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Is sleep apnoea a specialist condition? The role of general practitioners

M.A. Martínez-García, P. Catalán Serra
Breathe 2010 7: 144-156; DOI: 10.1183/20734735.009210
M.A. Martínez-García
1Pneumology Unit, Requena General Hospital, Valencia, Spain
2CIBER de enfermedades respiratorias (CIBERES)
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  • For correspondence: miangel@comv.es
P. Catalán Serra
1Pneumology Unit, Requena General Hospital, Valencia, Spain
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    Figure 1

    Functions and obligations of primary care and sleep units with respect to the handling of patients with OSA, or suspected of having OSA.

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    Figure 2

    Protocol for referral of OSA in primary care

Tables

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  • Table 1 Risk of cardiovascular complications or accidents in patients with untreated obstructive sleep apnoea
    DiseaseOdds ratio (95% CI)
    Arterial hypertension1.37 (1.03–1.83)
    Ischaemic heart failure1.27 (0.99–1.62)
    Heart failure2.38 (1.22–4.62)
    Ischaemic stroke1.58 (1.02–2.46)
    Auricular fibrillation4.02 (1.03–15.5)
    Pulmonary hypertension1.4 (1.1–2.8)
    Diabetes mellitus1.7 (1.1–2.7)
    General mortality6.24 (2.01–19.4)
    Traffic accidents6.3 (2.4–16.2)
    Traffic accident plus alcohol consumption11.2 (3.8–32.9)
    Workplace accidents2.2 (1.3–3.8)
    • Data are taken from [5, 8–11].

  • Table 2 Most important functions of primary care staff with respect to a patient with sleep apnoea or suspected sleep apnoea
    Detection of patientsFor every patient who sees a PCP
    Three key questions: snoring, witnessed apnoeas and hypersomnia
    Referral protocolsIt is necessary to protocolise referral of patients to avoid mistakes
    Prioritisation of patientsSerious hypersomnias, professions entailing risk and high cardio-respiratory risk
    Information for the patient and general populationOn the risk factors, consequences and treatment of the disease
    Control of risk factorsAdvice on diet and general treatment
    Follow-up of patients with CPAPCommon and mild adverse effects
    Monitoring of compliance
    New referral to a sleep unit
  • Table 3 Key questions for every patient who comes to primary care for any reason, in order to identify individuals with a high clinical probability of obstructive sleep apnoea
    Do you snore?
    The absence of snoring makes it very difficult to arrive at a diagnosis of OSA. If the answer is yes, or don’t know, continue to the following questions
    Has anybody remarked to you on any occasion that you stop breathing when you are sleeping?
    Isolated apnoeas are very common in snorers, but prolonged or repeated apnoeas witnessed by somebody accompanying the patient are highly indicative of OSA
    Do you sleep during the day more easily than you think is normal?
    Hypersomnia is also a very common occurrence, but when it is accompanied by snoring or apnoeas, without any apparent cause, or by cardiovascular manifestations it must be investigated, and if it is accompanied by decapacitating forms, association with high-risk professions or a great cardiovascular risk it requires a preferential referral
  • Table 4 Medical history and basic physical examination required for patients in primary care suspected of having OSA
    Basic clinical findings: snoring, observed apnoeas and hypersomnia (Epworth Scale)
    Other symptoms and day- and night-time signs (see table 7)
    General history (especially cardiovascular and respiratory findings and medication)
    Sleep habits (timetable, siestas, duration, sleep hygiene)
    Anthropometric exploration: weight, height, BMI and neck perimeter
    Distance from hyoid bone to jaw (short neck)
    Facial constitution: maxilla, jawbone, type of bite and evaluation of retro-micrognathia.
    Oropharyngoscopy: hypertrophy of soft palate and/or tonsils
    Examination using Mallampati Scale
    Rhinoscopy: nasal examination (rhinorrhoea, septum, obstruction)
    Cardiopulmonary auscultation and measurement of blood pressure
  • Table 5 Possible adverse effects of CPAP that can be resolved in primary care
    Adverse effectsTreatment
    Nasal congestion or obstructionDecongestants; nasal steroids; ipratropium bromide, suitable humidification and room temperature. ENT evaluation if there is no improvement
    Irritation of the skinLocal protection; change mask. Topical treatment for atopical dermatitis
    Dry pharynxHydration; humidification
    NoisePut generator on the floor; avoid leaks
    ConjunctivitisAdjust mask
    HeadacheAnalgaesics before going to bed
    EpistaxisHumidification and adjustment of room temperature. ENT evaluation if persistent
    ColdSuitable room temperature; humidifier–heater
    InsomniaPsychological measures for adaptation to the use of CPAP; pressure ramp; mild, non-benzodiazepine anxiolytic
    AerophagiaPsychological measures for adaptation to CPAP; mild anxiolytics; postural measures
    ClaustrophobiaPsychological adaptation measures
    • ENT: Ear, nose and throat specialist

  • Table 6 Advice related to risk factors for sleep apnoea in primary care
    Sleep hygieneSee table 8
    ObesitySlimming
    Bariatric surgery
    AlcoholTo be avoided at least 6 h before sleeping
    TobaccoTo be avoided at least 6 h before sleeping
    MedicationMinimise the consumption of benzodiazepines
    Preference to zolpidem or zopiclone
    Associated diseasesHypothyroidism
    Gastro-oesophageal reflux
    Body positionAvoid supine position:
    Obstacles in the back
    Headrest at 30°
    Nasal obstructionDecongestants
    Nasal corticoids
    Ipratropium bromide
  • Table 7 Most frequent daytime and night-time symptoms of OSA identifiable in a primary care consulting room
    Daytime symptomsNight-time symptoms
    Excessive daytime sleepinessSnoring
    Sense of unrefreshing sleepObserved apnoeas
    Chronic tirednessChoking episodes
    Morning headachesAbnormal movements
    IrritabilityDiaphoresis
    ApathyFrequent arousals
    DepressionNicturia (adults) and enuresis (children)
    Difficulty in concentratingNightmares
    Memory lossRestless sleep
    Reduced sex driveInsomnia
    Personality changesGastro-oesophageal reflux
  • Table 8 Advice on sleep hygiene that can be given in primary care
    Go to bed only when you feel sleepy
    If you do not fall asleep within 20 min, get up and do something boring until you feel sleepy
    Do not have long siestas (i.e. more than 30 min)
    Try to always go to bed at the same time. Develop rituals for going to bed
    Avoid intense exercise in the hours prior to going to bed
    Use your bed only for sleeping or having sex. Avoid watching TV in the bedroom
    Avoid taking caffeine, nicotine or alcohol for at least 4–6 h prior to going to bed
    Ensure that your bedroom is quiet and comfortable
    Use sunlight and physical activity to synchronise your biological clock
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Is sleep apnoea a specialist condition? The role of general practitioners
M.A. Martínez-García, P. Catalán Serra
Breathe Dec 2010, 7 (2) 144-156; DOI: 10.1183/20734735.009210

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Is sleep apnoea a specialist condition? The role of general practitioners
M.A. Martínez-García, P. Catalán Serra
Breathe Dec 2010, 7 (2) 144-156; DOI: 10.1183/20734735.009210
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  • Article
    • Abstract
    • Obstructive sleep apnoea and its consequences
    • OSA as an important public health problem
    • OSA in primary care: identifying the problem
    • Continuous training about OSA in primary care: the search for solutions
    • Actual and future role of primary care in OSA
    • Educational questions
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  • Epidemiology, occupational and environmental lung disease
  • Pulmonary pharmacology and therapeutics
  • Respiratory clinical practice
  • Sleep medicine
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