Snoring Is No Laughing Snoring Is No Laughing MatterMatter

A Primary Care Perspective OnA Primary Care Perspective On

Obstructive Sleep ApneaObstructive Sleep Apnea

Andrew Okas, D.O.Andrew Okas, D.O.

Case PresentationCase Presentation CC: Wife made me come!!CC: Wife made me come!! HPI: A 32 y.o. stubborn male doctor presents to HPI: A 32 y.o. stubborn male doctor presents to

his PCP for the first time in 15 years because his his PCP for the first time in 15 years because his wife (a doctor) threatens to suture his mouth shut wife (a doctor) threatens to suture his mouth shut because of earth shaking snoring. because of earth shaking snoring.

Past Medical/Snoring History: Past Medical/Snoring History: 1.1. Gets Kicked Out of Medical School Library for Gets Kicked Out of Medical School Library for

snoring and slobering on text books.snoring and slobering on text books.2.2. In Residency, He Fell Asleep daily on Neurology In Residency, He Fell Asleep daily on Neurology

rotation (while standing)rotation (while standing)3.3. Residents ban him from ICU call rooms because Residents ban him from ICU call rooms because

of sonic boom snoring.of sonic boom snoring.The Diagnosis= A FREAK OF NATUREThe Diagnosis= A FREAK OF NATURE

I Am A SnorerI Am A Snorer

Is Snoring Destroying Your Is Snoring Destroying Your Children?Children?

ADHD

ObesitySIDS

Is Snoring Destroying Your Is Snoring Destroying Your Marriage?Marriage?

""Stop snoring week aims to restore happy sex livesStop snoring week aims to restore happy sex lives" (" (Telegraph.co.ukTelegraph.co.uk))

""It's snore fun when you have to sleep all aloneIt's snore fun when you have to sleep all alone" (" (ScotsmanScotsman))

""SEX IS A REAL SNORE POINTSEX IS A REAL SNORE POINT" (Glasgow Daily Record)" (Glasgow Daily Record)

""Snoring can be the cause of divorceSnoring can be the cause of divorce" (Pravda, Russia)" (Pravda, Russia)

""World ; Snoring ruins your sex life!:World ; Snoring ruins your sex life!:" (Keralanext, India)" (Keralanext, India)

""You snore? Don't score?You snore? Don't score?" (Sydney Morning Herald, Australia)" (Sydney Morning Herald, Australia)

Is Snoring Destroying The World?Is Snoring Destroying The World?

OSA is also associated OSA is also associated with a variety of with a variety of disasters, such as disasters, such as Three Mile Island and Three Mile Island and Chernobyl. (Research Chernobyl. (Research Review, February Review, February 2006)2006)

Is Snoring Destroying Lives?Is Snoring Destroying Lives?

Reverend Reggie White (43yo) most likely Reverend Reggie White (43yo) most likely had a condition (Sarcoidosis and Obstructive had a condition (Sarcoidosis and Obstructive Sleep Apnea) resulting in "fatal cardiac Sleep Apnea) resulting in "fatal cardiac arrhythmia," said Dr. Mike Sullivan, the arrhythmia," said Dr. Mike Sullivan, the medical examiner for Mecklenburg County medical examiner for Mecklenburg County and a forensic pathologistand a forensic pathologist

"It's scary as hell when it happens to "It's scary as hell when it happens to

you," Tosti said. you," Tosti said.

OSA caused him to doze off sometimes OSA caused him to doze off sometimes in the middle of a conversation, at work in the middle of a conversation, at work and, on two occasions, in the car.and, on two occasions, in the car.

"We had three of our grandchildren in "We had three of our grandchildren in

the back seat. They were singing and the back seat. They were singing and the radio was blasting and he went off the radio was blasting and he went off the road," said his wife, Irene. the road," said his wife, Irene.

Is Snoring Going To Destroy You?Is Snoring Going To Destroy You?

Sleep apneaSleep apnea

affects more affects more than twelve than twelve million million Americans, Americans, according to the according to the National National Institutes of Institutes of HealthHealth

The vast majority of these Americans with sleep apnea have not been diagnosed.

