Strategies for the effective diagnosis and management of OSA in primary care setting

09 Oct 2023

Obstructive sleep apnea (OSA) is important and relevant to primary care physicians since it has an impact on patients’ sleep quality.1 However, there is a struggle in identifying OSA in patients as there is no focus on respiratory diseases and sleep in clinical practice despite its enormous burden.1 OSA is included under the same code with other conditions like insomnia and sleepwalking, rather than being recognized as a standalone disease.1 Hence, it is crucial for primary care physicians to individually investigate each patient and identify the risks that are associated with OSA.1 In the ERS Congress 2023, Dr. Cláudia Sofia De Almeida Vicente Ferreira from the Respiratory Diseases Interest Group (GRESP) of the Portuguese Association of General and Family Medicine (APMGF), Portugal, discussed the challenges of OSA in the clinical setting and presented the tools and strategies for diagnosing and managing this disease.1

OSA occurs in around 2%-4% of the general population.1 A study conducted in Switzerland found that the prevalence of moderate to severe diseases was about 23.4% in women and 49.7% in men.1 Dr. Ferreira stated “This disease is being underdiagnosed and its risk is underestimated”.1 We should be asking patients who snore, are obese, have excessive sleepiness, or have other relevant symptoms about their quality of sleep.1 In addition, many risk factors such as structural factors, genetic factors, and sexual differences exist.1

The pathophysiology of OSA involves increasingly obstructed airways which leads to an effort to overcome the obstruction and re-establish breathing.1 Sometimes, total or partial collapse of the upper airway occurs repeatedly during sleep, leading to intermittent oxygen saturation and sleep fragmentation.1 Additionally, OSA increases the sympathetic activity, catecholamines activity, daytime sleepiness, as well as cardiovascular (CV) risks such as arrhythmias, myocardial infarctions (MI) and strokes.

Symptoms can be divided into night and day symptoms, but are sometimes difficult to identify, making it important to actively ask the patients about their symptoms.1 Patients with suspected OSA syndrome (OSAS) should always be evaluated to make a properreferral.1 A typical OSAS patient profile is a male aged between  40 to 60 years, who smokes and drinks (mainly at night or within  6 hours before sleeping) and may have car and work accidents involved with sleepiness.1 Such patients may be on continuous positive airway pressure (CPAP) and receive medication for insomnia, which may be involved with OSA.1 Physical exam includes BMI (≥30kg/m2),  neck circumference (≥42cm in men and ≥40cm in women), a high Mallampati score, face abnormalities, and nasal problems.1 There also exists some helpful questionnaires that are cheap, fast, and easy and can be performed by nurses, which include the Berlin questionnaire, STOP questionnaire, STOP-BANG questionnaire, and the Epworth sleepiness scale.1 The STOP-BANG questionnaire is easy to apply and stratifies patients based on the risk of OSA (high risk, intermediate risk, or low risk) whereas the Epworth sleepiness scale is not for OSA but for assessing sleepiness and is self-filling.1

Moreover, we should evaluate comorbidities in all patients, especially those with high CV risk.1 Patients with some conditions such as resistant hypertension, pulmonary hypertension, and recurrent atrial fibrillation (AF) after cardioversion/ablation should be screened for OSA.1 This disease is now considered an independent risk factor for CV disease and is responsible for a lot of deaths.1 There appears to be a dangerous association between these diseases and OSA and we need individualized care for these patients.1 Also, there appears to be a bidirectional relationship between these comorbidities and OSA.1 It is important to continuously follow up with patients after the diagnosis, assess the efficacy parameters, compliance, and adverse effects in patients with CPAP, provide education for patients and their families, and take the necessary hygienic-dietary measures.1

In summary, the role of primary care physicians in the context of OSA is important.1 They should have a comprehensive understanding of the widespread prevalence of OSA, recongnize the potential dangers it poses to patients, and be knowledgeable about the patient’s environment and their management of chronic diseases and comorbidities.1 This level of awareness and expertise is crucial for primary care physicians to effectively address OSA in their patients.1

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