A Special Report for Physicians Regarding Obstructive Sleep Apnea

When Mr. SH was referred to the Arkansas Sleep Disorders Diagnostic Center in late 1999, he presented with complaints of loud snoring and witnessed apnea. He rated himself as severely sleepy on the Epworth Sleepiness Scale. At 70 inches and 233 pounds, he had a body mass index of 33.5.

A 451-minute polysomnogram in our sleep laboratory revealed 15 apneas and 16 hypopneas per hour of sleep. Each of these events led to transient arousals or awakenings. Arterial oxygen saturation dropped as low as 73%. He snored approximately 70% of his sleep time. His sleep efficiency was very low at 69%.

We diagnosed Mr. SH with moderate obstructive sleep apnea. Our usual approach to obstructive sleep apnea is CPAP (Continuous Positive Airway Pressure), but the mask induced claustrophobia in this patient.

I recommended that Mr. SH diet to lose all excess weight. I also advised him to refrain from sleeping on his back and to avoid central nervous system depressants. I offered him desensitivity exercises for a nasal CPAP mask and asked him to consider returning for an all-night CPAP evaluation.

On July 20, 2000, Mr. SH returned to our clinic to assess the effect of his 63-pound weight loss and to retry CPAP if necessary. He reported significant improvement in daytime alertness. The 429-minute polysomnogram revealed significant overall improvement. His sleep efficiency was 90%. He had a combined total of 3 apneas and hypopneas, and only one respiratory effort-related arousal per hour of sleep. His lowest arterial oxygen saturation was 86%. He snored for only 8% of his sleeptime. Mr. SH’s OSA was controlled by his weight loss.

Sleep apnea affects some 20 million Americans, according to the National Center on Sleep Disorders Research. The most common type is obstructive sleep apnea (OSA). OSA is primarily encountered in middle-aged men but can affect both sexes and all age groups. It is often associated with obesity but can not be ruled out based on age, sex, weight or other characteristics alone. Upon examination, OSA patients are typically found to have narrow airways with redundant tissue. Other contributing factors include craniofacial abnormalities, use of alcohol or sedatives before bedtime, a neck size larger than 17 inches, and massively enlarged tonsils and adenoids.

Symptoms include snoring, often loud and accompanied by snorting and gasping; periodic cessation of breathing during sleep; daytime sleepiness; sleep drunkenness; and early morning headaches. Often, those affected attribute their fatigue and other symptoms to age, stress or some other health problem.

Patients frequently seek help after a bed partner or roommate complains. In others, daytime sleepiness becomes so profound that they can no longer function normally. It is not uncommon for patients to report falling asleep while at their desks, standing in line, driving or even while giving a presentation before a group. Such patients often are misdiagnosed as having narcolepsy.

In its most severe form, OSA can be life-threatening, as it leaves the patient more vulnerable accidents on the road or on the job. It has been linked to heart failure, systemic and pulmonary hypertension, and stroke.

Besides the obvious physical risks, OSA can lead to social isolation, problems with employers, marital trouble and depression. These problems, combined with the confusion and agitation that come from lack of sleep, can add up to a very troubled patient.

At the Arkansas Sleep Disorders Diagnostic Center, a joint service of UAMS Medical Center and the Central Arkansas Veterans HealthCare System, the most commonly prescribed treatment for OSA is CPAP, an approach that is simple, effective, noninvasive, safe and reliable. The patient wears a fitted mask connected to a machine that delivers a carefully adjusted stream of air pressure to keep the airway open, creating what amounts to a splint made of air.

However, CPAP is not for every patient. Long-term compliance is estimated to be about 70%. Some patients, such as Mr. SH, find that the mask induces claustrophobia. Others find the machine inconvenient for travel. A few experience adverse effects such as a dry throat, rhinorrhea, facial irritation and, if the mask is worn incorrectly, ocular dryness. Some patients tend to swallow air, which may cause abdominal fullness and flatulence.

The most effective treatment for sleep apnea is the one that was once the treatment of choice: the tracheotomy. However, most patients find it cosmetically unappealing. Other surgical options include somnoplasty, UPPP (uvulopalatopharyngoplasty), UPPGP (uvulopalatopharyngoglossoplasty) and MMO (maxillomandibular osteotomy). In a few cases, dental appliances can help by advancing the jaw, advancing the tongue, or lifting the soft palate.

However, when the cause of the condition is clear and the patient is motivated, it may be best to manage the problem at its root. In Mr. SH’s case, his obesity was contributing to his OSA. His weight loss was not only the key to controlling his disorder but will certainly yield other health benefits.

Teofilo L. Lee-Chiong Jr., M.D., is medical director of the Arkansas Sleep Disorders Diagnostic Center, a joint service of UAMS Medical Center and the Central Arkansas Veterans HealthCare System. He is an assistant professor of medicine with the University of Arkansas for Medical Sciences.

DEGREE: University of the East, Philippines

INTERNSHIP/RESIDENCY: Internal Medicine
Yale University School of Medicine
New Haven, Connecticut

FELLOWSHIP:
Pulmonary and Critical Care
Yale University School of Medicine New Haven, Connecticut

POSTFELLOWSHIP:
Sleep Medicine Dartmouth College School of Medicine Hanover, New Hampshire

CERTIFICATION:
Internal Medicine
Pulmonary Medicine Critical Care Medicine Sleep Medicine

For more information or to make a referral to Dr. Teofilo Lee-Chiong, call 501/257-6064.