II. Epidemiology

  1. More common in men (by 3 fold)
    1. However women are likely underdiagnosed (esp. postmenopausal, not on HRT)
  2. Prevalence increases with age (esp. over age 60 years old)
  3. Incidence: Apneas and Hypopneas (AHI) >5/hour in ages 30 to 60 years of age
    1. Without daytime Somnolence: 24% of men and 9% of women
    2. With daytime Somnolence: 4% of men and 2% of women

III. Causes

  1. Adults
    1. Narrow airway (key factor)
      1. Narrows most in the hypopharynx (below Tongue)
      2. Can narrow to pencil diameter in some patients
    2. Obesity and short neck
    3. Hypognathia
    4. Jaw deformities
    5. Large Tongue and uvula
    6. Neurologic deficits (central or peripheral)
  2. Children (occurs in 1-3% of children)
    1. See Obstructive Sleep Apnea in Children

IV. Risk Factors

  1. Sleep deprivation or excessive Daytime Sleepiness
  2. CNS Depressant medications
  3. Chronic nasal congestion
  4. Obesity (especially morbid Obesity qualifying for Bariatric Surgery, BMI >35 kg/m2)
  5. Middle age or older (ages 40-70 years old)
  6. Male gender (or post-menopausal women not on HRT)
  7. Alcohol Abuse
  8. Tobacco abuse
  9. Family History of Obstructive Sleep Apnea

V. Associated Conditions

  1. Atrial Fibrillation (OR 4.0)
  2. Major Depression (OR 2.6)
  3. Congestive Heart Failure (OR 2.4)
  4. Cerebrovascular Accident (OR 1.6 to 4.3)
  5. Hypertension, especially Refractory Hypertension (OR 1.4 to 2.9)
  6. Coronary Artery Disease (OR 1.3)
  7. Type 2 Diabetes Mellitus (OR 1.2 to 2.6)
  8. Nocturnal cardiac arrhythmia
  9. Pulmonary Hypertension

VI. Symptoms: Adults

  1. Excessive Daytime Sleepiness (daytime Somnolence)
    1. Falling asleep at wheel or in conversation
    2. May also present with alternative terminology
      1. Fatigue
      2. Tiredness
      3. Lack of energy
  2. Loud snoring
  3. Gasping or Choking during sleep
  4. Nocturnal Hypertension and arrhythmias
  5. Morning Headache
  6. Nocturia
  7. Nocturnal confusion
  8. Intellectual deterioration or cognitive Impairment

VII. Symptoms: Children

  1. Minimal Hypersomnolence if any
  2. Nocturnal Enuresis
  3. Excessing nighttime sweating
  4. Developmental delay
  5. Learning difficulties (e.g. ADHD)

VIII. Signs

  1. General appearance
    1. Short neck
    2. Overweight (Obesity in 70% of cases)
  2. Nasopharynx
    1. Nasal Polyps
    2. Severe septal deviation
    3. Large residual adenoid tissue
  3. Oropharynx
    1. Macroglossia
    2. Large Tonsils
    3. High arched Palate and narrow oropharyngeal opening
    4. Micrognathia (small jaw) and Retrognathia (posterior chin position)
    5. Mallampati Score 3 or 4
      1. Disproven: Does not predict Obstructive Sleep Apnea risk
  4. Larynx and trachea
    1. Large obstructive lesions
  5. Neck circumference (best predictor of Sleep Apnea)
    1. Men: >17 inch (42.5 cm) neck circumference
    2. Women: >16 inch (40.6 cm) neck circumference

IX. Differential Diagnosis

X. Complications

  1. See Sleep Apnea
  2. Increased mortality risk and stroke risk
    1. Yaggi (2005) N Engl J Med [PubMed]
  3. Hypertension is closely associated with Sleep Apnea
    1. Risk of developing Hypertension with mild to moderate OSA: Odds Ratio 2-3
    2. Peppard (2000) N Engl J Med [PubMed]
  4. Public health concern
    1. Higher health care utilization (more frequent hospitalizations, for longer durations, and higher costs)
    2. Associated with more MVAs and workplace injuries

XI. Diagnostics

  1. Screening Tools (USPTF does not recommend general screening)
    1. STOP-Bang Questionnaire
      1. Consider as part of preoperative assessment
    2. Elbow Signs
      1. Of those with Sleep Apnea, 97% report being elbowed by their bed partner due to apnea or snoring
      2. Fenton (2014) Chest 145(3): 518-24 [PubMed]
  2. See Polysomnogram (Sleep Study)
  3. Portable home monitoring devices (overnight oximetry)
    1. Less specific than Polysomnogram
    2. Unable to distinguish CHF, COPD or parasomnias from Sleep Apnea

