© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 161 (5): ITC5-1. * For Best Viewing:...

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in the clinic

Obstructive sleep apnea


All adults who answer yes to either question:

Are they dissatisfied with their sleep?

Do they have daytime sleepiness?

Patients with risk factors

Obesity, especially BMI >35 kg/m2

Family history of obstructive sleep apnea

Retrognathia

Treatment-resistant hypertension

CHF, atrial fibrillation, stroke

Type 2 diabetes

Patients with high-risk driving occupations or daytime sleepiness + motor vehicle crash

Who should be screened for OSA?


What are the screening tools?

Berlin questionnaire (primary care setting)

10 items

Snoring severity, significance of daytime sleepiness, witnessed apnea, obesity, hypertension

STOP-BANG screening test (preoperative setting)

8 items

STOP: Snoring, Tired, Observed apnea, high blood Pressure history

BANG: elevated BMI, Age > 50, increased Neck circumference, Gender male

Neither tool precludes formal sleep testing


Can OSA be prevented?

Weight loss can reduce severity

May also achieve remission


CLINICAL BOTTOM LINE: Screening and Prevention... Ask all adults about sleep problems or daytime sleepiness If response is positive: perform OSA screening

Take further clinical history Use validated questionnaire

Screen is also warranted for all patients with: Significant obesity CVD History of drowsiness while driving


What symptoms should prompt consideration of OSA?

Witnessed episodes of apnea

Loud, frequent, bothersome snoring

Choking/gasping during sleep

Excessive daytime sleepiness

Drowsy driving

Unrefreshing sleep, sleep fragmentation

Insomnia

Nocturia

Morning headaches

Decreased concentration, memory loss

Decreased libido


In the absence of symptoms, what other diseases should prompt evaluation?

Morbid obesity

If patient scheduled for bariatric surgery

Hypertension

If refractory to medical therapy


What other conditions should be considered?

Chronic sleep deprivation disorder (shift-work disorder)

Circadian rhythm disorder

Depression and anxiety

Hypothyroidism

Obesity hypoventilation syndrome

Central sleep apnea syndrome

Congestive heart failure (Cheyne-Stokes respiration)

Opiate-induced central sleep apnea


What physical exam findings are important?

Respiratory, CV, and neurologic systems

Presence and degree of obesity

Signs of upper airway narrowing

Neck >16” women, >17” men

Mallampati score of 3 or 4

Macroglossia, tonsillar hypertrophy

Enlarged or elongated uvula, high/arched palate

Nasal obstruction

Retrognathia


What type of sleep study should be ordered?

Polysomnography in the sleep laboratory

Standard method for diagnosis and determining severity

Assesses other sleep disorders

Recommended: “full-night” sleep study

Alternative: “Split-night” study

Initial diagnostic recording

Then positive airway pressure titration the same night


What is the role of in-home sleep studies?

Used for uncomplicated cases

Clinical probability high + no cardiopulmonary disease

Validity + utility unclear with serious comorbidities

Convenient and lower cost

May underestimate severity

If test is negative: in-lab sleep study

Definitively exclude diagnosis


What variables are reported on a sleep study report, and what do they mean?

Apnea-hypopnea index (AHI)

Episodes of apnea and hypopnea per hour of sleep

Mild OSA: AHI ≥5 and <15/h

Moderate OSA: AHI ≥15 and <30

Severe OSA: AHI ≥30

Apnea: airflow cessation ≥10 sec

Hypopnea: airflow reduction ≥10 sec plus 3% or 4% OxyHb desaturation or arousal from sleep

Other measures of sleep-disordered breathing, total sleep time, measures of sleep quality

Epileptiform EEG, limb movement, nocturnal arrhythmia


Do patients need to be seen by a sleep specialist before a sleep study is ordered?

Sleep specialist evaluation recommended

Complex sleep-disordered breathing processes suspected

Other sleep disorder suspected

To ensure proper diagnostic tests ordered

Prior evaluation not needed in other cases

But clinician should discuss options with patient first

Explain OSA therapy and why it may be initiated


CLINICAL BOTTOM LINE: Diagnosis...

Evaluate patients with symptoms that suggest OSA Loud snoring, nocturnal choking or gasping Significant daytime sleepiness, history drowsy driving Witnessed episodes of apnea Evaluate patients with no symptoms if

Undergoing bariatric surgery Have treatment-resistant hypertension

In-lab sleep testing: gold standard In-home sleep testing: if high clinical suspicion for OSA and

no significant cardiopulmonary comorbid conditions


Which patients with OSA require treatment?

Counsel overweight patients about weight loss

Treat any nasal congestion

Advise alcohol avoidance close to bedtime

Offer trial of therapy (CPAP) if patient has

Daytime sleepiness or frequent nocturnal awakenings

Recent accident or near-miss attributable to sleepiness

Controversial: whether to treat asymptomatic patients with mild or moderate OSA


What is the role of weight loss and exercise?

