Asymptomatic sleep apnea

Asymptomatic sleep apnea DEFAULT

What do snoring, daytime sleepiness and mood changes have in common?

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They’re all signs of sleep apnea, a common disorder in both men and women.

“Sleep apnea is grossly under-recognized,” says Nancy Foldvary-Schaefer, DO, MS. “We estimate that 85 to 90 percent of people with sleep apnea in this country don’t know they have it.”

A 2013 study shows that the number of people with known sleep apnea continues to grow, affecting:

  • 10 percent of men aged 30 to 49, and 17 percent of men aged 50 to 70.
  • 3 percent of women aged 30 to 49, and 9 percent of women aged 50 to 70.

“These numbers have risen substantially since the 1990s, as Baby Boomers age and our obesity epidemic worsens,” says Dr. Foldvary.

What happens during sleep apnea

In sleep apnea, episodes of upper airway collapse interrupt your breathing so that oxygen can’t reach your cells.

“Each time your body has to restore normal breathing and oxygen levels, you’re briefly aroused from sleep,” says Dr. Foldvary. “This fragments the brain waves that characterize different sleep stages, leading to daytime sleepiness, fatigue and a host of other symptoms.”

If you have 15 or more of these episodes per hour, your apnea is considered moderate to severe. And the health impact is enormous.

“Most people don’t realize untreated apnea increases your risk of stroke, heart attack and high blood pressure,” she says. “If you have atrial fibrillation, sleep apnea doubles your odds for having a recurrence. If you have heart failure, it increases your risk of hospital admission.”

Sleep apnea also raises your risk of motor vehicle accidents, work-related injuries and accidents, and academic underachievement at all ages, even in early childhood.

Most telling: Worldwide, people with obstructive apnea rate their quality of life worse in every dimension.

Symptoms range from mild to severe

Mild sleep apnea presents in unpredictable ways. “Not all snorers have sleep apnea, but snoring is usually the first symptom,” says Dr. Foldvary.

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“When apnea is mild, you may experience mild daytime sleepiness, sleep that isn’t refreshing, and fatigue. You may wake up often without knowing why, or get morning headaches.”

When apnea is severe, you can wake up breathless, gasping for air. You may feel like you’re choking.

You may face declining performance at work or school, and mood changes (most often symptoms of depression). You can experience problems with sex, whether you’re male or female.

Your bed partner may tell you that it’s pretty scary watching you sleep.

“It’s easy to forget to bring up these symptoms at your annual checkup, but you have to tell your doctor,” says Dr. Foldvary. “Otherwise, sleep apnea can be missed for many, many years.”

It’s quite likely that your doctor won’t ask you about sleep apnea, she says. Sleep medicine is a young specialty and not a focus of training in medical education.

“Furthermore, doctors are challenged with the need to manage increasingly difficult health issues in less and less time, leaving sleep concerns off their radar,” she says.

The causes of sleep apnea

The most common type of apnea is obstructive sleep apnea, which occurs when muscles in back of the throat lose their tone, resulting in upper airway collapse.

“Obesity, increasing age and being male are the main risk factors,” says Dr. Foldvary. “Drinking alcohol and sleeping on your back can aggravate the condition.”

After menopause, women’s rate of apnea approaches that of men’s as female hormone levels — which help to stiffen and open the airway — fall.

When postmenopausal women see the doctor, they often present without classic symptoms. They usually don’t complain of loud, disruptive snoring, and rarely report gasping or choking during sleep. They may be thin instead of heavy.

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“Postmenopausal women commonly present with fatigue, which is often attributed to depression,” says Dr. Foldvary. “Thus, it can take women up to a decade longer than men to receive a diagnosis of sleep apnea.”

Other causes of sleep apnea include large tonsils or other obstructive tissues in the airway. In about 25 to 30 percent of cases, a family history of sleep apnea is present.

To find out if you have apnea, your doctor will take a sleep history and order a sleep study. In some cases, you may be referred to a sleep medicine specialist.

Many solutions are available

Sleep apnea is very treatable, says Dr. Foldvary — especially at centers that provide excellent patient education and a broad range of treatments.

The gold standard treatment for sleep apnea is continuous positive airway pressure (CPAP). “But it’s not one size fits all,” she says.

