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Obstructive sleep apnea

Updated : March 19, 2024





Background

Obstructive sleep apnea (OSA) is defined by episodes of the partial or complete collapse of the upper airway followed by a drop in saturated oxygen or awakening from sleep. This disruption causes fragmented, nonrestorative sleep.

Other symptoms include obnoxious snoring, apneas during sleep, and excessive daytime tiredness. OSA severely affects cardiovascular health, mental health, quality of life, and driving safety.

Epidemiology

OSA (defined as five or more occurrences per hour) affects nearly 1 billion individuals worldwide, with 425,000,000 individuals aged 30-69 years suffering from moderate to severe OSA (15 or more episodes per hour).

According to studies, 25-30% of males and 9% to 17% of women in the United States have obstructive sleep apnea. Hispanic, Asian, and Black groups have a greater prevalence. Prevalence increases with age; females outnumber males by age 50 and acquire this disease.

The increased prevalence of OSA is linked to rising obesity rates ranging from 14% to 55%. Certain risk factors, including obesity and upper airway soft tissue anatomy, are genetically inherited; therefore, there may be a genetic component.

Anatomy

Pathophysiology

Upper airway obstruction while sleeping is usually caused by negative collapsing pressure upon inspirations, although gradual expiratory constriction in the retropalatal region also plays a role.

The amount of upper airway constriction during sleep is frequently related to BMI, stating that anatomical and neuromuscular variables play a role in airway obstruction.

Etiology

Pharyngeal constriction and closure during sleep is a complicated process likely caused by a combination of factors. Sleep-related decreased ventilatory drive and neuromuscular risk factors, in conjunction with anatomical risk factors, are expected to play a substantial role in upper airway blockage during sleep.

Wide neck circumference, bone, soft tissue, or arteries are all anatomic variables that contribute to pharyngeal constriction. Many of these features can result in increased upper airway surrounding pressure, pharyngeal collapsibility, and inadequate room to facilitate airflow in a section of the upper airway during sleep.

Furthermore, as upper airway muscular tone declines, a repeated partial or complete airway collapse occurs. Obesity, the male gender, and increasing age are adults’ most prevalent causes of OSA. When BMI is considered, the severity of OSA diminishes with age. Additional risk factors that increase the incidence of this condition are smoking, alcohol, use of hypnotics and sedatives

Genetics

Prognostic Factors

The short-term prognosis for OSA therapy is favorable, but the long-term prognosis is uncertain. The most severe issue is non-adherence to CPAP, with almost half of patients discontinuing use within the first month despite instruction.

Many individuals have comorbidities or are at risk of heart attack or stroke. As a result, people who do not utilize CPAP are at a higher risk of cardiac and cerebral adverse events and higher yearly healthcare-related costs.

Additionally, OSA is linked to pulmonary hypertension, hypercapnia, hypoxemia, and daytime sedation. Furthermore, these people are at significant risk of being involved in a car accident.

Clinical History

Age Group:  

Obstructive sleep apnea affects people of all ages, including kids, teens, adults, and senior individuals. 

Physical Examination

  • Upper Airway Examination: Evaluation of the oropharynx and nasopharynx for signs of anatomical abnormalities such as enlarged tonsils, elongated uvula, or a deviated septum. 
  • Craniofacial Examination: Assessment of facial structure and craniofacial abnormalities that may predispose to airway obstruction. 
  • Cardiovascular Examination: Measurement of blood pressure to assess for hypertension, which is commonly associated with OSA. 
  • Respiratory Examination: Assessment of respiratory effort and pattern during sleep, if possible, although this is typically done during polysomnography. 
  • Neurological Examination: Evaluation of cranial nerves and motor function for signs of neurologic impairment that may be associated with OSA, such as daytime sleepiness or cognitive dysfunction. 

Age group

Associated comorbidity

Episodes of oxygen desaturation and the elevated sympathetic activity during apnea occurrences may cause stress and harm to the cardiovascular system.  

These symptoms such as insulin resistance, glucose intolerance, and type 2 diabetes are directly connected to OSA. Metabolic dysregulation can be caused by hormonal imbalances linked to OSA and disrupted sleep patterns. 

