This this episode of PodMD, dual-trained Respiratory, Sleep, and General Medicine Physician Dr Harshan Jeyakumar will be discussing the topic of obstructive sleep apnoea, including what obstructive sleep apnoea is, the risk factors in developing the condition, who should be tested using a sleep study, the types of sleep studies available, the treatment options available and more.
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*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Dr Harshan Jeyakumar
Dr Harshan Jeyakumar is a dual-trained Respiratory, Sleep, and General Medicine Physician working in South-East Melbourne and Gippsland.
Having graduated from Monash University in 2013, Dr Jeyakumar completed his internship and Basic Physician Training through Monash Health in 2018. Following this, he accepted a four-year dual training position in Respiratory and General Medicine through Monash Lung & Sleep and Latrobe Regional Hospital, receiving his Royal Australasian College of Physicians Fellowship in 2020. He then completed post-fellowship training in Acute & General Medicine (LRH) and a 12-month Sleep Fellowship (Monash Health)
Today, we’ll be discussing the topic of obstructive sleep apnea
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Harshan, thanks for talking with us on PodMD today.
Harshan : Thank you for having me.
The topic of today’s discussion is obstructive sleep apnea. Harshan, Can you describe for our listeners what obstructive sleep apnea is?
Harshan: Yes. So obstructive sleep apnoea is a very common condition. That is affecting the upper airway. The prevalence ranges depending on which studies you look at between 10 and 40% with certainly a male predominance. And it’s characterised by a repetitive upper airway compromise which leads to airway collapse, either partial or complete. And overall this can cause impaired ventilation, sleep fragmentation as well as daytime functional impairment.
What are the risk factors for obstructive sleep apnoea?
Harshan: So listeners will know that the more common risk factors are that of obesity. As well as a male sex. Some of the less common risk factors is the older the age of the patient, the higher the risk of sleep apnoea, as well as their genetics and ethnic origin, with a higher proportion of Asian patients developing sleep apnoea at every age, nasal congestion and overall facial structure also play a significant role in the risk of sleep apnoea.
How would a patient with obstructive sleep apnea typically present?
Harshan: So, on history, the more common features of that have loud snoring as well as witnessed apnoeic episodes often noted by the bed partner patients also report gasping or choking episodes that wake them from their sleep on waking, they can commonly have a dry mouth or a headache, as well as waking unrefreshed and daytime somnolence or sleepiness is also a very common feature. Insomnia may also be the primary presentation for patients who do have underlying sleep apnea and should be considered in all insomnia patients.
Once you pass through the history, we look into the examination and looking into the oropharynx. It can often be crowded with enlarged tonsils. There can be a larger neck or waist circumference as well as the obvious feature of obesity as a primary risk factor. It’s also important to recognise that symptoms can sometimes be minimal in obstructive sleep apnoea, but there may be an associated condition and if this condition is refractory to the standard treatment, then certainly consideration of obstructive sleep apnoea as a comorbid condition is warranted.
What are the more common associated conditions that should make GPs think of comorbid obstructive sleep apnoea?
Harshan: Cardiac conditions are the more common conditions to think of, and in particular atrial fibrillation and cardiac arrhythmias. As well as hypertension. As I mentioned, when these conditions are refractory to treatment, certainly there should be a heightened suspicion for obstructive sleep apnoea. In patients with obesity and genuine efforts to lose weight who are failing to do consideration towards comorbid obstructive sleep apnoea is certainly warranted, as this can certainly impact on the ability to lose weight. Likewise, type 2 diabetes is another condition of importance to recognise as both difficult to control in the setting of sleep apnoea, but also may be driven by sleep apnoea.
What are some of the consequences of untreated obstructive sleep apnoea?
Harshan: I would say it’s an extremely important condition to recognise, particularly because of the daytime symptoms, particularly that of daytime drowsiness, which can lead to poor performance and low mood, but also an increased risk of motor vehicle accidents. Beyond that, we know that OSA has an increased risk of cardiovascular issues such as hypertension and atrial fibrillation, as well as ischemic heart disease. There’s also an increased risk of stroke and metabolic syndrome, including type 2 diabetes.
Who should be tested for obstructive sleep apnoea with a sleep study?
Harshan: The more common reasons to refer for a sleep study would be that of excessive daytime somnolence. Patients reporting loud snoring or witnessed apnoea episodes. As well as those who wake up with choking or gasping. Other reasons to consider a sleep study include those with refractory comorbid conditions such as hypertension or atrial fibrillation. As well as in the perioperative setting, where a general anaesthetic is planned and we know that there is an increased risk of complications in patients with untreated obstructive sleep apnoea in that setting.
