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Key symptoms of OSAHS include daytime somnolence and nocturnal breathing disturbances (loud snoring, snorting, gasping, or breathing pauses). Other symptoms may include dry mouth, nocturia, morning headaches, and difficulty concentrating. Sleeping partners can provide essential historical information. Depression and hypertension are associated with OSAHS. Differential diagnosis of OSAHS includes insufficient amount of sleep, somnolence related to shift work, depression, drug effects (both stimulants and sedatives), narcolepsy, and idiopathic hypersomnolence.

Severity of OSAHS is based on the frequency of breathing disturbances (apnea-hypopnea index), duration of apneas and hypopneas, amount of oxygen desaturation during respiratory disturbances, degree of sleep fragmentation, and intensity of daytime somnolence.

Physical examination should include assessment of body mass index, jaw and upper airway structure, and blood pressure. Potentially related systemic illnesses, including acromegaly and hypothyroidism, should be considered.

Diagnostic testing often includes a polysomnogram in a sleep laboratory. However, home sleep studies without neurophysiologic monitoring may be used for screening. Significant daytime somnolence with a negative home screening study should be followed by a full polysomnogram.

Treatment: Sleep Apnea

In pts with OSAHS, efforts to reduce weight in obese pts, limit alcohol use, optimize sleep duration, regulate sleep schedules, treat nasal allergies, and carefully withdraw sedative medications should be pursued.

The primary therapy for OSAHS is continuous positive airway pressure (CPAP), delivered through a nasal or nasal-oral mask. Selecting a comfortable mask delivery system and titrating the appropriate amount of CPAP are essential. Airway drying related to CPAP can be reduced by including a heated humidification component in the CPAP system. Alternative OSAHS therapies include mandibular repositioning splints (oral devices), which hold the jaw and tongue forward to widen the pharyngeal airway. These devices are typically used for mild OSAHS pts or pts who do not tolerate CPAP. Several types of surgical procedures have been used in OSAHS, including bariatric surgery in obese pts, tonsillectomy, jaw advancement surgery, and pharyngeal surgery. Tracheostomy is curative since it bypasses the upper airway obstruction site, but it is rarely used. No drugs have been proven to reduce apneic events.

Treatment of CSA involves managing any predisposing conditions, such as congestive heart failure. Adaptive servoventilation, which provides variable inspiratory ventilatory support in response to apneas and hypopneas, may be helpful in CSA.

For a more detailed discussion, see Wellman A, Redline S: Sleep Apnea, Chap. 319, p. 1723, in HPIM-19.

Outline

Section 9. Pulmonology