Author:
AjayBhatt
Description
- Disorder characterized by cessation of breathing during sleep:
- Defined as apneic episodes >10 s with brief EEG arousals or >3% oxygenation desaturation
- Risk factors:
- Obesity (strongest risk factor)
- Male
- >40 yr of age
- Upper airway anomalies
- Myxedema (hypothyroidism)
- Alcohol/sedative abuse
- Smoking
- Associated illness:
- Various dysrhythmias, particularly atrial fibrillation and bradyarrhythmia
- Right and left heart failure
- MI
- Stroke
- Motor vehicle accidents
- Hypertension poorly controlled by medical therapies
Epidemiology
- Affects about 15% of males and 5% of females
- Prevalence has increased due to higher rates of obesity
- 80% of moderate or severe cases undiagnosed in middle-aged adults
Etiology
3 classifications of sleep apnea:
- Obstructive (84%) is due to upper airway closure despite intact respiratory drive:
- Also known as Pickwickian syndrome
- Pharyngeal airway is narrowed
- Central (0.4%) is due to lack of respiratory effort despite patent upper airway
- Complex (15%) is due to a combination of obstructive and central sleep apnea
Signs and Symptoms
- Excessive daytime sleepiness and fatigue
- Snoring
- Irritability
History
- Significant other reports of apnea
- Difficulty sleeping
- Decreased attention/concentration
- Depression
- Decreased libido/impotence
Physical Exam
- Obesity
- Hypertension, hypoxemia
- Craniofacial anomalies
- Macroglossia
- Enlarged tonsils
- Elevated jugular veins (secondary to pulmonary hypertension)
- Large neck circumference
Essential Workup
Diagnostic Tests & Interpretation
Lab
ABG is the best test to demonstrate hypercarbia and hypoxemia
Imaging
- Consider lateral neck soft tissue radiograph to rule out other etiologies of upper airway obstruction
- Chest radiograph to assess other etiologies of hypoxemia
- Chest CT rarely indicated
Diagnostic Procedures/Surgery
In-laboratory polysomnogram (PSG) is required for diagnosis:
- >5 apneic episodes per hour
- Home sleep apnea testing (HSAT) may suffice for those without comorbidities
- Not a consideration for ED management
Differential Diagnosis
- Asthma
- Cheyne-Stokes breathing
- COPD
- Diaphragmatic paralysis
- High altitude-induced periodic breathing
- Hypothyroidism
- Left heart failure
- Narcolepsy
- Obesity hyperventilation syndrome
- Primary pulmonary hypertension
Prehospital
Caution not to overventilate patient with chronic CO retention
Initial Stabilization/Therapy
Chin lift/jaw thrust maneuver, oxygen as needed, oral or nasal airway devices
ED Treatment/Procedures
- Proper technique is required for airway management:
- Supplemental oxygen as needed
- Bag-valve-mask ventilation may be difficult:
- Consider the use of nasal and oral airways
- 2-person technique to ensure a good seal
- Continuous positive airway pressure (CPAP) is the stand ard of treatment:
- Acts as a pneumatic splint by maintaining upper airway patency
- BiPAP is an alternative for patients requiring high pressures or with comorbid breathing disorders
- Long-term CPAP therapy decreases BP, insulin resistance, metabolic syndrome, and risk of cardiovascular disease
Endotracheal Intubation
- Higher prevalence of difficult intubation:
- Patients frequently have higher Mallampati scores
- Excess pharyngeal tissue in lateral walls often obstructs airway visualization
- Patients have overall lower arterial oxygen saturation
- Plan and consider several methods of definitive airway control:
- Have alternative devices (laryngeal mask airway, bougie) available
- Be prepared to perform cricothyroidotomy if necessary
- Use neuromuscular blockade only if successful oral intubation is reasonably likely and bag-mask ventilation is easy
- Positive end-expiratory pressure for ventilated patients
Medication
- Insufficient evidence to recommend any medication for treatment
- See “Airway Management” for details on induction agents and neuromuscular blockade
- Wakefulness-promoting agents (modafinil and armodafinil) are approved as an adjunct to CPAP patients with excessive sleepiness
ALERT |
Avoid sedative use:- Relaxes the upper airway and worsens airway obstruction and snoring
- Long-term Management Gold Stand ard
- CPAP compliance and weight loss strongly recommended by the American College of Physicians
- Surgical considerations:
- Most intend to reduce or bypass the excessive pharyngeal/airway resistance that occurs during sleep
- Efficacy is unpredictable
- Not a consideration for ED management
- Dental devices:
- Currently recommended by the American Academy of Sleep Medicine (AASM)
- Available appliances include tongue repositioning and mand ibular devices or soft-palate lifters
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Disposition
Admission Criteria
- Ventilatory failure, especially if intubation is necessary
- Hemodynamic instability
Discharge Criteria
- Maintenance of O2 saturation >85% for several hours using oxygenation or ventilation equipment available to the patient at home
- Very low likelihood of decompensation overnight
- Patients with sleep apnea who present after motor vehicle crashes:
- Manage initially like other blunt trauma patients
- Later, consider the increased risk with sleep apnea and intervene to prevent future accidents
Follow-up Recommendations
- PCP referral for sleep apnea and associated comorbidities
- Encourage compliance, use of CPAP
- Referral of patients with suspected sleep apnea to a pulmonologist
- Encourage weight loss and diet control
- Cardiology referral is appropriate when sleep apnea is complicated by heart failure or dysrhythmias
- BuchnerNJ, SannerBM, BorgelJ, et al. Continuous positive airway pressure treatment of mild to moderate obstructive sleep apnea reduces cardiovascular risk . Am J Respir Crit Care Med. 2007;176(12):1274-1280.
- ChirinosJA, GurubhagavatulaI, TeffK, et al. CPAP, weight loss, or both for obstructive sleep apnea . N Engl J Med. 2014;370:2265-2275.
- DempseyJA, VeaseySC, MorganBJ, et al. Pathophysiology of sleep apnea . Physiol Rev. 2010;90:47-112.
- EpsteinLJ, KristoD, StrolloPJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults . J Clin Sleep Med. 2009;5(3):263-276.
- FavaC, DorigoniS, Dalle VedoveF, et al. Effect of CPAP on blood pressure in patients with OSA/hypopnea a systematic review and meta-analysis . Chest. 2014;145:762-771.
- GottiliebDJ, PunjabiNM, MehraR, et al. CPAP versus oxygen in obstructive sleep apnea . N Engl J Med. 2014;370(24):2276-2285.
- MulgrewAT, FoxN, AyasNT, et al. Diagnosis and initial management of obstructive sleep apnea without polysomnography: A rand omized validation study . Ann Intern Med. 2007;146(3):157-166.
- PeppadPE, YoungT, BarnetJH, et al. Increased prevalence of sleep-disordered breathing in adults . Am J Epidemiol. 2013;177(9):1006-1014.
- QaseemA, HoltyJE, OwensDK, et al. Clinical Guidelines Committee of the American College of Physicians. Management of obstructive sleep apnea in adults: A clinical practice guideline from the American College of Physicians . Ann Intern Med. 2013;159:471-483.
- RosenbergR, DoghramjiP. Optimal treatment of obstructive sleep apnea and excessive sleepiness . Adv Ther. 2009;26:295-312.
See Also (Topic, Algorithm, Electronic Media Element)
The authors gratefully acknowledge Mark Sagarin for his contribution to the previous edition of this chapter.