Obstructive sleep apnea: Difference between revisions

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===History and physical===
===History and physical===
Age, body mass index, male sex, and snoring are the best predictors of sleep apnea.<ref name="pmid1863025">{{cite journal| author=Viner S, Szalai JP, Hoffstein V| title=Are history and physical examination a good screening test for sleep apnea? | journal=Ann Intern Med | year= 1991 | volume= 115 | issue= 5 | pages= 356-9 | pmid=1863025 | doi= | pmc= | url= }} </ref> Obstructive sleep apnea is difficult to diagnose based on the history and [[physical examination]]s.<ref name="pmid20143278">{{cite journal| author=Abrishami A, Khajehdehi A, Chung F| title=A systematic review of screening questionnaires for obstructive sleep apnea. | journal=Can J Anaesth | year= 2010 | volume= 57 | issue= 5 | pages= 423-38 | pmid=20143278 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&retmode=ref&cmd=prlinks&id=20143278 | doi=10.1007/s12630-010-9280-x }} </ref>
Age, body mass index, male sex, and snoring are the best predictors of sleep apnea.<ref name="pmid1863025">{{cite journal| author=Viner S, Szalai JP, Hoffstein V| title=Are history and physical examination a good screening test for sleep apnea? | journal=Ann Intern Med | year= 1991 | volume= 115 | issue= 5 | pages= 356-9 | pmid=1863025 | doi= | pmc= | url= }} </ref> Obstructive sleep apnea is difficult to diagnose based on the history and [[physical examination]]s.<ref name="pmid20143278">{{cite journal| author=Abrishami A, Khajehdehi A, Chung F| title=A systematic review of screening questionnaires for obstructive sleep apnea. | journal=Can J Anaesth | year= 2010 | volume= 57 | issue= 5 | pages= 423-38 | pmid=20143278 | url=http://www.springerlink.com/content/0384103252r31637/fulltext.html | doi=10.1007/s12630-010-9280-x }} </ref>


* A score of more than 5 on the [http://www.ssc.ca/documents/case_studies/2006/documents/sleep_BQ_e.pdf Berlin Questinnaire] has a [[sensitivity (tests)|sensitivity]] of 86% in one study.<ref>Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999 Oct 5;131(7):485-91. PMID 10507956</ref> [[Clinical prediction rule]]s are available to help diagnose sleep apnea.<ref>Rodsutti J, Hensley M, Thakkinstian A, D'Este C, Attia J. A clinical decision rule to prioritize polysomnography in patients with suspected sleep apnea. Sleep. 2004 Jun 15;27(4):694-9. PMID 15283004</ref>
* A score of more than 5 on the [http://www.ssc.ca/documents/case_studies/2006/documents/sleep_BQ_e.pdf Berlin Questinnaire] has a [[sensitivity (tests)|sensitivity]] of 86% in one study.<ref>Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999 Oct 5;131(7):485-91. PMID 10507956</ref>
* The Epworth Sleepiness Scale may help diagnose. However, the optimal cut-off level is not certain and may be 10<ref name="pmid18477888">{{cite journal| author=Rosenthal LD, Dolan DC| title=The Epworth sleepiness scale in the identification of obstructive sleep apnea. | journal=J Nerv Ment Dis | year= 2008 | volume= 196 | issue= 5 | pages= 429-31 | pmid=18477888 | doi=10.1097/NMD.0b013e31816ff3bf | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18477888  }} </ref> or 12 if combined with the [[body mass index|BMI]].<ref name="pmid9178919">{{cite journal| author=Pouliot Z, Peters M, Neufeld H, Kryger MH| title=Using self-reported questionnaire data to prioritize OSA patients for polysomnography. | journal=Sleep | year= 1997 | volume= 20 | issue= 3 | pages= 232-6 | pmid=9178919 | doi= | pmc= | url= }} </ref>.
* The Wisconsin Sleep Questionnaire may help diagnose.<ref name="pmid12812817">{{cite journal| author=Teculescu D, Guillemin F, Virion JM, Aubry C, Hannhart B, Michaely JP et al.| title=Reliability of the Wisconsin Sleep Questionnaire: a French contribution to international validation. | journal=J Clin Epidemiol | year= 2003 | volume= 56 | issue= 5 | pages= 436-40 | pmid=12812817 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12812817  }} </ref>
* Another [[clinical prediction rule]]s may help diagnose sleep apnea.<ref>Rodsutti J, Hensley M, Thakkinstian A, D'Este C, Attia J. A clinical decision rule to prioritize polysomnography in patients with suspected sleep apnea. Sleep. 2004 Jun 15;27(4):694-9. PMID 15283004</ref>


