October 11, 2016

Obstructive Sleep Apnea: Screening the Right People at the Right Time with the Right Tests

Identifying and diagnosing individuals with OSA

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Obstructive sleep apnea’s (OSA’s) presence in the United States is high, proven by the numbers. According to new research by Mahesh Manne, MD, and colleagues, it’s estimated to be 2 percent in women and 4 percent in men in the middle-aged work force, and even more in blacks, Asians and older adults.

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Only 10 percent of people with OSA are diagnosed — an unsettling statistic since OSA is associated with resistant hypertension and with a greater risk of stroke, cardiovascular disease and death.

“Through this work, we are hoping to boost awareness of OSA testing options for patients who have symptoms of sleep apnea or with risk factors, such as obesity, retrognathia and resistant hypertension,” says Dr. Manne, whose article appeared in the January 2016 issue of the Cleveland Clinic Journal of Medicine. “Screening for this population is truly critical.” Symptoms of sleep apnea include as loud snoring, observed episodes of apnea, gasping or choking at night, unrefreshing sleep, morning headaches, unexplained fatigue and excessive tiredness during the day, which may merit assessment for sleep apnea.

The right time for screening

The American Academy of Sleep Medicine recommends three opportunities to screen for OSA1:

  • At routine health maintenance visits
  • If the patient reports clinical symptoms of OSA
  • If the patient has risk factors.

What happens when OSA is untreated?

When OSA is left untreated, a number of conditions may occur including:

  • Arrhythmias
  • Coronary artery disease
  • Diabetes
  • Heart failure
  • Hypertension
  • Stroke
  • Sudden cardiac death

Identifying who needs testing

Sleep disorder questionnaires, such as the Berlin and the Epworth Sleepiness Scale, are often used to identify OSA. There’s also the STOP-Bang questionnaire, which is an easy-to-use tool that expands on the STOP questionnaire (snoring, tiredness, observed apnea, high blood pressure) with the addition of body mass index, age, neck size and gender. The STOP-Bang questionnaire has been validated in preoperative settings but not in the primary care setting (although it has been commonly used in primary care). The Berlin questionnaire has been validated in the primary care setting.

Asking the right questions

The STOP-Bang questionnaire includes the following questions:

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Snoring. Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?

Tired. Do you often feel tired, fatigued or sleepy during the daytime?

Pressure. Do you have or are you being treated for high blood pressure?

Age. Are you over 50?

Neck circumference. Is it larger than 40 cm?

Gender. Male?

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Score 1 for each yes answer. A score < 3 indicates low risk of OSA. A score ≥ 3 indicates moderate to high risk.

Ordering the right test

If the score on the questionnaire indicates a moderate or high risk of OSA, the patient should undergo objective testing with polysomnography or, in certain circumstances, home testing. Polysomnography is the gold standard. Home testing costs less and is easier to arrange, but the Academy of Sleep Medicine recommends it as an alternative to polysomnography, along with a comprehensive sleep evaluation, only in the following instances:

  • If the patient has a high pretest probability of moderate to severe OSA
  • If immobility or critical illness makes polysomnography unfeasible
  • If direct monitoring of the response to non-CPAP treatments for sleep apnea is needed

Diagnosing OSA

If the number of apnea events per hour (i.e. the apnea-hypopnea index) on polysomnography or home testing is more than 15, irrespective of symptoms, the presence of OSA is confirmed. This is also applicable for patients with an apnea-hypopnea index more than five with OSA symptoms. An apnea-hypopnea index of five to 14 indicates mild OSA, 15 to 30 indicates moderate OSA and more than 30 indicates severe OSA.

Leveraging benefits of treatment

Using CPAP to treat OSA lowers the 10-year risk of fatal and non-fatal car accidents by 52 percent, the 10-year expected number of myocardial infarctions by 49 percent and the 10-year risk of stroke by 31 percent. It’s also beneficial and cost-effective to treat men and women of all ages dealing with moderate to severe OSA.

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