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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 12 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
Dont 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.