Obstructive Sleep Apnea (OSA) Flashcards
A 55-year-old man comes to the clinic for evaluation of persistent high blood pressure despite compliance with antihypertensive therapy. His past medical history is also significant for type 2 diabetes mellitus. He has been taking lisinopril, amlodipine, and hydrochlorothiazide for the past six months. He reports starting lifestyle modifications and salt restriction. He does not smoke or drink alcohol. On review of systems, he reports morning headaches and excessive daytime fatigue. BMI is 36 kg/m?. Temperature is 36.7°C (98.1°F), blood pressure is 155/95 mmHg, pulse is 78/min, respiratory rate is 16/min, and oxygen saturation is 96% on room air. Physical examination is significant for obesity but is otherwise unremarkable. Laboratory results are shown below. Which of the following is the best next step in the evaluation of this patient’s hypertension?
In patients with resistant hypertension and symptoms and findings suggestive of obstructive sleep apnea (e.g. daytime fatigue, morning headaches, and obesity), a polysomnography can be used to make the diagnosis. This patient presents with difficult-to-control hypertension despite adherence to three antihypertensive medications, indicating treatment resistant hypertension. He also has obesity (BMI of 36 kg/m?), morning headaches, and daytime fatigue. This clinical presentation is strongly suggestive of obstructive sleep apnea (OSA), which is a common cause of secondary hypertension.
OSA is characterized by repeated episodes of partial or complete upper airway obstruction during sleep, leading to oxyhemoglobin desaturation and sleep fragmentation. Common clinical features include loud snoring, witnessed apnea, and daytime sleepiness. Morning headaches are often due to nocturnal hypercapnia from repeated apneic episodes. Furthermore, chronic intermittent hypoxia and hypercapnia can contribute to the development of treatment-resistant hypertension. Evaluation for OSA typically involves using the STOP-BANG questionnaire, a screening tool that gauges the likelihood of OSA based on the patient’s clinical presentation and a subsequent polysomnography to confirm the diagnosis. The diagnosis can be made when an abnormal apnea-hypopnea index is observed.
Positive airway pressure therapy is the standard treatment for OSA. Not only does it effectively treat OSA, but it can also help decrease blood pressure in patients with resistant hypertension.
What is the most common cause of excessive daytime sleepiness in adults?
Obstructive Sleep Apnea (OSA). Patient also have a history of headaches, history of daytime fatigue, obesity and morning headaches.
How does OSA affect driving and workplace safety?
OSA increases the risk of motor vehicle accidents and workplace errors due to impaired alertness and reaction time.
What is the primary screening tool for Obstructive Sleep Apnea (OSA)?
The STOP-BANG questionnaire, which assesses risk based on Snoring, Tiredness, Observed Apneas, high Blood pressure, BMI >35, Age >50, Neck circumference >17 inches (men) or >16 inches (women), and Male gender.
What are the scoring criteria for the STOP-BANG questionnaire?
0-2 points: Low risk for OSA
3-4 points: Intermediate risk for OSA
5 or more points: High risk for OSA
What are some distinguishing features of OSA compared to habitual snoring?
OSA presents with excessive daytime sleepiness, poor concentration, morning headaches, hypertension, and observed apnea episodes, whereas habitual snoring lacks these systemic features.
What lifestyle modifications are recommended before considering further diagnostic testing for snoring?
Smoking cessation and elimination of alcohol before bedtime to reduce pharyngeal muscle relaxation and snoring.
How does obesity contribute to OSA?
Increased fat deposition around the upper airway leads to airway collapse during sleep.
Why is habitual snoring alone not an indication for polysomnography?
Because over 50% of patients who snore do not have OSA. Screening tools like STOP-BANG help identify those at high risk who require further testing.
Which patient characteristics increase the likelihood of OSA?
Male gender, obesity (BMI >35), age >50, large neck circumference (>17 inches in men, >16 inches in women), and hypertension.
How does alcohol consumption before sleep contribute to snoring?
Alcohol relaxes pharyngeal muscles, increasing airway collapse and snoring frequency.
What are the hallmark symptoms of OSA?
Loud snoring, excessive daytime sleepiness, choking or gasping during sleep, morning headaches, poor concentration, and hypertension.
What is the gold standard diagnostic test for OSA?
Polysomnography (sleep study) which monitors nocturnal oxygen saturation and respiratory events.
What is the Apnea-Hypopnea Index (AHI) and how is it used?
AHI is the average number of apnea and hypopnea episodes per hour of sleep: Mild OSA (5-15), Moderate OSA (15-30), Severe OSA (>30).
What is the first-line management for mild OSA?
Weight loss, smoking cessation, alcohol avoidance before sleep, and positional therapy to avoid supine sleeping.
When is CPAP therapy indicated for OSA?
For moderate to severe OSA or when lifestyle modifications fail to improve symptoms.
What is the role of oral appliances in OSA management?
Mandibular advancement devices can be used in patients with mild to moderate OSA who do not tolerate CPAP.
What surgical options exist for OSA management?
Uvulopalatopharyngoplasty (UPPP) and hypoglossal nerve stimulation for refractory cases.
What are the long-term complications of untreated OSA?
Hypertension, cardiovascular disease, arrhythmias (e.g., atrial fibrillation), stroke, metabolic syndrome, and impaired cognitive function.
How does smoking contribute to snoring and OSA?
Smoking causes upper airway inflammation and edema, leading to increased airway resistance.
What is the recommendation for children who suffer from obstructive sleep apnea?
In contrast to the treatment for obstructive sleep apnea (OSA) in adults, first-line therapy for OSA in children is tonsillectomy and adenoidectomy. Children with loud snoring, pauses in breathing, and gasping for breath during sleep likely has obstructive sleep apnea (OSA). As in adults, OSA in children is a sleep disorder in which episodic upper airway obstruction results in difficulty breathing and disrupted sleep. This often manifests as restless sleep, loud snoring, periods of apnea, and gasping for breath at night. Other symptoms in children may include enuresis and parasomnias.
In adults, OSA is often associated with obesity, so weight loss is usually recommended. In contrast, young children with OSA are often underweight, and severe cases may result in failure to thrive. In these patients, adenotonsillar hypertrophy contributes to a significant narrowing of the upper airway, resulting in intermittent obstruction. Therefore, first-line management for pediatric OSA is tonsillectomy and adenoidectomy. In young children, adenotonsillectomy is often curative, obviating the need for an intervention unlikely to be successful due to significant difficulty with adherence. Some children with OSA may benefit from avoiding environmental allergens (eg, cat) or irritants (eg, tobacco smoke), but it is unlikely that this alone would resolve OSA symptoms. Therefore, this is recommended as adjuvant, rather than initial, therapy.