“There are multiple forms of PAP therapy and a wide range of masks. Patients with difficulty tolerating the constant flow of air pressure often prefer auto- or bi-level PAP therapy, and need help with mask options,” says Dr. Foldvary.

When apnea is mild, options include a body pillow or positional device that helps promote sleeping on the side, and oral appliances that advance the lower jaw forward.

Some people require surgery to remove tonsils or other tissues that block the airway.

Finally, “a limited number of people will benefit from a revolutionary new treatment called hypoglossal nerve stimulation,” she says.

Why sleep is critical for you

Dr. Foldvary and other sleep medicine experts are committed to educating the public and healthcare providers about the importance of sleep.

“Sleep is as important to good health as diet and exercise,” says Dr. Foldvary. “We need sleep to restore every cell in our bodies. If we neglect it, some aspect of our health will suffer.”



Grade: I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Specific Recommendations

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for obstructive sleep apnea (OSA) in asymptomatic adults.

Frequency of Service

No information available.

Risk Factor Information

Risk factors associated with OSA include male sex, older age (40 to 70 years), postmenopausal status, higher BMI, and craniofacial and upper airway abnormalities.


Clinical Considerations

Patient Population Under Consideration

This recommendation applies to asymptomatic adults (18 years and older). It also applies to adults with unrecognized symptoms of OSA. This includes persons who are not aware of their symptoms or do not report symptoms as being a concern to their clinician. This recommendation does not apply to persons presenting with symptoms (e.g., snoring, witnessed apnea, excessive daytime sleepiness, impaired cognition, mood changes, or gasping or choking at night) or concerns about OSA, persons who have been referred for evaluation or treatment of suspected OSA, or persons who have acute conditions that could trigger the onset of OSA (e.g., stroke). Care of these persons should be managed as clinically appropriate. This recommendation also does not apply to children, adolescents, or pregnant women.

Suggestions for Practice Regarding the I Statement

Potential Preventable Burden

Based on data from the 1990s, the estimated prevalence of OSA in the United States is 10% for mild OSA and 3.8% to 6.5% for moderate to severe OSA.1-3 Current prevalence may be higher, given the increasing prevalence of obesity.4,5 Extrapolation from long-term follow-up data from the Wisconsin Sleep Cohort Study (1988–1994 to 2007–2010) results in an estimated prevalence of 16% for mild OSA and 10% for moderate to severe OSA.4 The prevalence of severe OSA in asymptomatic persons is unknown. In the Wisconsin Sleep Cohort Study, approximately 6% of adults with no or mild OSA progressed to moderate to severe OSA over 4 years.7

Risk factors associated with OSA include male sex, older age (40 to 70 years), postmenopausal status, higher BMI, and craniofacial and upper airway abnormalities. The evidence on other risk factors, such as smoking, alcohol and sedative use, and nasal congestion, is sparse or mixed.1

Observational studies have reported an association between severe OSA and mortality risk.8 In theory, screening for OSA could improve mortality by identifying OSA early and providing treatment before it can adversely influence mortality. Although studies generally show that treatment of OSA with CPAP and MADs improves intermediate outcomes, such as AHI and ESS score, there is a lack of studies demonstrating that change in AHI or ESS score improves health outcomes, and no well-controlled trials have demonstrated an improvement in mortality with treatment of OSA.

In trials reviewed by the USPSTF, treatment with CPAP effectively reduced AHI to normal (<5) or near-normal (<10) levels. Treatment with MADs showed more modest improvements in AHI. Treatment with either CPAP or MADs improved ESS scores by approximately 2 points, and trials evaluating treatment with CPAP also found reductions in blood pressure. However, the clinical significance of these small reductions is unclear. Of note, trials that evaluated treatment with CPAP or MADs were primarily conducted in referred or sleep clinic patients, not screen-detected patients from primary care settings.

