OSA: Ignoring snoring is not OK

Clinical pearls for frontline PCPs

A 70-year-old man presents to the office reporting that his wife made him come in to get evaluated for “horrible snoring.”

He has been snoring off and on since about the age of 50, but his wife said that it has been getting progressively worse, especially in the past 3 months.

She has had to sleep in another room in the house for the past 3 months. She refuses to go on any vacations with him because he keeps her up at night in the hotel room. The patient also notes that he is much more tired than he has ever been in his life.

Philip A. Bain

The medical assistant (MA) checks him in.

His past medical history (PMH) includes hypertension (HTN), myocardial infarction (MI) 2 years ago and chronic low back pain for more than 10 years. The patient’s medications include atorvastatin 20 mg daily, acetylsalicylic acid 81 mg daily, lisinopril 10 mg daily and hydrocodone 2 to 4 tablets per day for his chronic low back pain (LBP). He is a former smoker who quit 20 years ago, and he drinks three to four beers a day. His height is 70” and weight is 230 lbs. His BMI is 33 kg/m². His BP is 160/95.

The MA presents the history to the physician: “Doc, this patient is here because his wife is frustrated with his horrible, longstanding snoring and feels that he is way more tired than he should be. She can’t sleep in the same part of the house with him anymore. His PMH is positive for HTN, MI and chronic LBP. I remembered the guy last week that you diagnosed with sleep apnea, and this guy reminds me of him. I did a STOP-BANG on him because you wanted me to do it on the other guy, and it was 7. His Epworth Sleepiness Scale score was 15. I remember that you showed me how to check his neck size, and this patient’s circumference was 18 inches.”

The physician reviews the chart and enters the room. The patient dozed off and was a bit groggy when he was awakened.

The physician confirms his history and informs the patient that he very likely has obstructive sleep apnea (OSA). His physical exam was notable for a Mallampati score of class IV.

 Patients with higher Mallampati scores are considered at higher risk for OSA. 

The physician recommends the following:

1. Cut down on alcohol to no more than two drinks a day. Specifically, he was asked to consider trying any of the currently available nonalcoholic (NA) beers.
2. Cut down on hydrocodone to no more than 2 tablets/day.
3. Referral to comprehensive weight management program.
4. Labs to be done: comprehensive metabolic panel, fasting blood sugar and HbA1c.
5. Referral for Home Sleep Apnea Test (HSAT).
6. Follow-up visit in 1 month.

At the follow-up visit, the physician reviews the labs with the patient: normal thyroid-stimulating hormone; fasting blood sugar is 124; and HbA1c is 6.2. In the weight management clinic, the advanced practice clinician started him on semaglutide 0.25 mg weekly, then increasing to 0.5 mg weekly. He met with the nutritionist and downloaded a calorie/activity tracker. Since the initial visit, the patient’s weight dropped to 227 lbs. His follow-up BP is 145/92. The HSAT shows an Apnea Hypopnea Index (AHI) of 34, compatible with severe OSA. His O2 saturation was less than 90% for 72% of the time recorded, with the lowest O2 saturation at 70%. He found an NA beer that he liked and has been able to reduce his alcohol intake to one a day. He was able to cut down on his hydrocodone to one to two tablets per day. He is still quite fatigued during the day.

The physician makes additional recommendations:

1. Completely stop the hydrocodone.
2. Continue to follow up with the weight management clinic.
3. Start a home exercise program.
4. Refer to a sleep medicine specialist for continuous positive airway pressure (CPAP) recommendations.
5. Follow up in 3 months.

At the follow-up visit, the patient is accompanied by his wife, who reports that he snores much less and that he has more energy to do things around the home. She even agreed to go on a weekend getaway with him and slept well. She does not remember him snoring at all. The sleep medicine physician started him on CPAP 5 to 15 cmH2O. Initially, he was not able to tolerate the full mask or the nasal mask, but he tolerated the nasal pillows reasonably well. He has been able to keep it on for 3 to 4 hours nearly every night. His weight is now 220 lbs — a 10-lb weight loss from the initial visit (4% weight loss). His back pain is not significantly worse after discontinuing the hydrocodone, and he responds in general to ibuprofen and acetaminophen. He continues to drink about one alcoholic beer a day.

