Scott Biggs, PA-C
When most people hear the term “Sleep Apnea”, they picture a character in the movies or on TV who is loudly snoring and grunting in their sleep, oblivious to the world around them. While this serves as a great comedic representation, the reality is that millions of people worldwide suffer from sleep apnea symptoms nightly. But how do you tell if your snoring patient has sleep apnea? Well, let’s dive into it.
Sleep apnea, or more properly, Obstructive Sleep Apnea (OSA), is a medical condition wherein the upper airway relaxes during sleep. This causes obstruction and periods of apnea or hypopnea. These events happen frequently enough to disturb the patient’s normal resting sleep, causing them to wake frequently during the night. Most patients with OSA complain of excessive daytime sleepiness (EDS) and fatigue despite getting what should be a normal amount of sleep each night. They also may complain of insomnia, morning headaches, and palpitations or angina-type symptoms in the middle of the night. In the US, the majority of patients with OSA are male, obese, and have other comorbid conditions. These commonly include CHF, GERD, COPD, and hypertension.
Patients mostly present complaining of chronic EDS and fatigue, or their partner is complaining about their excessive snoring or abnormal breathing during the night. These complaints, plus the presence of risk factors, should prompt the consideration of sleep apnea testing. Despite the prevalence of questionnaires and tools such as the Epworth Sleepiness Scale and the Fatigue Severity Scale, making the diagnosis still requires objective testing.
Full-night polysomnography in a monitored sleep lab Is the gold standard test for diagnosis. Depending on the pre-test probability of moderate to severe sleep apnea without the presence of another condition causing sleep disturbances, the patient may do at-home sleep testing where the date is collected at home and reviewed by a sleep specialist off site.The patient is observed throughout the normal sleep cycle and evaluated for episodes of apnea and hypopnea. These episodes are calculated as an index (the Apnea-Hypopnea index). This Index is the sum of the number of apneas (pauses in breathing) plus the number of hypopneas (periods of shallow breathing) that occur, on average, each hour. The usual threshold for diagnosis is an apnea-hypopnea index (AHI) >15. Patients at this level have moderate to severe sleep apnea. They may benefit from positive airway pressure therapy.
|<5||Normal (No sleep apnea)|
|5-15||Mild Sleep Apnea|
|15-30||Moderate Sleep Apnea|
|>30||Severe Sleep Apnea|
Positive Airway Pressure (PAP) Therapy for Sleep Apnea
Once diagnosed, the patient must have a second full-night polysomnography study to correctly titrate their PAP. An alternative to a full-night study is a split-night study. This study observes the patient for apnea or hypopnea during the first half of the night. The second half of the night allows for adjustment and titration of PAP therapy.
Overall, OSA is a relatively common condition that affects millions of people yet is probably underdiagnosed and treated. Left untreated, patients with OSA are at increased risk of cardiovascular disease, pulmonary hypertension and stroke. Patients are also more likely to be involved in motor vehicle collisions or other accidents due to excessive daytime sleepiness. Some municipalities monitor and track compliance with PAP therapy. They may also suffer from poor work performance and decreased social interaction with friends and family due to their chronic fatigue and sleepiness. So the next time you have a patient with chronic fatigue and sleepiness and risk factors for OSA, consider recommending a sleep study to see if they would benefit from treatment. It might change their life.
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