Obstructive Sleep Apnea
Obstructive sleep apnea (OSA) consists of episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation (defined as a period of apnea or hypopnea > 10 sec). Symptoms include excessive daytime sleepiness, restlessness, snoring, recurrent awakening, and morning headache. Diagnosis is based on sleep history and polysomnography. Treatment is with nasal continuous positive airway pressure, oral appliances, and, in refractory cases, surgery. Prognosis is good with treatment. Most cases remain undiagnosed and untreated and are often associated with hypertension, atrial fibrillation and other arrhythmias, heart failure, and injury or death due to motor vehicle crashes and other accidents resulting from hypersomnolence.
(See also Obstructive Sleep Apnea in Children.)
In at-risk patients, sleep destabilizes patency of the upper airway, leading to partial or complete obstruction of the nasopharynx, oropharynx, or both.
Obstructive sleep hypopnea occurs when breathing is diminished, even if it is not absent.
The prevalence of OSA is 2 to 9% in adults; the condition is under-recognized and often undiagnosed even in symptomatic patients. Obstructive sleep apnea is up to 4 times more common among men and 7 times more common among people who are obese (ie, body mass index [BMI] > 30). Severe OSA (apnea-hypopnea index [AHI] > 30/h) increases the risk of death in middle-aged men.
Obstructive sleep apnea can cause excessive daytime sleepiness, increasing risks of automobile crashes, loss of employment, and sexual dysfunction. Relationships with bed partners and roommates and/or housemates may also be adversely affected because these people may also have difficulty sleeping.
Long-term cardiovascular sequelae of untreated OSA include poorly controlled hypertension, heart failure, and atrial fibrillation (even after catheter ablation) and other arrhythmias. OSA also increases the risk for nonalcoholic steatohepatitis, likely due to intermittent nocturnal hypoxia (1).
1. Musso G, Cassader M, Olivetti C, et al: Association of obstructive sleep apnoea with the presence and severity of non-alcoholic fatty liver disease. A systematic review and meta-analysis. Obes Rev14:417–431, 2013.
Anatomic risk factors for obstructive sleep apnea include
Anatomic risk factors are common among obese people.
Other identified risk factors include postmenopausal status, aging, and alcohol or sedative use. A family history of OSA is present in 25 to 40% of cases, perhaps reflective of heritable factors affecting ventilatory drive or craniofacial structure. The risk of OSA in a family member is proportional to the number of affected family members.
Acromegaly, hypothyroidism, and sometimes stroke can cause or contribute to OSA. Disorders that occur more commonly in patients with OSA include hypertension, stroke, diabetes, hyperlipidemia, gastroesophageal reflux disease, nocturnal angina, heart failure, and atrial fibrillation or other arrhythmias.
Because obesity is a common risk factor for both obstructive sleep apnea and obesity-hypoventilation syndrome, the conditions frequently coexist.
Inspiratory efforts against a closed upper airway cause paroxysms of inspiration, reductions in gas exchange, disruption of normal sleep architecture, and partial or complete arousals from sleep. These factors may interact to cause the characteristic symptoms and signs, including hypoxia, hypercapnia, and sleep fragmentation.
OSA is an extreme form of sleep-related upper airway resistance. Less severe forms that do not cause oxygen desaturation include
Patients with upper airway resistance syndrome are typically younger and less obese than those with OSA, and they complain of daytime sleepiness more than do patients with primary snoring. Frequent arousals occur, but strict criteria for apneas and hypopneas may not be present. Symptoms, diagnostic evaluation, and treatment of snoring and upper airway resistance syndrome are otherwise the same as for OSA.
Although loud disruptive snoring is reported by 85% of OSA patients, most people who snore do not have OSA. Other symptoms of obstructive sleep apnea may include
Most patients are unaware of these symptoms (because they occur during sleep) but are informed of them by bed partners, roommates, or housemates. Some patients may awake with a sore throat or a dry mouth. A morning headache is a common symptom.
When awake, patients may experience hypersomnolence, fatigue, and impaired concentration. The frequency of sleep complaints and the degree of daytime sleepiness do not correlate well with number of events or arousals from sleep.
The diagnosis of obstructive sleep apnea is suspected in patients with identifiable risk factors, symptoms, or both.
