Obstructive sleep apnoea

Question 1

A 45 year old man presents with daytime sleepiness and heavy snoring. How would you assess and manage him?

Answer 1

Impression
Given daytime hypersomnolence and heavy snoring, I am concerned about OSA as the provisional diagnosis in this case.

There are other disorders of sleep that I would like to consider that may be contributing to this including

• poor sleep hygiene
• insomnia (early, late, terminal)
• sleep-related movement disorder (restless legs syndrome)
• sleep-related respiratory disorder (OSA, central sleep apnoea)
• circadian rhythm sleep-wake disorder
• underlying mental illnesses (depression, anxiety, psychosis)

Furthermore, OSA is a cardiovascular risk factor so in addition to conducting thorough assessment to understand the likely underlying aetiology of this presentation, I would also like to assess and manage the patients cardiovascular disease risk factors.

Question 2

OSA - History

Answer 2

History

• sx: daytime fatigue, heavy snoring, wakes from sleep? collateral from bed partner - witnessed apnoeas, feel refreshed in AM? reduced concentration,
• insomnia: early, middle, late
• sleep hygiene: activities before bed and leading up to
• CVD risk factors: obesity, diabetes, HTN, fam history, male gender, smoking, alcohol
• psychosocial screening: evidence of psychiatric illness (depressive sx, anxiety, etc)
• Epworth sleepiness scale
• risk assessment: job, impact on function, do they drive for work?

Question 3

OSA - Examination

Answer 3

Examination

• general appearance: obesity, evidence of fatigue, increased neck and facial adiposity
• ENT examination: short thick neck, nasal septum deviation, polyps, malampatti score,
• anthropometric measurements: BMI calculation
• vital signs: BP, HR
• Cardiovascular examination

Question 4

OSA - Investigations

Answer 4

Investigations
Diagnostic
- Polysomnography (overnight sleep study) - looking at number of aponea’s.

• bedside: ECG, vitals
• bloods: lipid panel, HbA1C, fasting BSL, FBC, UEC, LFT
• Imaging: nil, consider ECHO for complications
• other: sleep studies, polysomnography -

Question 5

OSA - Management

Answer 5

Management
- referral to sleep physician

Definitive mx

• overnight CPAP
• modification of CVD risk factors (Lifestyle, pharmacological)
• Surgical: is last Line, ENT referral for uvulopalatopharyngoplasty (most common surgical procedure for OSA)

Other supportive:

• sleep hygiene
• positional therapy (sleep upright, etc)