OSA without Daytime Somnolence
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OSA without Daytime Somnolence
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There's a discussion in the Cardiology forum about screening heart failure patients for Central Sleep Apnoea, which has moved onto discussions regarding OSAin heart failure.
Once question which com
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Cat:OpenClinicalForum:8114d353-b41b-4a03-b052-dc009589d5cfDiscussion:eb744499-9834-4937-9078-143e8bceba4a
Forums » Open clinical » Respiratory medicine » OSA without Daytime Somnolence
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OSA without Daytime Somnolence
posted at 26/1/2012 11:44 AM GMT
on bmj.com
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Posts: 1181
First: 19/4/2010 Last: 23/5/2013 |
There's a discussion in the Cardiology forum about screening heart failure patients for Central Sleep Apnoea, which has moved onto discussions regarding OSAin heart failure. Once question which comes up in our service a fair bit is What do you do with a patient with a positive sleep study for OSA but no daytime somnolence? These patients have sleep disordered breathing, but no symptoms to give them sleep apnoea... Are they at risk of the complications of sleep apnoea? Should we give them CPAP? Should we review them? Should we forget about them? |
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Re: OSA without Daytime Somnolence
posted at 26/1/2012 12:05 PM GMT
on bmj.com
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Posts: 2948
First: 10/3/2009 Last: 23/5/2013 |
My worst patient with OSA stops breathing 600 times a night and with severe oxygen desaturation. He is on CPAP now. I see him regularly. You might forget them with your NHS. I don't.
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Re: OSA without Daytime Somnolence
posted at 26/1/2012 12:13 PM GMT
on bmj.com
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Posts: 1181
First: 19/4/2010 Last: 23/5/2013 |
Does he have daytime somnolence? Obviously if he has OSA he should be treated, and if he desaturates he has a low average saturation, he should have overnight O2. My question is, if he has a AHI of 25, but no daytime somnolence, would you give him CPAP, and if so, why? What are you treating? What are you trying to prevent? |
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Re: OSA without Daytime Somnolence
posted at 26/1/2012 7:53 PM GMT
on bmj.com
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Posts: 3
First: 26/1/2012 Last: 27/1/2012 |
As a GP how practical is it to screen obese patients for OSA and indeed who should be screened for incipient or occult Cardiac Failure? Prevention is better than treatment of pathology but are our patients interested or available? What are the complications of CPAP? (too many questions) |
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Re: OSA without Daytime Somnolence
posted at 26/1/2012 9:13 PM GMT
on bmj.com
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Posts: 2948
First: 10/3/2009 Last: 23/5/2013 |
Most with an AHI of 25 (moderate OSA) desaturate. Most are obese. If the NHS is on the skids, get them to lose weight. Google life-expectancy of people with moderate to severe OSA. Ask your insurance agent if you'd have a loading on an AHI of 25 (need the whole sleep study for the verum corpus) and why. Antipodean ones would load the policy or exclude you especially Scottish insurance companies as they are kenny with their pennies. I treat hypertension, hyperuricaemia, and hyperglycaemia sans symptômes. I also use domicilary oxygen nocte for people with no symptoms asleep. They live longer.