People with OSA are more likely to experience anxiety and depression. Mood disorders may be made worse by sleep fragmentation and prolonged sleep loss. 

Associated activity

Acuity of presentation

Chronic symptoms like snoring, excessive daytime sleepiness, exhaustion, and morning headaches are common in people with OSA. These symptoms could appear gradually over time, causing the person to become accustomed to them and put off getting help right away.   

Sometimes people may notice an abrupt worsening of their symptoms, particularly when they are ill, gaining weight, or taking new medicine. These flare-ups can cause serious disturbances to daytime functioning and sleep patterns, necessitating immediate medical attention for the affected person. 

Differential Diagnoses

  • Central Sleep Apnea (CSA): Unlike OSA, where airway obstruction causes breathing pauses, CSA is characterized by a lack of respiratory effort during sleep due to dysfunction in the brain’s respiratory control centers. 
  • Upper Airway Resistance Syndrome (UARS): UARS shares some symptoms with OSA, including daytime sleepiness and fatigue, but may not meet the criteria for apneas or hypopneas. 
  • Narcolepsy: The neurological condition known as narcolepsy is typified by extreme daytime sleepiness, abrupt episodes of paralysis or weakening of the muscles, hallucinations, and disturbed sleep patterns.    
  • Hypothyroidism: Hypothyroidism can lead to symptoms such as fatigue, weight gain, and cognitive impairment, which may overlap with those of OSA.  

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

  • Lifestyle Changes: Since obesity is a major risk factor for OSA, lowering symptoms can be achieved by reaching and maintaining a healthy weight through diet and exercise. 
  • Avoidance of alcohol and sedatives: Avoiding these substances, especially close to bedtime, can improve OSA symptoms. 
  • Continuous Positive Airway Pressure (CPAP) Therapy: It involves wearing a mask connected to a machine that delivers a continuous stream of air, keeping the airway open during sleep. 
  • Oral Appliances (OAs): Oral appliances are dental devices that reposition the jaw or tongue to prevent airway collapse during sleep. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Use of non-pharmacological approach for Obstructive sleep apnea

  • Sleep Position: Encourage side sleeping: Sleeping on the side rather than on the back can help reduce the severity of OSA by preventing the tongue and soft tissues from collapsing into the airway. 
  • Positional therapy devices: Specialized devices such as positional pillows or wearable devices can help individuals maintain a side sleeping position throughout the night. 
  • Bedding and Mattress: Elevate the head of the bed: Using a wedge pillow or adjustable bed frame to elevate the head and upper body can help reduce snoring and alleviate symptoms of mild OSA by promoting better airflow. 
  • Noise reduction: Minimize noise disturbances in the sleep environment by using earplugs, white noise machines, or soundproofing measures. 
  • Air Quality: Ensure proper maintenance of HVAC systems and use high-efficiency air filters to reduce allergens, dust, and pollutants in the bedroom. 

Use of CNS stimulants

  • Modafinil: It works by increasing the activity of certain neurotransmitters in the brain.  

By enhancing neurotransmitter activity, modafinil promotes wakefulness and reduces sleepiness without causing the jitteriness or rebound sleepiness associated with traditional stimulants. 

Use of Dopamine/Norepinephrine Reuptake Inhibitors

  • Solriamfetol: It is a selective dopamine and norepinephrine reuptake inhibitor (DNRI) that increases the levels of these neurotransmitters in the brain.  

It promotes wakefulness and reduces sleepiness without causing the jitteriness or rebound sleepiness associated with traditional stimulants. 

Use of Intervention with a procedure in treating Obstructive sleep apnea

  • Uvulopalatopharyngoplasty:  UPPP is typically considered for individuals with moderate to severe OSA who have not responded well to conservative treatments such as continuous positive airway pressure (CPAP) therapy or oral appliances. 

Removal of the uvula and a portion of the soft palate to create a wider airway space. Trimming or repositioning of the tonsils, if present and contributing to airway obstruction.

