eMedicine - Breathing-Related Sleep Disorder : Article by Mary E Cataletto, MD

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Breathing-Related Sleep Disorder

Last Updated: April 3, 2006

Synonyms and related keywords: chronic snoring, habitual snoring, upper airways resistance syndrome, UARS, obstructive sleep apnea, OSA, obesity hypoventilation syndrome, OHS, sleep-related breathing disorder, SRBD, obstructive apnea, central apnea, mixed apnea, hypopnea, nasal continuous positive airway pressure, n-CPAP, tongue-retaining device, TRD, sleep disorder

AUTHOR INFORMATION Section 1 of 11

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Author: Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Associate Professor, Department of Clinical Pediatrics, State University of New York at Stony Brook
Coauthor(s): Gila Hertz, PhD, ABSM, Director, Center for Insomnia and Sleep Disorders, Clinical Associate Professor of Psychiatry and Behavioral Sciences, State University of New York at Stony Brook

Mary E Cataletto, MD, is a member of the following medical societies: American Academy of Pediatrics, American Heart Association, and American Thoracic Society

Editor(s): Mohammed Memon, MD, Medical Director of Geriatric Psychiatry, Department of Psychiatry, Spartanburg Regional Hospital System; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eduardo Dunayevich, MD, Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories; Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine; and Stephen Soreff, MD, President of Education Initiatives, Nottingham, NH; Faculty, Metropolitan College of Boston University, Boston, MA

Disclosure

INTRODUCTION

Section 2 of 11

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Background: The term breathing-related sleep disorder refers to a spectrum of breathing anomalies ranging from chronic or habitual snoring to upper airway resistance syndrome (UARS) to frank obstructive sleep apnea (OSA) or, in some cases, obesity hypoventilation syndrome (OHS). Identified by Dement as a major public health concern, studies have shown that significant numbers of patients (93% of women and 83% of men) with moderate-to-severe OSA are undiagnosed. Significant cardiovascular morbidity (including systemic hypertension and congestive heart failure) as well as increased mortality rates have been associated with both OSA and OHS. The aim of this article is to increase the reader's awareness of the importance of sleep disordered breathing in daily practice.

Pathophysiology: Complex interactions among the central and peripheral nervous systems, upper airway musculature, and neurotransmitters may result in partial or complete collapse of a portion or portions of the upper airway. Basic factors, such as airway anatomy (eg, adenotonsillar hypertrophy), nasal obstruction, presence and distribution of body fat, and muscle tone, may contribute, alone or in combination, to the presence and severity of this disorder. Recent data suggest that the primary defect is an anatomically small or collapsible pharyngeal airway in combination with a sleep-related fall in upper airway muscular tone.

The brachycephalic English bull dog has been used as the animal model for upper airway obstruction during sleep.

Frequency:

In the US: According to estimates, 7-18 million Americans experience sleep-related breathing disorders. In a study by Young and associates (1997), 24% of men and 9% of women aged 30-60 years were reported to have sleep disordered breathing. Caples et al (2005) reviewed pooled data from 4 large prevalence studies on OSA and found that 20% of adult Caucasians with BMI between 25 and 28 kg/m² had an apnea hypopnea index (AHI) of 5 or greater and that approximately 6% of these same patients had AHIs of 15 or greater.
Prevalence studies in elderly people show significantly higher rates, with the rate for elderly men reported as 28-67% and the rate for elderly women as 20-54%. In the subset of patients with severe OSA, men have an 8-fold increased frequency. Childhood prevalence is estimated at 0.7-2.9%, peaking between ages 2-8 years.

Mortality/Morbidity: Obesity, advanced age, and snoring have been found to be important factors in the progression of sleep-disordered breathing.

Morbidity with OSA falls into 2 major categories, as follows:

Neuropsychiatric or psychosocial: This includes excessive daytime sleepiness, poor concentration and memory, decreased performance, irritability, depression, and disturbed social relationships. This population has a significantly increased risk of motor vehicle accidents, with reports of a 7-fold increased risk in patients with an AHI greater than 5.