Helps reduce severity and symptoms

Recommend dietary modification

Recommend regular exercise

Bariatric surgery can reduce severity in morbidly obese


Can OSA be effectively managed by alterations in sleep position?

If AHI lower when nonsupine: avoid supine position

Up to 1/3 mild or moderate cases are position-dependent

Methods for adherence

Tennis ball strapped to back while sleeping

Wearable positional avoidance devices

Monitors or alarms


How should CPAP be initiated?

CPAP prescription should include:

Pressure setting

Mask type and size

Heated humidifier

Associated supplies (tube, filters, mask straps)

Traditionally: in-lab overnight titration study

Alternative for uncomplicated OSA: autotitrating CPAP

Educate patients on equipment, maintenance, care

Also: on benefits of therapy and potential problems


What amount of CPAP use constitutes sufficient adherence?

Patients should use CPAP whenever they sleep

CMS: adequate CPAP use ≥4 h/night on 70% of nights

Linear relationship between hours of CPAP use and improvements in:

Sleepiness

Quality of life

Blood pressure


What factors can optimize patient adherence to CPAP therapy?

Early follow-up (within 1–2 weeks of therapy initiation)

Support groups and bed partner support

Cognitive behavioral therapy focused on CPAP

Aid in therapy goal-setting

Support in troubleshooting difficulties

Heated humidification + nasal steroid for congestion

Other PAP modes if patient has intolerance to pressure

Short-term sedative hypnotic (for select patients only)


How should CPAP masks be chosen?

No one mask type is superior to another

Select mask to maximize patient comfort

Oronasal (“full face”) masks

Patients who sleep with their mouth open

Nasal masks

Better tolerated with claustrophobia

Nasal pillows (sit under the nose and fit in the nares)

Also better tolerated with claustrophobia

Patients with unusual nasal bridge anatomy, facial hair, or absent dentition


What is the role of mandibular advancement devices?

Decrease airway collapsibility and enlarge upper airway

Requires adequate dentition, may exacerbate TMJ

Refer to experienced dentist (sleep dentistry accreditation)

Less effective than CPAP for normalizing the AHI

Mild or moderate OSA: May be reasonable initial therapy

Severe OSA: Not recommended as initial therapy

Patients tend to accept better than CPAP

Follow-up sleep study needed to document adequacy


What is the role of surgical intervention?

Uvulopalatopharyngoplasty (UPPP)

Small reduction in symptoms

Fewer than half of patients have reduction in severity

Tonsillectomy, nasal septoplasty

Increase CPAP tolerability + reduce snoring (not cure)

Maxillomandibular advancement

Invasive procedure with prolonged postop recovery

Cure rate >90%, particularly in nonobese with retrognathia

Tracheostomy

Cures OSA

Can be used in life-threatening situations


How should treatment be monitored? Ensure CPAP use during all sleep sessions

Assess symptom resolution

Monitor side effects of CPAP

Assess comorbid conditions associated with OSA

Monitor remission due to weight loss or surgery

Monitor remission in those with history drowsy driving

If relapse occurs, investigate stepwise:

Inadequate therapy adherence

Problems with CPAP delivery

Change in pressure needs

Non-OSA sleep factors


How should OSA be treated when a patient is admitted to the hospital?

Patients should use their CPAP or MAD in the hospital

Just as they would at home

Use sedative and opiate medications cautiously

If moderate sedation used intraoperatively

Monitor ventilation by continuous oximetry and continuous capnography

Consider CPAP administration during sedation

Beware untreated OSA in periop setting

Higher rate cardiopulmonary complications, ICU transfers


When should a sleep specialist be consulted for management?

Complicated management situations

CPAP-intolerance

Persistent symptoms despite therapy

Multiple sleep disorders

Complex sleep-disordered breathing


What should patients know about the effects of medications and supplemental oxygen?

Use sedatives and opiates cautiously (can worsen OSA)

Exogenous testosterone may exacerbate or induce OSA

Don’t use supplemental oxygen as primary therapy

Treats oxyhemoglobin desaturation associated with OSA

Little evidence that it reduces symptoms, BP, CV risk

Some patients require both CPAP and supplemental oxygen


Can treatment prevent or modify outcomes in other diseases?

CPAP and MAD therapy reduce blood pressure

Degree of adherence correlates with BP response

CPAP therapy may reduce hypertension

Effect of therapy on cardiovascular outcomes unclear

Other diseases may be modified by OSA therapy

May modestly increase ejection fraction in CHF

May reduce likelihood of Afib recurrence


CLINICAL BOTTOM LINE: Treatment... Conservative measures: weight loss, avoid alcohol at bedtime Patients who require CPAP, other therapy (MAD, surgery)

Symptomatic or severe OSA OSA-related drowsy driving Benefits of adequate adherence to therapy Symptom resolution Reduced cardiovascular risk

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