Sleep Apnea, Emergency Medicine

Basics

Description

Disorder characterized by cessation of breathing during sleep:
- Defined as apneic episodes >10 sec with brief EEG arousals or >3% oxygenation desaturation
Risk factors:
- Obesity
- Male
- >40 yr of age
- Upper airway anomalies
- Myxedema (hypothyroidism)
- Alcohol/sedative abuse
- Smoking
Associated illness:
- Various dysrhythmias, particularly atrial fibrillation and bradyarrhythmia
- Right and left heart failure
- MI
- Stroke
- Motor vehicle accidents
- Hypertension poorly controlled by medical therapies

Epidemiology

Affects about 9% of middle-aged men and 4% of middle-aged women
80% of moderate or severe cases undiagnosed in middle-aged adults

Etiology

3 classifications of sleep apnea: ‚

Obstructive (84%) is due to upper airway closure despite intact respiratory drive:
- Also known as Pickwickian syndrome
- Pharyngeal airway is narrowed
Central (0.4%) is due to lack of respiratory effort despite patent upper airway.
Complex (15%) is due to a combination of obstructive and central sleep apnea.

Diagnosis

Signs and Symptoms

Excessive daytime sleepiness
Snoring
Irritability

History

Significant other apnea report
Difficulty sleeping
Decreased attention/concentration
Depression
Decreased libido/impotence

Physical Exam

Hypertension, hypoxemia
Obesity
Craniofacial anomalies
Macroglossia
Enlarged tonsils
Elevated jugular veins (secondary to pulmonary hypertension)
Large neck circumference

Essential Workup

Pulse oximetry
ECG
Chest radiograph

Diagnosis Tests & Interpretation

Lab
ABG is the best test to demonstrate hypercarbia and hypoxemia. ‚
Imaging

Consider lateral neck soft tissue radiograph to rule out other etiologies of upper airway obstruction.
Chest radiograph to assess other etiologies of hypoxemia
Chest CT rarely indicated

Diagnostic Procedures/Surgery
Polysomnogram (PSG) is required for diagnosis: ‚

>5 apneic episodes per hour
Not a consideration for ED management

Differential Diagnosis

Asthma
Cheyne " “Stokes breathing
COPD
Diaphragmatic paralysis
High altitude " “induced periodic breathing
Hypothyroidism
Left heart failure
Narcolepsy
Obesity hyperventilation syndrome
Primary pulmonary hypertension

Treatment

Pre-Hospital

Caution not to overventilate patient with chronic CO retention ‚

Initial Stabilization/Therapy

Chin lift/jaw thrust maneuver, oxygen as needed, oral or nasal airway devices ‚

Ed Treatment/Procedures

Proper technique is required for airway management:
- Supplemental oxygen as needed
- Bag-valve-mask ventilation may be difficult:
  - Consider the use of nasal and oral airways
  - 2-person technique to ensure a good seal
Continuous positive airway pressure (CPAP) is the standard of treatment:
- Acts as a pneumatic splint by maintaining upper airway patency
- BiPAP is an alternative for patients requiring high pressures or with comorbid breathing disorders.
- Long-term CPAP therapy decreases BP, insulin resistance, metabolic syndrome, and risk of cardiovascular disease.

Endotracheal intubation

Higher prevalence of difficult intubation:
- Patients frequently have higher Mallampati scores.
- Excess pharyngeal tissue in lateral walls often obstructs airway visualization.
- Patients have overall lower arterial oxygen saturation.
Plan and consider several methods of definitive airway control:
- Have alternative devices (laryngeal mask airway, bougie) available.
- Be prepared to perform cricothyroidotomy if necessary.
Use neuromuscular blockade only if successful oral intubation is reasonably likely and bag-mask ventilation is easy.
Positive end-expiratory pressure for ventilated patients

Medication

Insufficient evidence to recommend any medication for treatment
See Airway Management for details on induction agents and neuromuscular blockade.
Wakefulness-promoting agents (modafinil and armodafinil) are approved as an adjunct to CPAP patients with excessive sleepiness.

