II. Definitions
- Obstructive Sleep Apnea
- Airway obstruction at night resulting in apnea, hypopnea and snoring
- Associated wih Daytime Somnolence and morning Headaches
- Hypopnea
- Slow or shallow breathing
- Apnea
- Paused breathing
III. Epidemiology
- More common in men (by 3 fold)
- However women are likely underdiagnosed (esp. postmenopausal, not on HRT)
-
Prevalence increases with age (esp. over age 60 years old)
- Diagnosis in 18 million adults in U.S.
-
Incidence: Apneas and Hypopneas (AHI) >5/hour in ages 30 to 60 years of age
- Without Daytime Somnolence: 24% of men and 9% of women
- With Daytime Somnolence: 4% of men and 2% of women
IV. Causes
- Adults
- Children (occurs in 1-3% of children)
V. Risk Factors
- Sleep deprivation or excessive Daytime Sleepiness
- CNS Depressant medications
- Chronic nasal congestion
- Obesity (especially morbid Obesity qualifying for Bariatric Surgery, BMI >35 kg/m2)
- Middle age or older (ages 40-70 years old)
- Male gender (or post-menopausal women not on HRT)
- Alcohol Abuse
- Tobacco Abuse
- Family History of Obstructive Sleep Apnea
VI. Associated Conditions
- Atrial Fibrillation (OR 4.0)
- Major Depression (OR 2.6)
- Congestive Heart Failure (OR 2.4)
- Cerebrovascular Accident (OR 1.6 to 4.3)
- Hypertension, especially Refractory Hypertension (OR 1.4 to 2.9)
- Coronary Artery Disease (OR 1.3)
- Type 2 Diabetes Mellitus (OR 1.2 to 2.6)
- Nocturnal Cardiac Arrhythmia
- Pulmonary Hypertension
VII. Symptoms: Adults
- Excessive Daytime Sleepiness (Daytime Somnolence)
- Loud snoring
- Gasping or Choking during sleep
- Nocturnal Hypertension and Arrhythmias
- Morning Headache
- Nocturia
- Nocturnal confusion
- Intellectual deterioration or Cognitive Impairment
VIII. Symptoms: Children
- Minimal Hypersomnolence if any
- Nocturnal Enuresis
- Excessing nighttime sweating
- Developmental Delay
- Learning difficulties (e.g. ADHD)
IX. Signs
-
General appearance
- Short neck
- Overweight (Obesity in 70% of cases)
- Nasopharynx
- Nasal Polyps
- Severe septal deviation
- Large residual adenoid tissue
- Oropharynx
- Macroglossia
- Large Tonsils
- High arched Palate and narrow oropharyngeal opening
- Micrognathia (small jaw) and Retrognathia (posterior chin position)
- Mallampati Score 3 or 4
- Disproven: Does not predict Obstructive Sleep Apnea risk
-
Larynx and trachea
- Large obstructive lesions
- Neck circumference (best predictor of Sleep Apnea)
- Men: >17 inch (42.5 cm) neck circumference
- Women: >16 inch (40.6 cm) neck circumference
X. Differential Diagnosis
XI. Complications
- See Sleep Apnea
- Increased mortality risk and stroke risk
- Cardiovascular Disease
- Arial fibrillation
- Congestive Heart Failure
- Cerebrovascular Accident
- Hypertension is closely associated with Sleep Apnea
- Risk of developing Hypertension with mild to moderate OSA: Odds Ratio 2-3
- Peppard (2000) N Engl J Med [PubMed]
- Public health concern
- Higher health care utilization (more frequent hospitalizations, for longer durations, and higher costs)
- Associated with more MVAs and workplace injuries
XII. Diagnostics
- Screening Tools for Symptomatic Patients (USPTF does not recommend general screening)
- STOP-Bang Questionnaire
- Consider as part of preoperative assessment
- Elbow Signs
- Of those with Sleep Apnea, 97% report being elbowed by their bed partner due to apnea or snoring
- Fenton (2014) Chest 145(3): 518-24 [PubMed]
- STOP-Bang Questionnaire
- See Polysomnogram (Sleep Study)
- See Sleep Study for diagnostic criteria
- Portable home monitoring devices (overnight oximetry)
- Less specific than Polysomnogram
- Unable to distinguish CHF, COPD or Parasomnias from Sleep Apnea
XIII. Management: Non-surgical
- See Sleep Hygiene
- Airway Management Measures
- Continuous Positive Airway Pressure (CPAP)
- See CPAP for Obstructive Sleep Apnea
- Do not use without Sleep Study (will worsen Central Sleep Apnea)
- Available with auto-titrating positive airway pressure (machine adjusted)
- Auto-titrating machines are contraindicated in patients with significant comorbidity
