Obstructive Sleep Apnea

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Contents 1 More Specific Terms 2 Etiology 3 Epidemiology 4 Pathology 5 Clinical-manifestations 6 Laboratory 7 Diagnostic-procedures 8 Radiology 9 Complications 10 Differential-diagnosis 11 Management 12 More General Terms 13 Additional Terms 14 References

More Specific Terms

• Pickwickian syndrome

Etiology

• (associated disorders)
• obesity
• adenotonsillar hypertrophy (especially in children)
• micrognathia
• retrognathia
• macroglossia
• vocal cord paralysis
• bulbar involvement with neuromuscular disease
• cordotomy
• poliomyelitis
• Shy-Drager syndrome
• sudden infant death syndrome
• severe altitude-related polycythemia
• Pickwickian syndrome
• hypothyroidism can worsen obstructive sleep apnea [17]
• stroke ? [22]

Epidemiology

• 1-2% of population
• 4% of middle-aged men & 2% of middle aged women
• more common in older age
• only a small percentage of cases are diagnosed

Pathology

• repetitive inspiratory occlusion of the upper airway during sleep, resulting in:

• respiratory efforts without airflow
• hypoxemia
• disrupted sleep patterns

• airway obstruction occurs at the level of the soft palate or posterior to the base of the tongue
• the tone of the genioglossus & geniohyoid muscles (abductors) decreases with the resulting pharyngeal collapse producing airway obstruction
• airway occlusion is exaggerated by a large neck circumference, increased size of the uvula & pharyngeal mucosal edema (from long-term snoring)

Clinical-manifestations

• obesity

• upper body, especially nuchal obesity

• neck circumference > 17 inches

• less likely in patient with stroke

• excessive daytime sleepiness, hypersomnolence

• less likely in patient with stroke

• snoring, gasping &/or choking episodes during sleep

• may be reports of witnessed apneas

• insomnia
• personality changes
• intellectual deterioration
• morning headache
• automatic behavior
• loss of libido
• night sweats
• nocturia
• erectile dysfunction
• hypertension (50%)
• ear, nose & throat examination

• nasal obstruction or congestion
• nasal septal deviation
• enlarged tonsils (especially in children)
• elongated soft palate (crowded pharynx)
• macroglossia
• narrow oropharynx
• micrognathia

• patients may be asymptomatic

Laboratory

• thyroid function testing

• serum TSH, free T4
• rule out hypothyroidism

• complete blood count ( CBC) may show polycythemia
• arterial blood gas for hypoxia, hypercarbia

Diagnostic-procedures

• polysomnography: gold standard (after 1-3 above)

• 5 or more hypopnea or apneas/hour of sleep ( apnea-hypopnea index > 5)
• recurrent arousals from sleep

• therapeutic trial of CPAP may be diagnostic [10]
• pulmonary function testing
• electrocardiogram:

• sinus arrhythmia seen in 90% of patients
• 2nd degree AV block
• premature ventricular contractions
• ventricular tachycardia

• echocardiogram may show

• pulmonary hypertension
• cor pulmonale

Radiology

• MRI: white matter hyperintensities
• white matter is extensively affected possibly from repeated hypoxia accompanying apneic events
• alterations include axons linking major structures within the limbic system, pons, frontal, temporal & parietal cortices, & projections to & from the cerebellum

Complications

• complications of repetitive hypoxemia

• systemic hypertension
• pulmonary hypertension

• initially episodic
• may become sustained

• cardiac arrhythmias

• late complications, especially with obesity & chronic lung disease

• hypoxemia
• hypercapnia

• obesity hypoventilation syndrome

• polycythemia
• cor pulmonale

• increased cardiovascular risk

• increased risk of coronary artery disease in women
• increased risk of stroke [11]
• increased cardiovascular mortality with severe OSA [9]

• CPAP may improve LVEF in patients with CHF
• CPAP may improve cardiovascular risk [26]

• other

• increased risk of motor vehicle accidents ? [19]
  
• disease interaction(s) of obstructive sleep apnea (OSA) with urinary incontinence
• disease interaction(s) of obstructive sleep apnea (OSA) with seizures
• disease interaction(s) of obstructive sleep apnea (OSA) with erectile dysfunction (ED)
• disease interaction(s) of obstructive sleep apnea (OSA) with heart failure

Differential-diagnosis

• endocrine disorders

• hypothyroidism
• acromegaly

• ear, nose & throat disorders
• narcolepsy
• severe COPD

Management

• treat underlying/associated disorders
• weight reduction in obese patients may mitigate symptoms [21]
• alcohol & sedative avoidance
• avoid medications for erectile dysfunction [17] ( phosphodiesterase-5-inhibitors) <see disease interactions>
• avoid supine sleep position
• ear, nose & throat examination to identify surgically correctable signs of upper airway obstruction
• nasal continuous positive airway pressure ( CPAP) for symptomatic patients [4]

• heated humidification may improve compliance
• CPAP may partially reverse metabolic syndrome in patients with OSA & metabolic syndrome [25]

• oral appliances [5]

