The Physical Examination For Adult Sleep Apnea

A sleep physical examination is directed at modifying the probability of sleep-disordered breathing based on the history, looking for evidence of associated or complicating disease, and excluding other potential causes for neurologic or cardiovascular symptoms. A broader examination incorporating many of the other organ systems should be employed when considering other sleep disorders that may be caused by or confounded by other diagnoses.

TABLE 2 Medications as Clues to Predisposing Factors

Medications associated with OSA

Barbiturates Benzodiazepines Ethanol, illicit narcotics Hypertensive and diabetic treatments

Medications that sedate and/or reduce respiratory drive

Medications that impair sleep onset or maintenance

Adrenocorticotropin and corticosteroids Alpha-agonists Anticholesterol agents Anticonvulsants Antineoplastic agents Appetite suppressants Atypical antidepressants Benzodiazepines Beta-blockers Caffeine, nicotine, ethanol, illicit narcotics Decongestants Diuretics Dopaminergics Monoamine oxidase inhibitors NSAIDs Opiates

Oral contraceptives Pemoline, dextroampheta-mines, methylphenidates Progesterone

Pseudoephedrine, ephedrine, phenylpropanolamine Quinidine

Quinolone antibiotics Theophylline, albuterol, ipratropium, terbutaline, salmeterol, metaproterenol, xanthine derivatives Thyroid supplements Tranquilizers

Alpha-blockers

Anticonvulsants

Antidiarrheal agents

Antiemtics

Antihistamines

Antimuscarinic

Antipsychotics

Antispasmotics

Antitussives

Anxiolytics

Atypical antidepressants

Barbituates

Benzodiazepines

Beta-blockers

Dopaminergics

Diphenhydramine, phenylhydramine Ethanol, illicit narcotics Genitourinary smooth muscle relaxants Hydantoins

Melatonin receptor agonists Monoamine oxidase inhibitors Muscle relaxants Nonbenzodiazepine hypnotics Opiate agonists Selective serotonin reuptake inhibitors Succinimides Tricyclic antidepressants Valerian root, kava kava, melatonin, chamomile, passiflora

Abbreviations: NSAIDs, nonsteroidal anti-inflammatory drugs; OSA, obstructive sleep apnea.

Blood Pressure

Many population-based studies have shown that hypertension is independently associated with sleep-disordered breathing studies (105-110). Blood pressure has been integrated into several clinical prediction rules for sleep apnea (4,12,17,18). One study found hypertension to have an adjusted OR of 11.9 for an AHI > 30 (17). More recently, a causal relationship has been suggested by a number of studies that have shown an improvement in hypertension with sleep apnea treatment (70-72).

Obesity

Although a number of different measures of obesity have been used in clinical studies the BMI is probably the best and certainly the most practical. It has been found to be strongly associated with the presence of sleep apnea (4,12-15,18,108,111-115) and has been incorporated into a number of clinical prediction rules (4,13,14,18) for this disorder (see also Chapter 2).

Neck Circumference

Neck circumference is, in part, a surrogate for obesity but clinical studies have also found an independent association with sleep apnea (12,15,113,114), and one study has incorporated it into a multivariate clinical prediction rule for sleep apnea (12). One epidemiological study found the OR for an AHI > 15 with an increment of one standard deviation (SD) in neck circumference to be 1.5 (15).

Nasal Function

Nasal obstruction has been implicated as a potential cause of sleep apnea. It can lead to higher inspiratory upper airway pressures and increased collapsibility of pharyngeal walls (116). Also, it appears to predispose to mouth breathing and the downward and backward displacement of the mandible (111), which may worsen airway obstruction at the level of the base of the tongue. Nasal resistance, as measured by posterior rhinometry, was significantly higher in patients with sleep apnea (115). A combination of nasal obstruction and a high Mallampati score (3 or 4; see below) are associated with an increased risk for the diagnosis of sleep apnea (RR 2.45, CI 1.23-4.84) (113). In this latter study, obstruction was measured by having the patient gently block one nostril, breathe through the other and having the physician listen for evidence of obstruction.

The external nasal valve comprises the columella, the nasal floor, and the nasal rim [inferior border of the lower lateral alae nasi (nasal cartilage)], which normally is dilated by the nasalis muscle during inspiration. Collapse of the nasal rim upon inspiration through the nose alone, is also often a sign of OSA-associated nasal resistance (Fig. 1).

Pharyngeal and Craniofacial Features

Pharyngeal and craniofacial morphology play an important role in the etiology of sleep apnea. Some anatomical variants result in a crowded oropharyngeal space

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