Cardiovascular: Systemic hypertension occurs in 45-90% of patients with OSA. Pulmonary hypertension has been reported in 15-20%.

Race: Comparison date between African American and Caucasian adults when corrected for BMI suggest that prevalence of sleep-disordered breathing in African Americans is at least equal to and may in fact exceed that of their Caucasian peers.

Sex:

Male sex appears to be related to a significant increase in the prevalence of sleep-disordered breathing, presumably because of hormonal influences. Testosterone in particular is associated with increased severity of sleep-related breathing disorders. In the subset of patients with severe obstructive sleep apnea, men outnumber women by eight fold.

Sex hormones play a role in the modulation of upper airway musculature. In adults, the prevalence in males exceeds that of females by 3 fold in middle age. In women with OSA, apneas tend to cluster during REM sleep. In men with OSA apneas predominated in the supine position.

No sex difference exists before puberty, and, after menopause, the differences again become small. The increase in frequency of sleep-related breathing disorders in women who are postmenopausal may be related to decreases in progesterone levels.

Age:

In children, those born prematurely have been found to be 3-5 times more likely to have sleep-disordered breathing compared with their full-term counterparts. Childhood OSA has its peak incidence between ages 2-8 years, corresponding to the time when tonsils and adenoids are the largest in relationship to upper airway size.

Both snoring and sleep-related breathing disorders increase in frequency with advancing age, at least until age 60 years. Older persons exhibit both central and obstructive apnea. The pattern of apnea in older persons having AHI greater than 5 resembles typical sleep apnea in regard to duration and degree of desaturation. However, the effect on general health in elderly people with OSA appears to be minimal.

In elderly people, little to no relationship seems to exist between sleep apnea and typical risk factors such as excess weight and increased airway resistance. The mechanisms underlying sleep apnea in elderly people are purportedly be different, and they may reflect a gradual increase in sleep instability, which results in both central apnea and OSA.

CLINICAL

Section 3 of 11

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History: Features of both a patient's history and the physical examination can direct attention to the possibility of a diagnosis of breathing-related sleep disorder. In addition, these disorders occur with greater frequency in patients with positive family histories. A genetic marker has not been identified, and this finding probably relates to a combination of factors, including craniofacial morphology, level of obesity, sex, age, and environment. Certain genetic syndromes have been associated with an increased incidence of sleep-disordered breathing. Patients with certain conditions should be asked about symptoms suggestive of the disorder. Among these conditions are Down syndrome (trisomy 21), Pierre Robin syndrome, Apert syndrome, Treacher Collins syndrome, Marfan syndrome, achondroplasia, Hurler syndrome, Hunter syndrome, myotonic dystrophy, acromegaly, Shy-Drager syndrome, and sickle cell disease. Patients with Prader-Willi syndrome are at risk for obesity-related hypoventilation.

Habitual snoring: This may be the presenting symptom and often is more distressing to the bed partner than to the patient. Along with a history of nasal obstruction or chronic mouth breathing, this symptom should direct the physician to consider evaluation for sleep-disordered breathing.

Excessive daytime sleepiness: Daytime sleepiness is the most commonly reported symptom in patients with OSA. The Epworth sleepiness scale (ESS) has been used to subjectively quantify the degree of sleepiness by having patients rate their likeliness to doze off in various sleep-conducive situations. This scale has been evaluated in patients with sleep apnea and has been correlated with AHI. Scores range from 0-24. Studies in various populations experiencing excessive daytime sleepiness have established mean ESS scores for sleep apnea at 11.7 as compared to 17.5 in people with narcolepsy and 5.9 in people without sleep disorders.

Psychosocial dysfunction: Symptoms include irritability, depression, decreased sex drive, and cognitive dysfunction, including poor concentration and impaired memory. These signs are consistent with chronic sleep deprivation. Morning headaches may also be reported.

Witnessed apnea: Reported by bed partners, these are more predictive than a history of waking up gasping for air, which can be observed with a number of other disorders. See Differentials.

