News reports about the unexpected death of Reggie White, just weeks after his 43rd birthday, highlight the potential danger of obstructive sleep apnea and related breathing disorders.
This information about Reggie White and a brief review of sleep apnea (based on a JAMA 2000 review article) may be useful in answering patient questions.
Reggie White, 43, a brief bio:
Reggie White played professional football for both the Philadelphia Eagles and the Green Bay Packers. As a defensive end White was twice named NFL Defensive Player of the Year and when he retired after the 2000 season he held the NFL's record for quarterback sacks.
During his career he was nicknamed "The Minister of Defense", a title that took on new meaning in his off-field role as the founder of Christian Athletes United for Spiritual Empowerment.
Obstructive Sleep Apnea:
Obstructive sleep apnea (OSA) affects an estimated 2% to 4% of the US population. It is associated with daytime sleepiness, cognitive impairment, hypertension, myocardial infarction, pulmonary hypertension, and arrhythmias as well as a two- to seven-fold increased risk of motor vehicle crashes.
OSA is characterized by brief periods of interrupted breathing during sleep. Typically episodes last 10 to 30 seconds and can recur at a rate of 400 times a night.
OSA occurs when the trachea is obstructed, so that a person is unable to draw sufficient air into the lungs. The blockage may be caused by the person's tongue, tonsils or uvula or by fatty tissue in the throat.
Diagnosis:
The cardinal manifestations of the obstructive sleep apnea syndrome are stentorian snoring and severe sleepiness. However, both snoring and sleepiness may be denied or minimized by the patient. Frequently the first clue about OSA comes from a sleeping partner who complains about snoring or long pauses in breathing during sleep. Individuals may complain of daytime sleepiness, morning headaches, forgetfulness, loss of libido, and mood changes.
The gold standard test for obstructive sleep apnea is all night polysomnography performed in a sleep laboratory. Home monitors are also available, but are recommended only when a patient cannot be tested in a lab.
Action Points
- Consider assessing patients who present with fatigue, morning headaches or daytime sleepiness for obstructive sleep apnea.
- Recognize that snoring and obesity are also markers for sleep apnea.
- For patients with suspected sleep apnea suggest changes in sleep hygiene: change sleep position, stop alcohol and sleep medication use.
- Consider use of continuous positive airway pressure (CPAP) if apnea is confirmed by polysomnography.
A diagnosis of sleep apnea is based on the Respiratory Distress Index (RDI) -- the number of respiratory disturbances per hour of sleep (apnea plus hypopnea (low blood oxygen). According to the American Academy of Sleep Medicine (AASM), an RDI of 0 to 5 in normal; 5 to 20 is mild; 20 to 40 is moderate; over 40 is considered severe.
Treatment:
Initial treatment includes elimination of alcohol and sleep medications, weight loss for overweight patients, and change in sleep position, ie, side rather than back.
For patients who don't respond to these simple methods, a trial of continuous positive airway pressure (CPAP) is recommended. Using air pressure, CPAP works like splint to hold the airway open.
Surgical treatment, which attempts to correct a defect in the upper respiratory tract anatomy, includes simple procedures such as tonsillectomy and more complex procedures such as maxillomandibular advancement in which both the maxilla and mandible are advanced simultaneously. Surgical indications include severity of apnea, degree of anatomic abnormality and failure of CPAP.
Primary Source
JAMA
Source Reference: Piccirillo, JF, Duntley, S, Schotland, H "Obstructive Sleep Apnea" JAMA 2000;284:Vol.12 (reprint).
Secondary Source
American Academy of Family Physicians website