Differences

Last edited on April 30, 2020

This shows you the differences between two versions of the page.

--- sleep:breathing:1-osa [on November 4, 2017]
+++ sleep:breathing:1-osa [on December 3, 2021] (current)
@@ Line 5: / Line 5: @@
 == Prevalence ==
-OSA affects 1-2% of children, 2-15% of middle-age adults, and more than 20% of older individuals. Undiagnosed OSA may be very high in elderly individuals. Since it is strongly associated with obesity, areas with high obesity rates also likely to have high rates of OSA.
+  * OSA affects 1-2% of children, 2-15% of middle-age adults, and more than 20% of older individuals.
+    * 9% of men and 4% of women are thought to have an Apnea-Hypopnea Index (AHI) > 15 (moderate sleep apnea)
+  * Undiagnosed OSA may be very high in elderly individuals.
+  * It is estimated that the majority (80%) of individuals with sleep apnea are not diagnosed.
+  * Since it is strongly associated with obesity, areas with high obesity rates also likely to have high rates of OSA.[([[https://pubmed.ncbi.nlm.nih.gov/18807673/|Lopez, P. P., Stefan, B., Schulman, C. I., & Byers, P. M. (2008). Prevalence of sleep apnea in morbidly obese patients who presented for weight loss surgery evaluation: more evidence for routine screening for obstructive sleep apnea before weight loss surgery. The American Surgeon, 74(9), 834-838.]])]
-===== Diagnostic Criteria =====
+== Comorbidity ==
+Individuals with OSA are at a significantly higher risk for developing obesity, hypertension,[([[https://pubmed.ncbi.nlm.nih.gov/18227409/|Kapa, S., Sert Kuniyoshi, F. H., & Somers, V. K. (2008). Sleep apnea and hypertension: interactions and implications for management. Hypertension, 51(3), 605-608.]])] atrial fibrillation and other arrhythmias, heart failure, stroke and transient ischemic attacks (TIAs), coronary heart disease, Type 2 diabetes, and dyslipidemia.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645253/|Golbin, J. M., Somers, V. K., & Caples, S. M. (2008). Obstructive sleep apnea, cardiovascular disease, and pulmonary hypertension. Proceedings of the American Thoracic Society, 5(2), 200-206.]])] More recent research has also shown a link between OSA and an increased risk for developing dementia.[([[https://pubmed.ncbi.nlm.nih.gov/24205289/|Chang, W. P., Liu, M. E., Chang, W. C., Yang, A. C., Ku, Y. C., Pai, J. T., ... & Tsai, S. J. (2013). Sleep apnea and the risk of dementia: a population-based 5-year follow-up study in Taiwan. PloS one, 8(10), e78655.]])][([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4828426/|Emamian, F., Khazaie, H., Tahmasian, M., Leschziner, G. D., Morrell, M. J., Hsiung, G. Y. R., ... & Sepehry, A. A. (2016). The association between obstructive sleep apnea and Alzheimer’s disease: a meta-analysis perspective. Frontiers in aging neuroscience, 8, 78.]])]
+== Risk Factors ==
+  * Genetic disorders including Marfan syndrome can increase the risk for OSA due to connective tissue laxity.[([[https://pubmed.ncbi.nlm.nih.gov/25189962/|Li, M., Quanying, H., Yinna, W., Birong, D., & Jinhan, H. (2014). High prevalence of obstructive sleep apnea in Marfan's syndrome. Chinese medical journal, 127(17), 3150-3155.]])]
+===== DSM-5 Diagnostic Criteria =====
 <WRAP group>
 <WRAP half column>
 == Criterion A ==
 Either item (1) or (2) is present:
-  - Evidence by polysomnography of at least ''5'' obstructive apneas or hypopneas per ''1'' hour of sleep and either of the following sleep symptoms: (A) Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses during sleep. //AND/OR// (B) Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder (including a sleep disorder) and is not attributable to another medical condition.
