Obstructive sleep apnea (OSA) is a prevalent but significantly underdiagnosed condition with serious systemic health implications.¹ As the first point of contact for most patients, family medicine and general practitioners (GPs) are in a unique and critical position to uncover this hidden epidemic. In an interview with Omnihealth Practice, Dr. To, Wing-Hei Zion, honorary clinical assistant professor from the Chinese University of Hong Kong (CUHK), discussed the critical, yet often overlooked, issue of OSA within the local population. He highlighted that OSA is far more than a simple snoring problem; it is a systemic disease linked to a cascade of serious comorbidities, including hypertension, stroke, and diabetes.¹ He provided a comprehensive overview for family medicine and GPs, covering practical screening methods, navigating local diagnostic pathways, and the latest patient-centered management, underscoring their vital role in improving long-term health outcomes by addressing this hidden epidemic.

Recognizing OSA as a systemic disease

More than just a sleep disorder, OSA is a chronic, multi-system disease that silently elevates a patient's risk for a cascade of comorbidities, including resistant hypertension, atrial fibrillation, congestive heart failure, stroke, and type 2 diabetes.¹ The repetitive nocturnal hypoxemia and sleep fragmentation act as a chronic stressor on the body, driving sympathetic nervous system overactivity and systemic inflammation.¹ This establishes a bidirectional relationship where OSA can both cause and be exacerbated by conditions like metabolic syndrome.² In fact, the modern understanding of the condition is deeply connected to its systemic effects.³ OSA is now recognized as an endocrine disorder with multiple comorbidities, reflecting its complex pathophysiology.⁴

Dr. To's perspective reframes the role of family medicine and GPs from a manager of disparate symptoms—fatigue, high blood pressure, poor concentration—to a proactive manager of a patient's entire systemic health trajectory. When a physician treats hypertension without considering OSA, they may only be managing a symptom while the underlying driver continues to inflict systemic damage.⁵ By maintaining a high index of suspicion and viewing common primary care complaints through the lens of OSA, physicians can intervene early, transforming the management of OSA into a primary prevention strategy for major adverse cardiac and metabolic events.

The OSA patient profile: Not just BMI

Understanding the local context is key to effective screening. In Hong Kong, the prevalence of OSA is comparable to global rates, affecting an estimated 4.1% of men and 2.4% of women.⁶ The condition is also a significant issue in children, with communitybased studies showing a prevalence of approximately 5%.⁷ Dr. To also highlighted that it is likely that a considerable number of patients with OSA remain undiagnosed at their practices.

While the Western image of an OSA patient is often centered on obesity, the Hong Kong profile is more nuanced and demands a paradigm shift in clinical screening.⁸ A very important and often overlooked risk factor in the local population is the East Asian craniofacial structure.⁹ Dr. To reminded that many individuals of East Asian descent have features such as a smaller or recessive jawline (retrognathia)— often described aesthetically as a "melon-seed face"—that physically reduce the posterior airway space. This anatomical predisposition means that even slim patients can suffer from severe OSA, as the smaller mandible provides less space for the tongue, making it more likely to collapse into the airway during the muscle relaxation of sleep.⁹

A symptom-based approach for diagnosis

Recognizing OSA begins with targeted history taking, with symptoms divided into nighttime and daytime complaints. For a busy clinic, a validated screening tool like the STOP-BANG questionnaire provides a rapid, evidence-based method to assess risk.¹⁰ At night, a critical sign of OSA is witnessed apnea, where a bed partner observes pauses in breathing, often followed by gasping or choking.¹¹ Other key nocturnal symptoms include loud, persistent snoring and frequent nocturia, linked to repeated arousals and negative intrathoracic pressure swings.^12,13 Dr. To noted that “the entire sleep architecture is affected in patients with sleep apnea,” and poor dream recall may indicate a lack of deep, restorative REM sleep. During the day, the hallmark symptom is excessive daytime sleepiness and profound fatigue, with patients feeling unrefreshed regardless of the hours spent in bed.¹⁴ This can be accompanied by morning headaches, caused by nocturnal hypercapnia and cerebral vasodilation, as well as poor concentration and cognitive fog due to sleep fragmentation impairing executive function.^15-17

