Obstructive Sleep Apnea (OSA)/ Reading & Sharing

Obstructive sleep apnea (OSA) is defined as a repetitive reduction or cessation of breathing during sleep due to narrowing or obstruction of the upper airway (Paul & Hays, Jr., 2018).

OSA is more prevalent in males than females in adult population (Paul & Hays, Jr., 2018). 10% of males aged 30 to 49 years and 17% of males aged 50 to 70 years have OSA (Paul & Hays, Jr., 2018). 3% of females aged 30 to 49 years and 9% of females aged 50 to 70 years have OSA (Paul & Hays, Jr., 2018). People who are obese and those that have hypertension, regardless of gender, have a higher prevalence of OSA than otherwise healthy adults (Glass & Hall, 2017). “The prevalence of OSA in the general pediatric population is estimated to be 1% to 6%. However, in obese children and adolescents, OSA is reported to occur in 19% to 61%” (Paul & Hays, Jr., 2018, p. 1189). The majority of children, who are not obese, with OSA are between the ages of 2 to 10 years and the cause is typically due to enlarged tonsils and adenoids (Glass & Hall, 2017).

OSA is thought to be caused by relaxation of the oropharynx muscles during sleep in people with increased tissue thickness of the structures of the tongue and soft tissues in the pharyngeal cavity, which decreases air passage to or obstructs the trachea (Glass & Hall, 2017). Other causes of OSA include upper airway muscular weakness, stroke, and metabolic disorders (Paul & Hays, Jr., 2018). Diseases associated with the development of OSA include hypothyroidism and acromegaly (Paul & Hays, Jr., 2018).

Factors that predispose people to OSA are: being male; advanced age; obesity; increased neck circumference (>17 inches in males and >15 inches in females); post menopause; hypothyroidism; alcohol; craniofacial abnormalities; tonsillar hypertrophy; allergic rhinitis; genetic conditions (e.g., down syndrome, Pierre Robin anomalies, Marfan syndrome); family history of OSA; diabetes; hypertension; and medications such as benzodiazepines; antipsychotics; opioid; beta-blocker; barbiturates; antihistamines; and sedative antidepressants (Glass & Hall, 2017).

Patient’s with OSA typically present with the following symptoms: daytime sleepiness; fatigue; and may have been told or awaken due to loud snoring, gasping for air, or snorting during sleep (Glass & Hall, 2017).

• Other signs and symptoms of OSA in adults include: restless sleep; not feeling rested upon awakening; dry mouth or sore throat; lack of physical or mental energy; falling asleep when watching TV, reading, driving/riding in a car; morning headache; short tempered; unable to focus; easily angered; and decreased libido and impotence (Shipley, 2017).
• Other signs and symptoms in children include: short attention span; behavioral problems; and bed wetting (Shipley, 2017).

Daytime somnolence, hypersomnolence and excessive snoring are the main signs suggesting OSA. Also, there are two common assessments that can be done to measure the degree of sleepiness; they are the Stanford Sleepiness Score (SSS) and Epworth Sleepiness Scale (ESS). According to the SSS, a score under 3 indicates the presence a serious sleep deficit and as for the ESS, a total score of 10 is out of the norm. Out of all the tests, a sleep study such as an overnight polysomnogram is the definite test to diagnose sleep apnea.

During the patient interview it is important to ask the patient if they experience any of the above signs and symptoms (Shipley, 2017). The Epworth Sleepiness Scale (ESS) questions could be used to determine the severity of the patient’s daytime sleepiness (Paul & Hays, Jr., 2018). The patient should also be asked about job performance, weight gain, and family history of OSA (Paul & Hays, Jr., 2018). Also, ask the patient about their alcohol consumption and what medications they are currently taking, including illicit drugs, OTC medications, and herbal supplements (Glass & Hall, 2017). It is important to remember that the signs and symptoms of OSA can be present for years (Shipley, 2017).

Obtain the patient’s vital signs, including height and weight to calculate BMI, and waist measurement; auscultate heart and lungs; palpate thyroid gland; assess mental status for confusion (Shipley, 2017). Inspect the oropharynx for the following: peritonsillar narrowing or hypertrophy; tongue for macroglossia; elongated or enlarged uvula; and palate for narrowness or high arch (Shipley, 2017). Inspect the nasal cavity for septal deviation and nasal polyps (Shipley, 2017). Inspect for signs of pulmonary hypertension or cor pulmonale by assessing for jugular venous distention and peripheral edema (Shipley, 2017). Except for findings of obesity, HTN, and enlarged neck circumference the physical exam findings are typically normal in patients with OSA (Paul & Hays, Jr., 2018).