Potential Harms

Direct evidence on the harms of screening for OSA is lacking. Commonly reported harms of treatment with CPAP include oral or nasal dryness, eye or skin irritation, rash, epistaxis, and pain.1 An estimated 14% to 32% of patients discontinue treatment with CPAP over 4 years.6 Commonly reported harms of treatment with MADs include oral mucosal, dental, or jaw symptoms, such as mucosal or dental pain, discomfort or tenderness, mucosal erosions, and jaw or temporomandibular joint pain or discomfort. Less common harms include oral dryness and excess salivation. Limited study data suggest that 7% of patients discontinue treatment with MADs because of harms.1

Current Practice

Most primary care clinicians do not routinely screen for OSA.1 According to a practice-based research network study of 44 practices, only 20% of patients with sleep-related symptoms who regularly visit a primary care clinician spontaneously reported their symptoms to their clinician.9 Some potential barriers to screening cited by clinicians include being unsure about how to identify and diagnose OSA, uncertainty regarding which type of sleep monitors are best for the diagnosis of OSA, and how to follow up patients who have been diagnosed with OSA.1

Screening Tests

Potential screening questionnaires and clinical prediction tools include the ESS, STOP Questionnaire (Snoring, Tiredness, Observed Apnea, High Blood Pressure), STOP-Bang Questionnaire (STOP Questionnaire plus BMI, Age, Neck Circumference, and Gender), Berlin Questionnaire, Wisconsin Sleep Questionnaire, and the Multivariable Apnea Prediction (MVAP) tool. However, none of these instruments have been adequately validated in a primary care setting.1

Other Considerations

Research Needs and Gaps

The identification of valid and reliable clinical prediction tools that could accurately determine which asymptomatic persons (or persons with unrecognized symptoms) would benefit from further evaluation and testing for OSA is needed. In addition, studies that evaluate the effect of OSA treatments or interventions on health outcomes (eg, all-cause and cardiovascular mortality, cardiovascular disease and cerebrovascular events, motor vehicle crashes, and cognitive impairment) that are adequately powered and have an appropriate length of follow-up are needed. Studies are also needed to evaluate whether improvement in AHI (for mild to severe OSA) leads to improvement in health outcomes. These represent critical gaps in the current evidence base. The USPSTF has identified the need for further research on the effect on health outcomes of screening for OSA among asymptomatic persons in the general population, as well as the role of sleepiness in determining health outcomes. More data on the natural history of mild OSA are also needed, in particular the rates of progression from mild to severe OSA, the length of duration before progression, and the magnitude of benefit if OSA is identified and treated earlier.




Based on data from the 1990s, the estimated prevalence of OSA in the United States is 10% for mild OSA and 3.8% to 6.5% for moderate to severe OSA.1-3 Current prevalence may be higher, given the increasing prevalence of obesity.4,5 The proportion of persons with OSA who are asymptomatic or have unrecognized symptoms is unknown. Severe OSA is associated with increased all-cause mortality;6 however, the role OSA plays in increasing overall mortality, independent from other risk factors (older age, higher body mass index [BMI], and other cardiovascular risk factors), is less clear. In addition to mortality, other adverse health outcomes associated with untreated OSA include cardiovascular disease and cerebrovascular events, diabetes, cognitive impairment, decreased quality of life, and motor vehicle crashes.


Evidence on the use of validated screening questionnaires in asymptomatic adults (or adults with unrecognized symptoms) to accurately identify who will benefit from further testing for OSA is inadequate. The USPSTF identified this as a critical gap in the evidence.

Benefits of Early Detection and Intervention or Treatment

The USPSTF found inadequate direct evidence on the benefit of screening for OSA in asymptomatic populations. The USPSTF found no studies that evaluated the effect of screening for OSA on health outcomes. The USPSTF found at least adequate evidence that treatment with continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) can improve intermediate outcomes (eg, the apnea-hypopnea index [AHI], Epworth Sleepiness Scale [ESS] score, and blood pressure) in populations referred for treatment. However, the applicability of this evidence to screen-detected populations is limited. The adequacy of the evidence varies based on the type of intervention and the reported intermediate outcomes. The USPSTF found inadequate evidence on the link between change in the intermediate outcome (eg, AHI) and reduction in the health outcome (eg, mortality). The USPSTF found evidence that treatment with CPAP can improve general and sleep-related quality of life in populations referred for treatment, but the applicability of this evidence to screen-detected populations is unknown. The USPSTF found inadequate evidence on whether treatment with CPAP or MADs improves other health outcomes (mortality, cognitive impairment, motor vehicle crashes, and cardiovascular or cerebrovascular events). The USPSTF also found inadequate evidence on the effect of treatment with various surgical procedures in improving intermediate or health outcomes.

