Definition
A.Obstructive sleep apnea (OSA) is the periodic reduction (hypopnea) or cessation (apnea) of breathing due to a narrowing or occlusion of the upper airway during sleep. OSA has been linked to motor vehicle accidents, cardiac diseases, stroke, diabetes, depression, sexual dysfunction, inattention, poor work performance, and visceral obesity. OSA is also associated with nocturnal cardiac arrhythmias and chronic and acute cardiac events, and is a risk factor for strokes. OSA worsens in the supine sleeping position. Either of the two following conditions are diagnostic criteria for OSA:
1.The presence of 15 or more apneas, hypopneas, or respiratory effort–related arousals per hour of sleep in an asymptomatic patient. More than 75% of the apneas and hypopneas must be obstructive.
2.Five or more obstructive apneas, obstructive hypopneas, or respiratory effort–related arousals per hour of sleep in a patient with symptoms or signs of disturbed sleep. More than 75% of the apneas or hypopneas must be obstructive.
Incidence
A.The incidence of OSA in the morbidly obese population is between 38% and 88%.
B.Obesity adds a fourfold added risk for disordered breathing.
C.OSA is the most common sleep-related breathing disorder and is increasing in prevalence due to increasing obesity rates.
D.OSA is more common in males than females.
Pathogenesis
A.Increased tissue thickness of the structures of the tongue and soft tissues in the pharyngeal cavity that decreases the passageway for air to the trachea is thought to be the mechanism of OSA. During the night the muscles of the oropharynx relax and results in the relative obstruction of the airway. Obesity and hypertrophy of tonsils and/or adenoids play a major role in OSA. Patients with severe OSA left untreated have a two- to threefold risk for all-cause mortalities.
Predisposing Factors
A.Obesity.
B.Increased neck circumference.
C.Age: Increases with age and plateaus in the sixth decade.
D.Gender: Males.
E.Postmenopause females.
F.Hypothyroidism.
G.Tonsillar hypertrophy.
H.Alcohol.
I.Craniofacial abnormalities.
J.Medications:
1.Benzodiazepines.
2.Antipsychotics.
3.Opioid analgesics.
4.Beta-blockers.
5.Barbiturates.
6.Antihistamines.
7.Sedative antidepressants.
K.Allergic rhinitis.
L.Genetic conditions (e.g., Down syndrome, Pierre Robin anomalies, Marfan’s syndrome, etc.).
M.Ethnic (e.g., African American, Asian, Hispanic, American Indians, Pacific Islanders).
N.Acromegaly.
O.Smoking.
P.End-stage renal disease.
Q.Pregnancy.
R.Congestive heart failure (CHF).
S.Chronic obstructive pulmonary disease (COPD).
Common Complaints
A.Daytime sleepiness.
B.Loud snoring, gasping, or snorting during sleep.
C.Fatigue.
D.Insomnia.
Other Signs and Symptoms
A.Adults:
1.Asymptomatic: Patients may not recognize they have OSA because they are able to go to sleep anytime.
2.Restless sleep.
3.Dry mouth or sore throat.
4.Lack of physical or mental energy.
5.Falling asleep when watching TV, reading, or driving/riding in a car.
6.Morning headaches.
7.Decreased libido and impotence.
8.Cognitive deficits.
9.Depression.
10.Mood disorders.
Subjective Data
A.Does the patient feel sleepy during the day? Is daytime sleepiness a problem?
B.Does the patient struggle to stay awake during the day?
C.Does the patient take naps? How often, and for how long?
D.Does the patient feel physically and mentally exhausted?
E.Does the patient’s bed partner complain about snoring, gasping, choking sensation, or snorting?
F.Ask the Epworth Sleepiness Scale questions related to how often the patient dozes off or falls asleep (in contrast to just feeling tired). Each situation is scored from 0 = would never doze, to 1 = a slight chance of dozing, 2 = moderate chance of dozing, and 3 = a high chance of dozing. There are eight situations to which the patient responds:
1.Sitting and reading.
2.Watching TV.
3.Sitting inactive in a public place (e.g., a theater or meeting).
4.As a passenger in a car for an hour without a break.
5.Lying down to rest during the day when circumstances permit.
6.Sitting and talking to someone.
7.Sitting quietly after lunch without alcohol.
8.In a car, while stopped for a few minutes in traffic.
G.Ask patient to list all medications currently being taken, particularly substances not prescribed, including over-the-counter (OTC) and herbal products.
H.Review alcohol use.
I.Men who present with sleep disorders should also be questioned about the presence of erectile dysfunction.
Physical Examination
A.Blood pressure, pulse, respirations, height, weight, body mass index (BMI), neck and waist circumference.
B.Inspect:
1.Face for deformities.