Follow-up recommendations include:

1. Referral to oral surgeon who sees patients with OSA.
2. Continue with weight management.
3. Follow up in 3 months.

At next visit, he reports feeling much more alert and refreshed in the morning. The weight management program was able to get him a 3-month trial at a local gym, and with a trainer, he came up with a good program using the treadmill 3 days a week for 30 minutes a session. His BP is 138/90, and his weight is 214 lbs (a 7% weight loss). He has increased his treadmill time to 60 minutes, 3 days a week. He had an oral appliance created for him by the oral surgeon and feels that helps. Because he is feeling so well, he wonders if he still needs the CPAP, even though he remains compliant with it. His primary care physician orders a follow-up HSAT, and his AHI is less than five events per hour. His O2 saturation is greater than 90% for 95% of the time recorded. He is told that he could stop his CPAP but that he should continue the oral appliance.

He continues to do well, lose weight and go to the gym.

Lessons learned

1. Sleep apnea is very common, affecting 25% to 30% of U.S. men and 9% to 17% of U.S. women.
2. The two main types of sleep apnea include obstructive (where the soft tissues in the posterior pharynx occlude the airway) and central (where there is a lack of drive to breathe during sleep). Obstructive sleep apnea is by far more common.
3. Primary risk factors include male gender, advanced age and obesity. Other contributing factors include anatomic abnormalities of the head and nasopharynx, alcohol use and medication use — especially sedating medications such as opioids, muscle-relaxing agents, sleep medications and benzodiazepines.
4. The screening tool STOP-BANG can be very helpful to determine the pre-test probability of having OSA. Fatigue can be assessed with the Epworth Sleepiness Scale.
5. The gold standard for diagnosing OSA is the in-lab polysomnogram (PSG), but it is not always covered by insurance. It is also inconvenient because the patient has to come to the sleep lab, and it may be difficult to sleep because of unusual surroundings.
6. HSAT can be used if there is a high pre-test probability for OSA. It is not indicated if central sleep apnea is suspected, if significant psychiatric conditions exist, if the patient has any form of neuromuscular disease or if the patient has a mission-critical occupation in which somnolence would put the patient or others at significant risk (eg, pilots). If the patient is interested in treating OSA, it may be preferable to refer the patient to a sleep medicine specialist before any testing because some preliminary results show that compliance improves when the patient sees the sleep medicine physician first if they are motivated to accept treatment.
7. Many conditions and negative consequences are associated with OSA, including atherosclerotic CVD, refractory HTN, obesity, diabetes, increased risk for automobile and industrial accidents, cognitive impairment and excessive daytime sleepiness resulting in lower job performance and quality of life.
8. Many cases of mild sleep apnea do not require treatment. The gold standard for treatment is positive airway pressure — either CPAP or bilevel positive airway pressure. Some patients can’t tolerate it. They should be able to try all three options — the full mask, nasal mask and nasal pillows — before abandoning PAP treatment.
9. If the patient is reluctant to do a sleep test (HSAT or PSG) and is not interested in using CPAP, it can be very difficult to convince them otherwise. Don’t send a patient to sleep medicine thinking that the practitioner will be able to convince them to use CPAP. Primary care, because of the long-term relationship with the patient, is better suited to help them understand over time that CPAP can help their moderate-to-severe OSA.
10. Oral appliances, if made by someone proficient in creating custom-made appliances, are really first-line treatment for mild OSA.
11. Weight loss is central to success. With the newer medications for weight loss, modest weight loss is very possible. Referral to a comprehensive weight management program is strongly recommended.
12. If weight loss and CPAP do not significantly improve the OSA, surgical procedures can be considered.

References:

• Obstructive sleep apnea for the primary care provider. Family & community medicine grand rounds. UT Health San Antonio. YouTube. https://www.youtube.com/watch?v=bxhAgYitV0Y. Accessed Feb. 16, 2024.
• Paidi G, et al. Cureus. 2022;doi:10.7759/cureus.26805.
• Sleep Foundation. Mallampati score and predicting sleep apnea. https://www.sleepfoundation.org/sleep-apnea/mallampati-score. Accessed Feb. 23, 2024.
• Slowik, JM, et al. Obstructive Sleep Apnea. [Updated 2022 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459252. Accessed Feb. 16, 2024.