Does This Patient Have Obstructive Sleep Apnea? The Rational Clinical Examination Systematic Review

Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada.
JAMA The Journal of the American Medical Association (Impact Factor: 35.29). 08/2013; 310(7):731-41. DOI: 10.1001/jama.2013.276185
Source: PubMed


IMPORTANCE Obstructive sleep apnea is a common disease, responsible for daytime sleepiness. Prior to referring patients for definitive testing, the likelihood of obstructive sleep apnea should be established in the clinical examination. OBJECTIVE To systematically review the clinical examination accuracy in diagnosing obstructive sleep apnea. DATA SOURCES MEDLINE and reference lists from articles were searched from 1966 to June 2013. Titles and abstracts (n = 4449) were reviewed for eligibility and appraised for evidence levels. STUDY SELECTION For inclusion, studies must have used full, attended nocturnal polysomnography for the reference standard (n = 42). MAIN OUTCOMES AND MEASURES Community and referral-based prevalence of obstructive sleep apnea; accuracy of symptoms and signs for the diagnosis of obstructive sleep apnea. RESULTS The prevalence of sleep apnea in community-screened patients is 2% to 14% (sample sizes 360-1741) and 21% to 90% (sample sizes 42-2677) for patients referred for sleep evaluation. The prevalence varies based on the apnea-hypopnea index (AHI) threshold used for the evaluation (≥5 events/h, prevalence 14%; ≥15/h, prevalence 6%) and whether the disease definition requires symptoms in addition to an abnormal AHI (≥5/h with symptoms, prevalence 2%-4%). Among patients referred for sleep evaluation, those with sleep apnea weighed more (summary body mass index, 31.4; 95% CI, 30.5-32.2) than those without sleep apnea (summary BMI, 28.3; 95% CI, 27.6-29.0; P < .001 for the comparison). The most useful observation for identifying patients with obstructive sleep apnea was nocturnal choking or gasping (summary likelihood ratio [LR], 3.3; 95% CI, 2.1-4.6) when the diagnosis was established by AHI ≥10/h). Snoring is common in sleep apnea patients but is not useful for establishing the diagnosis (summary LR, 1.1; 95% CI, 1.0-1.1). Patients with mild snoring and body mass index lower than 26 are unlikely to have moderate or severe obstructive sleep apnea (LR, 0.07; 95% CI, 0.03-0.19 at threshold of AHI ≥15/h). CONCLUSIONS AND RELEVANCE Nocturnal gasping or choking is the most reliable indicator of obstructive sleep apnea, whereas snoring is not very specific. The clinical examination of patients with suspected obstructive sleep apnea is useful for selecting patients for more definitive testing.