• elevation of soft palate
• advancement of tongue or mandible anteriorly
• objective benefit in 50% of patients with moderate OSA
• greater patient satisfaction
• almost as effective as CPAP [24]

• oropharyngeal exercises may be of benefit
• compression stockings may benefit patients with peripheral edema
• pharmaceutical agents

• glucocorticoid nasal spray may benefit children [6]

• fluticasone 1 spray each nostril BID

• modafanil ( Provigil) may be helpful for patients with excessive daytime sleepiness despite CPAP [7]

• surgery

• tracheostomy

• life-threatening hypoxemia
• life-threatening cardiac arrhythmia
• disabling hypersomnolence
• intolerance of or non-compliance with other therapies

• uvulopalatopharyngoplasty ( uvula & palate resection)

• objective improvement in 40% of patients
• no selection criteria identifies patients likely to benefit
• laser-assisted uvulopalatoplasty may reduce snoring, but does not benefit OSA

• staged genioglossal & maxillo- mandibular advancement

• objective improvement in 40% of patients
• limited centers with surgical experience

• hyoid myotomy & suspension
• tonsillectomy & adenoidectomy (children) [8]

More General Terms

• sleep apnea

Additional Terms

• acromegaly
• apnea-hypopnea index
• chronic obstructive pulmonary disease (COPD)
• fluticasone (Flonase, Veramyst, Flovent, Cutivate)
• hypothyroidism
• micrognathia
• modafinil (Provigil, Sparlon)
• narcolepsy
• obesity
• poliomyelitis
• polysomnography (PSG)
• Shy-Drager syndrome
• sudden infant death syndrome (SIDS)