XII. Management: Non-surgical

  1. See Sleep Hygiene
  2. Airway Management Measures
    1. Continuous Positive Airway Pressure (CPAP)
      1. See CPAP for Obstructive Sleep Apnea
      2. Do not use without Sleep Study (will worsen Central Sleep Apnea)
      3. Available with auto-titrating positive airway pressure (machine adjusted)
        1. Auto-titrating machines are contraindicated in patients with significant comorbidity
      4. Encourage at least 4 hours per night usage (50% discontinuation rate at 1 year)
        1. See CPAP for improving compliance
      5. Available as nasal pillows (preferred by patients) or full face mask
      6. Improves sleep, decreases snoring, less daytime Somnolence, better quality of life
      7. Decreases systolic Blood Pressure, LVEF, Insulin Resistance and serum Triglycerides
    2. Bilevel Pap (BIPAP) Indications
      1. Hypoventilation during sleep
      2. High airway pressures required
      3. Difficulty exhaling against fixed pressure
  3. Weight loss
    1. Sleep Apnea significantly improved with 9-14 kg loss
    2. Snoring in 19 asymptomatic obese male snorers
      1. Only mild decrease with interventions
        1. Oxymetazoline Nasal Decongestant
        2. Foam wedge support to sleep on side
      2. Marked decrease with weight loss
        1. Three kilogram weight loss
          1. Snores cut in half (176/hour)
        2. Six kilogram weight loss
          1. Snoring nearly eliminated
    3. Reference
      1. Braver (1995) Chest 107:1283-8 [PubMed]
  4. Avoid supine body position during sleep
    1. Sew a tennis ball in the back of a night shirt (or vests with posterior bumpers)
      1. Makes sleeping on back too uncomfortable
    2. Propping pillows
    3. Position alarms
  5. Oral appliance (less effective alternatives to CPAP)
    1. Indicated in patients intolerant of CPAP
    2. Mandibular Advancement Device (preferred)
    3. Tongue retaining device (insufficient evidence)
  6. Potentially helpful Medications
    1. Intranasal Corticosteroids
      1. Chronic Rhinitis
      2. Nasal Polyps
      3. Septal deviation
    2. Tricyclic Antidepressants
  7. Avoid harmful medications
    1. Avoid CNS depressant or sedative medications (e.g. Benzodiazepines, Benzodiazepine Receptor Agonists)
    2. Sedatives may worsen Sleep Apnea
  8. Hospitalized patients with undiagnosed OSA
    1. Elevate head of bed
    2. Provide Supplemental Oxygen while sleeping
    3. Schedule outpatient Sleep Study
    4. Do not use empiric CPAP (worsens central apnea)
      1. BIPAP is safer if empiric treatment is used
  9. Other experimental measures that may be helpful
    1. Neurostimulators to Hypoglossal Nerve (increases tone of upper airway muscles)

XIII. Management: Surgery

  1. Precautions
    1. Bariatric Surgery is effective in improving Sleep Apnea in 75% of obese patients
    2. No other surgical intervention (e.g. UPPP or mandibular advancement) has shown significant or consistent benefit
  2. Uvulopalatopharyngoplasty (UPPP)
    1. No longer recommended due to low efficacy
    2. Laser or excision of redundant posterior pharynx
    3. Only effective in 30-50% of patients
      1. Airway narrows below level where surgery occurs
    4. Modified procedures
      1. Laser-assisted uvulopalatoplasty
      2. Radiofrequency ablation
  3. Maxillomandibular advancement
    1. Indicated for receding chin and jaw
  4. Tracheotomy
    1. Measure of last resort only

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Ontology: Sleep Apnea, Obstructive (C0520679)