===Oximetry===
===Oximetry===

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Obstructive sleep apnea is a "disorder characterized by recurrent apneas during sleep despite persistent respiratory efforts. It is due to upper airway obstruction. The respiratory pauses may induce hypercapnia or hypoxia. Cardiac arrhythmias and elevation of systemic and pulmonary arterial pressures may occur. Frequent partial arousals occur throughout sleep, resulting in relative sleep deprivation and daytime tiredness. Associated conditions include obesity; acromegaly; myxedema; micrognathia; myotonic dystrophy; adenotonsilar dystrophy; and neuromuscular diseases. (From Adams et al., Principles of Neurology, 6th ed, p395)."[1][2]

Diagnosis

Polysomnography is the best test and abnormal is a apnea–hypopnea index (AHI) of 5 or greater. Moderate to sever OSA is a AHI of 15 or more episodes/hour. However, this test requires a patient to attend a sleep center and is not always required to diagnose sleep apnea.[3] A systematic review in 2000 concluded that the best alternative diagnostic test is not certain.[4]

History and physical

Age, body mass index, male sex, and snoring are the best predictors of sleep apnea.[5] Obstructive sleep apnea is difficult to diagnose based on the history and physical examinations.[6]

Oximetry

Oximetry, which may be performed overnight in a a patient's home, is an easier alternative to formal sleep study (polysomnography.

  • In one study, normal overnight oximetry was very sensitive and so if normal, sleep apnea was unlikely.[12] In addition, home oximetry may be equally effect in guiding prescription for automatically self-adjusting continuous positive airway pressure.[13]
  • Another study found that overnight oximetry was very overnight oximetry, defining abnormal as 15 or more 4% desaturations/hour, was very specific, but not sensitive.[14]

Treatment

Weight loss

Weight loss of 20 kg with a liquid very low energy diet(2.3 MJ/day) for seven weeks can reduce the AHI by 23 and lead to 20% of patients becoming disease free.[15]

Oral appliances

Regarding oral appliances, "CPAP appears to be more effective in improving sleep disordered breathing than OA. The difference in symptomatic response between these two treatments is not significant, although it is not possible to exclude an effect in favour of either therapy. Until there is more definitive evidence on the effectiveness of OA in relation to CPAP, with regard to symptoms and long-term complications, it would appear to be appropriate to recommend OA therapy to patients with mild symptomatic OSAH, and those patients who are unwilling or unable to tolerate CPAP therapy" according to the Cochrane Collaboration.[16]

Continuous positive airway pressure (CPAP)

Regarding continuous positive airway pressure (CPAP), a randomized controlled trial concluded "CPAP attenuated central sleep apnea, improved nocturnal oxygenation, increased the ejection fraction, lowered norepinephrine levels, and increased the distance walked in six minutes, it did not affect survival."[17]. Regarding research prior to this trial, the Cochrane Collaboration concluded "CPAP is effective in reducing symptoms of sleepiness and improving quality of life measures in people with moderate and severe obstructive sleep apnoea (OSA). It is more effective than oral appliances in reducing respiratory disturbances in these people but subjective outcomes are more equivocal. Certain people tend to prefer oral appliances to CPAP where both are effective"[18]

Continuous positive airway pressure can be automatically self-adjusting.[13][19]

