Suggested approach to patients with a history of loud snoring. Please note that although symptoms of obstructive sleep apnea (OSA) are suf fi cient to proceed with polysomnography, a sleepiness scale and a complete physical examination should always be obtained in patients suspected of having OSA. 

Context in source publication

Context 1

... node and conduction system of patients with sleep apnea. 59 – 62 These studies found that sinus node and atrioventricular conduction were normal or only slightly abnormal in all patients while awake, suggesting that the changes in heart rhythm are not due to fixed or anatomic disease of the sinus node and atrioventricular conduction system, but rather are due to autonomic changes, namely, an increase in vagal tone. That intravenous atropine administra- tion eliminates the marked sinus arrhythmia and bradyarrhythmias observed in patients with sleep apnea syndrome 61 supports this hypothesis. Hy- poxemia and cessation of breathing are essential for the development of bradycardia in patients with apnea, and the degree of bradycardia seems to cor- relate with the severity of hypoxemia. 62 The bra- dycardic response to hypoxia is usually counter- acted by the hyperventilation at the termination of each apneic episode. As such, marked bradycardia is apparent only with the cessation of breathing during each apneic event. Tachyarrhythmias and ventricular ectopy. Ventric- ular ectopy has been reported in up to 66% of patients with sleep apnea syndrome. 63 This incidence is significantly higher than what is reported in asymptomatic healthy persons (0% – 12%). 57 Unlike patients who do not have sleep apnea, patients with this syndrome experience ectopy mostly during sleep, suggesting a direct relation between arrhythmias and sleep apnea. Similarly, ventricular tachycardia, although less common, is also more common in patients with sleep apnea (0% – 15%) compared with the general population (0% – 4%). In most studies, the occurrence of ventricular tachycardia is almost exclusive to apneic events. 58,64 The mechanism by which sleep apnea causes ventricular arrhythmias is not known, but the decrease in arterial oxygen saturation among other factors has been shown to play an important role. Shepard et al 65 studied the relation between ventricular ectopy and oxyhemoglobin desaturation in patients with OSA and found an increase in premature ventricular contraction frequency with oxygen saturation decreasing below 60%. The authors concluded that patients with OSA whose arterial oxygen saturation is less than 60% are at increased risk and should be managed accordingly. The approach to patients with suspected sleep- related disorders should start with a thorough clinical evaluation, including a detailed history and physical examination, then a sleep study to confirm the diagnosis. A major challenge to diagnosis is the distinction between benign snoring and snoring related to apnea. A thorough investigation into the various signs and symptoms through a detailed history and a simple questionnaire to assess daytime sleepiness (The Stanford Sleepiness Scale 66 or the Epworth Sleepiness Scale 67 ) can help measure the severity of the condition. Such an evaluation is particularly important for the elderly patient, who might have other disorders, such as nocturnal my- oclonus and possibly dementia, that could render history taking harder. The most common symptoms include chronic loud snoring, excessive daytime sleepiness, person- ality changes, fatigue, depression, headache, and impairment of thinking. 68 The physical examination should focus on ruling out any discrete anatomic lesion, located anywhere from the nasal ves- tibule to the larynx, that could increase the likelihood of an obstructive event. Common physical findings include septal deviation, adenotonsillar hypertrophy, retrognathia, and crowding of the upper airway structure. Assessment of nasal obstruction and oropharyngeal or hypopharyngeal narrowing is made using fiberoptic endoscopy. Fiberoptic pharyngoscopy with the Mueller maneuver (forced expiration against closed upper airway) can repli- cate the obstructive events that occur during sleep in patients with OSA. 69,70 Obesity, increased nu- chal circumference, and a high body mass index are also common. Other signs to look for are cor pul- monale, hypertension, bradycardia or asystole during sleep, and pedal edema. 68,71 Based on the history, sleepiness scale scores, and physical examination, if OSA is highly suspected, then overnight polysomnography is strongly indi- cated. It should be emphasized that particular at- tention must be paid to the manifestations of OSA in the elderly because of the associated increase in morbidity and mortality. Indeed, several investiga- tors have found that sleep apnea can increase vascular morbidity and possibly mortality in untreated cases. 