Figures
- 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.
- Figure 2
Protocol for referral of OSA in primary care
Tables
- Table 1 Risk of cardiovascular complications or accidents in patients with untreated obstructive sleep apnoea
Disease Odds ratio (95% CI) Arterial hypertension 1.37 (1.03–1.83) Ischaemic heart failure 1.27 (0.99–1.62) Heart failure 2.38 (1.22–4.62) Ischaemic stroke 1.58 (1.02–2.46) Auricular fibrillation 4.02 (1.03–15.5) Pulmonary hypertension 1.4 (1.1–2.8) Diabetes mellitus 1.7 (1.1–2.7) General mortality 6.24 (2.01–19.4) Traffic accidents 6.3 (2.4–16.2) Traffic accident plus alcohol consumption 11.2 (3.8–32.9) Workplace accidents 2.2 (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 patients For every patient who sees a PCP Three key questions: snoring, witnessed apnoeas and hypersomnia Referral protocols It is necessary to protocolise referral of patients to avoid mistakes Prioritisation of patients Serious hypersomnias, professions entailing risk and high cardio-respiratory risk Information for the patient and general population On the risk factors, consequences and treatment of the disease Control of risk factors Advice on diet and general treatment Follow-up of patients with CPAP Common 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 effects Treatment Nasal congestion or obstruction Decongestants; nasal steroids; ipratropium bromide, suitable humidification and room temperature. ENT evaluation if there is no improvement Irritation of the skin Local protection; change mask. Topical treatment for atopical dermatitis Dry pharynx Hydration; humidification Noise Put generator on the floor; avoid leaks Conjunctivitis Adjust mask Headache Analgaesics before going to bed Epistaxis Humidification and adjustment of room temperature. ENT evaluation if persistent Cold Suitable room temperature; humidifier–heater Insomnia Psychological measures for adaptation to the use of CPAP; pressure ramp; mild, non-benzodiazepine anxiolytic Aerophagia Psychological measures for adaptation to CPAP; mild anxiolytics; postural measures Claustrophobia Psychological adaptation measures ENT: Ear, nose and throat specialist
- Table 6 Advice related to risk factors for sleep apnoea in primary care
Sleep hygiene See table 8 Obesity Slimming Bariatric surgery Alcohol To be avoided at least 6 h before sleeping Tobacco To be avoided at least 6 h before sleeping Medication Minimise the consumption of benzodiazepines Preference to zolpidem or zopiclone Associated diseases Hypothyroidism Gastro-oesophageal reflux Body position Avoid supine position: Obstacles in the back Headrest at 30° Nasal obstruction Decongestants Nasal corticoids Ipratropium bromide - Table 7 Most frequent daytime and night-time symptoms of OSA identifiable in a primary care consulting room
Daytime symptoms Night-time symptoms Excessive daytime sleepiness Snoring Sense of unrefreshing sleep Observed apnoeas Chronic tiredness Choking episodes Morning headaches Abnormal movements Irritability Diaphoresis Apathy Frequent arousals Depression Nicturia (adults) and enuresis (children) Difficulty in concentrating Nightmares Memory loss Restless sleep Reduced sex drive Insomnia Personality changes Gastro-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
Vol 7 Issue 2
Table of Contents
Is sleep apnoea a specialist condition? The role of general practitioners
Jump To
- 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
- Suggested answers
- Footnotes
- References
- Figures & Data
- Info & Metrics