What type of sleep studies are available and who can refer?
Harshan: So there are a number of different sleep studies available, and the level of the sleep study is dependent on the degree of monitoring that is included. Typically, we will conduct either a level 1 or a level 2 sleep study, a level one sleep study is our top of the line in-patient sleep study. Usually done in a hospital setting and beyond the standard measurements to sleep apnoea can also look at more in depth measures such as carbon dioxide monitoring as well as having a scientist available on site to troubleshoot any issues throughout the night, and a video of the patient sleeping which can often be helpful when assessing for parasomnias.
A level two study has become increasingly accurate over the last decade, and that’s typically known as a home-based sleep study. That includes most of the parameters of a level one study with the absence of a video, and is a very effective test in assessing for obstructive sleep apnoea. GP’s can refer for home based sleep studies directly based on screening tools such as the Epworth Sleepiness Scale, the Stop Bank score and the OSA 50 and there are Medicare requirements around these scores being positive before GP can refer directly. It’s important for listeners to recognise that sleep physicians can refer anyone for a sleep study after a formal assessment, regardless of whether they meet scores on their screening tools.
Who should be treated for obstructive sleep apnoea?
Harshan: So our decision to treat obstructive sleep apnoea is driven by a number of factors. In my own practice, that would be the severity of OSA, whether there are daytime symptoms that correlate to that severity, comorbid conditions such as atrial fibrillation or hypertension that also warrant management. As well as the impact on the bed partner and other household members. Sometimes we also have to consider occupational and commercial risks in our decision to treat patients, particularly in those with heavy vehicle licences.
What are the treatment options available?
Harshan: So our general measures for all patients would be to try and minimise risk factors such as smoking cessation as well as weight loss and alcohol use. Positional therapy is a common strategy used particularly in the setting of mild disease and typically a sleep study report would include positional information about when respiratory events were occurring. You may see it on your sleep study reports the mention of supine predominant or supine isolated sleep apnoea, and those patients may benefit from a positional therapy approach. In most settings, a dedicated approach to try and keep patients on their side with the use of a device which can be as simple as a pillow behind their back or a golf ball stitched into their bed clothing. Maybe enough to treat their mild sleep apnoea.
The majority of patients that require treatment with CPAP or continuous continuous positive airway pressure. Would be those with apnoea hypopnea index above 15 classified as moderate or severe disease. Those with symptoms consistent with sleep apnoea and apnoea hypopnea index above 5. As well as those with comorbid conditions, we would then follow up their response to CPAP therapy based on symptoms as well as their treatment adherence and assess whether this is a optimal long-term strategy.
The benefit of CPAP therapy is that it can be trialled in a minimally invasive approach with minimal cost to the patient. Renting a machine for a one-month period is relatively cost effective and provides an adequate time to assess whether there is a response to in terms of symptoms, but as well as adherence and comfort with the machine. And those who are adherent and have good symptom response, we typically would continue down a CPAP approach. But in other patients, especially those with moderate or mild disease, we may consider other techniques. For some patients, this may be a mandibular advancement splint fitted by a sleep specific dentist and in some patients, a surgical approach is also warranted, usually done by a dedicated sleep surgery with an ENT background.
What if patients have persistent sleepiness despite adequate OSA control on treatment?
Harshan: This is certainly a group of patients that we see on a not uncommon basis. Unfortunately they are a much more difficult group to treat. Usually, an assessment by a sleep physician is warranted in that setting, and we would evaluate and treat for any underlying comorbidities. Some of the common comorbidities associated with sleep apnoea that have insomnia as well as restless leg syndrome and idiopathic hypersomnolence. And so formal assessment for those conditions and optimising them along the standard treatment guidelines is warranted before assessing further for other non-sleep disorders that may be causing persistent sleepiness.
Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take home messages from today’s podcast on obstructive sleep apnea?
Harshan: Absolutely. So it’s important to recognise that number one, obstructive sleep apnoea is a very common condition and has significant symptom burden and that this has a risk of comorbidities that warrant assessment in treatment. Sleep studies are readily available and can be effectively performed in the home or in an inpatient setting. And finally, engaging with a sleep physician to devise an individualised management plan for a patient can help both adherence and control, leading to improved symptom response and treatment of obstructive sleep apnoea.
Thanks for your time and the insights you’ve provided.
Harshan: Thank you