+  - Evidence by polysomnography of at least ''5'' obstructive apneas or hypopneas per ''1'' hour of sleep and either of the following sleep symptoms:
+    * **(A)** Nocturnal breathing disturbances: snoring, snorting/gasping, or breathing pauses during sleep. //AND/OR//
+    * **(B)** Daytime sleepiness, fatigue, or unrefreshing sleep despite sufficient opportunities to sleep that is not better explained by another mental disorder (including a sleep disorder) and is not attributable to another medical condition.
   - Evidence by polysomnography of ''15'' or more obstructive apneas and/or hypopneas per hour of sleep //regardless// of accompanying symptoms
-== Specifiers ==
-<accordion collapsed="true">
-<panel icon="fa fa-search-plus" size="xs" title="Severity Specifiers">
-**Specify if:**
-  * **Mild**: Apnea hypopnea index is less than 15.
-  * **Moderate**: Apnea hypopnea Index is 15-30.
-  * **Severe**: Apnea hypopnea index is greater than 30.
-</panel>
-</accordion>
 </WRAP>
 <WRAP half column>
-== Signs and Symptoms ==
-Snoring, gasping for air, stopping breathing at night, memory complaints, irritability, depression, morning headaches, sexual problems, restless sleep, and sedation or tiredness during the day.
 == Apnea-Hypopnea Index (AHI) ==
@@ Line 39: / Line 37: @@
 </panel>
-<callout>Remember, 5 apneas within an hour are actually considered within normal range (apnea is > 10 seconds)</callout>
+<callout type="tip" icon="true">
-</WRAP></WRAP>
+Remember, 5 apneas within an hour are actually considered within normal range (apnea is > 10 seconds)
+</callout>
+</WRAP>
+</WRAP>
+==== Specifiers ====
+<panel icon="fa fa-search-plus" size="xs" title="Severity Specifiers">
+**Specify if:**
+  * **Mild**: Apnea hypopnea index is less than 15.
+  * **Moderate**: Apnea hypopnea Index is 15-30.
+  * **Severe**: Apnea hypopnea index is greater than 30.
+</panel>
+==== Signs and Symptoms ====
+  * Snoring, gasping for air, stopping breathing at night, memory complaints, irritability, depression, morning headaches, sexual problems, restless sleep, and sedation or tiredness during the day.
 ===== Screening =====
-The STOP-BANG is a screening tool that has been validated for the identification of obstructive sleep apnea.[([[http://www.stopbang.ca/osa/screening.php|STOP-Bang Questionnaire]])][([[https://www.ncbi.nlm.nih.gov/pubmed/28584309|Popević, M. B., Milovanović, A., Nagorni-Obradović, L., Nešić, D., Milovanović, J., & Milovanović, A. P. (2017). Screening commercial drivers for obstructive sleep apnea: Validation of STOP-Bang questionnaire. International Journal of Occupational Medicine and Environmental Health, 30(5), 1-11.]])] If more than 4 criteria are met, there is a sensitivity of 80% and specificity of 50%.
+The STOP-BANG is a screening tool that has been validated for the identification of obstructive sleep apnea.[([[http://www.stopbang.ca/osa/screening.php|STOP-Bang Questionnaire]])][([[https://www.ncbi.nlm.nih.gov/pubmed/18431116|Chung, F., Yegneswaran, B., Liao, P., Chung, S. A., Vairavanathan, S., Islam, S., ... & Shapiro, C. M. (2008). Stop questionnairea tool to screen patients for obstructive sleep apnea. Anesthesiology: The Journal of the American Society of Anesthesiologists, 108(5), 812-821.]])] If more than 4 criteria are met, there is a sensitivity of 80% and specificity of 50%.
 <panel title="Psychometric Scales for Depression" no-body="true">
-!^! Name                                               ^ Rater      ^ Description                                                                                                                                                                                   ^ Download  ^
+<mobiletable 1>
+^ Name                                               ^ Rater      ^ Description                                                                                                                                                                                   ^ Download  ^
 ^ STOP-Bang Questionnaire                    | Patient or Physician   | The STOP-BANG questionnaire screens for obstructive sleep apnea (OSA) only, not central sleep apnea.      | {{:sleep:stop-bang.pdf|STOP-BANG Download}}         |
+</mobiletable>
 </panel>
 ===== Pathophysiology =====
 == Children ==
-There is a peak of OSA in children ages 3-8 years, this is when the nasopharynx can compromised by a relatively large mass of tonsillar tissue compared with the size of the upper airway. As the airway grows and develops during childhood, there is regres
+There is a peak of OSA in children ages 3-8 years, when the nasopharynx has a relatively larger mass of tonsillar tissue relative to the upper airway. As the airway grows and develops during childhood, there is regression of lymphoid tissue and a corresponding reduction
-sion of lymphoi
+ in the incidence of OSA.
