4-26
Subjective: Symptoms
Early: Excessive daytime sleepiness, disrupted sleep, recent weight gain, repetitive awakenings with transient
sensation of shortness of breath or for unclear reasons, tired and unrefreshed upon AM awakening, poor
concentration, memory problems, decreased libido; spouse or others may witness apneas, loud snoring,
irritability or short temper.
Late: Morning headache, depression
Focused History: Quantity: How much weight have you gained in the last year? (> 20 pounds is a
significant risk factor). Quality: Do you fall asleep during the daytime? (Excessive daytime sleepiness is the
hallmark of this syndrome). Do you snore? How long have you snored? (loose or excessive pharyngeal
tissue can cause chronic snoring and apnea) Aggravating Factors: What seems to worsen your symptoms?
(Alcohol or sedatives, and additional weight gain will worsen sleep apnea).
Objective: Signs
Using Basic Tools:
Vital signs: Hypertension, tachycardia or bradycardia seen in chronic apnea.
Inspection: Narrowed airway, large tonsils, low-hanging soft palate or uvula may predispose to airway block-
age at night. Neck: Inspect for “bull neck” indicating possible intrathoracic disease, tumor, pneumothorax.
Auscultation: Turbulent airow during sleep may produce rhonchi that may be localized to neck or nasophar-
ynx. Extra heart sounds may suggest heart failure.
Using Advanced Tools: Lab: High hematocrit (polycythemia) on CBC may be a consequence of hypoxemia.
Assessment:
Differential Diagnosis
Excessive daytime somnolence - narcolepsy (usually associated with sudden loss of muscle tone during emo-
tional moments, and/or hallucinations on awakening), inadequate sleep (review history), depression/anxiety
disorder (see Symptom: Depression and/or Symptom: Anxiety).
Nocturnal awakenings - asthma, COPD, CHF. See respective sections in this book. If occurs suddenly, see
panic attacks in Symptom: Anxiety)
Hypothyroidism causes sleep disturbances and sluggishness (see Endocrine: Thyroid Disorders).
Gastroesophageal reflux may also cause awakenings with transient sensation of shortness of breath or for
unclear reasons (see GI: Acute Gastritis).
Plan:
Treatment
Primary:
- Treat the underlying specific etiology, which may mean weight loss in the obese.
- Treat with nasal Continuous Positive Airway Pressure (CPAP) to prevent apneas until body weight is lost.
The extra oxygen can have the dramatic effect of “waking” someone up that has been partially asleep for
years during the daytime.
Alternative: CNS stimulants provide some short-term effect. Protriptyline 10-30 mg or fluoxetine 20-60 mg
po can occasionally be helpful for mild to moderate sleep apnea.
Primitive: Apnea is related to sleep position (on the back), so have patient sleep on his side and elevate
the head of the bed.
Patient Education
General: Treat obesity with behavior modication. Regaining lost weight will generally cause a return of
symptoms.
Activity: Encourage exercise after ensuring cardiorespiratory system is healthy enough to tolerate the stress.
Prevention: Avoid sedatives and alcohol, which act as central nervous system depressants and worsen
sleep apnea.
Follow-up Actions
Return Evaluation: Long-term compliance is not high for CPAP unless the patient has severe sleep apnea
syndrome. Consider alternate therapies listed above in these patients.