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obstructive sleep apnea (OSA)

Etiology: 1) obesity (most important risk factor) [3] 2) adenotonsillar hypertrophy (especially in children) 3) micrognathia 4) retrognathia 5) macroglossia - tongue fat may contribute [67] 6) vocal cord paralysis 7) bulbar involvement with neuromuscular disease 8) cordotomy 9) poliomyelitis 10) Shy-Drager syndrome 11) sudden infant death syndrome 12) severe altitude-related polycythemia 13) Pickwickian syndrome 14) hypothyroidism can worsen obstructive sleep apnea [17] 15) stroke ? [22] 16) asthma in adults [47] (RR=2.7) 17) edentulous patients are at higher risk Epidemiology: 1) 1-2% of population 2) 4% of middle-aged men & 2% of middle aged women 3) more common in older age 4) only a small percentage of cases are diagnosed 5) 10%-30% of adults suffer from OSA; ~60% have mild disease [69] Pathology: 1) repetitive inspiratory occlusion of the upper airway during sleep, resulting in: a) respiratory efforts without airflow b) hypoxemia c) disrupted sleep patterns 2) airway obstruction occurs at the level of the soft palate or posterior to the base of the tongue - changes in the upper airway anatomy associated with the absence of teeth 3) the tone of the genioglossus & geniohyoid muscles (abductors) decreases with the resulting pharyngeal collapse producing airway obstruction 4) airway occlusion is exaggerated by a large neck circumference, increased size of the uvula & pharyngeal mucosal edema (from long-term snoring) 5) protective reflexes maintain pharyngeal airway patency during wakefulness 6) during sleep, protective reflexes are lost with reduced activity of the pharyngeal dilator muscle, causing collapse of the airway 7) fluctuations in activity of the central pattern generator in the brain stem lead to variable output to the diaphragm & upper-airway muscles, contributing to obstructive sleep apnea [38] 8) in older patients, compromised upper airway anatomy, poor pharyngeal muscle responsiveness, respiratory control instability, & low arousal threshold may all play a role [75] 9) autonomic dysfunction may play a role in cognitive impairment [75] History: - screening for obstructive sleep apnea: STOP-BANG Clinical manifestations: 1) obesity a) upper body, especially nuchal obesity - neck circumference > 17 inches (> 40 cm) b) less likely in patient with stroke 2) excessive daytime sleepiness, hypersomnolence a) less likely in patient with stroke b) daytime functional impairment 3) snoring, gasping &/or choking episodes during sleep - may be reports of witnessed apneas - may wake up gasping for breath or with palpitations 4) insomnia 5) personality changes 6) intellectual deterioration 7) morning headache (sleep apnea headache) 8) daytime sleepiness [40] 9) automatic behavior 10) loss of libido - hypogonadotropic hypogonadism [48,81] 11) night sweats 12) nocturia 13) erectile dysfunction 14) hypertension (50%) 15) dry mouth [40] 16) ear, nose & throat examination a) nasal obstruction or congestion b) nasal septal deviation c) enlarged tonsils (especially in children) d) elongated soft palate (crowded pharynx) e) macroglossia f) narrow oropharynx - erythematous, edematous oropharyngeal mucosa g) micrognathia 17) patients may be asymptomatic Laboratory: 1) thyroid function testing a) serum TSH, free T4 b) rule out hypothyroidism 2) complete blood count (CBC) may show polycythemia 3) arterial blood gas for hypoxia, hypercarbia - rule out obesity hypoventilation syndrome - precedence over pulmonary function testing - ambulatory oximetry not useful [81] 4) elevated serum C-reactive protein is an inflammatory marker of metabolic syndrome [44] Special laboratory: 1) polysomnography*: gold standard a) 5 or more hypopnea or apneas/hour of sleep (apnea-hypopnea index > 5) b) recurrent arousals from sleep c) indicated vs portable sleep monitor for - mission-critical workers - severe cardiorespiratory disease - possible respiratory muscle weakness - hypoventilation while awake - potential sleep-related hypoventilation - chronic opioid use - history of stroke or severe insomnia [55,59] 2) portable sleep monitor (home testing) [55,59] a) uncomplicated cases with high pre-test probability - without cormordid cardiopulmonary disease [3] - without neuromuscular disease [3] - when polysomnography is not available [45] - performs comparably to polysomnography in these patients - non-inferior to polysomnography [58] b) >= 4 hours of oximetry & flow data should be