-d tissue, there is reduction in the incidence of OSA.
 == Adults ==
 The major risk factors for obstructive sleep apnea hypopnea are obesity and male gender. As obesity prevalence increases in midlife and females enter menopause, obstructive sleep apnea hypopnea again increases.
 == Anatomy ==
-Maxillary-mandibular retrognathia or micrognathia, genetic syndromes that reduce upper airway patency (e.g., Down's syndrome, Treacher Collin's syndrome), adenotonsillar hypertrophy (especially in young children), and various endocrine syndromes (e.g., acromegaly) all increase the risk of OSA due to anatomical changes to airway patency.
+Maxillary-mandibular retrognathia or micrognathia, genetic syndromes that reduce upper airway patency (e.g., Down's syndrome, Treacher Collin's syndrome), adenotonsillar hypertrophy (especially in young children), and various endocrine syndromes (e.g., acromegaly) all increase the risk of OSA due to anatomical changes to airway patency. Anatomical studies have shown that Asian men are more likely to develop sleep apnea due to differences in craniofacial anatomy (crowded posterior oropharynx) rather than from obesity.[([[https://pubmed.ncbi.nlm.nih.gov/20815189/|Lee, R. W., Vasudavan, S., Hui, D. S., Prvan, T., Petocz, P., Darendeliler, M. A., & Cistulli, P. A. (2010). Differences in craniofacial structures and obesity in Caucasian and Chinese patients with obstructive sleep apnea. Sleep, 33(8), 1075-1080.]])][([[https://pubmed.ncbi.nlm.nih.gov/11037826/|Li, K. K., Kushida, C., Powell, N. B., Riley, R. W., & Guilleminault, C. (2000). Obstructive sleep apnea syndrome: a comparison between Far‐East Asian and white men. The Laryngoscope, 110(10), 1689-1693.]])]
+==== Physiologic Cycle ====
+  * In patients with OSA, there is first an initial decrease in the drive to breathe due to decreased sensitivity of the peripheral and central chemoreceptors.[([[https://pubmed.ncbi.nlm.nih.gov/12002197/|Cutler, M. J., Hamdan, A. L., Hamdan, M. H., Ramaswamy, K., & Smith, M. L. (2002). Sleep apnea: from the nose to the heart. The Journal of the American Board of Family Practice, 15(2), 128-141.]])]
+  * As a result, the airway collapses, causing an apneic event that limits lung gas exchange.
+  * This causes a hypoxic-hypercapnic (low oxygen, high carbon dioxide) state that increases the drive to breathe.
+    * This breathing effort, however, is impeded by the already obstructed airway, which causes further impairment of gas exchange.
+  * Eventually, the hypoxia and hypercapnia become severe enough to produce a breathing effort that is strong enough to terminate the apneic event.
+  * This effort often elicits an arousal that disrupts sleep architecture. This pattern will repeat many times during the night for individuals with OSA.
+  * During the periods of hypercapnia, there is also very strong sympathetic neural activity. This pattern of increased sympathetic activity is thought to be implicated in the development of hypertension in individuals with OSA.[([[https://pubmed.ncbi.nlm.nih.gov/12002197/|Cutler, M. J., Hamdan, A. L., Hamdan, M. H., Ramaswamy, K., & Smith, M. L. (2002). Sleep apnea: from the nose to the heart. The Journal of the American Board of Family Practice, 15(2), 128-141.]])]
