MEDizzy - A 52-year-old man is evaluated for loud snoring and daytime

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Disorders of the Respiratory System and Critical Care Illness

A 52-year-old man is evaluated for loud snoring and daytime fatigue. His wife urged him to come in for an evaluation because his snoring has become increasingly disruptive over the past 2 years after he gained about 30 lbs. She frequently sleeps in another room and reports that she has seen him stop breathing during sleep. During the day, he struggles to stay awake when he is in meetings or sitting at his computer, particularly after lunch. He has a 40-minute commute and has had to pull of the road due to feelings of sleepiness. He has a medical history of hypertension for the past 5 years and takes losartan 25 mg daily. He does not smoke and drinks one beer or glass of wine daily. His father, who is 75 years old, uses a CPAP machine for obstructive sleep apnea and has also had a myocardial infarction. On physical examination, the patient appears well. He has a body mass index of 37.1 kg/m2. When the patient opens his mouth, you can see most of his uvula, which appears somewhat edematous. Tonsillar tissue is visible and extends just beyond tonsillar pillars. The neck circumference is 43 cm. What is the next step in the evaluation and treatment of this patient?

ExplanationObstructive sleep apnea/hypopnea syndrome (OSAHS) is a common condition estimated to affect up to 2%–15% of middle-aged individuals and >20% of elderly individuals and is associated with the repeated collapse of the upper airway during sleep. This patient exhibits multiple risk factors and gives a strong history to support a diagnosis of OSAHS, placing him at high risk to have moderate to severe OSAHS. The greatest risk factor the patient has that places him at high risk for disease is obesity. Approximately 40%–60% of cases of OSAHS are attributable to excess body weight. The second major risk factor for OSAHS is male sex because men are two to four times more likely to have OSAHS than women. The reasons men develop more OSAHS include greater central obesity and relatively longer pharyngeal length, which in turn contribute to greater upper airway collapsibility. In addition, female sex hormones provide a stabilizing effect on the upper airway and stimulate ventilatory drive. Thus, premenopausal women are relatively protected from OSAHS at comparable levels of obesity when compared to men. Other risk factors that this patient has include a positive family history of the disease and hypertension. Other common risk factors for OSAHS in the general population include craniofacial abnormalities, adenotonsillar hypertrophy, various endocrine syndromes (acromegaly, hypothyroidism), increasing age, and some ethnic groups. For instance, individuals of Asian descent often develop OSAHS at a lower range of body mass index, most likely due to ethnic differences in craniofacial structure. In addition, individuals of African American race are at higher risk of OSAHS when compared to whites. This patient also gives many symptoms that are concerning for OSAHS including loud snoring, witnessed apneas, and daytime sleepiness. Given that there is a high clinical suspicion of disease, home sleep testing will likely be adequate for the diagnosis of disease in this patient. Home sleep tests can be performed in a variety of ways, but most will record respiratory effort, nasal flow, and oxygen saturation. In a patient with a high suspicion of disease, these tests can be a cost-efficient means of diagnosis. However, the home tests may yield false-negative results because these tests do not measure the electroencephalogram, and thus, no accurate measure of sleep time is obtained. Therefore, the respiratory events are determined based on total recording time rather than total sleep time. If a patient is awake during much of the recording time, this could cause a false-negative result. An attended in-lab polysomnogram remains the gold standard for diagnosis of OSAHS but is significantly more expensive. In this individual with a high pretest suspicion of disease, the cost would not be justifed. An overnight oximetry provides only oxygen levels and heart rate and is not adequate for diagnosis of OSAHS. Treatment with a CPAP device may be recommended after a diagnosis is confirmed, but this would not be the next step in the treatment of the patient. The patient has only minimally enlarged tonsils. A tonsillectomy would not be expected to alleviate his symptoms.