Harms of Early Detection and Intervention or Treatment

The USPSTF found inadequate evidence on the direct harms of screening for OSA. The USPSTF found adequate evidence that the harms of treatment of OSA with CPAP and MADs are small. Reported harms include oral or nasal dryness; eye or skin irritation; rash; epistaxis; pain; excess salivation; and oral mucosal, dental, and jaw symptoms. The USPSTF found inadequate evidence on the harms of surgical treatment of OSA.

USPSTF Assessment

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults. Evidence on screening tools to accurately detect persons in asymptomatic populations who should receive further testing and treatment of subsequently diagnosed OSA to improve health outcomes is lacking, and the balance of benefits and harms cannot be determined.


Recommendations of OthersThe American Academy of Family Physicians’ recommendation is consistent with that of the USPSTF and concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for OSA in asymptomatic adults.20 The American College of Physicians recommends conducting a sleep study for patients with unexplained daytime sleepiness (grade: weak recommendation, low-quality evidence). It also recommends polysomnography for diagnostic testing in patients with suspected OSA. For patients without serious comorbid conditions, portable sleep monitors are recommended when polysomnography is not available (grade: weak recommendation, moderate-quality evidence).21 The American Academy of Sleep Medicine recommends that routine health maintenance evaluations include questions about OSA and evaluation for risk factors (obesity, retrognathia, and treatment-refractory hypertension). Positive findings should trigger a comprehensive sleep evaluation.22 The National Institute for Health and Care Excellence states that moderate to severe OSA or hypopnea syndrome can be diagnosed from patient history and an in-home sleep study using oximetry or other monitoring devices. In some cases, further studies that monitor additional physiological variables in a sleep laboratory or at home may be required, especially when alternative diagnoses are being considered.23


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No Evidence to Support Screening Asymptomatic Patients for Obstructive Sleep Apnea


The USPSTF's conclusion is simply the result of a substantial gap in the research literature — a gap that certainly needs filling. Evidence shows that various interventions, particularly CPAP, improve intermediate outcomes in symptomatic patients referred to specialty centers and that treatment is valuable for improving certain symptoms. What is missing is the first step, evidence that screening people in the general population (some of whom might have unrecognized symptoms) leads to these same benefits.

An editorialist makes the key point that a substantial proportion of moderate-to-severe OSA cases are undiagnosed. The USPSTF's conclusions do not at all preclude clinicians from using any questionnaire or general questions to explore symptoms in patients who are known to be at high risk for OSA (e.g., obese older men) — positive responses should trigger more detailed evaluations.


Disclosures for Thomas L. Schwenk, MD, at time of publication


US Preventive Services Task Force. Screening for obstructive sleep apnea in adults: US Preventive Services Task Force recommendation statement. JAMA 2017 Jan 24/31; 317:407. (

Jonas DE et al. Screening for obstructive sleep apnea in adults: Evidence report and systematic review for the US Preventive Services Task Force. JAMA 2017 Jan 24/31; 317:415. (

Redline S. Screening for obstructive sleep apnea: Implications for the sleep health of the population. JAMA 2017 Jan 24/31; 317:368. (

Sleep apnea - causes, symptoms, diagnosis, treatment, pathology

Pro: should asymptomatic patients with moderate-to-severe OSA be treated?

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Sleep apnea asymptomatic

Obstructive Sleep Apnea is a disorder where you can repeatedly stop and start breathing throughout the night. This occurs because while you sleep your throat muscles relax and end up blocking your airway, making it hard for you to breathe. This disorder poses many problems for those who suffer from it, but one of the larger issues is that people often do not realize they have it as they do not know about the obstructive sleep apnea symptoms. Since it occurs while you are asleep, many go long stretches of time without realizing there is a problem.

Another issue with the disorder is recognizing the signs. As some of them can be as simple as snoring, those with the disorder may not realize the severity of the issue. Thankfully, there are a few simple symptoms you can look out for, as well as the obstructive sleep apnea treatments that are discussed below.

What are Obstructive Sleep Apnea symptoms?

One of the best ways to know which obstructive sleep apnea treatments will work for you is to know the symptoms. It can be helpful to have someone sleep with you, or at least in the same room, who will be able to recognize the signs of OSA.

