Obstructive Sleep Apnea


Article Author:
Jennifer Slowik


Article Editor:
Jacob Collen


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/11/2019 3:28:49 PM

Introduction

Obstructive sleep apnea (OSA) is characterized by episodes of complete collapse of the airway or partial collapse with an associated decrease in oxygen saturation or arousal from sleep. This disturbance results in fragmented, nonrestorative sleep. Other symptoms include loud, disruptive snoring, witnessed apneas during sleep, and excessive daytime sleepiness. OSA has significant implications for cardiovascular health, mental illness, quality of life and driving safety.[1][2][3]

Etiology

Sleep apnea occurs when there is not enough space to accommodate sufficient airflow in a portion of the upper airway during sleep. When muscle tone is decreased, the result is a repetitive total or partial collapse of the airway. In children, the most common cause of obstructive sleep apnea is enlarged tonsils and/or adenoids. In adults, it is most commonly associated with obesity, male sex, and advancing age.

Epidemiology

In the United States, it has been reported that 4% of men and 2% of women meet criteria for obstructive sleep apnea. More recently, prevalence has been reported to be as high as 14% of men and 5% of women in the United States. Prevalence is higher in Hispanic, African American, and Asian populations. Prevalence also increases with age, and when individuals reach 50 years of age or more, there are as many women as men who develop the disorder.

Pathophysiology

Muscle tone decreases during sleep and is lowest during REM sleep. An episode of apnea in obstructive sleep apnea is caused by at least 90% anterior to a posterior collapse of the airway for more than 10 seconds. A hypopnea is characterized by at least 30% reduction in airflow for more than 10 seconds associated with an oxygen desaturation or arousal on electroencephalogram (EEG).

History and Physical

The typical adult obstructive sleep apnea patient is overweight or obese middle-aged male or postmenopausal female with excessive daytime sleepiness and loud nightly snoring. They may also complain of waking to gasp for breath or choking, sleep maintenance insomnia, night sweats, nighttime reflux, and nocturia in the absence of excessive nighttime liquid intake. A physical exam is typically notable for a larger than average neck circumference (17 inches in males) with crowded oropharynx (Mallampati 3 to 4) and large tongue. Retrognathism may be present. Patients with refractory atrial fibrillation, resistant hypertension, and history of a stroke should be screened for sleep apnea regardless of symptoms.

The typical child with obstructive sleep apnea will have loud nightly snoring, may be hyperactive rather than sleepy, and may have academic difficulties. These children can be incorrectly diagnosed with attention deficit hyperactivity disorder (ADHD). Night sweats, nighttime reflux, sleep maintenance insomnia, restless sleep with frequent limb movements, and secondary nocturnal enuresis may also be present. A physical exam is often notable for adenoidal facies, tonsillar hypertrophy, hyponasal speech, and high arched palate. Patients with Down syndrome and any other condition associated with hypotonia should be screened for obstructive sleep apnea regardless of symptoms.

The Epworth Sleepiness Scale can be used to gauge the patient's likelihood of dozing in different settings as an indicator of inadequate restorative nighttime sleep. The score ranges from zero to 24, and more than ten is suggestive of a sleep disorder rather than generalized fatigue. More specific to obstructive sleep apnea is the STOP-BANG score. (S) snoring, (T) tired, (O) observed apnea, (P) pressure (blood pressure), (B) BMI more than 35, (A) older than 50 years old, (N) neck greater than 40 cm, and (G) gender (male). If there are three or more positive answers, the patient is considered high risk of obstructive sleep apnea and should be referred for further evaluation. There is a modified STOP-BANG questionnaire for older children and teens (nine to 17 years old) that allows parents to report how often the child snores loudly or has witnessed apneas and assesses for additional risk factors (presence of hypertension, obesity, neck circumference more than 95 percentile for age, male sex). Alternatively, the Berlin Questionnaire evaluates the presence, loudness, and frequency of snoring, the presence of apneas, daytime sleepiness, hypertension, and obesity to predict a high or low likelihood of sleep apnea.

Evaluation

Nighttime in-laboratory Level 1 polysomnography (PSG) is the standard gold test for diagnosis of obstructive sleep apnea. During the test, patients are monitored with EEG leads, pulse oximetry, temperature and pressure sensors to detect nasal and oral airflow, respiratory impedance plethysmography or similar resistance belts around the chest and abdomen to detect motion, an ECG lead, and EMG sensors to detect muscle contraction in the chin, chest, and legs. A hypopnea can be based on one of two criteria. It can either be a reduction in airflow of at least 30% for more than 10 seconds associated with at least 4% oxygen desaturation or a reduction in airflow of at least 30% for more than 10 seconds associated with at least 3% oxygen desaturation or an arousal from sleep on EEG.

