Updated: 12/15/2019

Sleep Apnea

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Snapshot
  • A 56-year-old man presents to your office for excessive fatigue. He complains of falling asleep all the time at work, which is “very distressing" as it has been affecting his work. He denies sudden loss of muscle tone or hallucinations before or after falling asleep. His wife reports that he snores at night. A physical examination demonstrates an obese, lethargic man with unremarkable findings.
Introduction
  • Clinical definition
    • sleep breathing disorder characterized by repeated cessation of breathing during sleep
    • results in sleep disruption and consequent daytime fatigue
    • subtypes
      • obstructive sleep apnea (OSA)
        • most common form characterized by the relaxation of throat muscles leading to a reduced/cessation of airflow despite a respiratory drive
      • central sleep apnea (CSA)
        • decreased central nervous system respiratory drive leading to decreased airflow and ventilatory effort during sleep
  • Epidemiology
    • demographics
      • OSA is 2-3 times more common in males than females
      • OSA is more prevalent in African Americans
    • risk factors  
      • age
      • male gender
      • obesity
      • craniofacial and upper airway abnormalities
      • chronic medical conditions (e.g., stroke)
      • medication use (e.g., opioids)
  • Pathogenesis
    • CSA
      • primary (e.g., idiopathic)
      • secondary (e.g., drug use)
      • commonly associated with Cheyne-Stokes breathing, especially among patients who have heart failure or stroke
    • OSA 
      • recurrent, functional collapse of the airway during sleep leading to reduced or complete cessation of airflow with breathing efforts
      • may occur secondary to decreased pharyngeal muscle tone, obese neck, or large tone size
Presentation
  • Symptoms
    • loud snoring
    • morning headache
    • difficulty staying asleep
    • excessive daytime fatigue/sleepiness
  • Physical exam
    • hypertension  
    • obesity
Studies 
  • Diagnostic testing
    • diagnostic approach
      • diagnosis is based on clinical history and physical exam (especially if significant risk factors are present) and confirmed via an in-laboratory polysomnography
    • studies
      • home sleep apnea testing
        • acceptable alternative for patients strongly suspected of OSA without medical comorbidities
      • in-laboratory polysomnography
        • gold standard diagnostic test for sleep apnea
        • differentiates OSA from CSA
  • Diagnostic criteria
    • OSA
      • 15 obstructive apneas/hour
      • 5 apneas/hour and snoring/breathing pauses with daytime somnolence
Differential
  • Narcolepsy 
    • distinguishing factor
      • clinical features such as cataplexy, hypnagogic hallucinations, sleep attacks, and sleep paralysis
      • can be differentiated on polysomnography  
  • Respiratory disease (e.g., chronic obstructive lung disease)
    • distinguishing factor
      •  positive medical history and polysomnography results   
Treatment
  • OSA
    • first-line
      • behavior/lifestyle medication  
        • indicated for most patients
        • weight loss, exercise, sleep position change, smoking cessation, abstain from alcohol, and avoid certain medications
      • positive airway pressure therapy
        • continuous positive airway pressure (CPAP) is the most common form  
    • second-line
      • oral appliances (e.g., mandibular advancement devices)
        • indicated in patients with mild to moderate OSA who fail positive airway pressure therapy or prefers such treatment
      • surgical treatment
        • indicated in patients with severe, obstructing lesions of the upper airway who have failed initial therapy
  • CSA
    • first-line
      • correction of conditions that may be causing or exacerbating the condition (e.g., stop taking opioids)
      • positive airway pressure therapy (e.g., BiPAP) for mechanical ventilation
Complications
  • Daytime fatigue (increased risk for motor vehicle accidents)
  • Hypertension and other cardiovascular conditions  
    • pulmonary hypertension may result in cor pulmonale
  • Type 2 diabetes and other metabolic conditions
  • Arrhythmias

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(M3.PY.13.6) A 59-year-old man presents to his primary care provider with the complaint of daytime fatigue. He often has a headache that is worse in the morning and feels tired when he awakes. He perpetually feels fatigued even when he sleeps in. The patient lives alone, drinks 2-3 beers daily, drinks coffee regularly, and has a 10 pack-year smoking history. His temperature is 99.0°F (37.2°C), blood pressure is 180/110 mm Hg, pulse is 80/min, respirations are 13/min, and oxygen saturation is 98% on room air. Physical exam is notable for a BMI of 39 kg/m^2. The rest of the patient's pulmonary and neurological exams are unremarkable. Which of the following is the best next step in management?

QID: 102605
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Alcohol avoidance in the evening

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Caffeine avoidance

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CT head

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Screening for depression

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Weight loss

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