2.Oropharynx examination for:
a.Peritonsillar narrowing or hypertrophy.
b.Tongue (evaluate for macroglossia).
c.Elongated or enlarged uvula.
d.Palate (high arch or narrow palate).
e.Measure neck circumference (>16 inches in a female or 17 inches in a male).
3.Nasal examination: Look for septal deviation and nasal polyps.
4.Inspect for signs of pulmonary hypertension or cor pulmonale:
a.Jugular venous distension.
b.Peripheral edema.
C.Palpate thyroid gland.
D.Auscultate heart and lungs.
E.Mental status: Assess for confusion, flat affect, level of attention/alertness, and somnolence.
Diagnostic Tests
A.Polysomnography (PSG) is the standard method of diagnosis. The apnea hypopnea index (AHI) or the respiratory disturbance index (RDI) is used to quantify hypopneas and classify the degree of sleep disturbance:
1.Full-night PSG (gold standard).
2.Split-night PSG.
3.Home testing with portable monitors.
Patients with cardiac, respiratory, or neurologic disease may be at the greatest risk for central sleep apnea, and the American Academy of Sleep Medicine (AASM) does not recommend the use of portable monitors for diagnosis in these patients.
B.Routine lab work is not helpful in the confirmation or exclusion of OSA.
Differential Diagnosis
A.OSA.
B.Primary snoring.
C.Narcolepsy.
D.Restless legs syndrome.
E.Swallowing disorder.
F.Nocturnal seizures.
G.Gastroesophageal reflux disease (GERD).
H.Obesity hypoventilation syndrome.
I.Sleep deprivation, including shift-work disorder.
J.Neurodegenerative disease (e.g., Parkinson’s, dementia, Alzheimer’s).
K.Substance abuse.
L.Alcoholism.
M.Asthma.
N.Central sleep apnea.
Plan
A.Patient teaching:
1.Educate patient about modifying controllable risk factors such as keeping diabetes and hypertension under control, diet, weight loss, exercise, and stopping smoking.
2.Behavioral strategies include sleeping in a nonsupine position using a positioning device (e.g., alarm, pillow, backpack, tennis ball are used for positional therapy).
3. 
See Section III: Patient Teaching Guide Sleep Apnea.
B.Continuous positive airway pressure (CPAP) or Bi-level positive airway pressure (BiPAP) is the mainstay of treatment for moderate to severe OSA. Treatment with CPAP and BiPAP is required at all times during the night and during naps.
C.Dietary management: Even a modest weight loss of 10% to 20% has been associated with an improvement.
D.Nonsurgical treatment:
1.Oral appliances (OAs): Require a thorough dental examination:
a.Custom-made OAs may improve airway patency during sleep by enlarging the upper airway and/or by decreasing the upper airway collapse.
b.Mandibular repositioning appliances (MRAs) cover the upper and lower teeth and hold the mandible in an advanced position.
c.Tongue-retaining devices (TRDs) hold the tongue in a forward position without mandibular repositioning.
2.Avoid alcohol even during the daytime due to central nervous system (CNS) depression and worsening apnea
3.Avoid prescribing medications with sedating properties unless the benefit outweighs worsening sleep apnea (anticonvulsants for seizure control may not be avoided as benefits outweigh risk)
4.See Section III: Patient Teaching Guide Nicotine Dependence.
E.Surgical treatment:
1.Tracheostomy can eliminate OSA but not central hypoventilation syndromes. This procedure should be considered only when other options have failed or when it is considered necessary by clinical urgency.
2.Maxillary-mandibular advancement (MMA) is indicated when the patient cannot tolerate/refuses CPAP and an OA is not appropriate/effective.
3.Multilevel or stepwise surgery (MLS) is a combined procedure or serves as a stepwise multiple surgery.
4.Bariatric surgery’s weight loss has been effective in improving sleep efficiency and increasing rapid eye movement (REM) sleep. The severity of presurgical OSA determines the degree to which OSA improves postbariatric surgery.
5.Radiofrequency ablation (RFA) is for treatment of mild to moderate OSA when the patient cannot tolerate/refuses CPAP and an OA is not appropriate/effective.
6.Laser-assisted uvulopalatoplasty is not recommended for OSA.
Follow-Up
A.There is no standard for recommending repeat PSG testing or a CPAP titration study after significant weight loss.
Consultation/Referral
A.Refer to a dentist for an OA.
B.Refer to a pulmonologist for management of therapy and/or surgical treatment.
C.Refer patient to a cardiologist as needed.
D.If patient is uninsured, refer to social worker for assistance in treatment purchases as needed.
Individual Considerations
A.Geriatrics:
1.OSA in older people is associated with worsening cardio-cerebrovascular, cognitive, and functional outcomes.
2.Fatigue, poor focus, and irritability can be sometimes attributed to dementia and treatment for any sleep-breathing problem may improve some or all of those symptoms.