Yvette C. Terrie, BSPharm, RPh
Especially when patients do not snore, sleep apnea can be hard to detect.
The great American author F. Scott Fitzgerald once said, “The worst thing in the world is to try to sleep and not to.”1
Those words describe what millions of Americans with untreated obstructive sleep apnea (OSA) endure every night.
OSA is a chronic medical condition that is characterized by recurring interruptions in breathing during sleep. These episodes occur because of complete or partial obstructions of the upper airway due to enlarged or malformed pharyngeal tissues, resulting in hypoxemia and chronic daytime fatigue.2-6
Most pauses in breathing range from 5 to 30 seconds, but sometimes can last a minute or longer.3-5
The brain responds to the lack of oxygen by causing a brief awakening from sleep that restores normal breathing.3-5
The majority of patients with OSA are typically unaware of apnea episodes. Unfortunately, this pattern may happen hundreds of times during the night and is responsible for fragmented sleep and recurrent oxyhemoglobin desaturations.3-5
OSA’s Dangerous Consequences
According to the World Health Organization, an estimated 100 million individuals worldwide have some degree of OSA.6
Statistics from the American Sleep Apnea Association report that OSA affects 1 in 4 men and 1 in 9 women in the United States—accounting for an estimated 22 million individuals—with 80% of moderate and severe OSA cases still undiagnosed.5,7-11
Left untreated, OSA can lead to a myriad of serious health consequences, including increased mortality and an increased incidence of hypertension, stroke, heart failure, coronary artery disease, cardiac rhythm problems, type 2 diabetes, gastroesophageal reflux disease, nocturnal angina, hypothyroidism, or neurocognitive difficulties.3,11-16
In addition, individuals with untreated OSA are 10 times more likely to die from a motor vehicle accident compared with the general population because of impaired driving performance.11,12
In May 2012, results from a study supported by the National Heart, Lung and Blood Institute suggests that OSA is linked to higher cancer death risk; however, more research needs to be conducted.16-18
In a study published in the April 2012 issue of the journal Sleep
, researchers suggest that untreated OSA may also be linked to greater risk of major depression.19
Results from another study presented at the 2012 International Stroke Conference reported that more than 50% of silent stroke patients had undiagnosed or untreated OSA.20
Although OSA commonly affects middleaged men, especially those who are overweight, it is important to note that OSA can affect anyone at any age regardless of weight.14,21-23
Unfortunately, the growing obesity epidemic in the United States is contributing to the increase in incidence of OSA among pediatric patients and the general patient population.24,25
In August 2012, the American Academy of Pediatrics updated guidelines for the diagnosis and management of OSA to recommend that all children or adolescents who snore regularly be screened.26
The updated guidelines also state that other symptoms may include labored breathing during sleep, disturbed sleep with frequent gasps, snorts, or pauses, and daytime learning problems.26
Some anatomic risk factors for OSA include tonsil and adenoid hypertrophy; large or increased volume of the tongue, soft tissue, or lateral pharyngeal walls; along soft palate; or a small or receding jaw.10,14
Other risk factors include history of smoking, neck circumference greater than 17 inches, post menopausal status, increased age, and the routine use of alcohol and sedatives.14,21
Familial history of OSA is also present in an estimated 25% to 40% of OSA cases.10,14
For many pediatric patients, enlarged tonsil and/or adenoid is a common cause of developing OSA.27
Studies have reported an increased incidence of OSA among women with polycystic ovarian syndrome, as well.28,29
Signs and Symptoms of OSA
Chronic snoring is the hallmark symptom associated with OSA.10,14,21
Although loud, disruptive snoring is observed in 85% of OSA cases, not everyone who snores has OSA.10,14,21
Other classic OSA signs and symptoms experienced during sleep include choking or gasping for breath and pauses in breathing.14,21,22
Patients may also have nocturia and difficulty staying asleep.14,21,22
While awake, patients may experience hypersomnolence, chronic fatigue, lack of energy, morning headaches, unintentional sleep episodes, episodes of irregular heartbeat, chronic elevation in daytime blood pressure, dry throat upon waking, impaired concentration, mood swings, anxiety, and depression, as well as alterations in quality of life that can impact social and familial relationships and professional performance.5,10,14,21,22
Some studies indicate that women may present with slightly different symptoms than the OSA “hallmark” symptoms.30
These nonspecific symptoms may include chronic fatigue, insomnia, difficulty falling asleep or staying asleep, morning headaches, anxiety, or mood changes.30
Women with OSA may have more subtle breathing disturbances and are more likely to have REM-related apneas.30
Unfortunately, because the patient is often unaware of the condition, OSA frequently goes unrecognized until another individual witnesses symptoms. Diagnosing OSA is often a difficult task for clinicians because of the patient’s unawareness and the variations in presentation.21
Diagnosis is typically based upon evaluating medical and family history, risk factors, patient symptoms, a physical examination, and results from the polysomnogram, if warranted (Table).
