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Sleep Apnea
Diagnosis/Definition
- The most common form of sleep apnea is Obstructive Sleep Apnea-Hypopnea Syndrome, which is marked by excessive daytime sleepiness, habitual snoring and witnessed apneas during sleep. Patients with this triad of symptoms have a greater than 90% chance of having sleep apnea. The diagnosis is confirmed with overnight polysomnography (sleep study). The syndrome requires the presence of excessive daytime somnolence. Obesity is a common risk factor for sleep apnea but normal weight patients can also get it, frequently in association with craniofacial abnormalities.
- Other presenting symptoms include morning headache, restless sleep, nocturia, short term memory loss, feeling unrefreshed after an adequate nights sleep (7-8 hours), erectile dysfunction and mood disturbance. Obstructive Sleep Apnea has been associated with increased risk of hypertension (HTN), coronary artery disease and strokes.
Initial Diagnosis and Management
Patient is suspected of having Obstructive Sleep Apnea. This will be based on following signs and symptoms:
- Habitual snoring: defined as snoring every day
- Witnessed apneas: defined as repeated awakenings by the patient’s bed partner
- Duration of greater than 10 seconds should be sought
- Note: normal individuals routinely have apneas
- Excessive daytime somnolence
- Defined as an Epworth Sleepiness Score of greater than 12
- Motor vehicle accident related to sleepiness
- Work or social impairment related to sleepiness
- Obesity
- Defined as a body mass index of greater than 35
- Neck size
- Greater than 16 inches in men and 14 inches in females
- Significant cardiovascular risk factors
- Hypertension that is not controlled on two agents
- Coronary artery disease
- Cerebrovascular disease
The greater the number of factors the higher the pre-test probability of OSA
- Patients will require documentation on the consult to Neurodiagnostics that at least 4 of these 6 factors are present
- Consideration prior to ordering the Polysomnogram should also include:
- Will this effect the patient’s quality of life
- Will they be able to wear CPAP via a face mask
- Do they have claustrophobia (makes treatment via a mask very difficult)
- Will there be a benefit to their cardiovascular risk factors
These factors are important to discuss with the patient prior to the sleep study as:
- Wearing CPAP is much more cumbersome for the patient than most medical treatments
- It can be construed as lifestyle limiting
- Significant costs and technical effort go into appropriately fitting and ensuring patient compliance with CPAP
- Patients with primary insomnia usually do not have significant sleep apnea and the insomnia should usually be dealt with first before pursuing a diagnosis of sleep apnea
- Patients with excessive daytime sleepiness should be counseled to avoid driving until their condition is treated
Ongoing Management and Objectives
- Patients with snoring and/or witnessed apneas without excessive daytime sleepiness or only mild symptoms (confirmed by partner) should be treated with conservative measures including weight loss, avoidance of alcohol, sleep deprivation and sedative medications. Patients who sleep on their back should be advised to sleep on their side
- Patients diagnosed with the OSAHS will require initiation of CPAP therapy by the ordering provider or appropriate surgical consultation
- NOTE: CPAP orders are not to be sent to the Pulmonary Clinic for initiation of therapy
Indications for Specialty Care Referral
All Active Duty members with sleep problems to include heroic snoring, excessive daytime somnolence, insomnia or other sleep concerns
When the diagnosis of OSAHS is not clear, i.e. does not have 4 of the 6 above noted criteria and has excessive daytime somnolence, the patient should then be referred for a Pulmonary or Neurology consultation
Patients that fail to respond to an adequate trial of CPAP
When the patient’s complaints of sleepiness are not felt to be due to sleep disordered breathing such as narcolepsy or idiopathic CNS hypersomnolence
Patients treated with CPAP should have an initial Consultation to the Outpatient Respiratory Technician no later than 2 months after initiation of CPAP to ensure that it is tolerated and effective. Once this is confirmed then the CPAP device can be purchased, which occurs at the 3rd month of usage. This requires a final order by the initiating provider
Criteria for Return to Primary Care
Patients should return to the Outpatient Respiratory Technician once every year to ensure that the equipment is still in working condition, effective and used nightly
Patients treated with surgery should follow up with their surgeon until post-operative healing is complete and to determine if their sleep apnea symptoms have resolved. After 3-4 months, successful surgical patients can return to primary care.
