Sleep apnea is a condition where breathing stops briefly during sleep. There are three main types: obstructive, central, and mixed. Screening tools like the Berlin questionnaire and STOP-BANG test can help identify patients at risk but formal sleep testing is still needed. Symptoms include loud snoring, witnessed apnea, daytime sleepiness, and insomnia. Physical signs may include neck size over 16" for women or 17" for men. Treatment options include lifestyle changes like weight loss and avoiding alcohol before bed. CPAP is often used but alternative options exist like oral appliances or surgery.

1. SLEEP APNEA
Dr Aditya Agrawal
Consultant Chest Physician
Allergy, Critical Care and Sleep Medicine Specialist
Bhatia Hospital
Apollo Spectra I Cumballa I Motinben Dalvi I St Elizabeth I Masina
Tel No: 9022163859

2. What is Apnea?
• Apnea: a Greek word - “want of breath”
• Obstructive
• Central
• Mixed

4. Barriers to Diagnosis & Treatment

5. What are the screening tools?
Berlin questionnaire (primary care setting)
10 items
Snoring severity, significance of daytime sleepiness, witnessed apnea,
obesity, hypertension
STOP-BANG screening test (preoperative setting)
8 items
STOP: Snoring, Tired, Observed apnea, high blood Pressure history
BANG: elevated BMI, Age > 50, increased Neck circumference, Gender male
Neither tool precludes formal sleep testing

6. Berlin questionnaire
Snoring severity,
significance of daytime sleepiness,
witnessed apnea,
obesity,
hypertension

7. STOP-BANG screening test
STOP:
Snoring,
Tired,
Observed apnea,
High blood Pressure history
BANG:
elevated BMI,
Age > 50,
increased Neck circumference,
Gender male

8. Screening and Prevention
Ask all adults about sleep problems or daytime sleepiness
If response is positive: perform OSA screening
 Take further clinical history
 Use validated questionnaire
Screen is also warranted for all patients with:
 Significant obesity
 CVD
 History of drowsiness while driving

9. What symptoms should prompt consideration of
OSA?
Witnessed episodes of apnea
Loud, frequent, bothersome snoring
Choking/gasping during sleep
Excessive daytime sleepiness
Drowsy driving
Unrefreshing sleep, sleep fragmentation
Insomnia
Nocturia
Morning headaches
Decreased concentration, memory loss
Decreased libido

10. Nocturnal presentation
• Apnea
• Dyspnea
• Snoring
• Mouth breathing
• Restless sleep

11. In the absence of symptoms, what other
diseases should prompt evaluation?
Morbid obesity
If patient scheduled for bariatric surgery
Hypertension
If refractory to medical therapy

12. What other conditions should be considered?
Chronic sleep deprivation disorder (shift-work
disorder)
Circadian rhythm disorder
Depression and anxiety
Hypothyroidism
Obesity hypoventilation syndrome
Central sleep apnea syndrome
Congestive heart failure (Cheyne-Stokes
respiration)
Opiate-induced central sleep apnea

13. Physical Examination
• Respiratory,
• Cardiovascular and
• Neurologic systems
• Presence of and degree of obesity
• Signs of upper airway narrowing
• Neck >16” women, >17” men
• Mallampati score of 3 or 4
• Macroglossia, tonsillar hypertrophy
• Enlarged or elongated uvula, high/arched
palate
• Nasal obstruction
• Retrognathia

14. Sources of Cost for Undiagnosed OSA
Comorbidities &
Mental Health
Hypertension
Heart Disease
Diabetes
Asthma/Breathing Disorders
Insomnia
Depression/Anxiety/Mental Health
Includes cost of healthcare
services, medication, and
quality of life.
Motor Vehicle
Accidents
Commercial
Non-Commercial
Includes medical costs,
emergency services, property
damage, lost productivity, and
monetized quality adjusted life
years (QALYs) incurred by
company, insurer, victims,
government and others.
Fatal
Non-Fatal
Fatal
Non-Fatal
$6.9 B
Includes fatal and non-fatal accidents. Includes medical costs and lost
productivity.
Workplace Accidents
Lost Productivity
Productivity
Absenteeism

15. TREATMENT

16. Initial Management
Counsel overweight patients about weight loss
Treat any nasal congestion
Advise alcohol avoidance close to bedtime
Offer trial of therapy (CPAP) if patient has
Daytime sleepiness or frequent nocturnal awakenings
Recent accident or near-miss attributable to sleepiness
Controversial: whether to treat asymptomatic patients with mild or moderate OSA

17. Alternative Treatment Modalities
Uvulopharyngopalatoplasty (UPPP):
 in CP pt and hypotonic upper airway muscles;
 it has not been studied in the uncomplicated pediatric patients
Oral appliances
 have not been reported in children (it may adversely affect the facial
configuration of the growing child)
 In children, CPAP is usually used when T&A is unsuccessful or
contraindicated rather than as a primary treatment
 Young infants
 Medical conditions