Overview of Sleep DisordersOverview of Sleep Disorders100 million Americans100 million Americans

Over 84 DisordersOver 84 Disorders

American Academy of Sleep MedicineAmerican Academy of Sleep Medicine

Narcolepsy100k

Central Sleep Apnea

Obstructive Sleep Apnea

12 million

Restless Leg Syndrome20 million

Insomnia50 million

DefinitionDefinition

0

5

10

15

20

25

snore tired osa

Men

Women

24% of men and 9% of women (30-60 24% of men and 9% of women (30-60 years of age) have excessive snoring years of age) have excessive snoring (an apnea/hypopnea index > 5) without (an apnea/hypopnea index > 5) without daytime hypersomnolence. (Flemons, daytime hypersomnolence. (Flemons, NEJM 2002).NEJM 2002).

In Sleep 2003 Punjabi discovered that In Sleep 2003 Punjabi discovered that 20%-25% of the general population 20%-25% of the general population screened with Epworth sleepiness screened with Epworth sleepiness scale had excessive daytime scale had excessive daytime hypersomnolence.hypersomnolence.

According to these criteria, 4% of men According to these criteria, 4% of men and 2% of women who are 30-60 years and 2% of women who are 30-60 years of age have OSA. (Flemons, NEJM of age have OSA. (Flemons, NEJM 2002).2002).

Obstructive Sleep Apnea syndrome is daytime Obstructive Sleep Apnea syndrome is daytime sleepiness in conjunction with 5 or more episodes sleepiness in conjunction with 5 or more episodes of apnea or hypopnea per hour of sleep.of apnea or hypopnea per hour of sleep.

The Consequences of Sleep ApneaThe Consequences of Sleep Apnea

CVACVA

CADCAD

HypercapneaHypercapnea

CHFCHF

HypoxiaHypoxia

HEADACHESHEADACHES

MEMORY LOSS

MEMORY LOSS DEPRESSIONDEPRESSION

NOCTURIANOCTURIA

IMPOTENCEIMPOTENCE

PULMONARYHYPERTENSION

PULMONARYHYPERTENSION

GERDGERDGERDGERD

OBESITYOBESITY

DIABETESDIABETES

HTNHTNARRHYTHMIASARRHYTHMIAS

OBSTRUCTIVESLEEPAPNEA

OBSTRUCTIVESLEEPAPNEA

Ischemic EventsIschemic Events

CVA: A large observational cohort study published in CVA: A large observational cohort study published in November 2005 in the New England Journal of Medicine November 2005 in the New England Journal of Medicine reported that obstructive sleep apnea greatly increases the reported that obstructive sleep apnea greatly increases the risk of stroke by a factor of 2-3, regardless of whether a risk of stroke by a factor of 2-3, regardless of whether a person has high blood pressure. person has high blood pressure.

Coronary Artery Disease Coronary Artery Disease - A 2-3 times increased risk of - A 2-3 times increased risk of heart attack in patients with OSA. There is speculation that heart attack in patients with OSA. There is speculation that OSA may be one factor in the higher frequency of heart OSA may be one factor in the higher frequency of heart attacks in the early morning hours. attacks in the early morning hours.

Sudden Cardiac DeathSudden Cardiac Death

Gami, et al, NEJM,March 2005 Observed Gami, et al, NEJM,March 2005 Observed that people with OSA have a peak in sudden that people with OSA have a peak in sudden death from cardiac causes during sleeping death from cardiac causes during sleeping hours which is significantly higher than the hours which is significantly higher than the normal population. Severe OSA patients normal population. Severe OSA patients had a 40% higher relative risk.had a 40% higher relative risk.

DrivingDriving

The Wisconsin Sleep Cohort Study reported The Wisconsin Sleep Cohort Study reported that: that:

Drivers with Mild OSA were 3 times as likely Drivers with Mild OSA were 3 times as likely to be involved in a car accident as those to be involved in a car accident as those without OSA, without OSA,

Drivers with Moderately Severe OSA were 7 Drivers with Moderately Severe OSA were 7 times as likely to be involved in a car times as likely to be involved in a car accident as those without OSA. accident as those without OSA.