Home sleep tests (HST) have gained popularity due to their relative accessibility and lower cost. They are appropriate for adults with a high pretest probability for sleep apnea and no significant medical comorbidities (advanced congestive heart failure, COPD, and neurologic disorders). These are level 3 sleep tests consisting of pulse oximetry, heart rate monitoring, temperature and pressure sensors to detect nasal and oral airflow, resistance belts around the chest and abdomen to detect motion, and a sensor to detect body position. Moderate and severe sleep apnea is detected on these tests, but due to the chance of underestimating the apnea-hypopnea index (AHI) relative to the total recording time (which may be longer than the total sleep time measured on an in-lab study), mild sleep apnea may go undiagnosed, and a repeat in-lab study may be needed.

The apnea-hypopnea index is the average number of obstructive event per hour. In adults, if the apnea-hypopnea index is greater than or equal to fifteen events per hour the diagnosis of obstructive sleep apnea is made with 15 to 29.9 per hour being moderate, and 30 or more events per hour being severe obstructive sleep apnea. An apnea-hypopnea index 5 to 14.9/hour is considered mild obstructive sleep apnea but only if there are clinical sequelae of the condition reported (excessive daytime sleepiness, sleep maintenance insomnia, cognitive dysfunction). Children are diagnosed with mild obstructive sleep apnea with an apnea-hypopnea index 1 to 4.9 per hour and clinical sequelae. Apnea-hypopnea index 5 to 9.9 events per hour is moderate and 10 or greater per hour is severe. Either adult or child criteria can be used for patients 13 to 17 years old at the discretion of the clinician depending on the clinical picture.[4][5][6]

Treatment / Management

For adults, the use of continuous positive airway pressure (CPAP) is the most effective treatment, and diligent adherence to nightly CPAP use can result in near complete resolution of symptoms. For patients unable or unwilling to use CPAP or those who will be unable to access electricity reliably, custom fitted and titrated oral appliances can be used to bring the lower jaw forward and relieve airway obstruction. This typically works best for candidates deemed to have appropriate dentition and mild to moderate sleep apnea. Severe obstructive sleep apnea can be treated with BiPAP as well and is better tolerated by patients who require higher pressure settings (greater than 15 cm to 20 cm H2O). For all patients, it is important to address any concomitant nasal obstruction with nasal steroids for allergic rhinitis or surgically for nasal valve collapse.

For obstructive sleep apnea with a strong positional component, a positioning device to keep a patient on his or her side can be an option. Although weight loss is recommended and can often decrease the severity of obstructive sleep apnea, it is not usually curative by itself.  

The primary treatment for obstructive sleep apnea in a child is tonsillectomy and adenoidectomy. The consideration for surgery should be balanced with the severity of symptoms, physical exam, and age. In mild cases, a trial of montelukast and nasal steroids may be enough to reduce the apnea-hypopnea index to goal. There are surgical options for adults, but these are usually reserved for severe obstructive sleep apnea and patients unable to tolerate noninvasive treatment modalities due to surgical risks and varying efficacy.

Uvulopalatopharyngoplasty (UPPP) is a term used to describe surgically removing the uvula and tissue from the soft palate to create more space in the oropharynx. This is sometimes done in conjunction with a tonsillectomy and adenoidectomy. More recently, drug-induced sleep endoscopy (DISE) has been used for preoperative planning to identify multiples levels of obstruction that are often present in these patients. This allows surgeons to address any nasal, soft palate and hypopharyngeal obstructions that may be present during a single surgery.

Another surgical option is maxillomandibular advancement (MMA) in which both the upper and lower jaws are detached and surgically advanced anteriorly to increase space in the oropharynx. This is best for patients with retrognathia and is less successful in older patients or those with larger neck circumferences.

A newer option is the implantable hypoglossal nerve stimulator. It works by stimulating the genioglossus (upper airway dilator muscle) during apneas resulting in protrusion of the tongue and relief of the obstruction. To be considered a candidate patient must meet the following criteria: BMI  less than 32, more than 22 years of age, apnea-hypopnea index 2 to 65 with less than 25% central apneas, unable to tolerate CPAP and no complete concentric collapse at the palate on drug induced sleep endoscopy.  The use of a permanent surgically-implanted device with limited time on the market and limited published long-term data on safety and efficacy should be pursued in specialty centers with experience in the surgical treatment of sleep-disordered breathing, in appropriately selected patients.

