Obstructive Sleep Apnea: Is it in your Differential?

Helene HillProfessor Sam PowdrillPAS 645

Agenda

Introduction Pathophysiology Risk Factors Comorbid Conditions Application

Obstructive Sleep Apnea AKA the “Spousal

Arousal” syndrome Prevention and

early treatment is essential

The problem is that PCP might not consider OSA in the non-stereotypical patients“Laugh and the world laughs with

you, snore and you sleep alone.” ~ Anthony Burgess

Obstructive Sleep Apnea

Epidemiology More prevalent than once was believed Wisconsin Sleep Cohort Study

9% women 24% men

Estimated that 80-90% are undiagnosed Comorbidities Awareness SES

Pathophysiology

A sleep breathing disorder due to a mechanical problem of tissue collapse

Apnea leads to Oxyhemoglobin desaturation Fragmentation in sleep cycle Variability in BP and HR/Increase in SNS

Persistent hypoxia manifests with numerous daytime Sx

Treatment

Mild 5-15/hr Lifestyle modification

Weight loss Elimination of products that suppress

respiration No BZDs Sleeping position modification

Treatment Moderate 15-30/hr

More in-depth plus lifestyle changes CPAP

Oral appliances Mandible advancing Tongue device Martin Dunitz

Treatment Severe > 30/hr

Surgical procedures in addition to previous changes Tonsillectomy/adenoidectomy Nasal surgery combined with

pharyngeal surgery Uvulopalatopharyngoplasty

(UPPP) Martin Dunitz

Risk Factors “Pickwickian Patient”

Male Sex Age 40-70 yr Familial Aggregation

Established risk factors Body habitus Craniofacial/Upper

Airway Abnormalities Suspected risk factors

Genetics Smoking Menopause Alcohol before sleep Nighttime nasal

congestion

Martin Dunitz

Comorbid Conditions

Decreased daytime functioning Daytime sleepiness Psychosocial problems – STRESS! Decreased cognitive function

Comorbid Conditions

Cardiovascular/Cerebrovascular Disease Stroke, pulmonary HTN, CHF Resistant hypertension

Increased sympathetic activity Vasculopathy

Activation of vasoconstrictors Sustained hypertensive effects “Non-dipping” phenomenon

Comorbid Conditions

Diabetes/Metabolic Syndrome Vascular disease that lead to endothelial

dysfunction OSA is independently associated with

insulin resistance Control OSA, see better control of DM

So is it in your Dif Dx?

Few easy steps Consider OSA in patients who snore or

have excessive daytime sleepiness Check out risk factors and get detailed

history Consider your alternatives Consider OSA when evaluating patients

for comorbidities associated with sleep apnea

Wrapping it up…

Don’t forget to treat the underlying condition!

Don’t forget the non-stereotypicals! Know risk factors and what OSA can

do if left untreated! Future ideas…

Hypoglossal nerve stimulation Serotonergic medications

References

Available upon request