Obstructive sleep apnea

Antonio Culebras MD (Dr. Culebras of SUNY Upstate Medical University has no relevant financial relationships to disclose.)
Originally released November 29, 1995; last updated July 13, 2016; expires July 13, 2019

This article includes discussion of obstructive sleep apnea, heavy snoring disease, OSA, OSAS, obstructive sleep apnea syndrome, Pickwickian syndrome, and sleep disordered breathing. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Some decades after pioneering reports of obstructive sleep apnea in the Pickwickian syndrome, obstructive sleep apnea is a recognized common clinical problem with important consequences such as excessive daytime sleepiness and cerebrovascular or cardiovascular disease (stroke, hypertension, and myocardial infarct). In this article, the authors provide information on historical notes and physiology of respiration during sleep as well as pathophysiology and clinical aspects of sleep-related breathing disorders, particularly obstructive sleep apnea syndrome. The article also summarizes diagnostic methodologies, describes the most common complications of obstructive sleep apnea and their pathogenetic mechanisms, and outlines available therapeutic approaches and their indications, suggesting issues for future research.

Key points

 

• Obstructive sleep apnea syndrome is characterized by repeated upper airway obstructions leading to oxygen desaturations and sleep fragmentation. Narrowing and closure of the upper airway, specifically the oropharynx, during sleep is the basis of the disease.

 

• Obstructive sleep apnea is a clinical problem, occurring more frequently in men than in women, with important consequences such as excessive daytime sleepiness and a higher risk of cerebrovascular or cardiovascular disease (stroke, hypertension, and myocardial infarct).

 

• Habitual snoring is the first stage of the disease, which may progress to obstructive sleep apnea syndrome (mild, moderate, and severe), in particular after body weight increase and advancing age, with obesity being the most important risk factor for the development of obstructive sleep apnea.

 

• A nocturnal video-polysomnogram performed in a sleep laboratory is the gold standard for diagnosis of obstructive sleep apnea, but an easier approach, mainly when focusing on screening purposes, consists in the use of ambulatory devices recording various combinations of pulse oximetry, breathing effort, airflow, snoring, heart rate, EEG, or other measures.

 

• The type of treatment for obstructive sleep apnea syndrome depends on the severity of the disorder. Treatment often includes losing weight, avoidance of alcohol and hypnotic drugs, and avoidance of the supine position during sleep. In moderate to severe obstructive sleep apnea, the treatment of choice is nasal continuous positive airway pressure (CPAP) application that functions as an air splint to maintain positive intraluminal pressure in the upper airway. Oral appliances and surgical procedures (uvulopalatopharyngoplasty, tracheostomy, maxillofacial surgery) designed to maintain nocturnal airway patency are additional options to be considered in selected cases. Neurostimulators of the oropharyngeal dilator muscles are available for patients who do not tolerate or fail PAP therapy.

Historical note and terminology

The first medical description of sleep apnea was made by Sidney Burwell and colleagues in 1956. Prior to that date there had been a few published cases of cardiopulmonary insufficiency with extreme obesity, periodic breathing, and hypersomnia or narcolepsy that were reviewed by Harvey Estes and colleagues in a 1957 article (Estes et al 1957). Burwell and associates described a case of a sleepy, obese patient and used the eponym of Pickwickian syndrome. The term “Pickwickian” was derived from The Posthumous Papers of the Pickwick Club written by Charles Dickens, in which the boy Joe resembles “modern” patients with obstructive sleep apnea because he was excessively fat, a heavy snorer, red-faced, and sleepy during the day (Dickens 1837).

Burwell attributed these symptoms to obesity that caused inefficient breathing (alveolar hypoventilation); the consequent rise in the carbon dioxide level in blood resulted in drowsiness (Burwell et al 1956). However, Rodman and colleagues and Lawrence, studying non-obese subjects, attributed the alveolar hypoventilation to a primary hypoexcitability of the respiratory center (Lawrence 1959; Rodman and Close 1959).

In 1965, Jung and Kuhlo first described the characteristic repetitive interruptions of breathing during sleep in these patients. They showed that carbon dioxide narcosis was not the cause of hypersomnia that may occur even in subjects whose gas analysis values are normal during wakefulness (Jung and Kuhlo 1965). At almost the same time, Gastaut and colleagues in France discovered that the recurrent breathing arrests typical of the syndrome were mainly due to an obstruction of the upper airway (Gastaut et al 1965).

In studies published in the “Bulletin de Physiopathologie Respiratoire,” Lugaresi and colleagues described the dramatic hemodynamic and respiratory consequences of sleep apnea using invasive monitoring of blood pressure in sleeping Pickwickian patients (Coccagna et al 1972; Lugaresi et al 1972).

In subsequent studies, the same authors highlighted the pathophysiological link between snoring and obstructive apneas, indicating the existence of a continuum of clinical conditions between snoring and the severest forms of obstructive sleep apnea syndrome (Lugaresi et al 1975; Lugaresi et al 1982). Epidemiological studies showed that obstructive sleep apnea is an important risk factor for arterial hypertension, ischemic heart disease, and stroke (Lugaresi and Partinen 1994).

Tracheostomy bypassing the pharyngeal obstruction appeared an efficacious therapy for obstructive sleep apnea (Kuhl et al 1969; Lugaresi et al 1970).

The introduction of nasal continuous positive airway pressure (CPAP) revolutionized the treatment of obstructive sleep apnea (Sullivan et al 1981). The recognition that obstructive sleep apnea is a common disorder with disabling symptoms and substantial associated morbidity and mortality has had a profound impact on the field of sleep medicine. Despite the increased recognition of obstructive sleep apnea, moderate to severe obstructive sleep apnea remains underdiagnosed and undertreated.

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