SLEEP APNEA PLAIN TEXT | What can GPs do to diagnose sleep-disordered breathing? And how do you advise sleep apnea sufferers on their fitness to drive? You asked our expert Dr. Lennart Knaack provided answers.
The current question and answer session in our DocCheck CME dealt with the topic of sleep apnea. The conversation with the expert took place again this time as a live stream. Mats Klas moderated the whole thing and your questions to our expert Dr. medical Lennart Knaack asked. You can read what our expert had to say here.
- Must protrusion splints individually to be adjusted and where is something like this done?
Yes, they should be adjusted individually in any case. What to avoid is applying an over-the-counter boil-and-bite splint that the patient adjusts themselves. That doesn’t work, I tried it myself. A dentist who feels competent should Parodontose-Status, examine the temporomandibular joint and the periodontium and then a good impression must be made. In any case, the rails should be adjustable. There is also the option of titrating the splints. Under no circumstances should this be left entirely to the patient. The patient should be instructed to adjust this in the millimeter range. The bed partner then often reports that the patient snores less, but it is very important to check that this is working.
There are also side effects. In the beginning, you may have more salivation. But that happens after a certain time. We also often use these splints for patients who travel. They have the mask for home use and when they travel they take splints with them. We’ll check that too. But we have to point out that the health insurance only pays for one.
- In the case of symptomatic obstructive sleep apnea syndrome, overpressure treatment at night using nCPAP therapy is often the method of choice. Is initial therapy with BIPAP also possible?
We see that again and again, patients saying that if the pressure is over 10 mbar, I have to get up BIPAP go. That’s wrong. We also have patients who are treated with CPAP pressures of 15, 16 mbar and are fine with it. BIPAP therapy is intended for patients with comorbidities where they have some ventilatory effect or CO2 washout effects COPD or in neuromuscular diseases. Or even if patients have problems with the setting. But I would go first CPAP or APAP to start.
- Are mouth breathers more likely to develop sleep apnea syndrome?
Et is a certain risk factor due to the lower jaw falling back. But that sleep apnea syndrome is not through alone the reclination of the lower jaw. I’m not aware of any study right now that shows mouth breathing is more likely to cause this. Since I would go for other symptoms, especially mouth breathing, when the intermittent snoring occurs, that explosive breathing. Das are things that are specified much more by the bed partners. The continuous snoring is actually more of a sign that the airways are still open even when breathing through the mouth.
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By the way, an important aspect: In one sleep apnea syndrome you can never actually treat sleep apnea with a nose operation to improve nasal breathing. You can improve the therapy for the mask, but you have to go into lower areas. DThis increase in resistance of the nose during sleep then accounts for only a fraction. There is the Resistance much more important due to the muscle relaxation of the pharynx.
- Can it make sense to use the protrusion splint in combination with CPAP therapy if that alone does not lead to sufficient improvement?
That’s an exciting thing. If you cannot clear the airways with CPAP therapy, it can actually make sense to reduce the tendency of the airways to collapse by combining therapy with a lower jaw-Protrusion splint to stabilize further. That means reducing the collapse so that the CPAP therapy works in the pressure range that is available to me, i.e. up to 19 mbar. That’s always the case. But you have to see – and this is very important – why the therapy with the mask does not work. Is the therapy pressure set incorrectly or too high, for example because you are using a nose and mouth mask right away. Or if the patient is intolerant, then I may not be successful if I give him an additional device. But there are cases where you can combine it and where it makes sense.
This is the case, for example, with a very overweight patient who needs high pressure, i.e. has a high PCRIT. I have to reduce the mechanical preload and then I use a lower jaw protrusion splint, which at least stabilizes that Musculus genioglossus and then makes the therapy possible in the first place.
- WWhat is the importance of outpatient polygraphy in the diagnosis or the exclusion of sleep related breathing disorder?
It is still true that the Polysomnographie – that is the measurement without EEG – one good at diagnosing sleep apnea or an obstructive sleep-related disorder. IIn the area of statutory health insurance, patients are often set directly to CPAP in the sleep laboratory and not diagnostic night need more.