Cardiovascular disease: Symptoms in this category often reflect the sequelae of chronic hypoventilation and include hypertension, coronary artery disease, and stroke. Bradycardic-tachycardic dysrhythmias have also been associated with apneas.

Enuresis/nocturia and impotence

Obesity: Defined as a body mass index (BMI) greater than 28 kg/m², obesity is reported in 60-90% of patients with OSA. Both central and truncal obesity correlate with the severity of OSA.

Drug use, particularly sedative and alcohol use: These substances may contribute to and exacerbate the severity of OSA.

Physical:

General characteristics: Obesity and craniofacial dysmorphology are important features to identify. Micrognathia, retrognathia, maxillary hypoplasia, cleft palate, and macroglossia are among the important initial features to assess. Image 1 shows a photograph of a patient with significant retrognathia that contributed to his OSA.

Mental status: The Mental Status Examination should be tailored to the individual patient, with particular attention to affect because depression is not an uncommon comorbidity in people with sleep deprivation. In patients with neuropsychiatric disease, this evaluation is more extensive.

Blood pressure: Systemic hypertension occurs in approximately 50% of patients with OSA. While diagnostic upper limits may vary somewhat by study site, most agree that hypertension exists when systolic blood pressure is documented repeatedly (ie, on 2 or more visits) as greater than 140 mm Hg or when the diastolic value equals or exceeds 90 mm Hg on 2 or more visits. Patients with hypertension have an increased incidence of OSA (ie, up to 30%), and questions about sleep should be included in the workup of patients with hypertension.

Height and weight (BMI): BMI greater than 28 is frequently associated with OSA.

Collar size: Collar size is measured at the level of the cricothyroid membrane and is another parameter associated with predicting risk for OSA. In snoring male patients with collar sizes greater than 17 inches, the prevalence of OSA is 30%. Women with collar sizes greater than 15 inches have also been found to be at increased risk.

Nasal examination: The nasal examination is critical in identifying potential anatomic sites of obstruction such as a deviated septum, enlarged adenoids, swollen nasal turbinates, polyps, or other mass lesions. The nasal examination is often conducted using a flexible fiberoptic nasopharyngoscope. In addition to the potential diagnostic value of this procedure, a patent nasopharyngeal airway is necessary if nasal continuous positive airway pressure (n-CPAP) is considered as a treatment option in OSA.

Craniodentofacial examination: In addition to the features described above (eg, retrognathia, micrognathia, macroglossia), mandibular alignment, dental occlusion, and cephalometric data are often helpful.

Oropharynx: A variety of anatomic feature can have an impact on airflow limitation at this level, including large tonsils, long soft palate, large uvula, pharyngeal flap, posterior pharyngeal stenosis and scarring, redundant fold, and tumors. The relationship of the tongue, palate, and posterior pharyngeal wall can cause posterior pharyngeal crowding and predisposition to OSA.

Neck: Fat distribution in this area can compromise airflow during sleep when muscle tone is reduced, especially during REM sleep. Masses, including significant lymphadenopathy, should be noted.

Causes: OSA results from airflow obstruction secondary to upper airway collapse or anatomic airway obstruction. In adults, the obstruction typically occurs at the level of the uvula/soft palate or tongue. The interrelationship of age, sex, obesity, and craniofacial size and dynamics is still poorly understood.

DIFFERENTIALS Section 4 of 11

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Depression
Gastroesophageal Reflux Disease
Hypothyroidism
Obstructive Sleep Apnea-Hypopnea Syndrome

Other Problems to be Considered:

Congestive heart failure
Narcolepsy
Nocturnal asthma
Daytime sequelae of sleep deprivation, including depression, irritability, poor concentration and memory, and daytime sleepiness

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Introduction
Clinical
Differentials
Workup
Treatment
Medication
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WORKUP

Section 5 of 11

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Lab Studies:

Testing procedures should be tailored to the individual patient.