There are 4 major signs that you have OSA, some of which you can recognize yourself and some of which you may need someone else around to recognize. The symptoms of Obstructive Sleep Apnea:

  • Snoring loud enough to disturb your sleep or that of others
  • Waking up gasping or choking
  • Intermittent pauses in your breathing during sleep
  • Excessive daytime drowsiness, which may cause you to fall asleep while you’re working, watching television or even driving a vehicle

It is important to note that many people who do not have OSA also snore. Simply snoring may not indicate an OSA diagnosis, but if it is paired with one or more of the other Obstructive Sleep Apnea symptoms, alert your doctor of the issue. If it is impairing your sleep or others, it may still be beneficial to tell your doctor and ask about possible remedies.

Are there other signs?

There are many other obstructive sleep apnea symptoms for you to look out for. If you notice that you have one or more of these symptoms and suspect that OSA may be the cause of it, let your doctor know of your concerns so you can discuss the appropriate obstructive sleep apnea treatments.

  • Excessive daytime sleepiness
  • Loud snoring
  • Observed episodes of stopped breathing during sleep
  • Abrupt awakenings accompanied by gasping or choking
  • Awakening with a dry mouth or sore throat
  • Morning headache
  • Difficulty concentrating during the day
  • Experiencing mood changes, such as depression or irritability
  • High blood pressure
  • Nighttime sweating
  • Decreased libido

Remember that some of these obstructive sleep apnea symptoms may be better noticed by a loved one rather than yourself, especially in the case of pauses in your breathing and loud snoring.

Contact South Florida Sinus and Allergy Center for Obstructive Sleep Apnea Treatments

There are multiple options for obstructive sleep apnea treatments, from devices meant to keep your airways open to minimally invasive procedures. If you think OSA is a problem for you, discuss possible treatment plans with your physician to determine which is best for you. If you have any questions about OSA or any of its signs or symptoms, please contact the South Florida Sinus and Allergy Center at 954-951-4773 or visit our locations in Fort Lauderdale or Plantation.

Sleep Apnea: A New Detection Device

Obstructive sleep apnea (OSA) is a disorder characterized by repeated episodes of partial or total upper airway obstruction that result in arousals from sleep, and changes in oxygen levels during sleep. OSA is one of the most common conditions I see as a sleep medicine specialist. This is not surprising, considering that OSA is estimated to affect about 20% of the general population, and is even more prevalent in patients who are obese, or who have heart or metabolic conditions like diabetes.

When untreated, OSA can negatively impact cardiac and metabolic health, quality of life, and result in excessive daytime sleepiness, insomnia, problems with thinking, and depression or anxiety. OSA impacts people of all ages, backgrounds, shapes, and sizes, and while both patients and doctors have become increasingly aware about OSA and its effects over recent years, about 80% of patients with OSA still go undiagnosed.

How is OSA diagnosed?

The severity of OSA is based on the number of respiratory sleep disruptions per hour of sleep during a sleep study, also called the apnea-hypopnea index (AHI). Basically, the higher the AHI, the more severe the sleep apnea. Most population studies suggest that about 60% of people with OSA fall into the mild category. In general, many studies demonstrate a linear relationship between the AHI and adverse health outcomes, lending strong support for treatment of moderate and severe OSA, but with less clear-cut support for clinical and/or cost-effective benefits for treating mild OSA.

Scores for OSA don’t always correlate with symptoms

Regardless of the criteria for categorizing OSA as mild, moderate, or severe, the severity of disease does not always correlate with the extent of symptoms. In other words, some people with very mild disease (based on their AHI) can be extremely symptomatic, with excessive sleepiness or severe insomnia, while others with severe disease have subjectively good sleep quality and do not have significant daytime impairment.

Sleep disorders also tend to overlap, and patients with OSA may suffer from comorbid insomnia, circadian (internal body clock) disorders, sleep movement disorders (like restless legs syndrome), and/or conditions of hypersomnia (such as narcolepsy). To truly improve a patient’s sleep and daytime functioning, a detailed sleep related history is needed, and sleep issues must be addressed via a comprehensive, multidimensional, and individualized approach.

