1. Obstructive Sleep Apnea: Is it in your Differential? Helene Hill Professor Sam Powdrill PAS 645

2. Agenda  Introduction  Pathophysiology  Risk Factors  Comorbid Conditions  Application

3. Obstructive Sleep Apnea  AKA the “Spousal Arousal” syndrome  Prevention and early treatment is essential  The problem is that PCP might not consider OSA in the non- stereotypical patients “Laugh and the world laughs with you, snore and you sleep alone.” ~ Anthony Burgess

4. Obstructive Sleep Apnea  Epidemiology More prevalent than once was believed Wisconsin Sleep Cohort Study  9% women  24% men Estimated that 80-90% are undiagnosed  Comorbidities  Awareness  SES

5. Pathophysiology  A sleep breathing disorder due to a mechanical problem of tissue collapse  Apnea leads to Oxyhemoglobin desaturation Fragmentation in sleep cycle Variability in BP and HR/Increase in SNS  Persistent hypoxia manifests with numerous daytime Sx

6. Treatment  Mild 5-15/hr Lifestyle modification  Weight loss  Elimination of products that suppress respiration  No BZDs  Sleeping position modification

7. Treatment  Moderate 15-30/hr More in-depth plus lifestyle changes  CPAP  Oral appliances Mandible advancing Tongue device Martin Dunitz

8. Treatment  Severe > 30/hr Surgical procedures in addition to previous changes  Tonsillectomy/adenoidectomy  Nasal surgery combined with pharyngeal surgery  Uvulopalatopharyngoplasty (UPPP) Martin Dunitz

9. Risk Factors  “Pickwickian Patient” Male Sex Age 40-70 yr Familial Aggregation  Established risk factors Body habitus Craniofacial/Upper Airway Abnormalities  Suspected risk factors Genetics Smoking Menopause Alcohol before sleep Nighttime nasal congestion

10. Martin Dunitz

11. Comorbid Conditions  Decreased daytime functioning Daytime sleepiness Psychosocial problems – STRESS! Decreased cognitive function

12. Comorbid Conditions  Cardiovascular/Cerebrovascular Disease Stroke, pulmonary HTN, CHF Resistant hypertension  Increased sympathetic activity  Vasculopathy Activation of vasoconstrictors Sustained hypertensive effects “Non-dipping” phenomenon

13. Comorbid Conditions  Diabetes/Metabolic Syndrome Vascular disease that lead to endothelial dysfunction OSA is independently associated with insulin resistance  Control OSA, see better control of DM

14. So is it in your Dif Dx?  Few easy steps Consider OSA in patients who snore or have excessive daytime sleepiness Check out risk factors and get detailed history Consider your alternatives Consider OSA when evaluating patients for comorbidities associated with sleep apnea

15. Wrapping it up…  Don’t forget to treat the underlying condition!  Don’t forget the non-stereotypicals!  Know risk factors and what OSA can do if left untreated!  Future ideas… Hypoglossal nerve stimulation Serotonergic medications

16. References Available upon request