Bi-level positive airway pressure (BiPAP) is often more tolerable, as it decreases the pressure when the patient exhales, reducing respiratory effort.[20] For both CPAP and BiPAP, there are a wide range of masks, nasal catheters called "nasal pillows", and it may take several devices and expert fitting to find the right appliance for individual patient."The optimum form of CPAP delivery interface remains unclear... nasal pillows or the Oracle oral mask may be useful alternatives when a patient is unable to tolerate conventional nasal masks" according to the Cochrane Collaboration.[18] A heated humidifier in the compressed air path also helps compliance by preventing drying of the nasal mucosa.

Eszopiclone, a sedative, used nightly for 14 nights may provide sustained increase in patient compliance[21]

Medications

Regarding medications, "there is insufficient evidence to recommend the use of drug therapy in the treatment of OSA" according to the Cochrane Collaboration.[22]

Oropharyngeal exercises

Oropharyngeal exercises my help.[23]

Surgery

Regarding surgery, studies "do not provide evidence to support the use of surgery in sleep apnoea/hypopnoea syndrome, as overall significant benefit has not been demonstrated" according to the Cochrane Collaboration.[24]

References

  1. ↑ Anonymous (2024), Obstructive sleep apnea (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ Caples SM, Gami AS, Somers VK. Obstructive sleep apnea. Ann Intern Med. 2005 Feb 1;142(3):187-97. PMID 15684207
  3. ↑ Mulgrew AT, Fox N, Ayas NT, Ryan CF (2007). "Diagnosis and initial management of obstructive sleep apnea without polysomnography: a randomized validation study.". Ann Intern Med 146 (3): 157-66. PMID 17283346. [e] Review in: Evid Based Med. 2007 Oct;12(5):148 Review in: ACP J Club. 2007 Sep-Oct;147(2):45
  4. ↑ Ross SD, Sheinhait IA, Harrison KJ, Kvasz M, Connelly JE, Shea SA et al. (2000). "Systematic review and meta-analysis of the literature regarding the diagnosis of sleep apnea.". Sleep 23 (4): 519-32. PMID 10875559. [e]
  5. ↑ Viner S, Szalai JP, Hoffstein V (1991). "Are history and physical examination a good screening test for sleep apnea?". Ann Intern Med 115 (5): 356-9. PMID 1863025. [e]
  6. ↑ Abrishami A, Khajehdehi A, Chung F (2010). "A systematic review of screening questionnaires for obstructive sleep apnea.". Can J Anaesth 57 (5): 423-38. DOI:10.1007/s12630-010-9280-x. PMID 20143278. Research Blogging.
  7. ↑ Netzer NC, Stoohs RA, Netzer CM, Clark K, Strohl KP. Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med. 1999 Oct 5;131(7):485-91. PMID 10507956
  8. ↑ Rosenthal LD, Dolan DC (2008). "The Epworth sleepiness scale in the identification of obstructive sleep apnea.". J Nerv Ment Dis 196 (5): 429-31. DOI:10.1097/NMD.0b013e31816ff3bf. PMID 18477888. Research Blogging.
  9. ↑ Pouliot Z, Peters M, Neufeld H, Kryger MH (1997). "Using self-reported questionnaire data to prioritize OSA patients for polysomnography.". Sleep 20 (3): 232-6. PMID 9178919. [e]
  10. ↑ Teculescu D, Guillemin F, Virion JM, Aubry C, Hannhart B, Michaely JP et al. (2003). "Reliability of the Wisconsin Sleep Questionnaire: a French contribution to international validation.". J Clin Epidemiol 56 (5): 436-40. PMID 12812817. [e]
  11. ↑ Rodsutti J, Hensley M, Thakkinstian A, D'Este C, Attia J. A clinical decision rule to prioritize polysomnography in patients with suspected sleep apnea. Sleep. 2004 Jun 15;27(4):694-9. PMID 15283004
