Obstructive sleep apnea

Background

• Obstructive sleep apnea (OSA) is a common, potentially serious sleep disorder
• Characterized by repetitive collapse of the upper airway leading to intermittent pauses in breathing during sleep
• Most common in adult males and postmenopausal women
• Risk factors include older age, male gender, obesity, and upper airway abnormalities
• Complications include drowsy driving/motor vehicle accidents, neuropsychiatric dysfunction, cardiovascular morbidity, pulmonary hypertension, and right heart failure.

Clinical Features

• Daytime sleepiness
  • May be underestimated due to chronic nature, insidious onset
• Loud snoring, gasping, interruptions in breathing while sleeping
• Morning headaches
  • Usually bifrontal, squeezing
  • Possibly secondary to hypercapnia, vasodilation, increased intracranial pressure, and impaired sleep quality

Differential Diagnosis

• Excessive daytime sleepiness
  • Insufficient sleep - shift work, underlying comorbidity, medication affects
  • Sleep disorders - circadian rhythm sleep-wake disorder, narcolepsy
  • Sleep related movement disorder - restless legs syndrome, periodic limb movement disorder
• Abrupt awakening or abnormal sounds during sleep
  • Primary snoring - Most patients who have OSA snore, but most patients who snore do not have OSA.
  • GERD- can produce a choking sensation and dyspnea at night
  • Nocturnal asthma
  • Nocturnal seizure
• Early morning headaches
  • Space occupying lesions of the brain
  • Obesity hypoventilation - would potentially show hypercapnia/hypercarbia on venous blood gas

Evaluation

Not typically an ED diagnosis

• Evaluate for alternative, emergent etiology of symptoms
• Not a clinical diagnosis and objective testing must be performed for diagnosis
• Consider diagnostic testing with patients with excessive day time sleepiness (EDS) on most days and two of the following clinical features: habitual loud snoring, witnessed apnea or gasping or choking during sleep, and diagnosed systemic hypertension.
• Evaluation tool parameters: No evaluation tools have been shown to be superior to history and physical examination and their poor accuracy make them imperfect diagnostic tools, but are often used in preoperative evaluation to assess risk of undiagnosed OSA
  • STOP-Bang questionnaire
  • Epworth Sleepiness Scale
• Polysomnography: gold standard diagnostic test for OSA. Preferred in-lab testing for those with suspected concomitant respiratory disorder (e.g. COPD), concomitant sleep disorder(e.g. narcolepsy), mild disease, negative or inconclusive home testing
• Home sleep apnea testing: Good for patients with high pretest probability for moderate to severe uncomplicated OSA.

Management

• Patient education
• Behavioral modification
  • Losing weight if overweight
  • Exercise
  • Changing sleep position if positional
  • Abstaining from alcohol or certain sedative medications
• Positive airway pressure during sleep
• Oral appliance is reasonable second line for mild-moderate OSA
• Surgical therapy
  • Surgical resection of obstructing lesion
  • Hypoglossal nerve stimulation

Disposition

• Discharge- consider sleep medicine referral