The slight sleep-related disorder, and unfortunately we see this again and again, cannot be ruled out with a polygraph because we are responsible for it need an EEG measurement, about the connection between snoring noises that may impede respiratory flow or even without snoring noises and wake-updetect reactions. And so it’s also in the guidelines.
- How do you get advice on fitness to drive? Is it just the AHI, or what other factors should be considered?
We have certain questionnaires for fitness to drive, like the Epworth Sleepiness Scale. This is an eight-question questionnaire. If you have more than ten points, then this is associated with increased sleepiness and should be considered a risk. However, this questionnaire also has limitations, as with all introspective sleep questionnaires. It makes sense to point out to the patient, if he has clinical symptoms, that this affects his ability to drive and that he may have an increased risk of microsleep.
But you must not forbid patients to drive, you are not authorized to do so. But what you have to do: inform, document and, if necessary, also write down with witnesses that someone is made aware that they have an increased risk of an accident. Then you have no legal problems. We always have cases where this is asked for. You have to explain to the patient that microsleep is also defined as a phenomenon that occurs for the first time and can then be fatal – even if you didn’t have any previous symptoms. This is important.
Most patients say I notice it. If someone has 30 or 40 breathing pauses during their sleep and they are not sleepy, then we use objective methods such as the Pupillary Restlessness Index to measure again and again that there is considerable objectifiable sleepiness. People adapt, have coping strategies. If I drink ten coffees, I’m not so sleepy. Then I think I can drive too – but I have a lousy reaction time.
- How important is weight reduction before starting CPAP therapy?
There are patients who are slim and slim and have a BMI of 23 or 22, so it’s pointless. But with a BMI of around 26, 27 – actually already in this range – it would make sense to lose five kilos. There are CT-guided studies showing that when the airway becomes more passive during sleep, the parapharyngeal fat tissue decreases and the ambient pressure decreases. Again and again we have patients who no longer snore, even in these small areas, by losing five to ten kilograms, and who no longer have breathing pauses.
- Gives es connections between to the Schlafapnea syndrome, polycythemia and atrial fibrillation?
We know that Hypoxia actually one if you have severe sleep apnea Polyglobulie can cause. Also at atrial fibrillation there is a connection. There are studies that show that the incidence of pre-fibrillation is significantly increased over 12 years of age with the onset of moderate to severe sleep apnea. The recurrence rate is also very impressive. If they have intermittent fibrillation and we do sleep apnea screening, we often find patients. If the sleep apnea is treated with the mask, the recurrence rate goes down.
- Does sleep tracking with a smartwatch make sense in the context of sleep apnea?
The number of people who have an abnormal finding in their smartwatch, then go to a sleep laboratory and say something is wrong – and then something is actually wrong – is increasing. That is clear. Because the more smartwatches I have, the more restless sleep is measured. But beware, a smartwatch does not measure sleep. It indirectly measures restless sleep or sleep with special characteristics via movement patterns, heart rate variability, oxygen and pulse fluctuations. To really measure sleep, arterial tonometry is clearly superior. So I would strongly discourage anyone who says I’m dog tired, I snore, but my smart watch isn’t saying anything, from relying on their smart watch. This can go wrong!
- How can man as a family doctor can tell if someone has a sleep apnea hat? What are the clues?
There is one questionnaire that I recommend to all colleagues is the STOP Bang questionnaire. For example, he asks about snoring, loud and interrupted snoring. This is found in over 95% of sleep apnea patients. Then daytime sleepiness: This is not the normal sleepiness that we have in the evening when we have been awake for a long time, but daytime sleepiness is defined in such a way that if I sleep enough, I still feel sleepy again after a short time – i.e. have a tendency to fall asleep. Obesity is a risk factor, high blood pressure and especially lack of lowering of blood pressure at night. These factors combine to give a huge hit rate. Anyone who simply wants to test this in practice should use this STOP-Bang questionnaire if they are unsure. This gives you a high hit rate.