Allergists encouraged to screen for obstructive sleep apnea
Key takeaways:
- Allergists should ask patients about the regularity, quantity and quality of their sleep.
- STOP-BANG assesses eight risk factors that predict obstructive sleep apnea.
ANAHEIM, Calif. — Allergists can screen patients for obstructive sleep apnea, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.
“A really terrible question to ask a patient is, ‘How are you sleeping?’” Brian D. Robertson, MD, FACAAI, chief medical officer at NightWare, said during his presentation.
Instead, he continued, physicians should ask patients if they wake up and go to sleep at the same time every day, how many hours of sleep they get each night, and if they still feel sleepy when they wake up.
“Ask about the regularity of their sleep, the quantity of their sleep, and the quality of their sleep,” said Robertson, who also is the incoming chair of the ACAAI respiratory sleep-related disorders committee. “If they’re answering, ‘Well, my sleep’s all over the place,’ that’s a problem, and they need to go see a sleep doctor.”
Excessive daytime sleepiness or fatigue is among the most common symptoms of obstructive sleep apnea, Robertson said, and it increases the risks for motor vehicle accidents by a factor of two to seven.
“I was in the military,” Robertson said. “I’ve had patients tell me they’ve fallen asleep flying planes, flying helicopters and, very scary, falling asleep while riding a motorcycle.”
Drowsy driving is a major contributor to risks for these patients and for the people around them, Robertson said.
“Nobody dies of anything in sleep medicine except behind the wheel of a vehicle,” he said.
Fragmented sleep or awakenings, snoring and witnessed apneas also are common symptoms.
Sleep-related choking and gasping are common too, which a lot of people believe is GERD, Robertson continued.
“But reflux is associated with apnea, and we take that seriously too,” he said.
OSA symptoms also include decreased vigilance, loss of cognitive or memory function and impaired concentration, morning dry mouth, mood disorders, morning headaches, GERD, nocturia/enuresis, and impotence or decreased libido.
“If they say, ‘I get, like, less than 6 hours a night’ — adults especially — they need to go see a sleep doctor, too,” Robertson said.
Multiple comorbidities are associated with OSA as well, Robertson continued, including drug-resistant hypertension (83%), congestive heart failure (76%), dysrhythmias (58%), pulmonary hypertension (77%), type 2 diabetes (70%), morbid obesity (males: 90%; females: 50%), and GERD (60%).
Atrial fibrillation (49%), stroke (90%) and trisomy 21 are associated with OSA as well, Robertson continued, all of which indicate the need for polysomnography.
“A good night’s sleep is taken for granted in this country,” Robertson said. “It’s partly electronics, and the fact that we can keep the day going through electricity instead of just when it gets dark, we fall asleep.”
Allergists with concerns about their patients’ sleep can screen for STOP-BANG, which is an acronym of eight risk factors, to determine if they should be referred to a sleep doctor.
The first factor is snoring.
“Do you snore? It’s about 50-50 for sleep apnea,” Robertson said.
Next is tiredness.
“Do you feel tired during the day?” he asked.
Third is observed, as in whether someone has observed the patient stop breathing while they were sleeping.
The fourth factor is high blood pressure, and the fifth is a BMI greater than 35 kg/m2. Sixth is age 50 years or older.
The seventh factor is neck circumference of greater than 43 cm for men and 41 cm for women.
“Men almost always know their neck size because that’s how shirts are sized. Women may not know that so much,” Robertson said.
The final factor is male gender.
“Three or more positive responses here indicates a high risk for sleep apnea,” Robertson said. “If you have a man who snores and sometimes is tired and falls asleep watching TV, that guy needs a sleep study.”
Robertson acknowledged that these criteria are very common, adding that almost every patient who came into his sleep clinic when he was practicing at Walter Reed National Military Center qualified for some kind of sleep study.
“It doesn’t take much,” he said.
Part of this is because it is impossible for patients to judge the quality of their sleep while they are sleeping, Robertson said.
“They don’t give you good histories. They don’t know what’s going on because they’re asleep,” he said. “You really have to put them in a lab to figure things out.”
Allergists can screen children too, Robertson said, with some differences between them and adults.
“Children don’t get really sleepy, like you’d guess. What they get is hyperactive, and they get inattentive,” Robertson said.
Robertson also associated ADHD and allergic rhinitis with OSA.
“You’ve seen these patients in your clinic because kids with allergic rhinitis get diagnosed with ADHD a lot more than kids without allergic rhinitis,” he said. “Especially if they have obesity too.”
Children who have enlarged tonsils may have OSA as well, Robertson said.
“Sleep apnea is fundamentally a mechanical problem. It’s a not enough space problem. There’s not enough space to breathe in the airway,” he said.
When patients fall asleep, their airway relaxes and collapses. But in patients with OSA, Robertson explained, the airway collapses completely, and patients will not be able to breathe unless they wake up.
“The patient wakes up so they can open up their airway and breathe. They fall asleep again, it collapses again, they wake up to breathe,” he said. “You’ll see these chains of events.”
Finally, snoring is another sign of OSA in children.
“Every once in a while, if they have a cold, don’t worry about it,” Robertson said. “But if it’s a chronic problem, that’s something to pay attention to.”
Robertson noted the pressing need caused by the prevalence of OSA, particularly among men, postmenopausal women, and certain populations of children, and why specialists such as allergists should become more involved in its diagnosis.
“There are not enough sleep doctors, frankly, in the world to take care of all of the people who have this particular issue, and we need the help from other clinicians,” he said.