Arterial blood gas: Baseline blood gases obtained when the patient is awake provide an indication of ventilatory function and oxygenation. Patients who have chronic obstructive pulmonary disease or chronic interstitial lung disease may have worsening ventilatory function, as well as oxygen desaturation, during sleep.

Imaging Studies:

Imaging studies are generally used in research protocols or in the course of presurgical evaluations, and they should be tailored to address specific questions or concerns.

Acoustic reflection is rarely used in clinical practice because of limited resolution. It is a noninvasive modality designed to enable visualization of upper airway dynamics.

Somnofluoroscopy: This technique has been employed by otolaryngologists to evaluate the area of pharyngeal collapse and maximal airway narrowing during sleep. While this technique has been used to predict surgical success in some patients undergoing uvulopalatopharyngoplasty (UPPP), its use remains limited, especially in patients with obstruction distal to the velopharyngeal region. Although this is a dynamic study, it does not allow for accurate cross-sectional measurements nor is it sensitive enough to be used to define the contribution of soft tissue dynamics in the upper airway.

Cephalometry: This radiographic technique is used to evaluate the craniofacial skeleton for deficiencies. The airway can be measured in 2 dimensions. Hyoid position seems to be most predictable. However, because the study is performed during wakefulness, it is of limited value.

CT scan of the upper airway: Shepard and associates (1989) performed CT scans of the upper airway in a group of 23 patients before and after UPPP in an attempt to find predictors for surgical success. Cross-sectional areas of the upper airway were analyzed. While UPPP increased the anatomic size of the upper airway in all patients, response defined as decreasing AHI by greater than 50% was observed in only 35%. CT scan alone was not useful in predicting response.

Magnetic resonance imaging: This is the only currently available technique that allows for dynamic imaging of the airway with good resolution of the airway, soft tissues, and fat.

Other Tests:

Overnight polysomnogram

Overnight polysomnogram (PSG) is the criterion standard for the diagnosis and characterization of sleep-related breathing disorders. The study measures both oral and nasal airflow, respiratory effort, and pulse oximetry, along with a 2-lead electrocardiogram, leg and chin electromyelogram (EMG), electrooculogram (EOG), and 2-lead electroencephalogram (EEG). From this data, obstructive apnea (ie, continued muscle activity in the setting of cessation of airflow), central apnea (ie, absent muscle and airflow activity), mixed apnea, and hypopnea (ie, drop in airflow by at least 50% and associated with oxygen desaturation) can be identified and the AHI calculated.

The AHI is a measure that is defined as the total number of apneas and hypopneas divided by the total sleep time in hours. This value plays an important role in both defining and grading the severity of sleep disordered breathing. Not only is the PSG used to define the frequency and duration of the respiratory events; it is also used to evaluate the physiologic consequences of these events; specifically, associated oxygen desaturations, cardiac dysrhythmias, and sleep fragmentation. Image 2 shows a hypnogram of a patient with severe OSA.

Multiple sleep latency test (MSLT): The MSLT is designed to evaluate a patient's propensity to sleep and is particularly valuable in patients in whom the findings on the overnight PSG are normal and the etiology of the daytime sleepiness remains unknown. This noninvasive study is conducted in a sleep laboratory following an overnight PSG. All psychoactive medications should be suspended for at least 2 weeks prior to the study. Generally, patients are allowed 4 opportunities to sleep in a sleep-conducive environment beginning 90-180 minutes following the PSG. Subsequent opportunities are provided at 2-hour intervals, and sleep latencies are measured. For patients in whom the criteria for narcolepsy have not been met, a fifth nap may be offered. Adults without sleep disorders have a mean sleep latency of 10-20 minutes, while values of less than 5 minutes indicate pathological sleepiness.

Pulmonary function testing (PFT): PFT, in the form of prebronchodilator and postbronchodilator spirometry, lung volumes, and diffusing lung capacity for carbon monoxide (DLCO), provides further insight into the presence of underlying lung disease and may raise concerns about nocturnal asthma to explain a patient's symptomatology.

