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SOURCE

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Source: Dopp JM, Phillips BG. Sleep–wake disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 10th ed. New York, NY: McGraw-Hill; 2017. http://accesspharmacy.mhmedical.com/content.aspx?bookid=1861&sectionid=134128126. Accessed May 11, 2017.

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DEFINITION

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  • Repetitive episodes of cessation of breathing during sleep.

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ETIOLOGY

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  • OSA is characterized by partial or complete closure of the upper airway, posterior from the nasal septum to the epiglottis, during inspiration.

  • Obstructive sleep apnea results from relaxation of soft tissue in back of throat during sleep, blocking airway.

  • Central sleep apnea occurs when brain does not signal muscles that control breathing.

  • Complex sleep apnea is combination of obstructive sleep apnea and central sleep apnea.

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PATHOPHYSIOLOGY

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  • Obstructive sleep apnea caused by upper airway obstruction secondary to loss of pharyngeal muscle tone during sleep.

  • Central sleep apnea caused by temporary loss of respiratory effort during sleep due to autonomic nervous system lesions, neurologic diseases, high altitudes, or heart failure.

  • Contributing factors include:

    • Neck obesity.

    • Narrow airway.

    • Fixed upper airway lesions (eg, polyps, enlarged tonsils)

    • Acromegaly.

    • Amyloidosis.

    • Hypothyroidism.

  • Apneic episodes terminated by a reflex action in response to fall in blood oxygen saturation that causes brief arousal, during which breathing resumes.

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EPIDEMIOLOGY

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  • Common disease affecting 20–25 million Americans.

  • Prevalence higher in men.

  • More common in African American and Hispanic populations.

  • Can occur in children and adolescents.

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RISK FACTORS

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  • Obesity.

  • Cigarette smoking.

  • Hypothyroidism.

  • Ingestion of alcohol or sedatives before sleep and nasal obstruction may precipitate or worsen condition.

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CLINICAL PRESENTATION

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SIGNS AND SYMPTOMS
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  • Hallmarks are witnessed apnea, gasping, or both.

  • Complaints of:

    • Daytime somnolence or fatigue.

    • Morning headache.

    • Poor memory.

    • Irritability.

  • History of loud snoring with witnessed apneic events.

  • May have systemic hypertension.

  • Severe episodes involve:

    • Heavy snoring.

    • Severe gas exchange disturbances.

    • Respiratory failure, causing gasping.

    • Episodes may occur up to 600 times/night.

  • Complications include:

    • Arrhythmias.

    • Hypertension.

    • Cor pulmonale.

    • Sudden death.

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DIAGNOSIS

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DIAGNOSTIC PROCEDURES
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  • Overnight polysomnography shows apneic episodes with hypoxemia.

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DESIRED OUTCOMES

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  • Alleviation of sleep-disordered breathing.

  • Prevention of associated complications are the primary goals of treatment.

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TREATMENT: NONPHARMACOLOGIC THERAPY

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  • Weight loss in overweight patients.

  • Nasal positive airway pressure (PAP), which may be continuous or bilevel.

  • Surgical therapy.

    • Uvulopalatopharyngoplasty opens the upper airway by removing the tonsils, trimming and reorienting the posterior and anterior tonsillar pillars, and removing the uvula and posterior portion of the palate.

    • Not first-line due to invasiveness.

    • Tracheostomy may be necessary in severe cases.

      • Selected individuals include morbidly obese, those that have severe facial skeletal deformity, experience severe drops in oxygen saturation (eg, less than 70%), or have significant cardiac arrhythmias ...

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