+===== Differential Diagnosis =====
+  * Primary snoring and other sleep disorders
+  * Insomnia disorder
+  * Panic attacks (nocturnal)
+  * Attention-deficit/hyperactivity disorder
+  * Substance/medication-induced insomnia or hypersomnia
+===== Investigations =====
+==== Polysomnography ====
+<alert icon="fa fa-arrow-circle-right fa-lg fa-fw" type="success">See main article: **[[neurology:polysomnography|]]**</alert>
+On polysomnography, apneic episodes are always worse during REM sleep due to the atonia that occurs from REM.
 ===== Treatment =====
-  * Weight loss and lifestyle changes
+==== CPAP ====
-  * Surgical intervention
+  * Continuous positive airway pressure (CPAP) therapy is the first line of treatment for moderate to severe sleep apnea. However, patient compliance is a major problem. Most studies have shown that even in adherent patients, the actual usage of CPAP is around 50%.
-  * Dental Device
-  * CPAP
-  * EPAP
+==== Surgical ====
+  * Surgical interventions include uvulopalatopharyngoplasty, soft palate implants (Pillar Procedure), and hyoid advancement.
+==== Dental Device ====
+  * Dental devices called mandibular advancement devices can be used.
+==== Positional Sleep Trainer =====
+  * Positional sleep trainers have also been shown to be effective in reducing apnea in patients with positional sleep apnea.[([[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3581237/|Cowan, D. C., & Livingston, E. (2012). Obstructive sleep apnoea syndrome and weight loss. Sleep disorders, 2012.]])][([[https://pubmed.ncbi.nlm.nih.gov/28522078/|Benoist, L., de Ruiter, M., de Lange, J., & de Vries, N. (2017). A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea. Sleep Medicine, 34, 109-117.]])]
+==== Lifestyle ====
+  * Weight loss and lifestyle changes can have a significant impact on reducing the severity of symptoms. A 10% reduction in weight can lead to a 26% decrease in the AHI.[([[https://pubmed.ncbi.nlm.nih.gov/11122588/|Peppard, P. E., Young, T., Palta, M., Dempsey, J., & Skatrud, J. (2000). Longitudinal study of moderate weight change and sleep-disordered breathing. Jama, 284(23), 3015-3021.]])] Conversely, a 10% increase in weight can lead to a 6-fold increase in the risk of developing a sleep-related breathing disorder.
 ===== Clinical Pearls =====
+  * Dry mouth upon awakening is a common symptom (~40%) in OSA[([[https://pubmed.ncbi.nlm.nih.gov/16911034/|Oksenberg, A., Froom, P., & Melamed, S. (2006). Dry mouth upon awakening in obstructive sleep apnea. Journal of sleep research, 15(3), 317-320.]])]
   * CPAPs are not a panacea and may not always be prescribed properly!
   * CPAPs can cause //more// insomnia if your patients are unable adjust to using a CPAP
@@ Line 84: / Line 132: @@
   * Are there medical comorbidities?
-===== Differential Diagnosis =====
-  * Primary snoring and other sleep disorders
-  * Insomnia disorder
-  * Panic attacks (nocturnal)
-  * Attention-deficit/hyperactivity disorder
-  * Substance/medication-induced insomnia or hypersomnia
 ===== Resources =====
@@ Line 96: / Line 138: @@
 <WRAP quarter column>
 ==== For Patients ====
+  * [[https://www.zzomaosa.com/|Zzoma - Positional Therapy for Sleep Apnea]]
+  * [[https://rematee.com/|Rematee]]
 </WRAP>
 <WRAP quarter column>
 ==== For Providers ====
+  * **[[https://www.nature.com/articles/nrdp201515|Lévy, P. et al. (2015). Obstructive sleep apnoea syndrome. Nature reviews Disease primers, 1(1), 1-21.]]**
+  * [[http://www.stopbang.ca/|STOP-Bang Tool Website]]
 </WRAP>
 <WRAP quarter column>
 == Articles ==
   * [[https://www.menshealth.com/health/sleep-apnea-could-be-killing-you|Men's Health: How Sleep Apnea Could Be Killing You (Even if You're Not Overweight)]]
+  * [[https://www.nytimes.com/2020/02/19/smarter-living/wirecutter/anti-snoring-devices.html|NYT:I Tried 6 Popular Anti-Snoring Devices. Here’s How They Did.]]
 </WRAP>
 <WRAP quarter column>