When Is Snoring More Than Just A When Is Snoring More Than Just A Snore Point?Snore Point?

You are High Risk for OSA if you have 2 of the 4 You are High Risk for OSA if you have 2 of the 4 following criteria.following criteria.

1. Snoring1. Snoring 2. Anyone who has daytime hypersomnolence or 2. Anyone who has daytime hypersomnolence or

fall asleep while driving (night or day)fall asleep while driving (night or day) 3. Obesity3. Obesity 4. Hypertension4. Hypertension

(78-95% sensitivity, Flemons, et al. Sleep Medicine (78-95% sensitivity, Flemons, et al. Sleep Medicine Review 1997)Review 1997)

THE EPWORTH SLEEPINESS SCALE (Johns, Sleep 1991)THE EPWORTH SLEEPINESS SCALE (Johns, Sleep 1991)

11 = Slight chance of dozing = Slight chance of dozing 2 = Moderate chance of dozing2 = Moderate chance of dozing

3 = High chance of dozing3 = High chance of dozing

1. Sitting and reading 1. Sitting and reading     0 1 2 3     0 1 2 3

2. Watching TV 2. Watching TV     0 1 2 3     0 1 2 3

3. Sitting inactive in a public place (e.g. a theater or a 3. Sitting inactive in a public place (e.g. a theater or a meeting) meeting)     0 1 2 3     0 1 2 3

4. As a passenger in a car for an hour without a break 4. As a passenger in a car for an hour without a break     0 1 2 3     0 1 2 3

5. Lying down to rest in the afternoon 5. Lying down to rest in the afternoon     0 1 2 3     0 1 2 3

6. Sitting quietly after a lunch without alcohol 6. Sitting quietly after a lunch without alcohol 0 1 2 3 0 1 2 3 7. Sitting and talking to someone 7. Sitting and talking to someone

    0 1 2 3     0 1 2 3 8. In a car, while stopped for a few minutes in the 8. In a car, while stopped for a few minutes in the

traffic traffic     0 1 2 3     0 1 2 3

Epworth Sleepiness Scores by Epworth Sleepiness Scores by DiagnosisDiagnosis

Controls 6.0 ± 2.5Controls 6.0 ± 2.5 OSA 11.7 ± 4.6 OSA 11.7 ± 4.6 Narcolepsy 17.5 ± 3.5Narcolepsy 17.5 ± 3.5 Insomnia 2.2 ± 2.0Insomnia 2.2 ± 2.0 In OSA, ESS > 16 was only seen in patients In OSA, ESS > 16 was only seen in patients

with moderate to severe disease.with moderate to severe disease.

Flemons, W. W. N Engl J Med 2002;347:498-504

Approach to a Patient with Suspected Sleep ApneaAdjusted Neck Adjusted Neck Circumference:Circumference:

actual neck size actual neck size plus plus

3cm for snoring3cm for snoring 3cm for choking 3cm for choking

/gasping,/gasping,4cm for HTN4cm for HTN

If score is over If score is over 48 then high 48 then high

probability (over probability (over 20 times as 20 times as probableprobable).).

Respiratory Disturbance IndexRespiratory Disturbance Index Apnea/Hypopnea IndexApnea/Hypopnea Index

THE MAJORITY OF OSA THE MAJORITY OF OSA PATIENTS ARE NOT OBESEPATIENTS ARE NOT OBESE

The article "Association of Sleep-Disordered Breathing, Sleep Apnea, The article "Association of Sleep-Disordered Breathing, Sleep Apnea, and Hypertension in a Large Community-Based Study" published in and Hypertension in a Large Community-Based Study" published in the the Journal of the American Medical AssociationJournal of the American Medical Association in April 2000 is the in April 2000 is the largest published population-based study to provide the breakdown of largest published population-based study to provide the breakdown of subjects’ apnea-hypopnea index (AHI) by body-mass index (BMI). subjects’ apnea-hypopnea index (AHI) by body-mass index (BMI).