obtained [55] - limited to measuring SaO2, airflow, & thoracic & abdominal movement [58] c) if home testing yields negative or inconclusive results, or is not technically adequate, polysomnography is indicated [55] 3) therapeutic trial of CPAP may be diagnostic [10] 4) pulmonary function testing 5) overnight pulse oximetry is useful for rule-out OSA in low-risk patients [3] - has not been validated as a screening tool for OSA [3] 6) clinical tools, questionnaires, or prediction algorithms inadequate without testing (polysomnography or portable sleep monitor) [55] 7) electrocardiogram: a) sinus arrhythmia seen in 90% of patients b) 2nd degree AV block c) premature ventricular contractions d) ventricular tachycardia e) component of polysomnography 8) echocardiogram may show a) pulmonary hypertension b) cor pulmonale * MKSAP19 [3] & GRS11 [40] differ on indications for polysomnography; * suspicion of OSA on the basis of snoring, hypertension, obesity, low SaO2 on room air is an indication for polysomnography per GRS11 [40] 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 Differential diagnosis: 1) endocrine disorders a) hypothyroidism b) acromegaly 2) ear, nose & throat disorders 3) narcolepsy 4) severe COPD 5) obesity-hypoventilation syndrome - obesity, COPD, hypercapnia during waking hours - may occur with obstructive sleep apnea Complications: 1) complications of repetitive hypoxemia a) systemic hypertension: CPAP may reduce risk [27] - resistant hypertension [46] b) pulmonary hypertension - initially episodic - may become sustained c) cardiac arrhythmias 2) late complications, especially with obesity & chronic lung disease a) hypoxemia b) hypercapnia - obesity hypoventilation syndrome c) polycythemia d) cor pulmonale 3) increased cardiovascular risk a) increased risk of coronary artery disease in women b) increased risk of stroke [11,78] c) increased cardiovascular mortality with severe OSA [9] - CPAP may improve LVEF in patients with CHF - CPAP may improve cardiovascular risk [26] - CPAP does not lower cardiovascular risk [68] d) increased risk of sudden cardiac death [35] - increased nocturnal hypercoagulability [34] 4) nocturia - release of atrial natriuretic peptide caused by cardiac distension brought about by the negative-pressure environment - patients may be bothered by nocturia, but the primary problem may be awakening due to a sleep disorder 5) other a) increased risk of motor vehicle accidents ? [19] b) postoperative pulmonary complications c) increased risk of pneumonia [39] d) insomnia worsens daytime functional impairment [40] e) hypogonadotropic hypogonadism [48] f) increased risk for depression & anxiety [65] g) cognitive impairment [40,75] - may play a role in tau accumulation in brain [66] - autonomic dysfunction assessed by nocturnal pulse rate variability may play a role [75] - may cause cognitive impairment in middle age [79] - severe OSA may result in reduced slow-wave sleep, the combination associated with increased white matter hyperintensities & possibly increased risk of cognitive impairment, dementia & stroke [82] h) testosterone deficiency & secondary hypogonadism in men [80] i) increased mortality [40] Management: 1) treat underlying/associated disorders 2) weight reduction in obese patients a) may mitigate symptoms [3,21,36] b) decreases serum C-reactive protein, an inflammatory marker of metabolic symdrome c) tirzepatide may be of benefit [87] d) non-surgical options should be tried prior to bariatric surgery [77] 3) alcohol & sedative avoidance, especially before bedtime 4) avoid medications for erectile dysfunction [17] (phosphodiesterase-5-inhibitors) disease interactions> - avoid testosterone replacement therapy - may exacerbate OSA [81] 5) avoid supine sleep position, sleep in lateral position - MKSAP suggests sleeping with head of bed elevated may be acceptable if patient desaturates when sleeping supine but is asymptomatic when awake & upright [3,84] 6) ear, nose & throat examination to identify surgically correctable signs of upper airway obstruction 7) positive airway pressure for symptomatic patients [3] - nasal continuous positive airway pressure (CPAP or APAP) [4,36] - heated humidification may improve compliance - CPAP may partially reverse metabolic syndrome in patients with OSA & metabolic syndrome [25] - may reduce blood pressure in OSA patients with resistant hypertension [37] - even patients with mild symptoms may benefit [29] - CPAP lowers systolic blood pressure [44] - CPAP