Navigating the diagnostic pathway in Hong Kong

Once a patient is identified as high-risk, the definitive diagnosis of OSA is made with gold standard polysomnography (PSG).¹⁸ Navigating this step requires the physician to act as a healthcare system navigator, counseling the patient on the options and barriers unique to Hong Kong. There is a stark disparity between the public and private systems; the wait time for a PSG in the public sector can be up to 12 months, a delay that poses a serious health risk for patients with severe OSA.^19-20 The private sector offers quicker access but at a cost. In-hospital PSG is the gold standard, providing the most accurate data, and is essential for complex cases, such as when other sleep disorders are suspected or when surgery is being considered.²¹

Home sleep tests (HST) have been shown to be applicable to certain public and private adult cases that offering a convenient alternative for less complicated presentations, allowing the patient to sleep in their own bed.¹⁹ Dr. To noted that “Especially after COVID-19, many patients do not want to be hospitalized if they are not sick. To some extent, this has led to a paradigm shift, with more patients choosing to do home sleep tests.” However, HSTs are less comprehensive, and signal loss from detached sensors can sometimes necessitate a repeat test.²² He noted that, particularly for patients who have many medical comorbidities, or are considering surgical treatment, an in-hospital PSG is recommended.

A patient-centred, stepwise approach to OSA management

OSA management is not one-size-fits-all; the goal is to create a personalized, stepwise treatment plan based on disease severity, patient anatomy, and patient preference.²³ Common treatment options include non-invasive therapies such as continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs).²⁴ Alongside device therapy, lifestyle changes are crucial.²⁵ For overweight patients, weight loss is a key component of management.²⁶ The emergence of injectable glucagon-like peptide-1 (GLP-1) receptor agonists, which are now FDA-approved for weight loss in patients with both obesity and OSA, represents a significant new pharmacological tool.²⁷ Furthermore, treating underlying nasal congestion with sprays or medications is a critical adjunctive therapy that improves the comfort and adherence of CPAP therapy.²⁸

For patients who cannot tolerate non-invasive therapies or have a clear, correctable anatomical obstruction, surgical options are considered.²⁹ Dr. To recalled in his experience, “The vast majority of patients, perhaps more than half of the patients usually don't need surgery. Around one third of cases really need to consider surgical treatment." Modern surgical treatment is highly personalized. A pre-surgical drug-induced sleep endoscopy is essential to pinpoint the exact site(s) of airway collapse, allowing for a tailored procedure that could range from soft tissue surgeries like uvulopalatopharyngoplasty (UPPP) to skeletal procedures like maxillomandibular advancement.^30-32 Representing the cutting edge of treatment is hypoglossal nerve stimulation (HNS).³³ This involves a small implantable device that stimulates the hypoglossal nerve, causing the tongue to move forward with each breath and preventing airway collapse.³³ It is a highly promising option for moderate-tosevere OSA patients who have failed CPAP.³³ While still in its early stages in Hong Kong, initial results are encouraging, and it is a therapy physicians should be aware of for the future.³⁴

Building an interdisciplinary care network

Effective management of OSA requires a coordinated, multidisciplinary approach, with the physician serving as the central care coordinator.³⁵ Diagnosis is only the beginning; long-term adherence to therapy is the true challenge, and where physicians can make the greatest impact.³⁵ CPAP non-adherence rates vary widely, from 29% to 83% in global studies.³⁶ Notably, a Hong Kongbased elderly cohort showed promising compliance, with 72% of patients using CPAP for over four hours per night over 12 months.³⁷ However, evidence generally suggests that acceptance and sustained use remain difficult for many.³⁶ Dr. To reminded that a robust care network includes respiratory physicians for diagnosis and CPAP titration, ear, nose & throat (ENT) surgeons for surgical evaluation and sleep endoscopy, dentists or maxillofacial surgeons for fitting MADs or performing jaw surgeries, pediatricians for childhood OSA cases, and psychiatrists to manage co-existing conditions such as insomnia or depression— both common in OSA patients. By fostering collaboration across disciplines, physicians can help improve treatment adherence, optimize outcomes, and ensure continuity of care.

Conclusion

Dr. To emphasized that today's practicing family medicine and GPs hold a power ful oppor tunity to change lives by recognizing and managing a common yet consequential condition—OSA. During consultations, it is essential to routinely ask about sleep quality, snoring, and daytime fatigue. Early intervention can prevent a lifetime of health issues. Educating patients about the systemic risks associated with untreated sleep apnea can motivate adherence to treatment. Additionally, proactively addressing therapy challenges—particularly by managing nasal congestion— will help ensure long-term success in their care.