- Encourage at least 4 hours per night usage (50% discontinuation rate at 1 year)
- See CPAP for improving compliance
- Available as nasal pillows (preferred by patients) or full Face Mask
- Improves sleep, decreases snoring, less Daytime Somnolence, better quality of life
- Decreases systolic Blood Pressure, LVEF, Insulin Resistance and Serum Triglycerides
- Bilevel Pap (BIPAP) Indications
- Hypoventilation during sleep
- High airway pressures required
- Difficulty exhaling against fixed pressure
- Continuous Positive Airway Pressure (CPAP)
- Weight loss
- Obesity is present in 70% of patients with Obstructive Sleep Apnea
- Sleep Apnea significantly improved with 9-14 kg loss
- Snoring in 19 asymptomatic obese male snorers
- Only mild decrease with interventions
- Oxymetazoline Nasal Decongestant
- Foam wedge support to sleep on side
- Marked decrease with weight loss
- Three kilogram weight loss
- Snores cut in half (176/hour)
- Six kilogram weight loss
- Snoring nearly eliminated
- Three kilogram weight loss
- Only mild decrease with interventions
- Reference
- Avoid supine body position during sleep
- Sew a tennis ball in the back of a night shirt (or vests with posterior bumpers)
- Makes sleeping on back too uncomfortable
- Propping pillows
- Position alarms
- Sew a tennis ball in the back of a night shirt (or vests with posterior bumpers)
- Oral appliance (less effective alternatives to CPAP)
- Indicated in patients intolerant of CPAP, to move jaw forward or fix Tongue in position during sleep
- Require frequent replacement (typically fitted by dentist)
- Mandibular Advancement Device (preferred)
- Tongue retaining device (insufficient evidence)
- Potentially helpful Medications
- Intranasal Corticosteroids
- Chronic Rhinitis
- Nasal Polyps
- Septal deviation
- Tricyclic Antidepressants
- Intranasal Corticosteroids
- Avoid harmful medications
- Avoid CNS Depressant or Sedative medications (e.g. Benzodiazepines, Benzodiazepine Receptor Agonists)
- Sedatives may worsen Sleep Apnea
- Hospitalized patients with undiagnosed OSA
- Elevate head of bed
- Provide Supplemental Oxygen while sleeping
- Schedule outpatient Sleep Study
- Do not use empiric CPAP (worsens central apnea)
- BIPAP is safer if empiric treatment is used
- Other experimental measures that may be helpful
- Neurostimulators to Hypoglossal Nerve (increases tone of upper airway Muscles)
XIV. Management: Surgery
- Precautions
- Bariatric Surgery is effective in improving Sleep Apnea in 75% of obese patients
- Refer to Bariatric Surgery for BMI >35 kg/m2, unable to use PAP, and failing conventional weight loss strategy
- No other surgical intervention (e.g. UPPP or mandibular advancement) has shown significant or consistent benefit
- However, consider in BMI <40 kg/m2 and unable to use PAP
- May reduce Sleepiness, snoring, Blood Pressure and quality of life
- Longterm adverse effects are associated with airway procedures, but are uncommon
- Dysphagia
- Dysgeusia
- Mandibular Paresthesia
- Aspiration Pneumonia
- Globus Pharyngeus
- Poor cosmetic result
- References
- Bariatric Surgery is effective in improving Sleep Apnea in 75% of obese patients
- Procedures
- Uvulopalatopharyngoplasty (UPPP)
- No longer recommended due to low efficacy
- Laser or excision of redundant posterior pharynx
- Only effective in 30-50% of patients
- Airway narrows below level where surgery occurs
- Modified procedures
- Laser-assisted uvulopalatoplasty
- Radiofrequency ablation
- Maxillomandibular advancement
- Indicated for receding chin and jaw
- Tracheotomy
- Measure of last resort only
- Uvulopalatopharyngoplasty (UPPP)
XV. References
- Bower (2000) Otolaryngol Clin North Am 33(1):49-75 [PubMed]
- Flemons (2002) N Engl J Med 347:498-504 [PubMed]
- Gozal (1998) Pediatrics 102:616-20 [PubMed]
- Holder (2022) Am Fam Physician 105(4): 397-405 [PubMed]
- Owens (1998) Pediatrics 102:1178-84 [PubMed]
- Piccinillo (2000) JAMA 284:1492-4 [PubMed]
- Semelka (2016) Am Fam Physician 94(5): 355-60 [PubMed]
- Sliverberg (2002) Am Fam Physician 65(2):229-236 [PubMed]
- Victor (1999) Am Fam Physician 60(8):2279-86 [PubMed]