72 In one study, the respiratory disturbance index was found to be an independent predictor of cardiovascular mortality in patients with coronary artery disease. A careful sleep history and polysomnography are therefore essential and should be obtained often in the workup of an elderly patient with cardiac disease or hypertension who has a history of loud snoring. A suggested approach to patients with a history of loud snoring is provided in Figure 2. Because the cost of overnight polysomnography is expensive ($1,000 – $1,400), several different portable devices have been developed to record nocturnal breathing and oxygenation at home for the diagnosis of OSA. 73 Although the cost of these home studies is much less ($400 – $500) than overnight polysomnography, the home studies have been found to have a lower efficacy for OSA diagnosis compared with overnight polysomnography. 74 Recently, Chervin et al 74 performed a cost- utility analysis comparing polysomnography, home testing, and no sleep testing for the diagnosis of OSA. Polysomnography resulted in the greatest gain in 5-year quality-adjusted life-years (QALYs) compared with home testing and no sleep testing. Furthermore, Chervin et al showed that the incre- mental charges for polysomnography, compared with home testing or no testing, were $13,400 and $9,200, respectively, per QALY gained. 74 Compared with other medical procedures (ie, renal di- alysis costs $47,200 in 1996 dollars and screening asymptomatic patients for carotid stenosis costs about $120,000 in 1997 dollars), the benefits gained from using overnight polysomnography for the diagnosis of OSA seem justified. 74 An effective therapeutic approach must be started as soon as the diagnosis of sleep apnea has been established so that the associated morbidity and mortality are limited. Proper patient counseling pertinent to each treatment modality must be discussed. The ultimate goals are to restore airway patency and sleep continuity and to improve daytime functioning and quality of life. The resolution of the clinical signs and symptoms of OSA are reflected by a decrease in the apnea-hypopnea index and an increase in the oxyhemoglobin saturation level. 71 The treatment of sleep apnea entails modification of behavioral factors, medical treatment, use of nCPAP, application of oral or dental devices, and surgical procedures. Relief of the syn- drome usually results in improved clinical symptoms. Behavioral changes, such as weight loss, avoidance of alcohol, sedatives, antihistamines, and smoking, and body position training, are key in the management of patients with OSA. This therapy requires active patient participation, however, and rarely achieves the desired outcome. 71,75 Similarly, pharmacologic treatment with progesterone, mazindol, and other drugs has been scarcely effective and disappointing. 76 Currently, nCPAP is the most common and most successful treatment for OSA. Nasal CPAP functions as a pneumatic stent to keep the upper airway open during inspiration by preventing the pharyngeal collapse associated with the negative inspiratory pressure. In addition, genioglossus dysfunction observed in patients with OSA has been normalized after treatment with nCPAP. 77 Tousignant et al, 78 using the standard gamble method, showed an average gain of 5.4 QALYs in 19 patients whose OSA was treated with nCPAP. Furthermore, the cost- utility ratio in the Tousignant et al study was between Can$3,397 and Can$9,792 for each QALY. 78 Compared with many other clinical interven- tions, nCPAP is clearly a cost-effective treatment choice for OSA. Moreover, nCPAP has consistently been shown to be effective in lowering the apnea-hypopnea index in OSA patients. For exam- ple, Clark et al 79 showed a 60% decrease in the apnea-hypopnea index in OSA patients managed with nCPAP. Tousignant et al, 78 using nCPAP, found improvement in 9 of 12 symptoms commonly associated with OSA. Furthermore, all patients in this study showed a decreased severity of polysomnographic indicators of OSA after treatment with nCPAP. Ferguson et al 80 also showed dramatic improvements in the apnea-hypopnea index with treatment. Before treatment, patients had an average apnea-hypopnea index of 17.6 Ϯ 13.2; after treatment with nCPAP, the average apnea- hypopnea index was 3.6 Ϯ 1.7. Using the Medical Outcomes Study Short Form-36 questionnaire to assess quality of life in OSA patients, D’Ambrosio et al 81 found marked impairment of all aspects of quality of life (physical functioning 75%, vitality 41%, role functioning [physical 54%, emotional 61%, social 66%], general health 88%, and mental health 76%). After 8 weeks of treatment with nCPAP, the following improvements were seen: vitality 75%, social functioning 90%, and mental health 96%. Thus, nCPAP is consistently associated with a significant clinical outcome. Although nCPAP has been shown to improve quality of life and survival, 82 its use is sometimes limited by poor long-term compliance. 83 Nasopha- ryngeal symptoms that are common in patients with OSA, such as dryness, sneezing, mucous in the throat, blocked nose, and rhinorrhea, tend to increase with use of nCPAP. 84 Intraoral appliances have been described as an alternative to nCPAP for the treatment of mild OSA. They modify the upper airway by either advancing the mandible or retain- ing the tongue. In one study, snoring improved in most patients, and OSA was ...