Definition (NCI) A disorder characterized by recurrent episodic disruptions of breathing during sleep. It is caused by the intermittent relaxation of pharyngeal muscles leading to the narrowing or complete blockage of the upper airway. This results in compensatory arousal from sleep to breathe again. An anatomically narrow airway from body habitus or enlarged pharyngeal structures may also predispose to obstruction. Clinical presentation usually includes snoring, daytime sleepiness, difficulty concentrating and fatigue. Clinical course may progress to chronic hypoxemia with cardiovascular and cerebrovascular sequelae.
Definition (MSH) 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)
Concepts Disease or Syndrome (T047)
MSH D020181
ICD9 327.23
ICD10 G47.32 , G47.33
SnomedCT 78275009, 194441007, 196167006
Dutch obstructief slaap apneu syndroom, obstructief slaapapneusyndroom, Obstructief slaap-apnoesyndroom, Obstructieve slaap-apnoe, Syndroom, obstructief slaap-apnoe-
French Syndrome des apnées obstructives du sommeil, SAOS, Syndrome d'apnée obstructive du sommeil, Apnée obstructive du sommeil, Syndrome d'apnées obstructives du sommeil
German obstruktives Schlafapnoe-Syndrom, Obstruktive Schlafapnoe, Schlafapnoe, obstruktive
Italian Sindrome da apnea ostruttiva nel sonno, Sindrome dell'apnea da sonno ostruttiva, Apnea da sonno ostruttiva
Portuguese Síndrome de apneia obstrutiva do sono, Síndrome de apeia obstrutiva do sono, Apneia do Sono Tipo Obstrutiva, Apneia Obstrutiva do Sono, Apneia do Sono Obstrutiva, Síndrome da Apneia Obstrutiva do Sono
Spanish Síndrome de apnea obstructiva del sueño, Síndrome de apnea del sueño obstructiva, síndrome de apnea obstructiva del sueño, síndrome de apnea del sueño obstructiva (trastorno), síndrome de apnea obstructiva del sueño (trastorno), síndrome de apnea del sueño obstructiva, Apnea del Sueño Obstructiva, Apnea Obstructiva del Sueño
Swedish Sömnapne, obstruktiv
English OSA, SLEEP APNEA/HYPOPNEA SYNDROME, OSAS, OBSTRUCTIVE SLEEP APNEA SYNDROME, SAHS, APNEA, OBSTRUCTIVE SLEEP, Sleep Apnea, Obstructive, obstructive sleep apnea, obstructive sleep apnea (diagnosis), Apneas, Obstructive Sleep, Obstructive Sleep Apnea, Obstructive Sleep Apneas, Sleep Apneas, Obstructive, Obstructive Sleep Apnea Syndrome, Sleep Apnea Syndrome, Obstructive, Syndrome, Obstructive Sleep Apnea, Syndrome, Sleep Apnea, Obstructive, Obstructive sleep apnea (adult) (pediatric), Sleep Apnea, Obstructive [Disease/Finding], obstructive sleep apnea syndrome, sleep apnea obstructive syndrome, obstructive sleep osa apnea, apnea obstructive sleep, apnea obstructive sleeping, obstructive sleep apnoea, Obstructive sleep apnea, Obstructive sleep apnea (adult)(pediatric), OSAHS, Apnea/Hypopnea Syndrome, Sleep, Apnea/Hypopnea Syndromes, Sleep, Apnea, Obstructive Sleep, Sleep Apnea/Hypopnea Syndromes, Syndrome, Sleep Apnea/Hypopnea, Syndromes, Sleep Apnea/Hypopnea, Sleep Apnea/Hypopnea Syndrome, Obstructive sleep apnoea (disorder), Sleep apnea (& [obstructive]), Obstructive sleep apnoea, Sleep apnoea (& [obstructive]), Sleep apnoea (& [obstructive]) (disorder), Obstructive sleep apnea syndrome, Obstructive sleep apnoea syndrome, OSA - Obstructive sleep apnea, OSA - Obstructive sleep apnoea, Obstructive sleep apnea syndrome (disorder)
Japanese ヘイソクセイスイミンジムコキュウショウコウグン, 睡眠時無呼吸症候群-上気道抵抗性, 閉塞型睡眠時無呼吸症候群, 閉塞性睡眠時無呼吸低呼吸症候群, 閉塞型睡眠時無呼吸, 無呼吸-睡眠時-閉塞性, 閉塞型無呼吸, 閉塞性睡眠時無呼吸, 閉塞性睡眠時無呼吸症候群, 無呼吸-閉塞型, 上気道抵抗性睡眠時無呼吸症候群, 睡眠時無呼吸-閉塞性
Czech spánková apnoe obstrukční, Syndrom obstrukční spánkové apnoe, obstrukční syndrom spánkové apnoe, syndrom obstrukční spánkové apnoe
Finnish Obstruktiivinen uniapnea
Russian APNOE, OBSTRUKTSIIA, APNOE OBSTRUKTIVNOGO GENEZA VO VREMIA SNA, APNOE OBSTRUKTIVNOE VO SNE, АПНОЭ ОБСТРУКТИВНОГО ГЕНЕЗА ВО ВРЕМЯ СНА, АПНОЭ ОБСТРУКТИВНОЕ ВО СНЕ, АПНОЭ, ОБСТРУКЦИЯ
Polish Bezdech senny obturacyjny, Bezdech śródsenny obturacyjny, Zespół obturacyjnego bezdechu śródsennego, Obturacyjny bezdech podczas snu
Hungarian Obstructiv alvási apnoe syndroma, Obstructiv alvás apnoe syndroma
Norwegian Obstruktiv søvnapné