According to Nieto et al, the majority of subjects with an According to Nieto et al, the majority of subjects with an AHI ³ 5 are AHI ³ 5 are not obese. not obese.

Patient With Suspected Sleep Apnea

The FutureThe Future

A large HMO in Puget Sound, Washington is already using home sleep monitoring as the principal A large HMO in Puget Sound, Washington is already using home sleep monitoring as the principal method for diagnosing OSA.method for diagnosing OSA.

A Continuous Positive Airway Pressure Trial as a Novel Approach to the Diagnosis of the A Continuous Positive Airway Pressure Trial as a Novel Approach to the Diagnosis of the Obstructive Sleep Apnea Syndrome* Oliver Senn, MDObstructive Sleep Apnea Syndrome* Oliver Senn, MD University Hospital of Zurich, Switzerland. University Hospital of Zurich, Switzerland. Chest 2006 suggests empiric trial of cpap for moderate to high risk patients for 2 weeks before doing Chest 2006 suggests empiric trial of cpap for moderate to high risk patients for 2 weeks before doing any sleep studiesany sleep studies

Hypersomnolence and/or

>44cm neck circumference

Low Risk Moderate Risk High Risk

Conservativetreatment

Sleep Study Sleep Study

Home MonitoringHome Monitoring(Not Supprted by the(Not Supprted by the

American Thoracic SocietyAmerican Thoracic SocietyOr American Sleep Academy)Or American Sleep Academy)

Polysomnography (Gold Standard) Polysomnography (Gold Standard) (Over 16 Channels)(Over 16 Channels)

2 - 6 channels of EEG (Electroencephalogram - electrical activity in the brain) which allow the person 2 - 6 channels of EEG (Electroencephalogram - electrical activity in the brain) which allow the person interpreting the test to determine how the stages of sleep change during the nightinterpreting the test to determine how the stages of sleep change during the night

2 channels of EOG (Electrooculogram - movement of the eye) which are used to distinguish so-called 2 channels of EOG (Electrooculogram - movement of the eye) which are used to distinguish so-called REM (Rapid eye movement) sleep from Non-REM sleepREM (Rapid eye movement) sleep from Non-REM sleep

Chin EMG (Electromyography - electrical activity of the chin muscle) which is an indicator of arousal Chin EMG (Electromyography - electrical activity of the chin muscle) which is an indicator of arousal and activation of the upper airway muscles, and activation of the upper airway muscles,

Airflow from the nose and mouthAirflow from the nose and mouth

Respiratory effort which is measured with elastic belts around the chest and the abdomen Respiratory effort which is measured with elastic belts around the chest and the abdomen

Body positionBody position

1 channel of ECG (Electrocardiogram)1 channel of ECG (Electrocardiogram)

Oximetry (Recording of the oxygen saturation of the blood)Oximetry (Recording of the oxygen saturation of the blood)

2 channels of leg EMG (the electrodes are usually applied to the shins) to record limb movements 2 channels of leg EMG (the electrodes are usually applied to the shins) to record limb movements during sleep. during sleep.

Madison waiting period is 1-2 months. Madison waiting period is 1-2 months. Canadian waiting period is 8 monthsCanadian waiting period is 8 months

A 4-channel home sleep study is covered by Unity and A 4-channel home sleep study is covered by Unity and Physicians Plus $750.Physicians Plus $750.

Madison waiting period less than 1 weekMadison waiting period less than 1 week

6 Channel Home Sleep 6 Channel Home Sleep Monitor Monitor

Single leg activity Single leg activity (Channel 1). (Channel 1).

Body position (Channel Body position (Channel 2),2),

Snoring (Channel 3),Snoring (Channel 3), Airflow from the nose Airflow from the nose

and mouth (Channel 4), and mouth (Channel 4), Chest/Abdomen Chest/Abdomen

movement (Channel 5)movement (Channel 5) Oxygen saturation Oxygen saturation

(Channel 8)(Channel 8) Heart rate (Channel 7) Heart rate (Channel 7)

TreatmentTreatment

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70

80

90

100

mild moderate severe

Conservative

cpap

surgery

dental

drugs

pacing

CONSERVATIVE TREATMENTCONSERVATIVE TREATMENT Do not drink alcoholic beverages in the evening as this disturbs sleep.Do not drink alcoholic beverages in the evening as this disturbs sleep.

