Obstructive Sleep Apnea: Is it in your Differential?

Obstructive Sleep Apnea: Is it in your Differential? Helene Hill Professor Sam Powdrill PAS 645

Agenda • Introduction • Pathophysiology • Risk Factors • Comorbid Conditions • Application

Obstructive Sleep Apnea • AKA the “Spousal Arousal” syndrome • Prevention and early treatment is essential • The problem is that PCP might not consider OSA in the non-stereotypical patients “Laugh and the world laughs with you, snore and you sleep alone.” ~ Anthony Burgess

Obstructive Sleep Apnea • Epidemiology • More prevalent than once was believed • Wisconsin Sleep Cohort Study • 9% women • 24% men • Estimated that 80-90% are undiagnosed • Comorbidities • Awareness • SES

Pathophysiology • A sleep breathing disorder due to a mechanical problem of tissue collapse • Apnea leads to • Oxyhemoglobin desaturation • Fragmentation in sleep cycle • Variability in BP and HR/Increase in SNS • Persistent hypoxia manifests with numerous daytime Sx

Treatment • Mild 5-15/hr • Lifestyle modification • Weight loss • Elimination of products that suppress respiration • No BZDs • Sleeping position modification

Treatment • Moderate 15-30/hr • More in-depth plus lifestyle changes • CPAP • Oral appliances • Mandible advancing • Tongue device Martin Dunitz

Treatment • Severe > 30/hr • Surgical procedures in addition to previous changes • Tonsillectomy/adenoidectomy • Nasal surgery combined with pharyngeal surgery • Uvulopalatopharyngoplasty (UPPP) Martin Dunitz

Risk Factors • “Pickwickian Patient” • Male Sex • Age 40-70 yr • Familial Aggregation • Established risk factors • Body habitus • Craniofacial/Upper Airway Abnormalities • Suspected risk factors • Genetics • Smoking • Menopause • Alcohol before sleep • Nighttime nasal congestion

Martin Dunitz

Comorbid Conditions • Decreased daytime functioning • Daytime sleepiness • Psychosocial problems – STRESS! • Decreased cognitive function

Comorbid Conditions • Cardiovascular/Cerebrovascular Disease • Stroke, pulmonary HTN, CHF • Resistant hypertension • Increased sympathetic activity • Vasculopathy • Activation of vasoconstrictors • Sustained hypertensive effects • “Non-dipping” phenomenon

Comorbid Conditions • Diabetes/Metabolic Syndrome • Vascular disease that lead to endothelial dysfunction • OSA is independently associated with insulin resistance • Control OSA, see better control of DM

So is it in your Dif Dx? • Few easy steps • Consider OSA in patients who snore or have excessive daytime sleepiness • Check out risk factors and get detailed history • Consider your alternatives • Consider OSA when evaluating patients for comorbidities associated with sleep apnea

Wrapping it up… • Don’t forget to treat the underlying condition! • Don’t forget the non-stereotypicals! • Know risk factors and what OSA can do if left untreated! • Future ideas… • Hypoglossal nerve stimulation • Serotonergic medications

References Available upon request

Obstructive Sleep Apnea: Is it in your Differential?