Treating and Managing OSA
Continuous positive air pressure (CPAP) therapy, the most extensively studied treatment of OSA, is considered to be the gold standard treatment.10,24,31-33
Although CPAP therapy is not curative, it has been shown to decrease apnea episodes and blood pressure, improve hypersomnolence, mood changes, anxiety, cognitive impairments, and insulin sensitivity in patients with type 2 diabetes, and reduce the risk of stroke, congestive heart failure, coronary artery disease, and irregular heart rates.10,33,34
The optimal pressure for CPAP therapy is individualized and determined during a sleep study.23 An immediate improvement in symptoms is typically observed following treatment. Despite the effectiveness of CPAP therapy, many patients will not remain adherent.35-37
Some surveys report nonadherence rates as high as 50%.38
Common complications that contribute to patient nonadherence include difficulty falling asleep with mask, improper fit of mask, nasal dryness and congestion, feelings of claustrophobia, facial skin abrasions, air leaks, and conjunctivitis. 23,35-37
Health care professionals can help increase patient adherence by allowing the patient to try various types of mask and nasal pillows, adding humidification to treat nasal dryness, conducting routine follow-up, providing patient education and support programs, and encouraging patients to use the CPAP machine every time they sleep, including during naps.
To date, there are no FDA-approved pharmacologic agents available for treating OSA; however, adjunctive therapies are often used for treatment of nasal allergies and residual sleepiness, if warranted. 14 Other treatment options include the use of oral appliances and surgery.10,15,23
Weight loss, avoiding the use of alcohol at least 6 hours before bedtime, and sleeping on one’s side instead of the back or stomach may also be beneficial in relieving OSA symptoms.10,31-34
Pharmacists can identify those pharmacologic agents that may exacerbate OSA, such as central nervous system depressants (eg, benzodiazepines, opiates, alcohol).39,40
An overwhelming amount of evidence demonstrates the array of serious health consequences associated with undiagnosed and untreated OSA. Increasing public awareness about the dangers of untreated OSA is critical to preventing health problems and even premature deaths. Patients exhibiting warning signs or symptoms should be encouraged to discuss the possibility of being tested for OSA with their primary health care provider.
OSA is much more than a sleep disorder. With consistent monitoring and proper therapy, patients can finally get a good night’s sleep every night and improve their overall health and quality of life—and lives will be saved.
Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.
Quotations about sleep. Quote Garden website. www.quotegarden.com/sleep.html. Accessed May 23, 2012.
Obstructive sleep apnea. Medilexicon Medical Dictionary Online Edition. www.medilexicon.com/medicaldictionary.php?t=5512. Accessed May 23, 2012.
What is sleep apnea? National Heart Lung and Blood Institute website. www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea/. Accessed May 23, 2012.
Obstructive sleep apnea. American Sleep Apnea Association website. www.sleepapnea.org/learn/sleep-apnea/obstructive-sleep-apnea.html. Accessed May 23, 2012.
Obstructive sleep apnea. American Academy of Sleep Medicine website. www.aasmnet.org/resources/factsheets/sleepapnea.pdf. Accessed May 23, 2012.
Chronic disease epidemics. World Health Organization website. www.who.int/gard/publications/chronic_respiratory_diseases.pdf. Accessed May 23, 2012.
Sleep apnea. American Sleep Apnea Association website. www.sleepapnea.org/i-am-a-health-care-professional.html. Accessed May 23, 2012.
Kapur V, Blough DK, Sandblom RE, et al. The medical cost of undiagnosed sleep apnea. Sleep. 1999;22(6):749-755.
Dodson K. Cardiovascular effects of sleep apnea. The Journal for Nurse Practitioners. 2008; 4(6):439-444.
Downey R, Gold PM, Rowley, JA, Wickramasinghe H. Obstructive sleep apnea. Medscape website. http://emedicine.medscape.com/article/295807-overview. Accessed May 23, 2012.
George C. Sleep apnea, alertness, and motor vehicle crashes. Amer J Resp Crit Care Med. 2007;176:954-956.
Obstructive sleep apnea. American Society of Anesthesiologists website. www.lifelinetomodernmedicine.com/Anesthesia-Topics/Obstructive-Sleep-Apnea.aspx. Accessed May 23, 2012.