Avoid cafeinated beverages after noontime, as caffeine disturbs sleep. Limit total caffeine consumption to no more Avoid cafeinated beverages after noontime, as caffeine disturbs sleep. Limit total caffeine consumption to no more than two beverages per day.than two beverages per day.

Do not smoke just before bedtime or during the night as this disturbs sleep.Do not smoke just before bedtime or during the night as this disturbs sleep.

Exercise regularly during the day, but avoid exercise in the evening within 3 hours of bedtime.Exercise regularly during the day, but avoid exercise in the evening within 3 hours of bedtime.

Maintain a comfortable temperature in the bedroom.Maintain a comfortable temperature in the bedroom.

If you're overweight, lose weight.If you're overweight, lose weight. Being overweight is the most common cause of snoring. Flabby throat tissues Being overweight is the most common cause of snoring. Flabby throat tissues are more likely to vibrate as you breathe. are more likely to vibrate as you breathe.

Sleep on your side.Sleep on your side. Lying on your back allows your tongue to fall backward into your throat, narrowing your airway Lying on your back allows your tongue to fall backward into your throat, narrowing your airway and partially obstructing airflow. To prevent sleeping on your back, try sewing a tennis ball in the back of your and partially obstructing airflow. To prevent sleeping on your back, try sewing a tennis ball in the back of your pajama top. pajama top.

Treat nasal congestion or obstruction.Treat nasal congestion or obstruction. Adhesive strips applied to your nose widen nasal passages and may help Adhesive strips applied to your nose widen nasal passages and may help reduce congestion or obstruction. reduce congestion or obstruction.

Limit or avoid alcohol and sedatives.Limit or avoid alcohol and sedatives. Sedatives and hypnotics (sleeping pills) and alcohol depress your central Sedatives and hypnotics (sleeping pills) and alcohol depress your central

nervous system, nervous system,

At 156 kgsAt 156 kgs

At 127.3 At 127.3 kgskgs

Dental DevicesDental Devices

Indication: Indication: Mild/Moderate OSAMild/Moderate OSA

Disadvantage:Disadvantage:

1. Cost: Over $7001. Cost: Over $700

2. Side effects: Obstruct 2. Side effects: Obstruct Breathing, SloberBreathing, Slober

3. Low compliance3. Low compliance

Dental AppliancesDental Appliances

Neutral PositionNeutral Position Picture of the airway corresponding to the 70% setting

SurgerySurgery UUvulopalatopharyngoplasty (UPPP).vulopalatopharyngoplasty (UPPP). Your Your

tonsils and adenoids usually are removed as tonsils and adenoids usually are removed as well. This is the most common type of surgery to well. This is the most common type of surgery to treat sleep apnea. treat sleep apnea.

Laser-assisted uvulopalatoplasty (LAUP).Laser-assisted uvulopalatoplasty (LAUP). this procedure involves the use of a laser to this procedure involves the use of a laser to remove part of your soft palate and shorten remove part of your soft palate and shorten uvula. uvula.

Radiofrequency ablation (RFA).Radiofrequency ablation (RFA). In this office In this office procedure, radiofrequency energy to remove procedure, radiofrequency energy to remove tissue from your uvula, and soft palate. tissue from your uvula, and soft palate.

Both LAUP and RFA Are Not recommended for Both LAUP and RFA Are Not recommended for moderate to severe obstructive sleep apnea.moderate to severe obstructive sleep apnea.

Continuous positive airway Continuous positive airway pressure (CPAP)pressure (CPAP)

Some studies say that compliance is less Some studies say that compliance is less than 4 hours per night. than 4 hours per night.