Treatment approaches depend on the severity of your OSA

When sleep apnea is moderate or severe, continuous positive airway pressure (CPAP) is considered the first-line treatment, and is the recommended treatment by the American Academy of Sleep Medicine (AASM). CPAP, by eliminating snoring, breathing disturbances, and drops in oxygen saturation, can essentially normalize breathing during sleep. However, to be most beneficial, CPAP should be worn consistently throughout sleep. Unfortunately, many studies of OSA set a relatively low bar for treatment adherence (many use a four-hour-per-night threshold), and do not necessarily take into account treatment efficacy (whether sleep apnea and related daytime symptoms persist despite treatment).

What about mild sleep apnea?

There have not always been consistent outcomes data or consensus about treatment recommendations for people with mild sleep apnea. Nonetheless, there are several studies that have demonstrated quality of life benefits in treating mild OSA, including a recent study published in The Lancet, where researchers from 11 centers throughout the United Kingdom recruited and randomized 301 patients with mild OSA to receive CPAP plus standard of care (sleep hygiene counselling) vs. standard of care alone, and followed them over three months. The results found that in patients with mild OSA, treatment with CPAP improved their quality of life, based on a validated questionnaire.

This study supports a comprehensive approach to evaluation and treatment of mild OSA. While all people with mild OSA may not need to be treated with CPAP, there are patients who can greatly benefit from it.

Treatments may be trial and error until you and your doctor get it right

When sleep apnea is mild, treatment recommendations are less clear-cut, and should be determined based on the severity of your symptoms, your preferences, and other co-occurring health problems. Working in conjunction with your doctor, you can try a stepwise approach — if one treatment doesn’t work, you can stop that and try an alternative. Managing mild sleep apnea involves shared decision-making between you and your doctor, and you should consider just how bothered you are by sleep apnea symptoms, as well as other components of your health that could be made worse by untreated sleep apnea.

Take-home suggestions

Conservative approaches for mild OSA:

  • Maximize a side sleeping position; try not to sleep on your back.
  • Optimize weight if overweight or obese; even a 5-to-10-pound weight loss can make a difference in mild OSA.
  • Treat nasal allergies/congestion.
  • Avoid alcohol or respiratory depressant medications close to bedtime.
  • Make sure that you get an adequate amount of sleep, and keep fairly regular sleep and wake times across the week.

If you have bothersome symptoms related to OSA — such as loud, disruptive snoring, long pauses in breathing, repeated nighttime awakenings, unrefreshing sleep, insomnia, trouble thinking, or excessive daytime sleepiness — or significant health problems that might be exacerbated by OSA (even mild) — such as arrhythmia, high blood pressure requiring multiple medications to control, stroke, or a severe mood disorder — medical treatment(s) for OSA should be considered.

The medical treatments for mild OSA:

  • continuous positive airway pressure device (CPAP)
  • a dental appliance to treat sleep apnea
  • an evaluation with an ear, nose, and throat specialist (ENT), to see if there is an anatomic issue (like severe nasal septal deviation) that may be causing OSA, or making it worse.

If you are concerned you might have OSA, talk to your doctor

Based on your symptoms, exam, and risk factors, your doctor may recommend a sleep study, or you might be referred to see a sleep medicine specialist. A comprehensive sleep assessment is needed to accurately evaluate sleep complaints, since sleep disorders tend to overlap. Treatment for mild OSA may improve sleep-related symptoms and your quality of life. However, there is no one-size-fits-all approach when it comes to sleep disorders, but rather a multidimensional and individualized approach to find what works for you.

As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review or update on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

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Not sleeping but not sleepy with asymptomatic apnea

NEW ORLEANS—Usually in a discussion of treatment options, the patient has questions and the doctor offers the answers. However, during the session “Should we treat asymptomatic obstructive sleep apnea patients?” at the May meeting of the American Thoracic Society (ATS) in New Orleans, the only speaker with a definitive answer was the patient.

Less sleepy patients are less likely to stick with CPAP probably because they perceive less benefit Picture by PhotoResearchers

“My answer is yes,” said Michael Goldman, a corporate lawyer who had experienced no problems with daytime sleepiness before being diagnosed with sleep apnea. Yet treatment with continuous positive airway pressure (CPAP) changed his life. “It's just like a fog I didn't even know existed has been lifted,” he said.