The gold standard for diagnosing OSA is the nocturnal polysomnography (PSG), “which should be performed during the patient’s typical sleeping hours; it should include all stages of sleep as well as sleep in the supine position” (Shipley, 2017, p. 1189). The apnea-hypopnea index (AHI) is used to determine the severity of a patient’s OSA (Shipley, 2017). In adults, mild OSA is diagnosed if the patient has symptoms and the number of respiratory events they have per hour equals 5 to 15; moderate OSA, regardless if symptoms are present or not, equals 15 to 30 respiratory events per hour; severe OSA is diagnosed if more than 30 respiratory events per hour are recorded during the PSG (Shipley, 2017).

• If pulmonary HTN or cor pulmonale are suspected an ABG should be done to rule out daytime hypoxemia or hypercapnia (Shipley, 2017).
• Other labs that should be drawn are a TSH, fasting glucose, and CBC (Shipley, 2017).
• “ Pulmonary function testing if pulmonary disorder is suspected or to assess severity of neuromuscular disease, if present.
• ECG or echocardiogram is indicated if a cardiac disorder (e.g., arrhythmia, pulmonary HTN) is suspected (Paul & Hays, Jr., 2018, p. 1190).
• If anatomic abnormalities are suspected a plain radiography of the neck should be ordered to assess the soft tissues (Shipley, 2017).
• If pulmonary disease is suspected a chest x-ray should be ordered (Shipley, 2017).

Treatment Plan

• Treating OSA is guided by the cause of the condition.
• Dietary management, a 10 to 20 percent weight loss has been shown to improve the severity of OSA (Glass & Hall, 2017).
• Continuous positive airway pressure (CPAP) therapy is the primary medical treatment used to address sleep apnea (Shipley, 2017).
• Other methods of delivering positive pressure include: bi-level positive airway pressure (BIPAP); auto titrating positive airway pressure (APAP); adaptive servo ventilation (Paul & Hays, Jr., 2018).
• A custom made oral appliance (OA) may be effective for the treatment of mild OSA (Shipley, 2017).
• “Optimal treatment of allergic rhinitis is needed; nasal irrigation with saline followed by nasal corticosteroids is often helpful” (Paul & Hays, Jr., 2018, p. 1191).
• Surgical treatment should be considered after using an OA or positive airway pressure for 3 months have failed or patient refuses to use OA or positive airway pressure device (Paul & Hays, Jr., 2018).
• “Adenotonsillectomy is often curative for children with OSA” (Paul & Hays, Jr., 2018, p. 1191).
• Surgical treatment to correct craniofacial abnormalities (Paul & Hays, Jr., 2018).
• Bariatric surgery for weight loss if indicated may be effective (Glass & Hall, 2017).

 

Other Suggestions: 

• Sleep in a non-supine position (Glass & Hall, 2017).
• If the patient smokes, address the importance of smoking cessation and offer information on resources to help them stop smoking (Glass & Hall, 2017).
• CPAP or other positive pressure device or OA will need to be used anytime patient is sleeping, including naps (Shipley, 2017).
• Avoid consuming alcohol within 4 to 6 hours before bedtime (Paul & Hays, Jr., 2018).
• Avoid sedating medications such as muscle relaxants and sedatives (Paul & Hays, Jr., 2018).
• Stress the importance of exercise (Paul & Hays, Jr., 2018).
• If patient is experiencing significant daytime sleepiness they should not drive or operate dangerous equipment (Shipley, 2017)​​​​​​​.

 

Follow Up

Close follow-up after starting the use of continuous positive airway pressure (CPAP) is recommended to identify problems complicating and preventing its use. Children who are prescribed CPAP, particularly younger children and infants, need to be restudied frequently, as changes in body weight, muscle tone, airway size and compliance, and adenotonsillar size may either increase the pressure requirements or decrease them, possibly to the point of eliminating entirely the need for CPAP. Likewise, a low threshold for restudying children at risk for OSA such as with low muscle tone, craniofacial abnormalities, and chromosomal disorders should be maintained (Epocrates, 2017).

 

References:

Epocrates Online (2017) Obstructive sleep apnea in adults treatment options. Retrieved from online.epocrates.com/dx/indexprint?entire=false&iid=215&sid=42&activeTab=9

Glass, C. A., & Hall, M. A. (2017). Obstructive sleep apnea. In J. C. Cash & C. A. Glass (Eds.), Family practice guidelines (4th ed., pp. 174-176). New York, NY: Springer Publishing.

Paul, G. R., & Hays, Jr., D. (2018). Sleep Apnea. In F. F. Ferri (Ed.), 2018 Ferri’s clinical advisor (pp. 1189-1191). Philadelphia, PA: Elsevier.

Shipley, S. (2017). Sleep apnea, obstructive. In F. J. Domino, R. A. Baldor, J. Golding, & M. B. Stephens (Eds.), The 5-minute clinical consult (25th ed., pp. 972-973). Philadelphia, PA: Wolters Kluwer.