Procedures:

Nasopharyngoscopy with the M�ller maneuver: Nasopharyngoscopy is an office procedure used to evaluate the patency of the nasopharyngeal airway. It is generally performed during wakefulness, and the patient often performs a M�ller maneuver. In the supine position, the patient inhales against an occluded oronasal airway. The maneuver is performed as an attempt to simulate the pharyngeal collapse that may be occurring during sleep.

TREATMENT

Section 6 of 11

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Medical Care: General treatment measures include (1) behavior modification aimed at improving sleep hygiene and avoiding additional sleep deprivation, (2) avoidance of the supine positioning during sleep, and (3) avoidance of ethanol and sedative medications.

The medical options listed below require major changes in lifestyle. Appropriate weight management strategies and compliance with either positive airway support or use of the dental appliance usually is a lifetime commitment. For this reason, some patients have explored surgical alternatives.

Weight loss

This recommendation is critical in even mildly obese patients because even small amounts of weight loss may have significant impact on the respiratory disturbance index (RDI) and may reduce the degree of oxygen desaturation and improve sleep architecture.
Depression and fatigue may hamper weight loss plans, and, at least initially, weight loss may need to be combined with psychotherapy.

Positive airway pressure

n-CPAP is the most frequently used medical modality for the treatment of OSA. This technique involves the application of positive pressure to the upper airway via a nasal mask. In this way, n-CPAP is used to stent open the collapsed pharyngeal tissue and to improve airflow. Studies suggest that n-CPAP improves airway dimensions by approximately 20%, more so in the lateral than the anteroposterior dimension. Effective delivery pressures are titrated in the sleep laboratory. It is noninvasive and highly effective in reducing apnea and improving sleep architecture. However, it is often limited by poor patient compliance. Compliance studies have shown that 46% of patients used n-CPAP for at least 4 h/d for 5-7 days. Seventy-six percent of patients overestimated their compliance.

Three variations of positive pressure support via nasal masks are used at home for the treatment of OSA.
The first is n-CPAP, which delivers a constant pressure throughout inspiration and expiration. The second is bilevel positive airway pressure (BiPAP), which allows independent adjustment of inspiratory and expiratory pressures. This technique provides a lower mean airway pressure, and risk of barotrauma reportedly is decreased. No improvement in compliance has been observed with BiPAP as compared to n-CPAP. The third variation, autotitrating CPAP, has also been used in the home setting and has the advantage of adjusting to the individual patient's airflow patterns. Image 3 shows a patient receiving CPAP. Images 4-5 show CPAP maintaining upper airway patency during sleep. Images 6-8 show patient interfaces, including nasal CPAP masks and nasal pillows.
Possible adverse effects related to this type of nocturnal ventilatory support include those related to pressure, airflow, and the mask-face interface. Therefore, dry mouth, barotrauma, pneumothoraces, and aerophagia, as well as air leaks and pressure sores at the mask interface, may be observed. Image 3 shows a patient using a CPAP system.

Oral appliances

Customized dental appliances are designed to increase airway size and to facilitate airflow by advancing the mandible or tongue or lifting the soft palate. While success with oral appliances often is difficult to predict, this may offer a valid treatment option in nonobese patients with micrognathia or retrognathia who have mild or mild-to-moderate apnea.
Devices may be categorized into (1) those that advance the tongue, such as the tongue-retaining device (TRD); (2) those that advance the jaw, such as the mandibular advancing device (MAD); and (3) those that simultaneously lift the soft palate and advance the mandible. This combination appliance is known as the Z appliance. Adverse effects may include temporomandibular joint (TMJ) discomfort, excessive salivation, or dry mouth. In general, patients with severe OSA have had poor results. High cost, poor reimbursement, and patient discomfort have contributed to limited use of this option. Images 9-13 show a Herbst appliance used in the treatment of OSA. Image 14 shows an example of a TRD. Image 17 shows a customized original design known as the Z appliance, which combines features of both the Herbst appliance and the TRD.