The sleep apnea researchers who spoke during the session were less enthusiastic about the benefits of treating asymptomatic patients, whom they defined as those who don't complain of daytime sleepiness. The main problem is that there are so many of them. Studies have estimated the prevalence of sleep apnea as high as a quarter of the population.

“If we want to treat all these patients, we have a lot to do,” said Malcolm Kohler, MD, of the University Hospital of Zurich in Switzerland.

It's also unclear what benefits the patients will receive from treatment. A number of studies have tried to determine whether CPAP treatment reduces cardiovascular risk in patients who aren't sleepy. But it's difficult to draw definitive conclusions, Dr. Kohler said, because the evidence of an association with cardiovascular events comes from cohort studies, while most of the controlled studies looked only at surrogate markers.

Some additional data on the question were presented at the ATS meeting by a group of Spanish researchers. The trial included 724 non-sleepy patients randomized to CPAP or conservative treatment (advice on weight control and sleep). Treated patients were less likely to have cardiovascular events and hypertension. “We need to treat 32 patients with CPAP to avoid one new event,” said study author Ferran Barbé Illa, MD, of the Hospital Arnau de Vilanova in Spain.

However, the effect only reached statistical significance among patients who used their CPAP machine for at least four hours per night. Compliance tends to be a problem among these patients, noted Teri Weaver, PhD, RN, of the University of Pennsylvania in Philadelphia. Less sleepy patients are less likely to stick with CPAP, likely because they perceive less benefit.

“It may not be sleepiness itself but how sleepiness affects daily activities,” she said.

Daily functioning

The significance of sleepiness to daily functioning is a complicating factor in addressing sleep apnea in the elderly, who tend to have a higher prevalence of sleep-disorder breathing, but lower scores on sleepiness scales. “Older people have an increased opportunity to nap,” noted Mary J. Morrell, PhD, of the Imperial College School of Medicine in England.

The breathing problems of the elderly are hard to separate from comorbidities, but even super-healthy elderly patients have been shown to have breathing issues during sleep, possibly due to structural changes to the airway, Dr. Morrell said.

One study that used mortality as an outcome even found that moderate sleep apnea could be protective—patients who had it were actually less likely to die than those without. “It presents more questions than answers,” said Dr. Morrell. “There are potential cardiovascular consequences but I don't think there are enough data on it [in older people] yet.”

She hopes to have more data within the next few years, having just received funding to conduct a large trial of sleep apnea in elderly patients in the United Kingdom.

Assessing risk

Cardiovascular effects are not the only reason to treat sleep apnea, however. “Patients with obstructive sleep apnea are more likely to have motor vehicle crashes than normal individuals,” said John A. Fleetham, MD, of the University of British Columbia in Vancouver, Canada.

The risk appears to apply just as much to patients who say they are not sleepy. “There's no clear pattern with crash rate being associated with Epworth sleepiness scale,” he said.

In fact, patients who don't think they have daytime sleepiness could potentially pose more risk, because they are unaware of their sleepiness. Another potential issue is that patients may misrepresent their sleepiness to avoid consequences like losing their drivers' licenses.

Physicians treating these patients are put in the awkward position of having to balance public safety with a patient's individual benefit and wishes. The decision on how to treat the patient and whether to report him or her to authorities rests on relevant local law, which is “all over the map,” according to Dr. Fleetham. “Be aware of the motor vehicle legislation according to your local area,” he advised.

On a societal level, he has concerns about requiring doctors to report patients with sleep problems. “Such reporting may discourage many drivers from seeking treatment,” he said.

On an individual level, he bases his decisions on patients' attitudes, such as whether they agree to not drive when sleepy, and their driving habits. CPAP treatment is a priority for commercial drivers with apnea, for example.

Official guidelines from a 2006 joint task force of the American College of Chest Physicians, American College of Occupational and Environmental Medicine and the National Sleep Foundation call for taking commercial drivers off the road prior to further assessment if they have an Epworth sleepiness scale of 16 or more, but there's not much evidence to support that cutoff, according to Dr. Fleetham. “I was amazed by how little data there is,” he said.

It was a theme repeated throughout the session: Experts in the field are not ready to answer the question posed by the session title, even after years of study. Dr. Weaver noted that she also spoke on the subject at the 2001 ATS meeting. “I could still use the same slides,” she joked.


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