Obstructive Sleep Apnea: A Non-Silent Epidemic


Healthy Living – January 31, 2017
William Sturrock, MD 

Obstructive sleep apnea (OSA) is a problem that affects about 15 percent of the US population.  It describes a clinical syndrome wherein the collapse and obstruction of the upper airway during sleep results in reduced airflow and oxygen uptake. Experts divide this condition into categories based on the number and severity of abnormal breathing events per hour that can be demonstrated on a sleep study:  less than 15 episodes of apnea or hypopnea is defined as mild, and 30 or more considered severe. There have been many studies demonstrating that increasing severity of OSA can be associated with increased risk of all-cause mortality, cardiovascular disease and cerebrovascular events, increased risk of motor vehicle accidents, impaired work performance, and even long-term cognitive decline. 
What is less clear is how should we screen for this condition, and which treatments give the best outcomes. Last week the US Preventive Services Task Force issued its latest recommendations based on an exhaustive analysis of more than 170 studies that have examined these questions. Their advice: we do not currently have enough evidence of the benefit of specific screening protocols or on differing treatment techniques to justify screening of ‘asymptomatic’ adults (JAMA  Jan 2017: volume 317, no.4; pp 407-433).
 Many concerned individuals; both lay and with medical expertise, have wondered how, despite a significant volume of good medical research, the USPSTF could reach this decision. The crux of their analyses hinges on how well one can predict that someone identified with a screening tool will not only have the condition but further, how certain can you predict that they will have a real survival benefit from treatment.  In short, it is the policy of the USPTF to set a high bar, before they advise the commitment of medical resources toward fighting any particular disease. We have seen in the past how they have similarly advocated against universal screening for a number of conditions, including prostate cancer, dementia, and ADD, among others.
To better understand their logic, I often use the analogy of a border guard – he or she may not be able open the trunk of every car going across, which would be universal screening, but they can use their experience to determine which vehicles or individuals are more likely to have contraband, and focus their efforts on those high-risk situations. In other words, doctors may not be justified ordering a sleep study on every adult, but they would be very wise to focus their evaluations on patients who are already showing some signs of the problem. 
For sleep apnea, what are those indicator symptoms? Their report specifically listed snoring, witnessed apnea, gasping or choking at night, excess daytime sleepiness, impaired cognition, and even mood changes as concerning signs that could justify testing. Because some patients may themselves not be aware of these changes, I try to enlist their sleep partners to be aware of any of these events as good justification for testing and possible treatment. 
When I went was a boy and went camping with my family, we kids used to poke fun at my dad who snored like a bear. He was trim and fit, and did not fit the risk factors of increased weight or BMI, that many associate with OSA. I think we actually felt somewhat reassured by his nocturnal noise, thinking that he probably would scare away any wolves that might nose around our tent! Now, years later, I know it did not affect his mortality ( he is still going strong at 87) but as a doc, I would encourage him if he were my patient to consider getting tested – even if tests did not show severe disease, there are a number of  actions one can take: 
  1. Make sure you keep your weight in a good range
  2. Avoid sedatives or alcohol before bed as this can worsen airway patency
  3. Try to avoid sleeping on your back – if you don’t have a spouse to give you a well-intended shove, you can sew a racquet ball in the back of your nighty!