Obstructive Sleep Apnea: Is it in your Differential? Helene Hill Professor Sam Powdrill PAS 645

Agenda  Introduction  Pathophysiology  Risk Factors  Comorbid Conditions  Application

Obstructive Sleep Apnea  AKA the “Spousal Arousal” syndrome  Prevention and early treatment is essential  The problem is that PCP might not consider OSA in the non- stereotypical patients “Laugh and the world laughs with you, snore and you sleep alone.” ~ Anthony Burgess

Obstructive Sleep Apnea  Epidemiology More prevalent than once was believed Wisconsin Sleep Cohort Study  9% women  24% men Estimated that 80-90% are undiagnosed  Comorbidities  Awareness  SES

Pathophysiology  A sleep breathing disorder due to a mechanical problem of tissue collapse  Apnea leads to Oxyhemoglobin desaturation Fragmentation in sleep cycle Variability in BP and HR/Increase in SNS  Persistent hypoxia manifests with numerous daytime Sx

Treatment  Mild 5-15/hr Lifestyle modification  Weight loss  Elimination of products that suppress respiration  No BZDs  Sleeping position modification

Treatment  Moderate 15-30/hr More in-depth plus lifestyle changes  CPAP  Oral appliances Mandible advancing Tongue device Martin Dunitz

Treatment  Severe > 30/hr Surgical procedures in addition to previous changes  Tonsillectomy/adenoidectomy  Nasal surgery combined with pharyngeal surgery  Uvulopalatopharyngoplasty (UPPP) Martin Dunitz

Risk Factors  “Pickwickian Patient” Male Sex Age yr Familial Aggregation  Established risk factors Body habitus Craniofacial/Upper Airway Abnormalities  Suspected risk factors Genetics Smoking Menopause Alcohol before sleep Nighttime nasal congestion

Martin Dunitz

Comorbid Conditions  Decreased daytime functioning Daytime sleepiness Psychosocial problems – STRESS! Decreased cognitive function

Comorbid Conditions  Cardiovascular/Cerebrovascular Disease Stroke, pulmonary HTN, CHF Resistant hypertension  Increased sympathetic activity  Vasculopathy Activation of vasoconstrictors Sustained hypertensive effects “Non-dipping” phenomenon

Comorbid Conditions  Diabetes/Metabolic Syndrome Vascular disease that lead to endothelial dysfunction OSA is independently associated with insulin resistance  Control OSA, see better control of DM

So is it in your Dif Dx?  Few easy steps Consider OSA in patients who snore or have excessive daytime sleepiness Check out risk factors and get detailed history Consider your alternatives Consider OSA when evaluating patients for comorbidities associated with sleep apnea

Wrapping it up…  Don’t forget to treat the underlying condition!  Don’t forget the non-stereotypicals!  Know risk factors and what OSA can do if left untreated!  Future ideas… Hypoglossal nerve stimulation Serotonergic medications

References Available upon request