Snapshot A 49-year-old man with morbid obesity presents to the clinic complaining of heart palpitations and a pre-syncopal episode. An EKG at the office demonstrates some premature ventricular beats. The patient states that he feels more tired than usual, and it is difficult to stay awake lately. He denies any rhythmic jerking, chest pain, or shortness of breath. Physical examination was unremarkable. Introduction Clinical definition sleep breathing disorder characterized by repeated cessation of breathing during sleep results in sleep disruption and consequent daytime fatigue subtypes obstructive sleep apnea (OSA) most common form characterized by the relaxation of throat muscles leading to a reduced/cessation of airflow despite a respiratory drive central sleep apnea (CSA) decreased central nervous system respiratory drive leading to decreased airflow and ventilatory effort during sleep Epidemiology demographics OSA is 2-3 times more common in males than females OSA is more prevalent in African Americans risk factors age male gender obesity craniofacial and upper airway abnormalities chronic medical conditions (e.g., stroke) medication use (e.g., opioids) Pathogenesis CSA primary (e.g., idiopathic) secondary (e.g., drug use) commonly associated with Cheyne-Stokes breathing, especially among patients who have heart failure or stroke OSA recurrent, functional collapse of the airway during sleep leading to reduced or complete cessation of airflow with breathing efforts may occur secondary to decreased pharyngeal muscle tone, obese neck, or large tone size Presentation Symptoms loud snoring morning headache difficulty staying asleep excessive daytime fatigue/sleepiness Physical exam hypertension obesity large neck circumference crowded oropharynx micrognathia Studies Home sleep apnea testing acceptable alternative for patients strongly suspected of OSA without medical comorbidities In laboratory polysomnography gold standard diagnostic test for sleep apnea differentiates OSA from CSA Laboratory studies polycythemia due to chronic hypoxia stimulating EPO release usually mild if no daytime hypoxemia Diagnostic criteria OSA 15 obstructive apneas/hour 5 apneas/hour and snoring/breathing pauses with daytime somnolence Differential Narcolepsy distinguishing factor clinical features such as cataplexy, hypnagogic hallucinations, sleep attacks, and sleep paralysis can be differentiated on polysomnography Respiratory disease (e.g., chronic obstructive lung disease) distinguishing factor positive medical history and polysomnography results Treatment OSA lifestyle weight loss, exercise, sleep position change, smoking cessation, abstain from alcohol, and avoid certain medications medical positive airway pressure therapy first-line treatment continuous positive airway pressure (CPAP) is the most common form oral appliances (e.g., mandibular advancement devices) indicated in patients with mild to moderate OSA who fail positive airway pressure therapy or prefers such treatment surgical treatment indicated in patients with severe, obstructing lesions of the upper airway who have failed initial therapy CSA medical correction of conditions that may be causing or exacerbating the condition (e.g., stop taking opioids) positive airway pressure therapy (e.g., BiPAP) for mechanical ventilation Complications Arrhythmias non-sustained ventricular tachycardia, atrial fibrillation, and ventricular ectopy bradycardia and asystole may result in sudden death Daytime fatigue (increased risk for motor vehicle accidents) Pulmonary hypertension may result in mild pulmonary hypertension, but not definitively cor pulmonale if no daytime hypoxemia is present Type 2 diabetes and other metabolic conditions Severe OSA may be associated with CAD Right ventricular failure