H&P + Diagnosis
Pt assessed for risk factors and associated conditions.
BMI = __; Neck circumference = ____; Posterior chin position (retrognathia) is ______ present/absent. Morning headaches __ present/absent.
STOP-Bang questionnaire score:
Mallampati score:
Epworth Sleepiness scale:
Labs:
Treatment
Polysomnography: Will refer to sleep medicine for a nocturnal PSG in a sleep lab. Home OSA tests are generally less accurate.
CPAP: After confirmation with PSG, we will start CPAP. Early patient education and support will be initiated to increase adherence rates.
Education: Patient education provided and alternative treatments, risks, and benefits discussed. “CPAP decreases apnea/hypopnea episodes, sleepiness, lowers BP, rates of arrhythmia and stroke, improves LV EF in patients with CHF and reduces fatal and nonfatal cardiovascular events. It also improves the quality of life and performance and decreases metabolic syndrome.”
Discussed positional therapy.
Oral appliances: Will consider them if the patient cannot tolerate CPAP. Will prefer mandibular advancement devices over tongue-retaining devices. “A recent meta-analysis demonstrated similar rates of BP lowering between CPAP and mandibular advancement devices.” AAFP 2016
Lifestyle changes: Weight loss, exercise, diet, and behavior modification discussed. Pt informed that bariatric surgery can improve sleep parameters and symptoms in obese patients with OSA and can result in remission in many patients.
Avoid alcohol and sedatives.
Surgery: There is not enough evidence that surgery helps OSA.
F/u in 6 weeks.
—END—
- Daytime sleepiness is the OSA symptom that is most responsive to treatment with CPAP.
PSG = Diagnostic test of choice.
NB: CPAP = 1st line treatment.
Patients with OSA also have reduced distance and increased angles from the chin to the thyroid cartilage, and a narrow oropharyngeal opening.
“Daytime sleepiness is the clinically relevant symptom of obstructive sleep apnea (OSA) that is most responsive to treatment. Other associated symptoms such as snoring, insomnia, and fatigue are either less clinically relevant or less responsive to treatment. Hypertension, diabetes mellitus, and coronary artery disease are associated with OSA, but evidence is insufficient that continuous positive airway pressure(CPAP) improves outcomes for these conditions, especially if they are not associated with daytime sleepiness.
Ref: Qaseem A, Dallas P, Owens DK, et al: Diagnosis of obstructive sleep apnea in adults: A clinical practice guideline from
the American College of Physicians. Ann Intern Med 2014;161(3):210-220.
”
References
Am Fam Physician. 2016 Sep 1;94(5):355-360.
Chest. 2016 Mar;149(3):631-8. https://www.ncbi.nlm.nih.gov/pubmed/26378880
Anesthesiology. 2008 May;108(5):812-21. https://www.ncbi.nlm.nih.gov/pubmed/18431116
http://www.uptodate.com/contents/overview-of-obstructive-sleep-apnea-in-adults
Diagnosis of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2014;161(3):210-220.