Pretest questionnaires, such as STOP-Bang, Berlin, and Epworth Sleepiness Scale, can be used to assess risk. However, these questionnaires have low specificity and so have high false-positive rates (1, 2). The STOP-BANG appears to have better predictive value than the Epworth Sleepiness Scale and possibly the Berlin questionnaire (3).
Criteria for diagnosis consist of daytime symptoms, nighttime symptoms, and sleep monitoring that documents ≥ 5 episodes of hypopnea and/or apnea per hour with symptoms, or ≥ 15 episodes per hour in the absence of symptoms. Specifically, in regard to symptoms, there should be ≥ 1 of the following:
The patient and any bed partners, roommates, or housemates should be interviewed. The differential diagnosis of excessive daytime sleepiness is broad and includes
Reduced quantity or quality of sleep due to poor sleep hygiene
Sedation or mental status changes due to drugs, chronic diseases (including cardiovascular or respiratory diseases), or metabolic disturbances and accompanying therapies
Alcohol or drug abuse
Other primary sleep disorders (eg, periodic limb movement disorder, restless legs syndrome)
An extended sleep history should be taken in all patients who
Most patients who report only snoring, without other symptoms or cardiovascular risks, do not need an extensive evaluation for OSA.
The physical examination should include evaluation for nasal obstruction, tonsillar hypertrophy, and pharyngeal structure and identification of clinical features of hypothyroidism and acromegaly.
Polysomnography is best for confirming the diagnosis of obstructive sleep apnea and quantifying the severity of OSA. Polysomnography includes continuous measurement of breathing effort by plethysmography, airflow at the nose and mouth using flow sensors, oxygen saturation by oximetry, sleep architecture by EEG, chin electromyography (looking for hypotonia), and electro-oculography to assess the occurrence of rapid eye movements. Polysomnography records and helps classify stages of sleep and the occurrence and duration of apneic and hypopneic periods. The patient is also observed by video, and ECG monitoring is used to determine whether arrhythmias occur in conjunction with the apneic episodes. Other variables evaluated include limb muscle activity (to assess nonrespiratory causes of sleep arousal, such as restless legs syndrome and periodic limb movements disorder) and body position (apnea may occur only in the supine position).
The apnea-hypopnea index (AHI), which is the total number of episodes of apnea and hypopnea occurring during sleep divided by the hours of sleep time, is the common summary measure used to describe respiratory disturbances during sleep. AHI values can be computed for different sleep stages.
The respiratory disturbance index (RDI), a similar measure, describes the number of episodes of certain arousals related to respiratory effort (called respiratory effort-related arousals or RERAs) plus the number of apnea and hypopnea episodes per hour of sleep.
An arousal index (AI), which is the number of arousals per hour of sleep, can be computed if EEG monitoring is used. The AI may be correlated with AHI or RDI, but about 20% of apneas and desaturation episodes are not accompanied by arousals, or other causes of arousals are present.
An AHI > 5 is required for the diagnosis of obstructive sleep apnea; a value > 15 indicates a moderate level of sleep apnea, and a value > 30 indicates a severe level of sleep apnea. Snoring loudly enough to be heard in the next room confers a 10-fold increase in the likelihood of having AHI > 5. The AI and RDI correlate only moderately with a patient’s symptoms.
Portable diagnostic tools are being used more often to diagnose OSA. Portable monitors can measure heart rate, pulse oximetry, effort, position, and nasal airflow to provide fair estimates of respiratory disturbances during self-reported sleep, thereby estimating AHI/RDI. Portable diagnostic tools are often used in combination with questionnaires (eg, STOP-Bang, Berlin Questionnaire) to calculate patients’ risk (the sensitivity and specificity of the test depend on pretest probability). When portable tools are used, coexisting sleep disorders (eg, restless legs syndrome) are not excluded. Follow-up polysomnography may still be needed to determine AHI/RDI values in the different stages of sleep and with changes in position, especially when surgery or therapy other than positive airway pressure is being considered.
Measurement of thyroid-stimulating hormone can be done based on clinical suspicion. No other adjunctive testing (eg, upper airway imaging) has sufficient diagnostic accuracy to be recommended routinely.
1. Chung F, Yegneswaran B, Liao P, et al: STOP questionnaire: A tool to screen patients for obstructive sleep apnea. Anesthesiology2008;108:812–821, 2008.
