Obstructive Sleep Apnea

Obstructive Sleep Apnea
Article by: Janice L. Miles, DO

Obstructive sleep apnea (OSA) is occlusion of the upper airway by soft tissues causing cessation of airflow while sleeping. Patients, bed partners, or family members may present with various complaints such as insomnia, snoring, gasping episodes, snorting episodes, nocturnal dyspnea (shortness of breath), daytime sleepiness, poor performance, morning headaches, sinus congestion, dry mouth, and gastroesophageal reflux. Hypertension is an independent risk factor for OSA. Asthma and prior cardiologic disease and stroke are risk factors for having OSA. Patients that have trouble with waking from anesthesia or abnormal or absence of breathing with sedation can have OSA. Some patients may have accidents or near accidents secondary to sleepiness while driving. Weight gain may have occurred, but not all patients with OSA are obese. The bed partner or other family members may be disturbed from the loud snoring and be aware of apneas (periods that the patient does not breath that last 10 seconds or longer). Some bed partners no longer sleep in the same room as the patient. The patient may have cardiac disease, renal disease, hypertension, bilateral lower extremity swelling, weight gain, or obesity. Some patients are thin. Nasal deformities and facial deformities such as redundant tissues in the posterior pharnyx, macroglossia ( large tongue ), retrognatha ( a chin that is placed too far into the face ), or micrognatha ( small chin ) can sometimes be found in patients with OSA. Even large tonsils can be a problem in some patients. Endocrinologic disorders such as acromegaly and neurologic disorders such as Parkinsons and prior polio can be associated with OSA. Sickle cell disease also has a higher incidence of OSA.

Children with OSA may be labeled as poor performers or hyperactive. Snoring in small children is abnormal. Some children and adults do not snore and can have respiratory pauses or apneas.

Following a complete history and physical to identify other conditions that may worsen or contribute to the sleep problems, such as sedating medications, alcohol, severe anemia, cardiac disease, respiratory disease, endocrinologic disorders the patient is studied in a sleep laboratory with a technician present. The polysomnography moniters EEG, eye movements, snoring, leg movements, chin movements, air movement through the nose and mouth, EKG, pulse oximetry, abdominal and thoracic respiratory movements.

Treatment of OSA and UARS include weight loss if needed, cessation of sedating medications, CPAP (continuous positive airway pressure), uvulopalatopharnygoplasty (UPPP), jaw advancement surgery, oral appliances, positional therapy, or tracheostomy. It is preferred that the patient attempt a trial at CPAP before considering surgical options.

Usually a second night in the sleep lab is required to institute CPAP at the optimum pressure. Different masks are available should problems or complications occur in follow-up.

In patients that decide to have surgical options, then another polysomnography is required following the surgery to assure that there is total resolution of the obstructive events. Following surgery, snoring may no longer occur. In patients that continue to have obstructive events, then CPAP would have to be re-instituted.

Patients with obstructive sleep apnea that are not treated have an increased risk of developing cardiac problems including arrythmias, sudden death, heart attacks, cardiomyopathies, and congestive heart failure. Obstructive sleep apnea can cause hypertension or poorly controlled hypertension. It is also a cause of strokes and pulmonary hypertension. It has recently been associated with insulin resistance in diabetics. About 30% of patients with hypertension and 40% of OSA patients have hypertension. A high percentage of patients with cardiac patients have OSA as do stroke patients.

If the patient continues to have excessive daytime sleepiness with adequate treatment of obstructive sleep apnea, then other causes such as narcolepsy, idiopathic hypersomia, or recurrent hypersomia should be considered. This would require nighttime monitering in the sleep lab followed by multiple sleep latency testing.