Use of phases in managing Obstructive sleep apnea

  • Recognition and Diagnosis: The first phase involves recognizing the signs and symptoms of OSA, which may include snoring, excessive daytime sleepiness, observed breathing pauses during sleep, and morning headaches. 
  • Ongoing Management: Ongoing management of OSA involves monitoring treatment adherence, efficacy, and symptom control. Patients may undergo follow-up appointments with a sleep specialist to assess their progress and make any necessary adjustments to treatment. 
  • Long-Term Follow-Up: Long-term follow-up is important to monitor the effectiveness of treatment over time and assess for any changes in symptoms or disease progression. 

Medication

 

armodafinil

150 - 250

mg

Tablet

Oral

once a day

in the morning



solriamfetol 

Upon awakening, take 37.5mg orally everyday
The dose can be doubled at least every three days.
Maximum dose-150mg orally everyday



Dose Adjustments

Dosage Modifications
Renal Impairment
Severe-Initiate 37.5mg everyday orally
Moderate- Initiate 37.5mg everyday orally
Mild-Dosage adjustment is not necessary

 
 

Media Gallary

Obstructive sleep apnea

Updated : March 19, 2024




Obstructive sleep apnea (OSA) is defined by episodes of the partial or complete collapse of the upper airway followed by a drop in saturated oxygen or awakening from sleep. This disruption causes fragmented, nonrestorative sleep.

Other symptoms include obnoxious snoring, apneas during sleep, and excessive daytime tiredness. OSA severely affects cardiovascular health, mental health, quality of life, and driving safety.

OSA (defined as five or more occurrences per hour) affects nearly 1 billion individuals worldwide, with 425,000,000 individuals aged 30-69 years suffering from moderate to severe OSA (15 or more episodes per hour).

According to studies, 25-30% of males and 9% to 17% of women in the United States have obstructive sleep apnea. Hispanic, Asian, and Black groups have a greater prevalence. Prevalence increases with age; females outnumber males by age 50 and acquire this disease.

The increased prevalence of OSA is linked to rising obesity rates ranging from 14% to 55%. Certain risk factors, including obesity and upper airway soft tissue anatomy, are genetically inherited; therefore, there may be a genetic component.

Upper airway obstruction while sleeping is usually caused by negative collapsing pressure upon inspirations, although gradual expiratory constriction in the retropalatal region also plays a role.

The amount of upper airway constriction during sleep is frequently related to BMI, stating that anatomical and neuromuscular variables play a role in airway obstruction.

Pharyngeal constriction and closure during sleep is a complicated process likely caused by a combination of factors. Sleep-related decreased ventilatory drive and neuromuscular risk factors, in conjunction with anatomical risk factors, are expected to play a substantial role in upper airway blockage during sleep.

Wide neck circumference, bone, soft tissue, or arteries are all anatomic variables that contribute to pharyngeal constriction. Many of these features can result in increased upper airway surrounding pressure, pharyngeal collapsibility, and inadequate room to facilitate airflow in a section of the upper airway during sleep.

Furthermore, as upper airway muscular tone declines, a repeated partial or complete airway collapse occurs. Obesity, the male gender, and increasing age are adults’ most prevalent causes of OSA. When BMI is considered, the severity of OSA diminishes with age. Additional risk factors that increase the incidence of this condition are smoking, alcohol, use of hypnotics and sedatives

The short-term prognosis for OSA therapy is favorable, but the long-term prognosis is uncertain. The most severe issue is non-adherence to CPAP, with almost half of patients discontinuing use within the first month despite instruction.

Many individuals have comorbidities or are at risk of heart attack or stroke. As a result, people who do not utilize CPAP are at a higher risk of cardiac and cerebral adverse events and higher yearly healthcare-related costs.

Additionally, OSA is linked to pulmonary hypertension, hypercapnia, hypoxemia, and daytime sedation. Furthermore, these people are at significant risk of being involved in a car accident.

Age Group:  

Obstructive sleep apnea affects people of all ages, including kids, teens, adults, and senior individuals. 