In extreme cases, obstructive sleep apnea can also be treated with a tracheostomy to bypass the oropharyngeal obstruction. This management option is also best addressed at academic or specialty sleep centers that are experienced in the care of patients with tracheostomy.  Such patients will encounter numerous challenges with home care and durable medical equipment and family/partner education on tracheostomy management. Many patients with severe sleep disordered breathing requiring tracheostomy have comorbidities and require long term home-based mechanical ventilation, the management of which will be outside the scope of most community sleep medicine practices.

Patients should be counseled to avoid alcohol, benzodiazepines, opiates, and some antidepressants which may worsen their condition.  Most importantly, patients should reflect on the impact of sleep duration and their health, and place a priority on getting at least 7 to 8 hours of sleep per night. No treatment for OSA per se will correct insufficient sleep.[7][8][9]

Enhancing Healthcare Team Outcomes

The management of patients with OSA is with a multidisciplinary team that includes a sleep specialist, internist, cardiologist, ENT surgeon, dietitian, pulmonologist and neurologist. There are many options to treat OSA of which the primary one is CPAP. Unfortunately, compliance with CPAP remains low. Some patients may benefit from an oral or nasal device but again compliance remains an issue. Surgery is the last step and should only be considered after a thorough evaluation of the patient. Surgery does not cure the disorder, is expensive and associated with serious complications. The prognosis for most patients with OSA is guarded. Until the patient starts to lose weight, most therapies have poor efficacy.

 


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Obstructive Sleep Apnea - Questions

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Which of the following is a risk factor for postoperative respiratory complications for children undergoing adenotonsillectomy for obstructive sleep apnea (OSA)?



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What anthropomorphic measurement is the most important in predicting the presence of obstructive sleep apnea syndrome?



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Many factors influence the successful use of an oral appliance for obstructive sleep apnea. Which of the following is not one of those factors?



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Which of the following is the most common cause of obstructive sleep apnea in children?



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What diagnostic study should be ordered to evaluate a patient for possible obstructive sleep apnea?



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A 55-year-old male reports falling asleep at work during lunchtime meetings and while working at his desk. He has gained over 75 pounds in the last 2 years. On exam, his neck circumference is 19 inches. What is the most likely diagnosis?



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Which acid base disorder is most likely in a patient with obstructive sleep apnea? (pH/HCO3/PO2/PCO2)



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Which sleep disorder is most common in individuals over age 65?



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A morbidly obese patient has long-standing and severe untreated obstructive sleep apnea (OSA). Which of the following findings are least likely to be present?



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How many apneic or hypopneic episodes per hour occur during moderate sleep apnea?



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Which is NOT associated with longstanding, untreated obstructive sleep apnea?



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Which of the following is the best treatment for obstructive sleep apnea?



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Which of the following is a definite indication for tonsillectomy?



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What is a common feature of obstructive sleep apnea?



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Which of the following tests should be done to diagnose obstructive sleep apnea?



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Which of the following is an absolute indication for tonsillectomy in children?



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A male complains of falling asleep at work and during meetings. His wife complains about his snoring and reports he stops breathing for up to 20 seconds. The patient's body mass index is 33 and his neck measures 18 inches. The rest of his exam is normal. Select the appropriate management.



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Select the most common sleep disorder among the choices below.



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Select the incorrect statement about obstructive sleep apnea (OSA).



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Select the correct statement about sleep and headaches.



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Select the sleep disorder most commonly seen in the elderly.



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Which of the following is not increased in patients with obstructive sleep apnea?



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What is the most commonly used treatment for moderate to severe sleep apnea?



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According to the apnea-hypopnea index (AHI), how many episodes per hour is indicative of mild obstructive sleep apnea (OSA)?



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A male patient presents with daytime drowsiness. He falls asleep in meetings and once while driving. Which of the following is the most likely cause of his condition?



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Which of the following is true about obstructive sleep apnea (OSA)?



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Which of the following is an example of sleep apnea caused by the disruption of the central drive to breathe?



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A 50-year-old man complains of a lack of energy. He nods off during the day, although he sleeps eight hours. When asked about other medications, he reports none that would cause drowsiness. He states that his wife complains about his snoring. What is the most likely diagnosis?



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Who is most likely to suffer from obstructive sleep apnea (OSA)?



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Which of the following is not commonly part of the presentation of a patient with obstructive sleep apnea?