References

1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 257-58
2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1087-90
3. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, American College of Physicians, Philadelphia 1998, 2006, 2009
4. Journal Watch 21(13):107, 2001 Barbe F et al Treatment with continuous positive airway pressure is not effective in patients with sleep apnea but no daytime sleepiness. a randomized, controlled trial. Ann Intern Med 134:1015, 2001 PMID: [1]
   - Pack AI & Maislin G Who should get treated for sleep apnea? Ann Intern Med 134:1065, 2001 PMID: [2]
5. Journal Watch 21(13):108, 2001 Mehta A et al A randomized, controlled study of a mandibular advancement splint for obstructive sleep apnea. J Respir Crit Car Med 163:1457, 2001 PMID: [3]
6. Journal Watch 21(14):117, 2001 Brouillete RT et al Efficacy of fluticasone nasal spray for pediatric obstructive sleep apnea. J Pediatr 138:838, 2001 PMID: [4] Marcus CL, Nasal steroids as treatment for obstructive sleep apnea: Don't throw away the scalpel yet. J Pediatr 138:795, 2001 PMID: [5]
7. Journal Watch 22(2):17, 2002 Pack AI et al Modafinil as adjunct therapy for daytime sleepiness in obstructive sleep apnea. Am J Respir Crit Care Med 164:1675, 2001 PMID: [6]
8. Journal Watch 24(15):122, 2004 Goldstein NA, Pugazhendhi V, Rao SM, Weedon J, Campbell TF, Goldman AC, Post JC, Rao M. Clinical assessment of pediatric obstructive sleep apnea. Pediatrics. 2004 Jul;114(1):33-43. PMID: [7]
   - Chervin RD, Ruzicka DL, Giordani BJ, Weatherly RA, Dillon JE, Hodges EK, Marcus CL, Guire KE. Sleep-disordered breathing, behavior, and cognition in children before and after adenotonsillectomy. Pediatrics. 2006 Apr;117(4):e769-78. PMID: [8]
9. Journal Watch 25(10):79, 2005 Marin JM, Carrizo SJ, Vicente E, Agusti AG. Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet. 2005 Mar 16;365(9464):1046-53. PMID: [9]
10. Senn O, Brack T, Russi EW, Bloch KE. A continuous positive airway pressure trial as a novel approach to the diagnosis of the obstructive sleep apnea syndrome. Chest. 2006 Jan;129(1):67-75. PMID: [10]
    - Collop NA. Blue light special on CPAP, aisle 11. Chest. 2006 Jan;129(1):6-7. No abstract available. PMID: [11]
11. Arzt M et al, Association of sleep-disordered breathing and the occurrence of stroke. Am J Respir Crit Care Med 2005, 172:1447 PMID: [12]
12. Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP; American Academy of Sleep. Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005. Sleep. 2006 Feb 1;29(2):240-3. <PubMed> PMID: [13] <Internet> [14]
13. Institute for Clinical Systems Improvement (ICSI) Diagnosis and treatment of obstructive sleep apnea [15]
    - NINDS Sleep Apnea Information Page [16]
    - What Is Sleep Apnea? [17]
14. The American Academy of Sleep Medicine (AASM): Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep- related breathing disorders Guideline withdrawn (Dec 2011)
15. No authors listed] Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the american society of anesthesiologists task force on perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2006 May;104(5):1081-93. No abstract available. <PubMed> PMID: [18] <Internet> [19]
16. Yoshinaga K et al, The effects of continuous positive airway pressure on myocardial energetics in patients with heart failure and obstructive sleep apnea. J Am Coll Cardiol 2007, 49:450 PMID: [20]
    - Chareonthaitawee P and Somers V Continuous positive airway pressure and increased ejection fraction in heart failure and obstructive sleep apnea: Is there a metabolic cost or benefit? J Am Coll Cardiol 2007, 49:459 PMID: [21]
17. Prescriber's Letter 15(10): 2008 COMMENTARY: Medications that Can Exacerbate Sleep Apnea GUIDELINES: Sleep Apnea and Cardiovascular Disease
    - Somers VK st al, American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology; American Heart Association Stroke Council; American Heart Association Council on Cardiovascular Nursing; American College of Cardiology Foundation. Sleep apnea and cardiovascular disease: an American Heart Association/American College Of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council On Cardiovascular Nursing. In collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research (National Institutes of Health). Circulation. 2008 Sep 2;118(10):1080-111. Epub 2008 Aug 25. PMID: [22]
    - Somers VK et al Sleep apnea and cardiovascular disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing. J Am Coll Cardiol. 2008 Aug 19;52(8):686-717 <PubMed> PMID: &dopt=Abstract <Internet> [23] GUIDELINES: Diagnosis and Treatment of Sleep Apnea 2008 Update (Canadian) [24] GUIDELINES: Diagnosis and Treatment of Sleep Disordered Breathing in Adults
    - Fleetham J et al; CTS Sleep Disordered Breathing Committee. Canadian Thoracic Society guidelines: diagnosis and treatment of sleep disordered breathing in adults. Can Respir J. 2006 Oct;13(7):387-92. <PubMed> PMID: [25] <Internet> [26] Detail-Document#: [27] (subscription needed) [28]
18. Macey PM et al. Brain structural changes in obstructive sleep apnea. Sleep 2008 Jul 1; 31:967. PMID: [29]
19. Vakulin A et al, Effects of Alcohol and Sleep Restriction on Simulated Driving Performance in Untreated Patients With Obstructive Sleep Apnea Annals of Internal Medicine 2009 151:447 <PubMed> PMID: [30] <Internet> [31]
20. Epstein LJ et al, Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults Journal of Clinical Sleep Medicine 2009, 5(3):263 <PubMed> PMID: [32] <Internet> [33]
21. Johansson K et al Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: A randomised controlled trial. BMJ 2009 Dec 3; 339:b4609 <PubMed> PMID: [34] <Internet> [35]
22. Arzt M et al. Dissociation of obstructive sleep apnea from hypersomnolence and obesity in patients with stroke. Stroke 2010 Mar; 41:e129. PMID: [36]
23. Redolfi S et al. Attenuation of obstructive sleep apnea by compression stockings in subjects with venous insufficiency. Am J Respir Crit Care Med 2011 Nov 1; 184:1062. PMID: [37]
24. Holley AB et al. Efficacy of an adjustable oral appliance and comparison with continuous positive airway pressure for the treatment of obstructive sleep apnea syndrome. Chest 2011 Dec; 140:1511 PMID: [38]
25. Sharma SK et al. CPAP for the metabolic syndrome in patients with obstructive sleep apnea. N Engl J Med 2011 Dec 15; 365:2277 PMID: [39]
26. Campos-Rodriguez F et al. Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: A cohort study. Ann Intern Med 2012 Jan 17; 156:115. PMID: [40]
27. National Guideline Clearinghouse
    - Diagnosis and treatment of obstructive sleep apnea in adults. (Institute for Clinical Systems Improvement) ngc-guideline: [41]
    - Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with Obstructive Sleep Apnea. ngc-guideline: [42]
    - Practice parameters for the use of autotitrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome: an update for 2007 (American Academy of Sleep Medicine) ngc-guideline: [43]
    - Practice parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. American Academy of Sleep Medicine ngc-guideline: [44]
    - Screening for obstructive sleep apnea in the primary care setting. University of Texas at Austin School of Nursing, Family Nurse Practitioner Program ngc-guideline: [45]
    - Continuous positive airway pressure for the treatment of obstructive sleep apnoea/hypopnoea syndrome. National Institute for Health and Clinical Excellence (NICE) ngc-guideline: [46]
    - Best evidence statement (BESt). Long-term outcomes in obstructive sleep apnea. Cincinnati Children's Hospital Medical Center ngc-guideline: [47]
    - Management/Treatment of Obstructive Sleep Apnea Guideline Syntheses: recommendations from AASM, ICSI, & SIGN [48]
    - Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. American Academy of Sleep Medicine ngc-guideline: [49]
    - Clinical guidelines for the manual titration of positive airway pressure in patients with obstructive sleep apnea. American Academy of Sleep Medicine ngc-guideline: [50]
    - Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. American Academy of Sleep Medicine ngc-guideline: [51]
    - Clinical practice guideline: polysomnography for sleep- disordered breathing prior to tonsillectomy in children. American Academy of Otolaryngology - Head and Neck Surgery Foundation ngc-guideline: [52]

obstructive sleep apnea (OSA)