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Re: OSA without Daytime Somnolence
posted at 26/1/2012 11:28 PM GMT
on bmj.com
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Posts: 1181
First: 19/4/2010 Last: 23/5/2013 |
I accept all of the above. But do we make any difference to a patient with sleep disordered breathing with no daytime somnolence by giving them CPAP? What happens if we don't? They're not sleepy to start with, so they remain not sleepy. Does stopping their asymptomatic hypopnoeas improve their outcome? Is there any evidence either way? I know the Edinburgh group were planning a study in this patient group, but I've not seen the published data.... |
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Re: OSA without Daytime Somnolence
posted at 26/1/2012 11:41 PM GMT
on bmj.com
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Posts: 1181
First: 19/4/2010 Last: 23/5/2013 |
@Stirrin'Stuff - welcome to D2D! The patients to screen for OSA are those with excessive daytime somnolence. The typical phenotype is obese with a fat neck, and retrognathia, but it *can* occur in anyone, of any body habitus. The hallmark of OSA is being sleepy during the day - not tired, but specifically likely to fall asleep. Carry out an Epworth Sleepiness Score; if it's >12, probably worth a referral to the sleep centre, particularly if they snore, and/or a partner has witness overnight apnoeas. A limited polysomnograph is usually sufficient to make the diagnosis of sleep disordered breathing, with apnoeas and hypopnoeas, and coupled with daytime somnolence, the diagnosis is OSA. Treatment is CPAP, which is dramatically effective in reducing daytime somnolence. What interests me is whether treating the non-sleepy patients with CPAP gives any benefit - if they're already not sleepy, then what are we doing? Do these patients develop pulmonary hypertension, or have strokes, or MIs any more than similarly obese patients without sleep disordered breathing? Would giving them CPAP change these outcomes? I don't think we really know. It's instinctive to think that if a patient's Sats drop periodically during sleep that they should get oxygen, but does it make any difference? Is there any evidence either way? CPAP was hearalded as the best treatment for acute pulmonary oedema, but the CP30 trial showed nicely that it's no better than diuretics and supportive management. Side effects of CPAP? Tight fitting mask is uncomfortable, and can produce pressure sores if not properly fitted. There's a risk of aspiration if the patien vomits whilst on the mask. If the pressures are not titrated properly, there's a physiological effect of lessening venous return, and consequently cardiac output, but I've never been convinced by anyone that it's significant.... Patients usually welcome the CPAP therapy as they feel instantly refreshed in the morning, and their daytime somnolence vanishes. Welcome to Doc2Doc!
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Re: OSA without Daytime Somnolence
posted at 27/1/2012 12:13 AM GMT
on bmj.com
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Posts: 2948
First: 10/3/2009 Last: 23/5/2013 |
It is a myth that one has to be middle aged, fat and a slob to have OSA. I see nubile beauties with it. Malampatti class and a malocclusion may be the cause. Look at her mother. I use SomnoDent mandibular advancement splints for those with mild to moderate OSA who are not fat and have ten teeth and use a toothbrush bewteen Mars Bar butties. This is Plan A or B depending on CPAP acceptibilty. I do a sleep study with the MAS a few months later to see if it is adequately advanced and only use dentist certified to use this device. This is recommended by the Antipodean Sleep Association. Cheap single block devices are as effective as a boat anchor. SomnoDent is the best device. It allows the wearer to open the mouth. It works if they have bruxism too. If they have crowns they need the soft surface version. It is an Australian patented device. The use it auf Deutschland and the USA. CPAP was invented by Prof. Colin Sullivan from Sydney. The Epworth Sleepiness Scale was devised by Dr Murray Johns at the Epworth Private Hospital, Richmond, Melbourne. Patients with no symptoms are always a challenge. I am not here to make the cosmos perfect. I just do my best to do what I can for patients. I use mainly the Resmed S9 auto pumps. Somte which is a home monitoring sleep study device is made by Compumedics, Mlebourne, Greater Oz. Resmed is Oz. "Sleep" comes from the Old High German slafen and is not under patent. Hypnos, thanatos and morphea are all Greek. Your Antipodean Chum from Greater Oz, Odysseus.
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Re: OSA without Daytime Somnolence
posted at 27/1/2012 4:29 AM GMT
on bmj.com
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Posts: 2948
First: 10/3/2009 Last: 23/5/2013 |
The overall AHI is only part of the deal. It could be normal but with an abnormally high AHI in supine REM eg with severe oxygen desaturation. Some patients are very symptomatic even with low AHI in the mild range. Snoring can cause EDS (excessive daytime somnolence) in the absence of OSA. RERAs (Respiratory effort related arousals) are also part of the deal. Some patients have mainly RERAs and hypopnoeas with few if any apnoeas. The more rules you make, the more you need to break. I treat patients; not numbers.
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