  12. ↑ Sériès F, Marc I, Cormier Y, La Forge J (1993). "Utility of nocturnal home oximetry for case finding in patients with suspected sleep apnea hypopnea syndrome.". Ann Intern Med 119 (6): 449-53. PMID 8357109. [e]
  13. ↑ 13.0 13.1 Whitelaw WA, Brant RF, Flemons WW (2005). "Clinical usefulness of home oximetry compared with polysomnography for assessment of sleep apnea.". Am J Respir Crit Care Med 171 (2): 188-93. DOI:10.1164/rccm.200310-1360OC. PMID 15486338. Research Blogging. Review in: ACP J Club. 2005 Jul-Aug;143(1):21 Cite error: Invalid <ref> tag; name "pmid15486338" defined multiple times with different content
  14. ↑ Ryan PJ, Hilton MF, Boldy DA, Evans A, Bradbury S, Sapiano S et al. (1995). "Validation of British Thoracic Society guidelines for the diagnosis of the sleep apnoea/hypopnoea syndrome: can polysomnography be avoided?". Thorax 50 (9): 972-5. PMID 8539678. PMC PMC1021311. [e]
  15. ↑ Johansson K, Neovius M, Lagerros YT, Harlid R, Rössner S, Granath F et al. (2009). "Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial.". BMJ 339: b4609. DOI:10.1136/bmj.b4609. PMID 19959590. PMC PMC2788899. Research Blogging.
  16. ↑ Lim J, Lasserson TJ, Fleetham J, Wright J (2006). "Oral appliances for obstructive sleep apnoea". Cochrane Database Syst Rev (1): CD004435. DOI:10.1002/14651858.CD004435.pub3. PMID 16437488. Research Blogging.
  17. ↑ Bradley TD, Logan AG, Kimoff RJ, et al (November 2005). "Continuous positive airway pressure for central sleep apnea and heart failure". N. Engl. J. Med. 353 (19): 2025–33. DOI:10.1056/NEJMoa051001. PMID 16282177. Research Blogging.
  18. ↑ 18.0 18.1 Chai CL, Pathinathan A, Smith B (2006). "Continuous positive airway pressure delivery interfaces for obstructive sleep apnoea". Cochrane Database Syst Rev (4): CD005308. DOI:10.1002/14651858.CD005308.pub2. PMID 17054251. Research Blogging.
  19. ↑ Littner M, Hirshkowitz M, Davila D, Anderson WM, Kushida CA, Woodson BT et al. (2002). "Practice parameters for the use of auto-titrating continuous positive airway pressure devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. An American Academy of Sleep Medicine report.". Sleep 25 (2): 143-7. PMID 11902424. [e]
  20. ↑ Smith I, Lasserson TJ (2009). "Pressure modification for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea.". Cochrane Database Syst Rev (4): CD003531. DOI:10.1002/14651858.CD003531.pub3. PMID 19821310. Research Blogging.
  21. ↑ Lettieri CJ, Shah AA, Holley AB, Kelly WF, Chang AS, Roop SA et al. (2009). "Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial.". Ann Intern Med 151 (10): 696-702. DOI:10.1059/0003-4819-151-10-200911170-00006. PMID 19920270. Research Blogging.
  22. ↑ Smith I, Lasserson TJ, Wright J (2006). "Drug therapy for obstructive sleep apnoea in adults". Cochrane Database Syst Rev (2): CD003002. DOI:10.1002/14651858.CD003002.pub2. PMID 16625567. Research Blogging.
  23. ↑ Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G (May 2009). "Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome". Am. J. Respir. Crit. Care Med. 179 (10): 962–6. DOI:10.1164/rccm.200806-981OC. PMID 19234106. Research Blogging.
  24. ↑ Sundaram S, Bridgman SA, Lim J, Lasserson TJ (2005). "Surgery for obstructive sleep apnoea". Cochrane Database Syst Rev (4): CD001004. DOI:10.1002/14651858.CD001004.pub2. PMID 16235277. Research Blogging.
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