A 48-year-old woman comes to the clinic with her husband due to snoring. Her husband mentions that she snores sometimes and gets up to urinate 2 or 3 times during the night. The patient reports no daytime sleepiness, morning headaches, lack of concentration, or fatigue. She drinks a glass of wine every evening and does not smoke cigarettes. The patient works as a railroad operator, controlling the traffic of passenger trains through a large city. She last saw a physician 3 years ago and has no chronic medical conditions.
Blood pressure is 158/95 mm Hg, pulse is 76/min, and respirations are 14/min. BMI is 31 kg/m². The nasal septum is midline. Examination shows a neck circumference of 17 inches. The lungs are clear to auscultation. There is no peripheral edema.
Complete blood count, serum chemistries, and TSH are within normal limits. ECG shows left ventricular hypertrophy.
The patient agrees to take antihypertensive medication. Which of the following is the most appropriate recommendation for addressing this patient's snoring?

Question

Quizplus · Accepted Answer

This patient with snoring has suspected obstructive sleep apnea (OSA) based on the clinical features of large neck circumference (>16 in for women), hypertension, and nocturia (reflecting decreased arousal threshold). Approximately 50% of patients with OSA do not report excessive daytime sleepiness (EDS) (ie, non-sleepy OSA). Although some evaluation tools (eg, STOP-Bang) can help identify suspected OSA, they are less useful in determining which patients undergo formal OSA testing. Such testing is prioritized in the following patient groups: STOP-Bang EDS and signs of increased upper airway resistance (snoring, gasping arousals)EDS and cardiovascular comorbidities (atrial fibrillation, stroke, hypertensive heart disease)Signs of increased upper airway resistance with cardiovascular comorbiditiesAny clinical suspicion for OSA in a mission-critical worker EDS and signs of increased upper airway resistance (snoring, gasping arousals) EDS and cardiovascular comorbidities (atrial fibrillation, stroke, hypertensive heart disease) Signs of increased upper airway resistance with cardiovascular comorbidities Any clinical suspicion for OSA in a mission-critical worker In mission-critical workers (eg, airline pilot, rail traffic operator, military personnel), diagnosis and treatment of OSA have a large impact on public health and safety. The risk of work accidents is increased in these patients with OSA, even without EDS. Therefore, the threshold for testing is especially low in this group. This patient should undergo sleep apnea testing because of her occupation. Mission-critical workers should be evaluated with supervised in-laboratory polysomnography (PSG) due to higher sensitivity and specificity compared to portable home sleep apnea testing. (Choices A and C) Behavior modification (eg, alcohol avoidance, weight loss, lateral or prone sleep position) may improve snoring and OSA in some patients. External nasal dilator strips can be used for patients with uncomplicated snoring or mild OSA, presuming that upper airway resistance is highest in the nasal passage (eg, turbinate hypertrophy due to allergies) rather than the posterior pharynx. However, formal sleep apnea testing (home vs laboratory) should be performed to confirm OSA and assess disease severity before determining therapy, especially in a mission-critical worker. (Choice B) Nocturnal pulse oximetry (ie, continuous pulse oximetry during sleep) may detect "sawtooth" oxygen desaturation correlated with repetitive obstructive apneas. However, sensitivity is low (obstructive apnea may not always induce significant hypoxemia), and specificity is poor (many conditions can cause nocturnal hypoxemia). Supervised in-laboratory PSG is the gold standard. (Choice E) Nasal decongestants can relieve acute mucosal congestion, improving snoring in patients with allergic rhinitis or viral upper respiratory infection. They are ineffective for pharyngeal collapse due to OSA. In addition, many decongestants can worsen hypertension when taken chronically. Educational objective: Obstructive sleep apnea (OSA) testing should be evaluated with supervised in-laboratory polysomnography in patients who are mission-critical workers with any clinical suspicion of OSA. __________

A 48-Year-Old Woman Comes to the Clinic with Her Husband