2. Netzer NC, Stoohs RA, Netzer CM, et al: Using the Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome. Ann Intern Med 131(7):485–491, 1999.
3. Luo J, Huang R, Zhong X, et al: STOP-Bang questionnaire is superior to Epworth sleepiness scales, Berlin questionnaire, and STOP questionnaire in screening obstructive sleep apnea hypopnea syndrome patients.Chin Med J (Engl)127(17):3065–3070, 2014.
Prognosis of OSA is excellent if effective treatment is instituted.
Untreated or unrecognized obstructive sleep apnea can lead to cognitive impairment as a result of sleeplessness, which, in turn, can lead to serious injury or death caused by accidents, especially motor vehicle crashes. Sleepy patients should be warned of the risks of driving, operating heavy machinery, or engaging in other activities during which unintentional sleep episodes would be hazardous.
Adverse effects of hypersomnolence, such as loss of employment and sexual dysfunction, can affect families considerably.
In addition, perioperative complications, including cardiac arrest, have been attributed to OSA, probably because anesthesia can cause airway obstruction after a mechanical airway is removed. Patients should therefore inform their anesthesiologist of the diagnosis before undergoing any surgery and should expect to receive continuous positive airway pressure (CPAP) when they receive preoperative drugs and during recovery.
The aim of treatment is to reduce episodes of hypoxia and sleep fragmentation; treatment is tailored to the patient and to the degree of impairment. Cure is defined as a resolution of symptoms with AHI reduction below a threshold, usually 10/h.
Treatment is directed at both risk factors and at OSA itself. Specific treatments for obstructive sleep apnea include CPAP, oral appliances, and airway surgery.
Initial treatment aims at optimal control of modifiable risk factors for obstructive sleep apnea, including obesity, alcohol and sedative use, hypothyroidism, acromegaly, and other chronic disorders. Although modest weight loss (15%) may result in clinically meaningful improvement, weight loss is extremely difficult for most people, especially those who are fatigued or sleepy. Bariatric surgery frequently reverses symptoms and improves AHI in morbidly obese (BMI > 40) patients; however, the degree of these improvements may not be as great as the degree of weight loss. Weight loss, with or without bariatric surgery, should not be considered a cure for OSA.
Nasal continuous positive airway pressure (CPAP) is the treatment of choice for most patients with OSA and subjective daytime sleepiness; adherence is lower in patients who do not experience sleepiness. CPAP improves upper airway patency by applying positive pressure to the collapsible upper airway segment. Effective pressures typically range from 3 to 15 cm water. Disease severity does not correlate with pressure requirements. Many CPAP devices monitor CPAP efficacy and titrate pressures automatically, according to internal algorithms. If clinical improvement is not apparent, CPAP efficacy should be reviewed and patients should be reassessed for a second sleep disorder (eg, upper airway obstruction) or a comorbid disorder. If necessary, pressure can be titrated manually during monitoring with repeat polysomnography. Regardless of improvement in the AHI, CPAP will reduce cognitive impairment and improve quality of life, and it may reduce BP. If CPAP is withdrawn, symptoms recur over several days, though short interruptions of therapy for acute medical conditions are usually well tolerated. Duration of therapy is indefinite (1–4).
Failures of nasal CPAP are common because of limited patient adherence. Adverse effects include dryness and nasal irritation, which can be alleviated in some cases with the use of warm humidified air, and discomfort resulting from a poorly fitting mask.
CPAP can be augmented with inspiratory assistance (bilevel positive airway pressure) for patients with obesity-hypoventilation syndrome to increase their tidal volumes.
Oral appliances are designed to advance the mandible or, at the very least, prevent retrusion with sleep. Some are also designed to pull the tongue forward. Use of these appliances to treat both snoring and mild to moderate obstructive sleep apnea is gaining acceptance. Comparisons of appliances to CPAP show equivalence in mild to moderate OSA, but results of cost-effectiveness studies are not available.
Surgical procedures to correct anatomic factors such as enlarged tonsils and nasal polyps contributing to upper airway obstruction (called anatomic procedures) should be considered. Surgery for macroglossia or micrognathia is also an option. Surgery is a first-line treatment if anatomic encroachment is identified. However, in the absence of encroachment, evidence to support surgery as a first-line treatment is lacking.
