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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
in the clinic
Obstructive sleep
apnea
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
Who should be screened for OSA?
 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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
Can OSA be prevented?
 Weight loss can reduce severity
 May also achieve remission
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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)
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.
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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 161 (5): ITC5-1.