Treat sleep apnea, boost health
By Ryan DuBosar
ACP Member Sheila Tsai, MD, extrapolated on sleep apnea and related disorders at Internal Medicine Meeting 2022, reviewing prevalence and practical tips for primary care.
Dr. Tsai, of National Jewish Health in Denver, said that obstructive sleep apnea (OSA) occurs in 5% of men and 3% of women, but it's more common in overweight men ages 40 and older with family history. Typical symptoms include loud snoring, hypopneas or apneas, repeated sleep arousals or oxygen desaturations, and daytime sleepiness, said Dr. Tsai, who is also a physician advisory board member for CPAP manufacturer ResMed Corp.
To assess the prevalence of screening, she polled the audience of internists at the presentation, finding that 70% said they routinely screen for sleep disorders, and about 75% are comfortable diagnosing OSA.
Not all snoring is OSA, but it's a crucial characteristic, one that occurs in 60% of men, 40% of women, and 25% of children, Dr. Tsai said. Snoring is exacerbated by obesity, alcohol, defects in upper airway anatomy, and pregnancy.
Among OSA's many clinical presentations are daytime sleepiness, choke/gasp awakening, and witnessed apneas. It stems from obstructive events during sleep causing episodes of arousal, resulting in sleep fragmentation, sleepiness, and insomnia. These can trigger poor moods, memory and concentration issues, and missed work. Tellingly, people with OSA have three to seven times the number of car accidents compared to those who do not have it.
Untreated OSA impacts all facets of life and health, Dr. Tsai said. It can trigger hypertension, atrial fibrillation, and mild pulmonary hypertension. OSA is present in 50% of all cases of hypertension, 25% of all coronary heart failure, 30% of acute coronary syndromes, and 60% of strokes.
If untreated, it can cause endocrine conditions such as increased insulin resistance, an imbalance between leptin and ghrelin, and hypogonadism; psychiatric conditions including anxiety and depression; gastroenterological reflux disease; worse outcomes in overlap syndrome with chronic obstructive pulmonary disease (COPD); and neurological issues.
The eventual diagnosis helps direct therapy, and treatment with positive airway pressure (PAP) or noninvasive ventilation improves symptoms, quality of life, and sleep-disordered breathing, Dr. Tsai said.
A good work-up for OSA includes starting with the bread-and-butter history and physical exam, Dr. Tsai said, including an upper airway evaluation, assessment of body mass index, vital signs, neck circumference, facial morphology that might disrupt breathing, and nasopharyngeal and oropharyngeal structures.
The gold standard for testing is a laboratory-based polysomnogram, while more convenient options can include home tests such as limited channel devices and peripheral arterial tonometry, she noted. Also, Dr. Tsai said, "We like to look at the Mallampati classification to assess for OSA."
To further evaluate sleep, she finds the STOP (BANG) questionnaire most effective, she said. The Berlin questionnaire is more complicated, while the Epworth sleepiness scale is helpful to assess subjective symptoms, she said.
"When do you decide to do in-laboratory versus home sleep apnea testing?" Dr. Tsai asked the audience.
Lab testing is still the gold standard, offering a chance to evaluate other sleep disorders, providing better accuracy and information for PAP titration. But it's more expensive, requires more time to score and interpret, and is inconvenient for the patient, Dr. Tsai said.
Home sleep tests are "and good enough to give broad categories for sleep apnea" but can overestimate or, more likely, underestimate the presence of OSA, she said. They are less expensive and time-consuming but more prone to patient error.
Options to treat OSA include PAP therapy, the gold standard. Conservative management includes weight loss, positional therapy (if the patient declines PAP), avoiding alcohol and sedatives before bed, and smoking cessation.
Ideally, patients should aim for a BMI of 25 kg/m2 or less to combat OSA. "Every 10% weight loss is associated with 26% decrease in AHI [apnea-hypopnea index] in moderate to severe OSA," Dr. Tsai said. "Unfortunately, 10% weight gain increases odds of developing OSA by six times and increases AHI by 32%."
Positional therapy includes wedge pillows or elevating the head of the bed. Sleep positioners range from a device to keep patients on their side, a tennis ball in the pajamas to keep them on their side, or, better, a fanny pack, which at least lets patients move from side to side. ■