If your clinical practice is anything like mine, you have many patients who have been diagnosed with obstructive sleep apnea. If you don’t have many patients with obstructive sleep apnea, I think you should worry that the diagnosis is being missed in many of them.
And, in any case, let’s try to screen ALL our patients for possible obstructive sleep apnea. Why do I seem to be obsessed with this issue and emphasize this every time I get a chance? Because obstructive sleep apnea is very common and it goes undiagnosed in the vast majority of those who have it—with terrible consequences to them and to others.
Obstructive sleep apnea is very common
Before getting into how common obstructive sleep apnea (OSA) is, we should note that what we are most interested in is actually the prevalence of obstructive sleep apnea that is clinically significant. This is usually defined as an Apnea-Hypopnea Index (AHI) of 5 or more events per hour ALONG WITH symptoms of obstructive sleep apnea, especially excessive daytime sleepiness. The two together are known as the obstructive sleep apnea syndrome.
The prevalence of obstructive sleep apnea syndrome in community populations (not patients in outpatient or inpatient settings) varies a lot from study to study and we don’t need to get caught up in that. But, a good estimate (and one that we can remember easily) is about 5%—6% in men and about 4% in women (Franklin and Lindberg, 2015; Myers et al., 2013). This 5% estimate made me think that there’s a fair chance that many of the clinicians reading this article have clinically-significant obstructive sleep apnea!
Here are some more thing things to note about the high prevalence of the clinically-significant obstructive sleep apnea syndrome:
– The prevalence is even higher in clinical populations, especially patients with certain conditions. These include refractory hypertension, coronary artery disease, congestive heart failure, cardiac arrhythmias, type 2 diabetes mellitus, polycystic ovarian syndrome, etc. (Kapur et al., 2017).
– The prevalence is sky-high in persons being evaluated for bariatric surgery and those who have had a transient ischemic attack (TIA) or stroke (Kapur et al., 2017; Costa et al., 2015).
– While we said above that we are understandably most interested in obstructive sleep apnea accompanied by clinical symptoms, a troubling fact is that persons with an elevated Apnea-Hypopnea Index (AHI) who don’t have excessive daytime sleepiness may still be an increased risk for bad outcomes associated with obstructive sleep apnea, e.g., cardiovascular disease (Kapur et al., 2017).
– The prevalence of OSA appears to be increasing over the years (Franklin and Lindberg, 2015; Peppard et al., 2013). This may be because the prevalence of obesity, a major risk factor for OSA, is increasing.
OSA usually goes undiagnosed
The vast majority of persons with even clinically significant obstructive sleep apnea go undiagnosed (Costa et al., 2015; Lettieri et al., 2005; Kapur et al., 2002).
There are many reasons for the very commonly missed diagnosis of obstructive sleep apnea and the MAIN things we need to do it:
– Keep our suspicions high and look for it in all our patients
– Screen all our patients for possible sleep apnea by using the STOP-Bang questionnaire.
How to screen patients for possible obstructive sleep apnea is discussed in other articles on this website. See Related Pages below.
As discussed in another article on this website, many patients with major depressive disorder also have undiagnosed obstructive sleep apnea. See Are we missing the diagnosis of sleep apnea in our patients with major depressive disorder?
The question we all have to ask ourselves is—What are we going to do about this?
Please post your answer to that question under “Leave a Reply” below.
STOP-Bang Questionnaire (my summary and link to the questionnaire)
Kapur VK, Auckley DH, Chowdhuri S, Kuhlmann DC, Mehra R, Ramar K, Harrod CG. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Mar 15;13(3):479-504. doi: 10.5664/jcsm.6506. PMID: 28162150; PMCID: PMC5337595.
Franklin KA, Lindberg E. Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea. J Thorac Dis. 2015 Aug;7(8):1311-22. doi: 10.3978/j.issn.2072-1439.2015.06.11. PMID: 26380759; PMCID: PMC4561280.
Lin J, Suurna M. Sleep Apnea and Sleep-Disordered Breathing. Otolaryngol Clin North Am. 2018 Aug;51(4):827-833. doi: 10.1016/j.otc.2018.03.009. Epub 2018 May 17. Review. PubMed PMID: 29779616.
Myers KA, Mrkobrada M, Simel DL. Does this patient have obstructive sleep apnea?: The Rational Clinical Examination systematic review. JAMA. 2013 Aug 21;310(7):731-41. doi: 10.1001/jama.2013.276185. PMID: 23989984.
Patel SR. Obstructive Sleep Apnea. Ann Intern Med. 2019 Dec 3;171(11):ITC81-ITC96. doi: 10.7326/AITC201912030. PMID: 31791057.
Costa LE, Uchôa CH, Harmon RR, Bortolotto LA, Lorenzi-Filho G, Drager LF. Potential underdiagnosis of obstructive sleep apnoea in the cardiology outpatient setting. Heart. 2015 Aug;101(16):1288-92. doi: 10.1136/heartjnl-2014-307276. Epub 2015 Apr 20. PMID: 25897039.
Kapur V, Strohl KP, Redline S, Iber C, O’Connor G, Nieto J. Underdiagnosis of sleep apnea syndrome in U.S. communities. Sleep Breath. 2002 Jun;6(2):49-54. doi: 10.1007/s11325-002-0049-5. PMID: 12075479.
Lettieri CJ, Eliasson AH, Andrada T, Khramtsov A, Raphaelson M, Kristo DA. Obstructive sleep apnea syndrome: are we missing an at-risk population? J Clin Sleep Med. 2005 Oct 15;1(4):381-5. PMID: 17564406.
Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013 May 1;177(9):1006-14. doi: 10.1093/aje/kws342. Epub 2013 Apr 14. PMID: 23589584; PMCID: PMC3639722.
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