Apnea
Obstructive Sleep Apnea
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Obstructive Sleep Apnea
See Also
CPAP for Obstructive Sleep Apnea
Obstructive Sleep Apnea in Children
Sleep Apnea
Central Sleep Apnea
Definitions
Obstructive Sleep Apnea
Airway obstruction at night resulting in apnea, hypopnea and snoring
Associated wih
Daytime Somnolence
and morning
Headache
s
Hypopnea
Slow or shallow breathing
Apnea
Paused breathing
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
Causes
Adults
Narrow airway (key factor)
Narrows most in the hypopharynx (below
Tongue
)
Can narrow to pencil diameter in some patients
Obesity
and short neck
Hypognathia
Jaw deformities
Large
Tongue
and uvula
Neurologic deficits (central or peripheral)
Children (occurs in 1-3% of children)
See
Obstructive Sleep Apnea in Children
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
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
Symptoms
Adults
Excessive
Daytime Sleepiness
(
Daytime Somnolence
)
Falling asleep at wheel or in conversation
May also present with alternative terminology
Fatigue
Tiredness
Lack of energy
Loud snoring
Gasping or
Choking
during sleep
Nocturnal
Hypertension
and
Arrhythmia
s
Morning
Headache
Nocturia
Nocturnal confusion
Intellectual deterioration or
Cognitive Impairment
Symptoms
Children
Minimal
Hypersomnolence
if any
Nocturnal Enuresis
Excessing nighttime sweating
Developmental Delay
Learning difficulties (e.g.
ADHD
)
Signs
Gene
ral appearance
Short neck
Overweight
(
Obesity
in 70% of cases)
Nasopharynx
Nasal Polyp
s
Severe septal deviation
Large residual adenoid tissue
Oropharynx
Macroglossia
Large
Tonsil
s
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
Differential Diagnosis
See
Sleepiness
Central Sleep Apnea
Complications
See
Sleep Apnea
Increased mortality risk and stroke risk
Yaggi (2005) N Engl J Med [PubMed]
Heilbrunn (2021) BMJ Open Respiratory Research 8:e000656 [PubMed]
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
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]
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
Parasomnia
s from
Sleep Apnea
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 Triglyceride
s
Bilevel Pap (BIPAP) Indications
Hypoventilation during sleep
High airway pressures required
Difficulty exhaling against fixed pressure
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
Reference
Braver (1995) Chest 107:1283-8 [PubMed]
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
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 Corticosteroid
s
Chronic
Rhinitis
Nasal Polyp
s
Septal deviation
Tricyclic Antidepressant
s
Avoid harmful medications
Avoid
CNS Depressant
or
Sedative
medications (e.g.
Benzodiazepine
s,
Benzodiazepine Receptor Agonist
s)
Sedative
s 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
Muscle
s)
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
Kent (2021) J Clin Sleep Med 17(12):2499-505 +PMID: 34351848 [PubMed]
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
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]
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