Atrial Overdrive PacemakersAtrial Overdrive Pacemakers

NEJM 2002 Atrial overdrive (15 beats above NEJM 2002 Atrial overdrive (15 beats above baseline) pacemakers improved both OSA baseline) pacemakers improved both OSA and central sleep apneaand central sleep apnea

The FutureThe Future

Researchers at the University of Researchers at the University of Pennsylvania are studying Pennsylvania are studying whether serotonin can help whether serotonin can help English bulldogs, whose facial English bulldogs, whose facial structure causes them to snore structure causes them to snore and suffer apnea. and suffer apnea.

Lab tests show serotonin seems Lab tests show serotonin seems to help keep the bulldogs' to help keep the bulldogs' throats open during sleep. throats open during sleep.

The Family That Snores The Family That Snores Together Slobers TogetherTogether Slobers Together

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Upper Airway Resistance Syndrome Upper Airway Resistance Syndrome (UARS)(UARS)

A "typical" patient with UARS is a slender woman in her A "typical" patient with UARS is a slender woman in her 20's - 30's with a small jaw and a high, arched palate. 20's - 30's with a small jaw and a high, arched palate.

Some experts also believe that there is a group of patients, Some experts also believe that there is a group of patients, mostly female, who are mostly female, who are not loud snorersnot loud snorers, who , who do not show evidence of OSA on sleep monitoring, and yet and yet suffer the symptoms of OSA. In these patients, there is suffer the symptoms of OSA. In these patients, there is partial airway collapse without detectable change in airflow partial airway collapse without detectable change in airflow that results in repeated awakenings during sleep. that results in repeated awakenings during sleep.

The occurrence of these partial airway collapses can be The occurrence of these partial airway collapses can be documented by putting a catheter into the esophagus to documented by putting a catheter into the esophagus to measure pressure changes in the chest during breathing. measure pressure changes in the chest during breathing. These patients show marked changes in pressure during These patients show marked changes in pressure during inspiration that are similar to those seen in patients with inspiration that are similar to those seen in patients with OSA. OSA.

SLEEP EVALUATION SLEEP EVALUATION 1) Do you sometimes experience a creeping feeling in your legs? 1) Do you sometimes experience a creeping feeling in your legs?

    Yes No     Yes No 2) Do you or have you ever been told that you kick your legs at night? 2) Do you or have you ever been told that you kick your legs at night?

    Yes No     Yes No 3) Do you snore? 3) Do you snore?

    Yes No I don't know     Yes No I don't know If "yes" please continue with #4If "yes" please continue with #4

If "no" or "I don’t know" please continue with #8If "no" or "I don’t know" please continue with #8 4) Your snoring is... 4) Your snoring is...

    softer than talking     softer than talking     as loud as talking     as loud as talking     louder than talking     louder than talking

5) Your snoring occurs... 5) Your snoring occurs...     every/almost every night     every/almost every night     a few times each week     a few times each week     once a week or less     once a week or less

6) Your snoring is also... 6) Your snoring is also...     frequently interrupted by pauses/choking     frequently interrupted by pauses/choking     occasionally interrupted by pauses/choking     occasionally interrupted by pauses/choking     not interrupted as far as you know     not interrupted as far as you know

7) Do you snore in every body position? 7) Do you snore in every body position?     Yes No I don't know     Yes No I don't know

8) Do you have, or ever had a bed partner? 8) Do you have, or ever had a bed partner?     Yes No     Yes No

The MSLT measures how easily a person can fall The MSLT measures how easily a person can fall asleep when given the chance across the day.asleep when given the chance across the day.

The MSLT is the gold standard, but this one day The MSLT is the gold standard, but this one day test is not an accurate view of daily life. M. W. test is not an accurate view of daily life. M. W. Johns in The Journal of Sleep Research 2000 Johns in The Journal of Sleep Research 2000 showed that the ESS is a more discriminating test showed that the ESS is a more discriminating test of sleepiness in daily life than either the MSLT or of sleepiness in daily life than either the MSLT or the MWT in patients with Narcolepsy.the MWT in patients with Narcolepsy.

