Clinical presentation and diagnosis of obstructive sleep apnea in adults
- Lewis R Kline, MD
Lewis R Kline, MD
- Associate Professor of Medicine
- Temple University School of Medicine
Obstructive sleep apnea (OSA) is a disorder that is characterized by obstructive apneas and hypopneas caused by repetitive collapse of the upper airway during sleep. The diagnosis should be considered whenever a patient presents with symptoms such as excessive daytime sleepiness, snoring, and choking or gasping during sleep, particularly in the presence of risk factors such as obesity, male gender, and advanced age. The challenge is to select the patients who are most likely to have OSA for further diagnostic evaluation, since expensive and time consuming testing has traditionally been required to identify OSA.
The clinical presentation, clinical features, diagnostic approach, and differential diagnosis of OSA are reviewed here. The epidemiology, risk factors, pathogenesis, natural history, and management of OSA are described separately. (See "Overview of obstructive sleep apnea in adults" and "Management of obstructive sleep apnea in adults".)
Clinical presentation — Most patients with OSA first come to the attention of a clinician because the patient complains of daytime sleepiness, or the bed partner reports loud snoring, gasping, snorting, or interruptions in breathing while sleeping. These symptoms may be presenting complaints, reported during the evaluation of another complaint, detected during health maintenance screening, or reported during preoperative screening. Regardless of how the complaints are identified, all patients who report daytime sleepiness or snoring, gasping, snorting, or interruptions in breathing while sleeping, should be asked about and examined for other features of OSA. This information is important for determining which patients require diagnostic testing.
Signs and symptoms — Daytime sleepiness, distinct from fatigue, is a common feature of OSA. Sleepiness is the inability to remain fully awake or alert during the wakefulness portion of the sleep-wake cycle, while fatigue is a subjective lack of physical or mental energy that is perceived by the individual or caregiver to interfere with usual and desired activities . It is often unclear whether a patient's complaint of daytime sleepiness represents true sleepiness or fatigue. In such cases, series of directed questions can be combined with the Epworth Sleepiness Scale to quantitatively document the patient’s perception of sleepiness, fatigue, or both (table 1 and table 2) [2,3]. (See "Approach to the patient with excessive daytime sleepiness", section on 'History'.)
Daytime sleepiness may go unnoticed or its significance may be underestimated because of its insidious onset and chronicity. The patient may not describe the symptom as sleepiness, but may use other terms, such as fatigue, tiredness, and low energy . Careful questioning of the patient typically reveals a pattern of feeling sleepy or falling asleep in boring, passive, or monotonous situations. As an example, the patient may admit to consistently falling asleep while reading, watching television, or even while operating a motor vehicle. In addition, embarrassing or inappropriate episodes of sleep (eg, at religious services, while driving) may be reported. Reviewing patient behavior away from the workplace is essential because daytime sleepiness can be masked by activity. Patients should always be asked about behaviors that may mask sleepiness, such as caffeine consumption.
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- CLINICAL FEATURES
- Clinical presentation
- Signs and symptoms
- Physical examination
- Screening questionnaires
- INDICATIONS FOR DIAGNOSTIC TESTING
- DIAGNOSTIC TESTS
- - Full versus split-night study
- Home sleep apnea testing
- In-hospital testing
- DISEASE SPECTRUM
- DIFFERENTIAL DIAGNOSIS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS