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Obstructive Sleep Apnea (OSA)

Brief Overview: Obstructive Sleep Apnea (OSA) is a chronic sleep-related breathing disorder characterized by repeated partial or complete upper airway obstruction during sleep, leading to intermittent hypoxia, sleep fragmentation, and non-restorative sleep.
OSA is common, underdiagnosed, and associated with significant cardiovascular, metabolic, and neurocognitive risks. Management focuses on maintaining airway patency during sleep, improving symptoms, and reducing long-term complications.

Prevalence: According to UpToDate, “the estimated prevalence in North America is approximately 15 to 30 percent in males and 10 to 15 percent in females, when OSA is defined broadly as an apnea-hypopnea index (AHI) greater than five events per hour of sleep.”

Etiology:

  • Upper airway collapse during sleep due to reduced muscle tone.
  • Anatomical narrowing of the airway (large tonsils, crowded oropharynx).
  • Decreased neuromuscular control during REM sleep.
  • Obesity-related fat deposition around the neck and airway.

Risk Factors:

  • Older age (up until 60s-70s years of age)
  • Male
  • Obesity
  • Craniofacial/structural differences

Commonly Associated Conditions:

  • Obesity hypoventilation syndrome
  • CHF
  • A-fib
  • Pulmonary HTN
  • HTN
  • ESKD
  • Chronic lung disease (asthma, COPD, idiopathic pulmonary fibrosis)
  • Stroke and TIAs
  • Acromegaly
  • Hypothyroidism
  • PCOS
  • Parkinson’s disease
  • Floppy eyelid syndrome

Common Medications:

There is no medication that cures OSA. Medications are used to address residual symptoms, comorbid conditions, or contributing factors.

  • Weight loss medications: tirzepatide, phentermine/topiramate, liraglutide

Common Labs, Imaging, and Tests:

  • Attended, In-laboratory polysomnography
  • Unattended home sleep apnea testing

Common Symptoms:

  • Daytime sleepiness
  • Snoring, choking, gasping during sleep
  • Nonrestorative sleep, fatigue
  • Nocturnal restlessness
  • Witnessed apnea by bed partner
  • Insomnia
  • Difficulty concentrating
  • Changes in mood
  • Morning headaches
  • Vivid dreams
  • Nocturia
  • Cognitive deficits, like short-term memory loss

Common Treatments:

  • Positive Airway Pressure (PAP) therapy – first-line treatment: CPAP, APAP, or BiPAP
  • Oral appliances (mandibular advancement device, tongue retaining device)
  • Weight loss (dietary changes, exercise as tolerated, medications, bariatric surgery when indicated)
  • Positional therapy (avoid supine sleep)
  • Surgical options (selected patients):
    • Uvulopalatopharyngoplasty (UPPP)
    • Maxillomandibular advancement
    • Hypoglossal nerve stimulation (Inspire device)
  • Treatment of any contributing conditions

Physical Findings:

  • Obesity
  • Large neck circumference
  • Craniofacial abnormalities
  • Narrow or “crowded” oropharynx (Mallampati 3 or 4)

Potential Complications and Contraindications:

  • Complications of untreated OSA:
    • Cardiovascular disease (HTN, MI, stroke)
    • Arrhythmias (especially atrial fibrillation)
    • Type 2 diabetes
    • Motor vehicle and work-related accidents
    • Cognitive decline and mood disorders
    • Increased perioperative risk
  • Contraindications / cautions:
    • Untreated OSA increases anesthesia and opioid risk
    • Poor PAP adherence limits symptom improvement
    • Sedatives and alcohol worsen severity
    • Avoid medications/substances that can act as central nervous system depressants, disrupt sleep architecture, and potentially worsen OSA and daytime sleepiness

General Health and Lifestyle Guidance:

  • Encourage consistent PAP use (≥4 hours/night, ideally all sleep time).
  • Weight management through diet and regular physical activity.
  • Avoid alcohol and sedatives, especially before bedtime.
  • Side-sleeping when appropriate.
  • Maintain nasal patency (saline sprays, allergy management).
  • Reinforce importance of follow-up sleep medicine visits and equipment checks.
  • Advise patient to address mask fit and comfort issues early with healthcare provider to improve adherence.
  • Discuss vaccination recommendations with healthcare provider.
  • Avoid tobacco, cannabis, and vaping

Suggested Questions to Ask Patients:

  • Do you snore loudly or has anyone witnessed you stop breathing during sleep?
  • How refreshed do you feel upon waking?
  • Do you experience daytime sleepiness or fatigue?
  • Are you currently using CPAP or another device? How many hours per night?
  • Any issues with mask fit, dryness, or discomfort?
  • Have you had recent weight changes?
  • Do you take sedatives, sleep aids, or opioids?
  • Have you had any near-miss accidents due to sleepiness?

Suggested Talking Points:

  • OSA causes repeated breathing interruptions during sleep and can affect your heart, brain, and energy levels.
  • PAP therapy is the most effective treatment and works best when used consistently.
  • If CPAP feels uncomfortable, there may be adjustments and alternatives you can explore with your healthcare provider.
  • Weight loss and avoiding alcohol before bed can significantly improve symptoms.
  • Treating sleep apnea improves daytime energy and lowers long-term health risks.

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