- Obstructive sleep apnea (OSA) is a common disorder affecting at least 2% to 4% of the adult population.
- The signs, symptoms and consequences of OSA are a direct result of repetitive collapse of the upper airway: sleep fragmentation, hypoxemia, hypercapnia, marked swings in intrathoracic pressure, and increased sympathetic activity.
- Clinically, OSA is defined by the occurrence of daytime sleepiness, loud snoring, witnessed breathing interruptions, or awakenings due to gasping or choking in the presence of at least 5 obstructive respiratory events (apneas, hypopneas or respiratory effort-related arousals) per hour of sleep.
- The presence of 15 or more obstructive respiratory events per hour of sleep in the absence of sleep related symptoms is also sufficient for the diagnosis of OSA.
- OSA can be treated in a variety of ways. Although CPAP is standard, behavioral and surgical approaches, oral appliances, medications, oxygen and bariatric surgery can be effective in selected cases.
- The sleep specialist should review the results of objective testing with the patient, including education on the nature of the disorder and treatment options.
- Treatment options should be discussed in the context of the severity of the patient’s OSA, their risk factors, any associated conditions, and the patient’s expectations.
- OSA should be approached as a chronic disease requiring long-term, multidisciplinary management.
Diagnosis and Assesment
- The severity of OSA must be established by objective testing in order to make an appropriate treatment decision.
- The two accepted methods of objective testing are in-laboratory polysomnography (PSG) and home testing with portable monitors (PM).
Comment: PM testing is not indicated in patients with major comorbid conditions including, but not limited to, moderate to severe pulmonary disease, neuromuscular disease, or congestive heart failure, or those suspected of having a comorbid sleep disorder.
- A preoperative clinical evaluation that includes PSG or PM is routinely indicated to evaluate for the presence of OSA in patients before they undergo upper airway surgery for snoring or OSA.
- A preoperative clinical sleep evaluation that includes PSG is recommended to evaluate for the presence of OSA in patients before they undergo bariatric surgery.
- The use of PSG for evaluating OSA requires recording the following physiologic signals: electroencephalogram (EEG), electrooculogram (EOG), chin electromyogram, airflow, oxygen saturation, respiratory effort, and electrocardiogram (ECG) or heart rate.
- Additional recommended parameters include body position and leg EMG derivations.
- The diagnosis of OSA is confirmed if the number of obstructive events on PSG is greater than 15 events/hr or greater than 5/hr in a patient who reports any of the following: unintentional sleep episodes during wakefulness; daytime sleepiness; unrefreshing sleep; fatigue; insomnia; waking up holding breath, gasping, or choking; or the bed partner describing loud snoring, breathing interruptions, or both during the patient’s sleep. OSA severity is defined as mild for RDI ≥ 5 and < 15, moderate for RDI ≥ 15 and ≤ 30, and severe for RDI > 30/hr.
- Portable monitors for the diagnosis of OSA should be performed only in conjunction with a comprehensive sleep evaluation.
Table 1. Patients at High Risk for OSA Who Should Be Evaluated for OSA Symptoms
- Obesity (BMI > 35)
- Congestive heart failure
- Atrial fibrillation
- Treatment refractory hypertension
- Type 2 diabetes
- Nocturnal dysrhythmias
- Pulmonary hypertension
- High-risk driving populations
Table 2. Questions About OSA That Should Be Included in Routine Health Maintenance Evaluations
- Is the patient obese?
- Is the patient retrognathic?
- Does the patient complain of daytime sleepiness?
- Does the patient snore?
- Does the patient have hypertension?
Table 3. OSA Symptoms That Should Be Evaluated During a Comprehensive Sleep Evaluation
- Witnessed apneas
- Gasping/choking at night
- Excessive sleepiness not explained by other factors
- Nonrefreshing sleep
- Total sleep amount
- Sleep fragmentation/maintenance insomnia
- Morning headaches
- Decreased concentration
- Memory loss
- Decreased libido
FDA-Approved Drugs for OSA
|armodafinil Nuvigil®||150-250 mg PO qAM||Indicated for narcolepsy, shift work sleep disorder and as an adjunct to standard treatment(s) for the underlying obstruction in OSA||Serious skin and multi-organ allergic reactions, persistent sleepiness, psychiatric symptoms|
|modafinil Provigil®||200 mg PO qAM|