Fast Five Quiz: Sleep Disorders

Helmi L. Lutsep, MD; Zab Mosenifar, MD; Stephen Soreff, MD

Disclosures

August 03, 2020

Apnea is defined by the AASM as the cessation of airflow for at least 10 seconds. Apnea may last for 30 seconds or even longer. OSA symptoms generally begin insidiously and are often present for years before the patient is referred for evaluation.

The general physical examination is frequently normal in patients with OSA, other than the presence of obesity, an enlarged neck circumference, and hypertension. Perform an evaluation of the upper airway in all patients, but particularly in nonobese adults with symptoms consistent with OSA.

Physical examination findings may include the following:

  • Obesity: body mass index > 30 kg/m2

  • Large neck circumference: > 17 inches (43 cm) in men and > 15 inches (37 cm) in women

  • Abnormal (increased) Mallampati score (a subjective evaluation of the ratio of oral cavity volume to tongue volume)

  • Narrowing of the lateral airway walls: an independent predictor of the presence of OSA in men but not women

  • Enlarged tonsils

  • Retrognathia or micrognathia

  • Large degree of overjet

  • High-arched hard palate

  • Systemic arterial hypertension

  • Congestive heart failure

  • Pulmonary hypertension

  • Stroke

  • Metabolic syndrome

  • Type 2 diabetes mellitus

The following findings on polysomnography are characteristic of OSA:

  • Apneic episodes occur in the presence of respiratory muscle effort.

  • Apneic episodes lasting 10 seconds or longer are considered clinically significant.

  • Apneic episodes are most prevalent during REM sleep. In some patients, they may occur exclusively during REM sleep.

  • Patients may have a combination of apneas and hypopneas, or they may have one or the other exclusively.

  • Mixed apneas may occur.

  • Sleep disruption due to arousals is usually seen at the termination of an episode of apnea.

OSA should be diagnosed and treated promptly. People with mild apnea have a wider variety of options, whereas people with moderate to severe apnea should be treated with nasal continuous PAP. General and behavioral measures, such as weight loss, avoidance of alcohol for 4-6 hours before bedtime, and sleeping on one's side rather than on the stomach or back, are elements of conservative nonsurgical treatment.

AASM guidelines for the treatment of adults with OSA using PAP strongly recommend that clinicians use PAP to treat OSA in adults with EDS. The guidelines also strongly suggest that PAP therapy be initiated using either APAP at home or in-laboratory PAP titration in adults with OSA and no significant comorbidities. Continuous PAP or APAP is strongly recommended for ongoing treatment of OSA in adults, as are educational interventions at the initiation of PAP therapy.

Read more clinical information about OSA.

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