Surgical Care: Surgical options include (1) procedures designed to increase upper airway size, (2) procedures designed to bypass the upper airway, and (3) procedures that ensure weight loss. The latter two procedures have traditionally been reserved for the more severely affected and recalcitrant patients.

For patients with morbid obesity who are refractory to diet and drug therapy, bariatric surgery has been associated with effective weight loss and significant improvement in sleep-disordered breathing.

Techniques to increase upper airway size include the following:

Uvulopalatopharyngoplasty (UPPP): This is a surgical procedure designed to enlarge the pharyngeal airway dimensions at the level of the soft palate. It involves resection of the uvula and posterior margins of the soft palate, as well as the resection of any redundant nasopharyngeal tissue. It is successful in as many as 50% of cases; however, success may be only temporary. The overall incidence of complications is low but may include velopharyngeal insufficiency and nasopharyngeal stenosis with worsening apnea.

Maxillomandibular osteotomy and advancement: This procedure is designed to advance the maxilla, mandible, and chin in a patient with dentofacial deformity–related sleep apnea. Often, hyoid suspension and genioglossal advancement are performed simultaneously with these surgical procedures. Image 18 (A and B) shows the preoperative and postoperative radiographs of a patient with dentofacial deformity–related OSA for whom UPPP was unsuccessful.

Other techniques in this category include adenotonsillectomy, laser-assisted uvulopalatoplasty, lingual resection, lingualplasty, genioglossal advancement, hyoid suspension, and mandibular advancement procedures. Interested readers are referred to the surgical references listed in the bibliography for more details.

Techniques to bypass the upper airway include tracheostomy: While tracheostomy remains the criterion standard for the surgical relief of upper airway obstruction, this option is reserved for the most severe cases because of the very significant psychosocial implications and potential complications of the procedure. Excessive daytime sleepiness may persist despite tracheostomy in as many as 25% of patients. However, in most patients, a rapid response occurs, with return of sleep architecture to normal within the first postoperative month. Tracheostomy may be considered as a temporary or permanent option in patients with severe oxygen desaturation or cardiac dysrhythmias precipitated by OSA in whom continuous positive airway pressure therapy is refused, poorly tolerated, or unsuccessful and in those patients in whom underlying cardiac, pulmonary, or neuromuscular disease is exacerbated by the severity of the OSA.

Consultations: Most of the procedures involved in diagnosis, evaluation, and treatment involve subspecialty consultations.

Sleep medicine physicians are generally affiliated with a sleep disorder center. Their specialty training may come from a variety of sources, most commonly from pulmonology, neurology, or psychiatry. Additional training in the area of sleep disorders may lead to board certification from the American Board of Sleep Medicine. Once patients have been identified with OSA, titration of positive pressure ventilation can be achieved under supervision in the sleep laboratory.

Otolaryngologists: Many patients with OSA decide to explore the surgical options to allow complete correction or cure in an effort to avoid a lifetime commitment to n-CPAP or dental appliance.

Oral surgeons and dentists: The evaluation of patients with dentofacial abnormalities can be greatly assisted by the input of these specialists who can customize dental appliances and, in special cases, offer additional surgical options for patients.

Psychiatrists: Patients with OSA may have difficulties with the sequelae of chronic sleep deprivation, the need for n-CPAP or surgery, and the prospect of often-significant weight loss. Depression may coexist with chronic sleep deprivation and may require ongoing psychiatric intervention until both are under control.

Pulmonologists: Underlying pulmonary parenchymal or airway disease can influence the severity of the response to OSA. Treatment of such disorders can complement the treatment of OSA.

Cardiologists: Systemic and pulmonary hypertension have been associated with OSA. In such patients, the cardiologist can provide valuable assistance with management.
Bariatric surgeon: Bariatric surgery may be considered in morbidly obese patients who have failed to achieve effective weight loss despite diet and drug therapy. In Buchwald's analysis of 136 studies, which roughly included 22,000 patients who underwent bariatric surgery, those with OSA experienced a significant improvement in oxygen saturation, CO₂ retention, and arterial oxygen content.