If "yes" please continue with #9If "yes" please continue with #9 If "no" please continue with #12If "no" please continue with #12

9) Has your bed partner ever said that you have pauses in your breathing or periods of stopped breathing during your sleep? 9) Has your bed partner ever said that you have pauses in your breathing or periods of stopped breathing during your sleep?     Yes No     Yes No

10) Has your bed partner ever commented that you snore? 10) Has your bed partner ever commented that you snore?     Yes, loud snoring Yes, soft snoring No     Yes, loud snoring Yes, soft snoring No

11) If you snore, is it loud enough to bother her/him? 11) If you snore, is it loud enough to bother her/him?     Yes No     Yes No

12) Has anyone besides a bed partner ever commented on your snoring (roommate, neighbor, family, etc.)? 12) Has anyone besides a bed partner ever commented on your snoring (roommate, neighbor, family, etc.)?     Yes, loud snoring Yes, soft snoring No     Yes, loud snoring Yes, soft snoring No

13) Do you feel fatigued or exhausted or tired or not up to par? 13) Do you feel fatigued or exhausted or tired or not up to par?     nearly every day     nearly every day     3 to 4 times a week     3 to 4 times a week     once or twice a week     once or twice a week     once or twice a month     once or twice a month     never or hardly ever     never or hardly ever

14) Do you feel that in some way your sleep is not refreshing or restful? 14) Do you feel that in some way your sleep is not refreshing or restful?     nearly every day     nearly every day     3 to 4 times a week     3 to 4 times a week     once or twice a week     once or twice a week     once or twice a month     once or twice a month     never or hardly ever     never or hardly ever

15) Do you have periods of the day when you have trouble paying attention, remembering things or staying awake? 15) Do you have periods of the day when you have trouble paying attention, remembering things or staying awake?     nearly every day     nearly every day     3 to 4 times a week     3 to 4 times a week     once or twice a week     once or twice a week     once or twice a month     once or twice a month     never or hardly ever     never or hardly ever

16) Do you have high blood pressure? 16) Do you have high blood pressure?     Yes No     Yes No

If "yes" are you being treated for high blood pressure?If "yes" are you being treated for high blood pressure?     Yes No     Yes No

17) Do you wake up during the night or in the morning with headaches? 17) Do you wake up during the night or in the morning with headaches?     Yes No     Yes No

18) Are you a shift worker? 18) Are you a shift worker?     Yes No     Yes No

19) Do you have trouble initiating and/or maintaining sleep? 19) Do you have trouble initiating and/or maintaining sleep?     nearly every day     nearly every day     3 to 4 times a week     3 to 4 times a week     once or twice a week     once or twice a week     once or twice a month     once or twice a month     never or hardly ever     never or hardly ever

20) What do you feel is your ideal amount of sleep per day? 20) What do you feel is your ideal amount of sleep per day?     2-4 5 6 7 8 9 10     2-4 5 6 7 8 9 10

21) Estimate the average number of hours of sleep you had per day during the last week. 21) Estimate the average number of hours of sleep you had per day during the last week.     2-4 5 6 7 8 9 10     2-4 5 6 7 8 9 10

A number of studies have shown that The A number of studies have shown that The number of transient arousal periods and the number of transient arousal periods and the severity of hypoxia correlate with the severity of hypoxia correlate with the severity of hypersomnolence. (Newman et severity of hypersomnolence. (Newman et al., Journal of Epidemiology 2001)al., Journal of Epidemiology 2001)

OSA may be more common in certain ethnic OSA may be more common in certain ethnic groups such as Black Americans, and groups such as Black Americans, and Hispanics. It is our impression that the Hispanics. It is our impression that the prevalence will be quite high in Sikhs, in prevalence will be quite high in Sikhs, in certain South Asian populations, and in certain South Asian populations, and in Coastal Indians. Coastal Indians.

Sleep is usually in a Biphasic circadian Sleep is usually in a Biphasic circadian pattern with the maximal sleepiness pattern with the maximal sleepiness occurring between 2AM and 6AM and from occurring between 2AM and 6AM and from 2 PM and 4PM.2 PM and 4PM.

