Screening Obstructive Sleep Apnea in the Primary Care Setting - Part I

A young man in his mid-30s steps into the doctor's office. "My wife made me come in," he says before continuing. "She always tells me that I stop breathing when I sleep, that I snore...she's afraid im going to die." So I ask him, "How do you feel during day?" He looks really sleepy, and I ask if he ever wakes up refreshed. "No. Never. I'm always groggy." How does he cope? "I fill the sink with water and ice and put my head in. That’s how I wake up." As expected, he had severe sleep apnea. We treated it and his wife was very thankful.

Risk factors for obstructive sleep apnea (OSA) include obesity and high blood pressure; having diabetes increases that risk by 40-50%. Considering that half of all Americans have a one or more of these conditions, it is likely that many of your patients have undiagnosed OSA, due either to a lack of awareness, focus on the treatment of other diseases, or an attribution of OSA symptoms to the disease or reaction to treatment.

When screening for OSA in your patients, here are a few things to consider:

How you should approach treatment

After ruling out hypothyroidism, anemia, and other plausible disorders, turn to the Epworth Sleepiness Scale (ESS). Why? Because it’s a cheap, effective paper test that has been released into the public domain.

Typical results of an ESS evaluation:

Normal control — 5.9

Primary snorer — 6.5

OSA — 11.7

Narcolepsy — 17.5

Which primary care patients should you screen for sleep apnea?

Morbid obesity increases the risk of OSA by 75%

Hypertension — 35-45%

Atrial fibrillation — 49%

Diabetes — 40-50%

Congenital Heart Failure — 30-50%

Angina and Coronary Artery Disease — 20%

Certainly any combination of risk factors multiplies the likelihood of someone developing OSA, but presenters highlighted the following combination of risk factors as especially important to monitor:

  1. Any patients with witnessed apnea, heavy snoring, and/or daytime sleepiness should be evaluated;
  2. A combination of diabetes and refractory hypertension or diabetes, witnessed apnea and daytime sleepiness should also examined.

Men and Women are Different!

When comparing complaints of patients with OSA between men and women, it is more likely that women will complain about insomnia and partner snoring.

Women are more likely to present with insomnia, depression, thyroid disease, and nightmares/hallucinations.

A neck size of over 16” increases the risk for OSA in women. A 17” neck increases risk in men.

Making it official

Send them for a polysomnography, but not before you consider this: your patient will most likely have to pay upwards of $1500 out of pocket for this sleep study. They are going to balk at this, despite the fact that it is the best thing for them.

The recommendation: order a split night study. The patient will still be responsible for the out of pocket payment, but this will give them a better outcome and get them started on treatment more quickly. If you don’t opt for split night, the patient will have to come back and the sleep center will titrate treatment.

Interpreting the results

Severity criteria

Mild — 5-14.99 events/hour

Moderate — 15-29.99 events/hour

Severe — Greater than 29.99 events/hour

You must put your results into context, however. An individual with 10 or 13 events/hour may have clinically mild OSA, however if other risk factors are present, that apnea becomes clinically significant.

Click here for Part II