Uvulopalatopharyngoplasty (UPPP) is the most commonly used procedure. It involves resection of submucosal tissue from the tonsillar pillars to the arytenoepiglottic folds, including resection of the adenoids, to enlarge the upper airway. Equivalence with CPAP was shown in one study using CPAP as a bridge to surgery, but the interventions have not been directly compared. UPPP may not be successful in patients who are morbidly obese or who have anatomic narrowing of the airway. Moreover, after UPPP, recognition of sleep apnea is more difficult because of a lack of snoring. Such silent obstructions may cause apneic episodes as severe as those occurring before surgical intervention.
Adjunctive surgical procedures include midline glossectomy, hyoid advancement, and mandibulomaxillary advancement. Mandibulomaxillary advancement is sometimes offered as a 2nd-stage procedure if UPPP is not curative. The optimal multistage approach is not known.
Tracheostomy is the most effective therapeutic maneuver for OSA but is done as a last resort. It bypasses the site of obstruction and is indicated for patients most severely affected (eg, those with cor pulmonale).
Laser-assisted uvuloplasty, uvular splints, and radiofrequency tissue ablation have been promoted as treatments for loud snoring in patients without OSA. Although they may transiently decrease snoring loudness, efficacy declines over months to years.
A new nonanatomic procedure is upper airway stimulation. In upper airway stimulation, an implanted device is used to activate a branch of the hypoglossal nerve. This therapy can be successful in highly selected patients with moderate to severe disease who are unable to tolerate CPAP therapy (5).
Adjunctive treatments are commonly used but have no proven role as first-line treatment for obstructive sleep apnea.
Modafinil can be used for residual sleepiness in OSA in patients who are effectively using CPAP.
Supplemental oxygen improves blood oxygenation, but a beneficial clinical effect cannot be predicted. Also, oxygen may provoke respiratory acidosis and morning headache in some patients.
A number of drugs have been used to stimulate ventilatory drive (eg, tricyclic antidepressants, theophylline) but cannot be routinely advocated because of limited efficacy, a low therapeutic index, or both.
Nasal dilatory devices and throat sprays sold OTC for snoring have not been studied sufficiently to prove benefits for OSA.
1. McEvoy RD, Antic NA, Heeley E, et al: CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med 2016 375(10):919–931, 2-16. doi: 10.1056/NEJMoa1606599.
2. Gottlieb DJ, Punjabi NM, Mehra R, et al: CPAP versus oxygen in obstructive sleep apnea. N Engl J Med 370(24):2276–2285, 2014. doi: 10.1056/NEJMoa1306766.
3. Chirinos JA, Gurubhagavatula I, Teff K, et al: CPAP, weight loss, or both for obstructive sleep apnea. N Engl J Med 370(24):2265–2275, 2014. doi: 10.1056/NEJMoa1306187.
4. Pépin JL, Tamisier R, Barone-Rochette G, et al: Comparison of continuous positive airway pressure and valsartan in hypertensive patients with sleep apnea. Am J Respir Crit Care Med 2010 Oct 1;182(7):954-60. doi: 10.1164/rccm.200912-1803OC. Epub 2010 Jun 3.
5. Woodson BT, Soose RJ, Gillespie MB, et al: Three-year outcomes of cranial nerve stimulation for obstructive sleep apnea: The STAR Trial. Otolaryngol Head Neck Surg154(1):181–188, 2016. doi: 10.1177/0194599815616618.
Obesity, anatomic abnormalities in the upper airway passages, family history, certain disorders (eg, hypothyroidism, stroke), and use of alcohol or sedatives increase the risk of obstructive sleep apnea (OSA).
Patients typically snore, have restless and unrefreshing sleep, and often feel daytime sleepiness and fatigue
Most people who snore do not have OSA.
Disorders that occur more commonly in patients with OSA include hypertension, stroke, diabetes, gastroesophageal reflux disease, nonalcoholic steatohepatitis, nocturnal angina, heart failure, and atrial fibrillation or other arrhythmias.
Confirm the diagnosis by polysomnography.
Control modifiable risk factors and treat most patients with CPAP and/or oral appliances designed to open the airway.
Consider surgery for abnormalities causing airway encroachment or if the disorder is intractable.