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Which is not true regarding obstructive sleep apnea?



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Which treatment often is a complete cure for obstructive sleep apnea?



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An 8-year-old male is at the twenty-fifth percentile for height and the ninety-fifth percentile for weight. His mother reports that he snores loudly at night and his teacher complains that he often falls asleep in class. He complains of headaches. What is the next step in evaluation?



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A 5-year-old boy presents with his parents who report that he snores and occasionally stops breathing for up to 10 seconds. The child is otherwise healthy. He is at the tenth percentile for height, the fifth percentile for weight, and the fiftieth percentile for head circumference. The only physical finding is tonsillar hypertrophy. What symptom is he least likely to have?



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At what point is central sleep apnea significant in preschool children?



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In what way does obstructive sleep apnea (OSA) differ between children and adults?



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Which of the following is the least likely complication of obstructive sleep apnea in children?



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A 5-year-old child snores loudly and stops breathing for up to 20 seconds at night. The parents report this has been happening for a couple of years. The tonsils are 3+/4 enlarged, but the rest of the exam is normal. What is the initial step in evaluation?



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What is the initial treatment for most children with obstructive sleep apnea (OSA)?



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A child with obstructive sleep apnea (OSA) undergoes tonsillectomy and adenoidectomy. Which of the following is true?



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A 65-year-old male with a known diagnosis of obesity hypoventilation syndrome presents with worsening of nocturnal apneic episodes. Sleep studies show a PaCO2 of 60 mmHg for over 10 minutes. According to the German Society for Pneumology and Respiratory Medicine, what is the best initial treatment?



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A 65-year-old male presents with complaints of loud snoring, nocturnal choking episodes with witnessed apneas, and excessive daytime sleepiness of 2 months duration. Sleep studies show a PaCO2 of 50 mmHg for over 5 minutes. A diagnosis of obesity hypoventilation syndrome with concomitant sleep apnea is made. What is the best initial treatment?



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Obstructive Sleep Apnea - References

References

Mehrtash M,Bakker JP,Ayas N, Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea. Lung. 2019 Jan 7;     [PubMed]
Esteller E,Carrasco M,Díaz-Herrera MÁ,Vila J,Sampol G,Juvanteny J,Sieira R,Farré A,Vilaseca I, Clinical Practice Guideline recommendations on examination of the upper airway for adults with suspected obstructive sleep apnoea-hypopnoea syndrome. Acta otorrinolaringologica espanola. 2019 Jan 4;     [PubMed]
Carneiro-Barrera A,Díaz-Román A,Guillén-Riquelme A,Buela-Casal G, Weight loss and lifestyle interventions for obstructive sleep apnoea in adults: Systematic review and meta-analysis. Obesity reviews : an official journal of the International Association for the Study of Obesity. 2019 Jan 4;     [PubMed]
Tietjens JR,Claman D,Kezirian EJ,De Marco T,Mirzayan A,Sadroonri B,Goldberg AN,Long C,Gerstenfeld EP,Yeghiazarians Y, Obstructive Sleep Apnea in Cardiovascular Disease: A Review of the Literature and Proposed Multidisciplinary Clinical Management Strategy. Journal of the American Heart Association. 2019 Jan 8;     [PubMed]
Dey D,Chaudhuri S,Munshi S, Obstructive sleep apnoea detection using convolutional neural network based deep learning framework. Biomedical engineering letters. 2018 Feb;     [PubMed]
Sascău R,Zota IM,Stătescu C,Boișteanu D,Roca M,Maștaleru A,Leon Constantin MM,Vasilcu TF,Gavril RS,Mitu F, Review of Echocardiographic Findings in Patients with Obstructive Sleep Apnea. Canadian respiratory journal. 2018;     [PubMed]
Miller BJ,Gupta G, Adenoidectomy 2018 Jan;     [PubMed]
Green KK,Kent DT,D'Agostino MA,Hoff PT,Lin HS,Soose RJ,Boyd Gillespie M,Yaremchuk KL,Carrasco-Llatas M,Tucker Woodson B,Jacobowitz O,Thaler ER,Barrera JE,Capasso R,Liu SY,Hsia J,Mann D,Meraj TS,Waxman JA,Kezirian EJ, Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study. The Laryngoscope. 2018 Dec 27;     [PubMed]
Sutherland K,Kairaitis K,Yee BJ,Cistulli PA, From CPAP to tailored therapy for obstructive sleep Apnoea. Multidisciplinary respiratory medicine. 2018;     [PubMed]

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