may improve quality of life in adults with mild OSA [69] - improves snoring, daytime sleepiness, quality of life, & mood [54] - CPAP may improve cognitive function given the association of OSA with exacerbation of cognitive decline [40,73] - CPAP may or may not improve cardiovascular risk [54,57] - CPAP may diminish mortality in obese patients with severe OSA [64] - CPAP does not lower serum C-reactive protein [44] - CPAP does not improve glycemic control in diabetics with OSA [70] - compliance is an issue [3] - review data from the CPAP device in poor responders - auto-adjusting positive airway pressure & CPAP therapeutically equivalent for reducing apnea-hypopnea index [3] - bilevel positive airway pressure (BiPAP) may benefit patients who fail CPAP [3] - patients who improve with CPAP or APAP & have achieved significant weight reduction should be retested with a home sleep apnea test 8) oral appliances [5] a) elevation of soft palate b) advancement of tongue or mandible anteriorly (mandibular advance device) [36] c) objective benefit in 50% of patients with moderate OSA d) greater patient satisfaction e) almost as effective as CPAP [24] f) often better tolerated than CPAP [33] g) CPAP & mandibular advance devices affer similar reductions in blood pressure systolic BP (-2.5 mm Hg), diastolic BP (-2.0 mm Hg) [49] 9) oropharyngeal exercises may be of benefit 10) compression stockings may benefit patients with peripheral edema 11) pharmaceutical agents a) glucocorticoid nasal spray may benefit children [6] - fluticasone 1 spray each nostril BID b) modafanil (Provigil) may be helpful for patients with excessive daytime sleepiness despite CPAP [7] c) acetazolamide 750 mg PO QD helpful adjunct to CPAP for short trips to altitudes of 1600-2600 meters [30] d) ramelteon improves objective but not subjective sleep onset latency in patients with OSA on CPAP e) protriptyline not consistently effective in clinical trials f) mirtazapine not consistently effective in clinical trials [40,43] 12) supplemental oxygen is not recommended as a primary therapy for OSA [3] 13) surgery [41] a) tracheostomy 1] life-threatening hypoxemia 2] life-threatening cardiac arrhythmia 3] disabling hypersomnolence 4] intolerance of or non-compliance with other therapies b) maxillomandibular advancement surgery improves apnea-hypopnea index c) uvulopalatopharyngoplasty (uvula & palate resection) 1] objective improvement in 40% of patients 2] no selection criteria identifies patients likely to benefit 3] laser-assisted uvulopalatoplasty may reduce snoring, but does not benefit OSA 4] is a recommended surgical option for treatment of OSA [3] d) combined palatal & tongue surgery [71] e) staged genioglossal & maxillo-mandibular advancement 1] objective improvement in 40% of patients 2] limited centers with surgical experience f) hyoid myotomy & suspension g) tonsillectomy & adenoidectomy (children) [8,28] & in adults with tonsillar hypertrophy [40] h) cryolipolysis (cool sculpting) of tongue suggested [67] 14) hypoglossal nerve-stimulating device for OSA not responsive to CPAP [38] - hypoglossal nerve stimulation improves insomnia, sleepiness, quality of life, & depressive symptoms comparable to CPAP [72] - higher body mass index & supine sleeping position may decrease effects [86] 15) transcutaneous electrical stimulation of the submental area in patients with obstructive sleep apnea & poor compliance with CPAP can improve sleep apnea severity & associated sleepiness [83] 16) screening for obstructive sleep apnea - recommended prior to non-emergency surgery (see STOP-BANG) - insufficient evidence to recommend for or against routine screening (USPSTF) [56] Notes: - non-specialists can manage obstructive sleep apnea [60] - blistering report from AHRQ - studies are highly inconsistent in definition of breathing measures during sleep studies & of obstructive sleep apnea itself [76] - insufficient evidence exists to assess the validity of change in apnea-hypopnea index as a surrogate or intermediate measure for long-term health outcomes [76] - randomized controlled trials do not provide evidence that CPAP affects long-term, clinically important outcomes [76]

Interactions

disease interactions

Related

apnea-hypopnea index polysomnography (PSG) screening for obstructive sleep apnea sleep-related hypoventilation syndrome STOP BANG (STOP Questionnaire)

Specific

Pickwickian syndrome

General

sleep apnea

References

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