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In Sleep 2002 Drake and Roehrs discovered In Sleep 2002 Drake and Roehrs discovered that the prevalence of excessive daytime that the prevalence of excessive daytime sleepiness in the general population was 13 sleepiness in the general population was 13 to 25% if a Multiple Sleep Latency Test to 25% if a Multiple Sleep Latency Test (gold standard was used) (gold standard was used)

A Continuous Positive Airway Pressure Trial as a Novel Approach to the Diagnosis of the Obstructive Sleep A Continuous Positive Airway Pressure Trial as a Novel Approach to the Diagnosis of the Obstructive Sleep Apnea Syndrome* Apnea Syndrome*

Oliver Senn, MDOliver Senn, MD University Hospital of Zurich, Switzerland. Chest 2006 University Hospital of Zurich, Switzerland. Chest 2006

AbstractAbstract Objectives:Objectives: Treatment of obstructive sleep apnea syndrome (OSA) is often delayed because polysomnography, the Treatment of obstructive sleep apnea syndrome (OSA) is often delayed because polysomnography, the

recommended standard diagnostic test, is not readily available. We evaluated whether the diagnosis of sleep apnea recommended standard diagnostic test, is not readily available. We evaluated whether the diagnosis of sleep apnea could be inferred from the response to a treatment trial with nasal continuous positive airway pressure (CPAP). could be inferred from the response to a treatment trial with nasal continuous positive airway pressure (CPAP).

Patients:Patients: Seventy-six sleepy snorers consecutively referred for sleep apnea evaluation. Seventy-six sleepy snorers consecutively referred for sleep apnea evaluation. Interventions:Interventions: CPAP treatment trial over 2 weeks as an initial diagnostic test in comparison with polysomnography, CPAP treatment trial over 2 weeks as an initial diagnostic test in comparison with polysomnography,

and treatment success over 4 months. and treatment success over 4 months. Measurements and results:Measurements and results: The main outcome was diagnostic accuracy of the CPAP trial. The trial result was positive The main outcome was diagnostic accuracy of the CPAP trial. The trial result was positive

if the patient had used CPAP for > 2 h per night and wished to continue therapy. This suggested sleep apnea. The trial if the patient had used CPAP for > 2 h per night and wished to continue therapy. This suggested sleep apnea. The trial was evaluated in terms of predicting an obstructive apnea/hypopnea index (AHI) > 10/h during polysomnography was evaluated in terms of predicting an obstructive apnea/hypopnea index (AHI) > 10/h during polysomnography performed for validation, and in terms of identifying sleep apnea patients treated successfully over 4 months. Forty-performed for validation, and in terms of identifying sleep apnea patients treated successfully over 4 months. Forty-four of 76 patients (58%) had sleep apnea as confirmed by an AHI > 10/h. The CPAP trial predicted sleep apnea with four of 76 patients (58%) had sleep apnea as confirmed by an AHI > 10/h. The CPAP trial predicted sleep apnea with a sensitivity of 80%, a specificity of 97%, and positive and negative predictive values of 97% and 78%, respectively. In a sensitivity of 80%, a specificity of 97%, and positive and negative predictive values of 97% and 78%, respectively. In 35 of 76 sleep apnea patients (46%) with positive CPAP trial results, polysomnography could have been avoided. 35 of 76 sleep apnea patients (46%) with positive CPAP trial results, polysomnography could have been avoided. These patients were prescribed long-term CPAP therapy. After 4 months, 33 of 35 patients (94%) still used CPAP, These patients were prescribed long-term CPAP therapy. After 4 months, 33 of 35 patients (94%) still used CPAP, and their symptoms remained improved. These patients were identified by the CPAP trial with positive and negative and their symptoms remained improved. These patients were identified by the CPAP trial with positive and negative predictive values of 92% and 100%, respectively. predictive values of 92% and 100%, respectively.

Conclusions:Conclusions: In a selected population, a CPAP trial may help to diagnose OSA, to identify patients who benefit from In a selected population, a CPAP trial may help to diagnose OSA, to identify patients who benefit from CPAP, and to reduce the need for polysomnography. CPAP, and to reduce the need for polysomnography.

TreatmentTreatment

MildMild ModerateModerate SevereSevere

Patient not wearing a Patient not wearing a dental appliancedental appliance

Same patient wearing Same patient wearing a dental appliancea dental appliance