CPAP therapy reduces stridor symptoms, but with no evidence of increased survival.50 Tracheostomy eliminates stridor symptoms, and may increase survival, but evidence for this is weak.50
Sleep-related syndromes	REM sleep behaviour disorder. Discuss creating a safe-sleep environment for patient and partner. If medication needed for MSA patients, first line is melatonin and second line is clonazepam, owing to potential drowsiness and stridor.34 Obstructive sleep apnoea. If symptoms interfere with quality of life or Epworth scores >9, refer to a sleep specialist. Restless legs syndrome. Check serum iron concentrations in all patients and replace iron as appropriate. For ongoing symptoms treat with gabapentin/pregabalin or consider a dopamine agonist (eg, ropinirole).

CPAP, continuous positive airway pressure; ENT, ear, nose and throat; MSA, multiple system atrophy; REM, rapid eye movement .