Diet: Weight loss is critical in even mildly obese patients because even small amounts of weight loss may have significant impact on the RDI and may reduce the degree of oxygen desaturation and improve sleep architecture.

MEDICATION Section 7 of 11

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Several pharmacotherapeutic options have been explored with regard to stimulating breathing, improving diaphragmatic function, and altering sleep architecture. Studies on these drug options are limited in number and variable in response. With limited exception, they are not effective options. Individuals interested in exploring the pharmacologic studies in this area are referred to the paper by Hudgel (1998) that reviews the published literature (see the bibliography).

Drug categories that have been explored include ventilatory stimulants, such as medroxyprogesterone, which have had limited success in some patients with hypercapnic OSA. Recent clinical trials with modafinil (a wakefulness-promoting agent) have shown some efficacy in patients with OSA who continued to have daytime sleepiness in spite of effective treatment.

FOLLOW-UP Section 8 of 11

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Further Inpatient Care:

Patients with comorbidities, eg, obesity, depression, should receive appropriate evaluation as inpatients, and arrangements should be made for specific follow-up for both their respiratory intervention (eg, n-CPAP) and any comorbidities.

Further Outpatient Care:

Outpatient follow-up is tailored to the individual patient and the interventions selected to address the diagnoses. For example, a patient with obesity, depression, and severe OSA who has undergone a tracheostomy requires more intensive follow-up from a therapeutic team than does a healthy young man with mild apnea who requires an adenoidectomy or repair of a deviated nasal septum.

Education of all patients in basic sleep hygiene is recommended.

Complications:

Untreated OSA may be associated with hypertension and congestive heart failure. Even patients with mild changes in their AHI, with values ranging between 0.1 and 4.9, had an increased risk of developing systemic hypertension when compared with those who had AHIs of 0.

Daytime fatigue may affect a person's daytime function and sense of well-being.

Depressive symptoms associated with disrupted sleep may require additional intervention after the airway obstruction of OSA has been addressed.

Patient Education:

As described previously, teaching patients to identify sleep-related breathing disorders is important. Chronic snoring, witnessed apnea, and daytime sleepiness warrant further workup.

Education regarding the benefits of good sleep hygiene is beneficial to all patients but has specific importance for patients with sleep-related breathing disorders. Physicians should be alert to the presence of comorbidities.

Daytime sleepiness is associated with poor focus and performance. Patients with OSA and daytime sleepiness should be counseled about their increased risk of accidents while driving vehicles or operating heavy machinery.

For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center and Sleep Disorders Center. Also, see eMedicine's patient education articles Snoring, Sleep Disorders and Aging, and Insomnia.

MISCELLANEOUS

Section 9 of 11

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Medical/Legal Pitfalls:

The time between diagnosis and treatment (typically a second continuous positive airway pressure study) of breathing-related sleep disorders may be extended for various reasons. The most common is scheduling limitations at the sleep center. In addition, the sleep center often serves as a diagnostic facility, leaving the treatment decision to the referring physician. Patients diagnosed with OSA commonly go without treatment for weeks or even months after the initial diagnostic test.

Physicians must issue a warning for patients who report excessive daytime sleepiness, particularly after confirming the diagnosis of OSA; the warning should address driving a car and/or operating heavy machinery while excessively sleepy. This should be documented in the patient's chart as well as in the PSG report sent to the referring physician.

In cases of severe OSA, centers should make every effort to treat patients as soon as possible. Although OSA-related death is rare, a few patients with very severe OSA died in their sleep soon after being diagnosed with the disease.

Statistics show alarming numbers of fatigue-related accidents in sleepy drivers. This creates potential liability issues for the sleep physician caring for OSA patients whose employment requires driving or use of heavy machinery.

Failure to screen high-risk patients, including black children and those born prematurely, is a potential source of medicolegal liability.

PICTURES

Section 10 of 11

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