Sleep Apnea Disease

DESCRIPTION

Repetitive episodes of upper airway occlusion during sleep, often with oxygen desaturation. Nearly always associated with snoring. Apneas often terminate with a snort or gasp. Repetitive apneas produce sleep disruption, leading to excessive daytime sleepiness (EDS). Usual course is chronic.

System(s) affected: Pulmonary, Nervous
Genetics: Hereditary factors unknown. Familial patterns sometimes seen.
Incidence/Prevalence in USA: 4% of middle-age and older males; 2% middle-age and older females
Predominant age: Middle-age
Predominant sex: Males > Females

SIGNS AND SYMPTOMS

Cardinal symptom is excessive daytime sleepiness (EDS)
Loud snoring
Complaints of disrupted sleep
Repetitive awakenings with transient sensation of shortness of breath or for unclear reasons
Tired and unrefreshed upon A.M. awakening
Witnessed apneas at night
Complaints of poor concentration, memory problems, irritability
Morning headaches
Short-tempered
Decreased libido is also common
Depression
Systemic and pulmonary hypertension

CAUSES

Upper airway narrowing may be due to obesity, enlarged tonsils or uvula, low soft palate, redundant tissue in soft palate or tonsillar pillars, large or posteriorly located tongue or craniofacial abnormalities. Anatomical narrowing superimposed upon a coexistent abnormality of neurological control of upper airway muscle tone or ventilatory control during sleep.

RISK FACTORS

Obesity
Nasal obstruction (due to polyps, rhinitis or deviated septum)
Hypothyroidism
Macroglossia
Micrognathia (retrognathia)
Acromegaly
Persons with hypertension, cardiovascular or arteriovascular disease, or alveolar hypoventilation have a much higher risk of obstructive sleep apnea (OSA)

LABORATORY

Polycythemia (occasional) reflects the degree of nocturnal hypoxemia due to OSA
Thyroid function should be evaluated to rule out concomitant hypothyroidism
Daytime hypercapnia occasionally seen

Drugs that may alter lab results: Benzodiazepines or other sedatives can accentuate the severity of apnea seen on sleep study
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Anatomically small upper airway common
CNS abnormalities rare

SPECIAL TESTS

Echocardiography may demonstrate right and/or left ventricular enlargement or pulmonary hypertension
Polysomnogram (nighttime sleep study) including O₂ saturation, CO₂
Multiple sleep latency testing (MSLT) provides an objective measurement of daytime sleepiness

IMAGING

Cephalometric measurements from lateral head and neck x-rays are occasionally useful if surgery is contemplated
MRI, CT scans or fiberoptic evaluation of upper airway occasionally helpful

DIAGNOSTIC PROCEDURES

Nighttime sleep study (polysomnogram)
- Shows repetitive episodes of cessation or marked reduction in airflow despite continued respiratory efforts
- These apneic episodes must last at least 10 seconds and occur 10-15 times per hour to be considered clinically significant
- Polysomnogram demonstrates severity of hypoxemia, sleep disruption and cardiac arrhythmias associated with OSA and elevated end tidal CO2

APPROPRIATE HEALTH CARE

Outpatient for treatment or sleep study; inpatient for surgery

GENERAL MEASURES

For patients with significant EDS and 15-20 apneas per hour or more, CPAP is probably the best treatment
If OSA present only when supine, keep patient off the back (e.g., tennis ball sewn on nightshirt or fanny-pack with tennis balls worn at back)
Mild to moderate OSA - surgery (tonsillectomy or uvulopalatopharyngoplasty [UPPP]), dental appliances or nasal continuous positive airway pressure (CPAP)
Moderate to severe OSA: CPAP or BiPAP (biphasic positive airway pressure) is the standard therapy
Avoid driving if EDS is significant
No alcohol within 6 hours of bedtime
Avoid sedatives and sleeping pills

SURGICAL MEASURES

Severe OSA that is not controllable with nasal CPAP or UPPP - tracheostomy or craniofacial surgery (mandibular advancement)

ACTIVITY

Significantly sleepy patients should not drive motor vehicle or operate equipment with risk for injury until treated

DIET

Obese patients must lose weight. All patients must avoid weight gain and alcohol.

PATIENT EDUCATION

Stress the fact that obesity can be the cause of OSA and that weight loss may "cure" the condition
Emphasize the necessity to avoid alcohol and sedatives
Stress the dangers of driving while suffering from excessive daytime sleepiness (EDS)

PREVENTION/AVOIDANCE

See Patient Education

POSSIBLE COMPLICATIONS

Untreated OSA can be associated with development of pulmonary hypertension, ventricular arrhythmias, cor pulmonale, and congestive heart failure (CHF)
Significant morbidity and mortality due to accidents caused by excessive daytime sleepiness (EDS) and inattentiveness
Acute blood pressure elevations

EXPECTED COURSE AND PROGNOSIS

With appropriate control of apneas, excessive daytime sleepiness (EDS) dramatically improves quickly
All therapeutic measures other than surgery and aggressive weight loss in obese patients are methods of apnea control, rather than cure; lifelong compliance with weight loss or nasal CPAP is necessary for therapy of OSA
Untreated OSA appears to progress in severity
Death due to OSA usually occurs secondary to arrhythmias, cardiac ischemia, hypertensive complications, or motor vehicle accidents

ASSOCIATED CONDITIONS

Hypertension
Arteriosclerotic vascular disease
Coronary arterial disease
Diabetes
Obesity
Nasal obstructive problems
Acromegaly
Hypothyroidism

AGE-RELATED FACTORS

Pediatric:

OSA not as common in pediatric age group. If present, often due to tonsillar enlargement, craniofacial abnormalities. Response to tonsillectomy often good.
Seen commonly in children with neuromuscular diseases, such as cerebral palsy, spinal muscular atrophy

Geriatric: OSA appears to increase in frequency after middle age and after the menopause in women. Often coexists with other health problems in the elderly.
Others: N/A

PREGNANCY

Rare

OTHER NOTES

OSA rare in premenopausal women unless there is coexistent morbid obesity or neurologic/craniofacial abnormalities

ABBREVIATIONS

CPAP = continuous positive airway pressure
BiPAP = bilevel positive airway pressure
UPPP = uvulopalatopharyngoplasty
EDS = excessive daytime sleepiness
OSA = obstructive sleep apnea

Clinical Investigations

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