Yaggi HK, Concato J, Kernan, WN, et al. Obstructive sleep apnea as a risk factor for stroke and death. N Engl J Med. 2005;353(19):2034-2041.
Obstructive sleep apnea. Merck Manual for Healthcare Professionals Online Edition. www.merckmanuals.com/professional/pulmonary_disorders/sleep_apnea/obstructive_sleep_apnea.html. Accessed May 23, 2012.
Lin CM, Huang YS, Guilleminault C. Pharmacotherapy of obstructive sleep apnea. Expert Opin Pharmacother. 2012;13(6):841-857.
Marin JM, Agusti A, Villar I, et al. Association between treated and untreated obstructive sleep apnea and the risk of hypertension. JAMA. 2012;307(20):2169-2176.
Nieto FJ, Peppard PE, Young T, et al. Obstructive sleep apnea and cancer mortality: results from the Wisconsin Sleep Cohort study. Am J Respir Crit Care Med. 2012;185:A1047.
Sleep apnea tied to hikes in cancer, death. MedPage Today website. www.medpagetoday.com/MeetingCoverage/ATS/32936. Accessed May 23, 2012.
Wheaton AG, Perry GS, Chapman DP, Croft JB. Sleep disordered breathing and depression among U.S. adults: National Health and Nutrition Examination Survey, 2005-2008. Sleep. 2012;35(4):461-467.
Kepplinger J, Barlinn K, Boehme AK, et al. Sleep apnea as a risk factor in patients with chronic microvascular changes and silent infarcts. ISA. 2012; Abstract 3434.
Lurie A. Obstructive sleep apnea in adults: epidemiology, clinical presentation, and treatment options. Adv Cardiol. 2011;46:1-42.
Kumar R, Macey PM, Cross RL, Woo MA, Yan-Go FL, Harper RM. Neural alterations associated with anxiety symptoms in obstructive sleep apnea syndrome. Depress Anxiety. 2009;26(5):480-491.
Victor LD. Treatment of obstructive sleep apnea in primary care. Am Fam Physician. 2004;69(3):561-568.
Abad VC, Guilleminault C. Pharmacological treatment of obstructive sleep apnea. Curr Pharm Des. 2011;17(15):1418-1425.
Fritscher LG, Canani S, Mottin CC, et al. Obesity and obstructive sleep apnea-hypopnea syndrome: the impact of bariatric surgery. Obes Surg. 2007;17(1):95-99.
Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714-e755.
Cataletto M. Childhood sleep apnea. Medscape website. http://emedicine.medscape.com/article/1004104-overview#showall. Accessed May 23, 2012.
Tasali E, Van Cauter E, Ehrmann DA. Polycystic ovary syndrome and obstructive sleep apnea. Sleep Med Clin. 2008;3(1):37-46.
Vgontzas AN. Polycystic ovary syndrome is associated with obstructive sleep apnea and daytime sleepiness: role of insulin resistance. J Clin Endocrinol Metab. 2001;86(2):517-520.
Woman and sleep apnea. National Sleep Foundation website. www.sleepfoundation.org/article/ask-the-expert/women-and-sleep-apnea. Accessed May 23, 2012.
Cook V, Schooff M. Oral appliances for obstructive sleep apnea? Am Fam Physician. 2006;73(5):801-803.
Bradley TD, Phillipson EA. Sleep disorders. In: Murray JF, Nadel JA, eds. Textbook of Respiratory Medicine. Vol 2, 3rd ed. Philadelphia, PA: WB Saunders; 2002:2153-2169.
OSA Treatment Options. American Sleep Apnea Association website. http://sleepapnea.org/diagnosis-and-treatment/treatment-options.html. Accessed May 23, 2012.
Benefits of CPAP. American Academy of Sleep Medicine website. http://yoursleep.aasmnet.org/cpapcentral/benefitscpap.aspx. Accessed May 23, 2012.
Rose MW. Positive airway pressure adherence: problems and interventions. Sleep Med Clin. 2006:1(4):533-539.
Chowdhuri S. Continuous positive airway pressure for the treatment of sleep apnea. Otolaryngol Clin North Am. 2007;40:807-827.
Zoidis JD. Improving compliance with CPAP. RT for Decision Makers in Respiratory Care. 2007;20(6).
Johnson D. Patient education increases CPAP compliance. Focus Journal. Sept/Oct 2008.
Strollo PJ, Rogers RM. Obstructive sleep apnea. N Engl J Med. 1996;334:99-104.
Pagel JF. Medications for the treatment of sleep disorders: an overview. Prim Care Companion J Clin Psychiatry. 2001;3(3):118-125