Avoid sedative use: ‚

Relaxes the upper airway and worsens airway obstruction and snoring

Long-term Management

Gold Standard
- CPAP compliance and weight loss strongly recommended by the American College of Physicians
Surgical considerations:
- Most intend to reduce or bypass the excessive pharyngeal/airway resistance that occurs during sleep.
- Efficacy is unpredictable; no good randomized trials
- Not a consideration for ED management
Dental devices:
- Currently recommended by the American Academy of Sleep Medicine (AASM)
- Available appliances include tongue repositioning and mandibular devices or soft-palate lifters.

Follow-Up

Disposition

Admission Criteria

Ventilatory failure, especially if intubation is necessary
Hemodynamic instability

Discharge Criteria

Maintenance of O2 saturation >85% for several hours using oxygenation or ventilation equipment available to the patient at home
Very low likelihood of decompensation overnight
Patients with sleep apnea who present after motor vehicle crashes:
- Manage initially like other blunt trauma patients.
- Later, consider the increased risk with sleep apnea and intervene to prevent future accidents.

Follow-Up Recommendations

PCP referral for sleep apnea and associated comorbidities
Encourage compliance, use of CPAP
Referral of patients with suspected sleep apnea to a pulmonologist
Encourage weight loss and diet control
Cardiology referral is appropriate when sleep apnea is complicated by heart failure or dysrhythmias.

Pearls and Pitfalls

Sleep apnea increases risk of cardiovascular disease, stroke, and diabetes mellitus.
CPAP is the standard of treatment.
Avoid the use of sedatives.
Preparation is essential, as sleep apnea increases intubation complications.
Primary care referral and CPAP compliance education improve therapy.

Additional Reading

Buchner ‚ NJ, Sanner ‚ BM, Borgel ‚ J, et al. Continuous positive airway pressure treatment of mild to moderate obstructive sleep apnea reduces cardiovascular risk. Am J Respir Crit Care Med. 2007;176(12):1274 " “1280.
Caples ‚ SM, Gami ‚ AS, Somers ‚ VK. Obstructive sleep apnea. Ann Intern Med. 2005;142(3):187 " “197.
Epstein ‚ LJ, Kristo ‚ D, Strollo ‚ PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263 " “276.
Mulgrew ‚ AT, Fox ‚ N, Ayas ‚ NT, et al. Diagnosis and initial management of obstructive sleep apnea without polysomnography: A randomized validation study. Ann Intern Med. 2007;146(3):157 " “166.
Qaseem ‚ A, Holty ‚ JE, Owens ‚ DK, Dallas ‚ P, Starkey ‚ M, Shekelle ‚ P, for the Clinical Guidelines Committee of the American College of Physicians. Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2013;159:471 " “483.
Rosenberg ‚ R, Doghramji ‚ P. Optimal treatment of obstructive sleep apnea and excessive sleepiness. Adv Ther. 2009;26:295 " “312.
Sharma ‚ SK, Agrawal ‚ S, Damodaran ‚ D, et al. CPAP for the metabolic syndrome in patients with obstructive sleep apnea. N Engl J Med. 2011;365:2277 " “2286.

Codes

ICD9

327.21 Primary central sleep apnea
327.23 Obstructive sleep apnea (adult)(pediatric)
780.57 Unspecified sleep apnea
327.29 Other organic sleep apnea
327.27 Central sleep apnea in conditions classified elsewhere
780.53 Hypersomnia with sleep apnea, unspecified

ICD10

G47.30 Sleep apnea, unspecified
G47.31 Primary central sleep apnea
G47.33 Obstructive sleep apnea (adult) (pediatric)
G47.39 Other sleep apnea
G47.37 Central sleep apnea in conditions classified elsewhere

SNOMED

73430006 Sleep apnea (disorder)
78275009 Obstructive sleep apnea syndrome (disorder)
27405005 Central sleep apnea syndrome (disorder)
230493001 Mixed sleep apnea

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