Sleep Apnea Essay
Obstructive sleep apnea (OSA) is a sleep disorder that if left untreated can result in death. According to a recent journal article, “up to 93% of women and 82% of men may have undiagnosed moderate to severe OSA” (Park MD, Ramar MD, Olson MD, 2011, p. 549). OSA is characterized by pauses in breathing or shallow breathing during sleep. These are called apneas and hypopneas. A recent journal article published by the Mayo Clinic defined OSA as “a disorder in which a person frequently stops breathing during his or her sleep. “It results from an obstruction of the upper airway during sleep that occurs because of inadequate motor tone of the tongue and/or airway dilator muscles” (Park MD, Ramar MD, Olson MD, 2011, p. 549). There are many reasons this can occur. Typically, all of the muscles in the body become relaxed during sleep. This includes the muscles that help keep the airway open and allow air to flow into the lungs. Normally, the upper throat still remains open enough to let air pass. However, some people have narrower airways.
When the muscles in the upper throat relax during sleep, breathing can stop for a period of time and there is a decrease in oxygen saturation and arousals from sleep. The other factors that may play a part in this as well are, shorter lower jaw, certain shapes of the palate, large tonsils or adenoids, large tongue, larger than normal neck size, and excess fatty tissue in the throat and neck area. Primary care provider’s (PCP’s) can play a major role in detecting this sleep disorder.
This disorder is commonly undiagnosed, and because of that PCP’s need to incorporate screening for OSA in all patients, existing and new. “The Institute of Medicine of the National Academies recognized that sleep disorders are commonly undiagnosed and called for primary care providers (PCP’s) to play a greater role in screening and treating these conditions. ” “As a consequence, the American Board of Medical Specialties has approved a Certificate of Added Qualifications in Sleep Medicine for PCP’s” (Doghramji MD, 2008, p. S17).
In my opinion, a process needs to be established in the PCP’s office for screening obstructive sleep apnea. There is paperwork, the most common being the Epworth Sleepiness Scale, that can be included in all new patient packets and given to existing patients as well. This is a significant screening tool that allows the physician to determine the level of excessive daytime sleepiness, also referred to as excessive sleepiness (ES) which is the most common indicator of obstructive sleep apnea.
Predisposing factors the primary care provider should be aware of and look out for are genetic predisposition, male sex, cardiovascular disease, coronary artery disease, sleep complaint, craniofacial variation, pharyngeal crowding and nasal obstruction, recurrent atrial fibrillation, hypertension, obesity, type 2 diabetes, large neck circumference and alcohol and/or sedative use (Doghramji MD, 2008, p. S17). This process would allow PCP’s to detect OSA and provide a treatment plan for the patient.
This would also reduce the co-morbidities that accompany OSA which could lower the percentages of cardiovascular disease, pulmonary hypertension, stroke and many other consequences of this undiagnosed sleep disorder. There are many symptoms that accompany obstructive sleep apnea. The number one indicator is excessive daytime sleepiness (EDS/ES). The confusion with this indictor is that many people feel sleepy during the day or feel the need to take a nap. They most likely attribute this feeling of no energy to their busy lifestyle, work, and day to day busy living.
This could be the case; however, if a person feels this way all of the time they should check with their primary care provider. The Journal of Family Practice lists the typical, frequent, and less common symptoms associated with OSA (Doghramji MD, 2008, p. S17). Typical symptoms are excessive daytime sleepiness, snoring, unrefreshed sleep and restless sleep. Frequent symptoms include witnessed apneas, nocturnal choking, morning headache, nocturia and dry mouth.
If a person chokes or gasps for air while asleep they will sometimes wake up because of it or their sleep partner will witness it. Less common symptoms may be enuresis (bed-wetting), gastroesophageal reflux disease (GERD) and reduced libido. There are many consequences of untreated obstructive sleep apnea. “Untreated OSA is currently recognized as an independent risk factor for the development of certain comorbid conditions and mortality” (Park MD, Ramar MD, Olson MD, 2011, p. 549). The quality and duration of sleep affect both our performance and our physical well-being. How we function during our waking hours is greatly influenced by duration and the quality of nighttime sleep. ” “Concentration, alertness and reaction time are among the many performance factors that can suffer when sleep is acutely or chronically disturbed” (Texas A&M System, 2006, p. 3). The physiological consequences include heart attack, congestive heart failure (CHF), stroke, impotence/sexual dysfunction, weight gain, headaches, irregular heartbeat, high blood pressure and kidney disease (Texas A&M System, 2006, p. 3).
Once a person has been diagnosed with obstructive sleep apnea, the most important factor is compliance with the treatment prescribed by the primary care provider (PCP). There are a few different positive airway pressure devices (PAP’s) that can be prescribed for treatment. These devices deliver forced air into the airway that acts like a pneumatic splint and opens the airway. The most common treatment option and the golden standard for treating OSA is continuous positive airway pressure (CPAP) or auto positive airway pressure (APAP).
CPAP delivers a single, fixed pressure of air and APAP automatically customizes the air pressure to the patient’s needs. If the patient is unable to tolerate CPAP/APAP the PCP may prescribe bilevel positive airway pressure (BIPAP) in which the device delivers a higher inspiratory pressure (IPAP) than expiratory pressure (EPAP). For patients that are not compliant with CPAP/APAP or BIPAP, there is a device called Provent Therapy. Provent is applied directly to the nostrils and looks similar to a band aide.
There are micro-valves on this device that cover each nostril which uses the patient’s own breathing to create expiratory positive airway pressure (EPAP). There are also oral appliances which look similar to mouth pieces worn by football players; however, these are typically used for patients with a very low level of OSA. The last resort that some patients will try is surgery. Unfortunately, although surgery is often effective in treating snoring, it is much less effective in treating OSA.
Obstructive sleep apnea has been described as the most physiologically disruptive and dangerous of the sleep-related disorders. “As first-line medical providers, PCP’s play a vital role in recognizing the symptoms as well as screening for possible OSA in their patients, including both those presenting with characteristic symptoms, such as ES, and more commonly for those not reporting symptoms but who have significant risk factors” (Doghramji MD, 2008, p. S17).
Primary care providers need to incorporate procedures and processes in their office that allows all patients to be screened for this disorder. By doing so, this could reduce the number of undiagnosed people, provide early treatment for some, and provide treatment for those who have been living with OSA for many years but never knew it. “Follow-up of all patients with OSA in the primary care setting is mandatory to ensure proper continued therapy, to address omorbidities, and in particular to identify the presence of residual ES” (Doghramji MD, 2008, p. S17). By incorporating proper education and training on OSA to the primary care providers in the primary care setting, and providing screening tools, the statistics for co-morbidities associated with OSA could drastically decrease. What a potentially wonderful and promising outcome.