  • Upper Airway Examination: Evaluation of the oropharynx and nasopharynx for signs of anatomical abnormalities such as enlarged tonsils, elongated uvula, or a deviated septum. 
  • Craniofacial Examination: Assessment of facial structure and craniofacial abnormalities that may predispose to airway obstruction. 
  • Cardiovascular Examination: Measurement of blood pressure to assess for hypertension, which is commonly associated with OSA. 
  • Respiratory Examination: Assessment of respiratory effort and pattern during sleep, if possible, although this is typically done during polysomnography. 
  • Neurological Examination: Evaluation of cranial nerves and motor function for signs of neurologic impairment that may be associated with OSA, such as daytime sleepiness or cognitive dysfunction. 

Episodes of oxygen desaturation and the elevated sympathetic activity during apnea occurrences may cause stress and harm to the cardiovascular system.  

These symptoms such as insulin resistance, glucose intolerance, and type 2 diabetes are directly connected to OSA. Metabolic dysregulation can be caused by hormonal imbalances linked to OSA and disrupted sleep patterns. 

People with OSA are more likely to experience anxiety and depression. Mood disorders may be made worse by sleep fragmentation and prolonged sleep loss. 

Chronic symptoms like snoring, excessive daytime sleepiness, exhaustion, and morning headaches are common in people with OSA. These symptoms could appear gradually over time, causing the person to become accustomed to them and put off getting help right away.   

Sometimes people may notice an abrupt worsening of their symptoms, particularly when they are ill, gaining weight, or taking new medicine. These flare-ups can cause serious disturbances to daytime functioning and sleep patterns, necessitating immediate medical attention for the affected person. 

  • Central Sleep Apnea (CSA): Unlike OSA, where airway obstruction causes breathing pauses, CSA is characterized by a lack of respiratory effort during sleep due to dysfunction in the brain’s respiratory control centers. 
  • Upper Airway Resistance Syndrome (UARS): UARS shares some symptoms with OSA, including daytime sleepiness and fatigue, but may not meet the criteria for apneas or hypopneas. 
  • Narcolepsy: The neurological condition known as narcolepsy is typified by extreme daytime sleepiness, abrupt episodes of paralysis or weakening of the muscles, hallucinations, and disturbed sleep patterns.    
  • Hypothyroidism: Hypothyroidism can lead to symptoms such as fatigue, weight gain, and cognitive impairment, which may overlap with those of OSA.  
  • Lifestyle Changes: Since obesity is a major risk factor for OSA, lowering symptoms can be achieved by reaching and maintaining a healthy weight through diet and exercise. 
  • Avoidance of alcohol and sedatives: Avoiding these substances, especially close to bedtime, can improve OSA symptoms. 
  • Continuous Positive Airway Pressure (CPAP) Therapy: It involves wearing a mask connected to a machine that delivers a continuous stream of air, keeping the airway open during sleep. 
  • Oral Appliances (OAs): Oral appliances are dental devices that reposition the jaw or tongue to prevent airway collapse during sleep. 

  • Sleep Position: Encourage side sleeping: Sleeping on the side rather than on the back can help reduce the severity of OSA by preventing the tongue and soft tissues from collapsing into the airway. 
  • Positional therapy devices: Specialized devices such as positional pillows or wearable devices can help individuals maintain a side sleeping position throughout the night. 
  • Bedding and Mattress: Elevate the head of the bed: Using a wedge pillow or adjustable bed frame to elevate the head and upper body can help reduce snoring and alleviate symptoms of mild OSA by promoting better airflow. 
  • Noise reduction: Minimize noise disturbances in the sleep environment by using earplugs, white noise machines, or soundproofing measures. 
  • Air Quality: Ensure proper maintenance of HVAC systems and use high-efficiency air filters to reduce allergens, dust, and pollutants in the bedroom. 

  • Modafinil: It works by increasing the activity of certain neurotransmitters in the brain.  

By enhancing neurotransmitter activity, modafinil promotes wakefulness and reduces sleepiness without causing the jitteriness or rebound sleepiness associated with traditional stimulants. 

  • Solriamfetol: It is a selective dopamine and norepinephrine reuptake inhibitor (DNRI) that increases the levels of these neurotransmitters in the brain.  

It promotes wakefulness and reduces sleepiness without causing the jitteriness or rebound sleepiness associated with traditional stimulants. 

  • Uvulopalatopharyngoplasty:  UPPP is typically considered for individuals with moderate to severe OSA who have not responded well to conservative treatments such as continuous positive a