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    • "Obstructive Sleep Apnea (OSA) is a type of sleep apnea characterized by repeated episodes of reduction or cessation of airflow during sleep, caused by pharyngeal narrowing or collapse [1]. OSA is associated with an increased risk of morbidity and mortality [2] [3] [4] but, once diagnosed, it can be treated effectively with causal therapy (e.g., weight loss), intraoral devices, continuous positive airway pressure (CPAP), and surgery [5]. For these reasons, the main challenge is to identify these patients in order to treat them early. "
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    ABSTRACT: Rationale. The gold standard for the diagnosis of Obstructive Sleep Apnea (OSA) is polysomnography, whose access is however reduced by costs and limited availability, so that additional diagnostic tests are needed. Objectives. To analyze the diagnostic accuracy of the Obstructive Airway Adult Test (OAAT) compared to polysomnography for the diagnosis of OSA in adult patients. Methods. Ninety patients affected by OSA verified with polysomnography (AHI ≥ 5) and ten healthy patients, randomly selected, were included and all were interviewed by one blind examiner with OAAT questions. Measurements and Main Results. The Spearman rho, evaluated to measure the correlation between OAAT and polysomnography, was 0.72 ( p < 0.01 ). The area under the ROC curve (95% CI) was the parameter to evaluate the accuracy of the OAAT: it was 0.91 (0.81–1.00) for the diagnosis of OSA (AHI ≥ 5), 0.90 (0.82–0.98) for moderate OSA (AHI ≥ 15), and 0.84 (0.76–0.92) for severe OSA (AHI ≥ 30). Conclusions. The OAAT has shown a high correlation with polysomnography and also a high diagnostic accuracy for the diagnosis of OSA. It has also been shown to be able to discriminate among the different degrees of severity of OSA. Additional large studies aiming to validate this questionnaire as a screening or diagnostic test are needed.
    01/2015; 2015(4):1-8. DOI:10.1155/2015/915185
    • "Other sophisticated imaging modalities are not readily available in most clinical settings. Therefore, in addition to a detailed medical history (Myers et al. 2013), systematic evaluation of craniofacial morphology (Friedman et al. 2004; Lee et al. 2009) and standard PSG, further studies are needed to determine the optimum office procedure for evaluating the severity and localization of UA occlusion during obstructive events. Ultrasonography is a simple dynamic imaging modality that can reveal most anatomic structures surrounding the UA. "
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    ABSTRACT: Dynamic tongue base thickness (TBT) may be an important anatomic factor in airway narrowing in patients with obstructive sleep apnea (OSA). The development of an accurate clinical assessment of the retroglossal airway in patients with OSA is still evolving. Submental ultrasound was used to investigate the association between measurements of TBT in response to negative airway pressure and the existence of OSA. Twenty OSA patients and 20 control participants underwent ultrasound measurement of TBT on eupneic breathing and with the Mueller maneuver, as well as clinical and polysomnographic assessments. Logistic regression analyses indicated that after adjustment for confounding factors, independent predictors of OSA included TBT in response to negative airway pressure, as measured by submental ultrasound with the Mueller maneuver (odds ratio: 2.11, 95% confidence interval: 1.15-3.87, p < 0.05), and the difference between TBT with the Muller maneuver and that without the Mueller maneuver (odds ratio: 2.47, 95% confidence interval: 1.09-5.58, p < 0.05). Ultrasound measurement of TBT during the Mueller maneuver provides a quantitative assessment of the retroglossal airway in OSA patients with minimal invasiveness and easy accessibility.
    Ultrasound in Medicine & Biology 09/2014; 40(11). DOI:10.1016/j.ultrasmedbio.2014.06.019 · 2.21 Impact Factor
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    • "OSA is increasingly recognized as an intricate manifestation of several systemic disorders, creating a disease that directly threatens the basic life processes of breathing and sleep [1]. OSA is characterized by repeated episodes of upper airway obstruction during sleep, causing expiratory dyspnea, intermittent oxygen desaturation, systemic and pulmonary arterial blood pressure surges, and sleep disruption [2]. Long-term chronic intermittent hypoxia, hypoxemia, and sleep fragmentation causes and aggravates cardiovascular and cerebrovascular diseases [1], [3], [4], metabolic syndrome [5], diabetes [6], resistant hypertension [7], and cognitive disorders [8]; and reduces the quality-of-life [9]. "
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    ABSTRACT: Aim To seek accurate and credible correlation manner between gender, age, and obesity; and the severity of obstructive sleep apnea (OSA) in large-scale population. Methods Totals of 1,975 male and 378 female OSA patients were sequentially recruited. Centralized covariant tendencies between age, body mass index (BMI), and waist hip ratio (WHR); and OSA severity, were explored in a gender-specific manner via multiple statistical analyses. The accuracies of observed correlations were further evaluated by adaptive multiple linear regression. Results All of age, BMI, WHR, smoking, drinking, and OSA severity differed between males and females. BMI and WHR were positively and (approximately) linearly associated with OSA severity in both males and females. Restricted cubic spline analysis was more effective than was the Pearson correlation approach in correlating age with AHI, and provided age crossover points allowing further piecewise linear modeling for both males and females. Multiple linear regression showed that increasing age was associated with OSA exacerbation in males aged ≤40 years and in females aged 45–53 years. BMI, WHR, and diabetes were independently associated with OSA severity in males with age-group-specific pattern. In females, only BMI was associated with OSA severity at all ages. Conclusions In male patients, BMI and WHR are prominent risk factors for OSA exacerbation. Age and diabetes are associated with OSA severity in males of particular ages. In females, BMI is also a prominent risk factor for severe OSA, and OSA severity increased with age in the range 45–53 years.
    PLoS ONE 09/2014; 9(9):e107380. DOI:10.1371/journal.pone.0107380 · 3.23 Impact Factor
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