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Naresh Punjabi, M.D.
03-01-2010
- Sleep apnea is a common medical comorbidity in patients with type 2 diabetes and treatment with CPAP may improve glycemic control.
- 25% of men and 9% of women in the general adult population have OSA (Young).
- Approximately 80% of the patients with type 2 diabetes have OSA with 20% affected with severe disease (Foster).
- Patients with type 2 diabetes have increased prevalence of Cheyne-Stokes respiration (Resnick).
- Presence of autonomic neuropathy is associated with a high prevalence of sleep apnea (Bottini).
- Treatment of OSA with CPAP may improve glycemic control (Babu).
- Overnight sleep study (polysomnography) 'gold-standard' diagnostic test
- Apnea event: complete cessation of airflow during sleep
- Hypopnea event: decreased airflow during sleep associated with oxygen desaturation or arousal from sleep
- Obstructive event: Diminished or no airflow with respiratory effort
- Central event: Diminished or no airflow without respiratory effort
- Apnea-hypopnea index (AHI): Apneas + hypopneas per hour of sleep
- Sleep apnea: AHI > 5 events/hr
- OSA: Greater than 50% of disordered breathing events during sleep obstructive
- Central sleep apnea: Greater than 50% of disordered breathing events during sleep central
- Techniques for monitoring sleep (e.g., oximetry, airflow) available for diagnosis for the home setting
- Loud snoring with pauses in breathing during sleep witnessed by a bed partner or family member (Steier)
- Nocturnal episodes of choking and gasping
- Restless sleep (tossing and turning) and awakenings for nocturia
- Morning headache, excessive daytime sleepiness and fatigue, impotence
- Impairments in concentration, attention, and memory
- Personality changes (aggressiveness, irritability, anxiety, or depression).
- Neck circumference larger than 40 cm
- Retronagthia, dental overjet (a forward extrusion of the upper incisors beyond the lower incisors).
- Small oropharynx, tonsillar enlargement, macroglossia, edema or erythema of uvula
- Obesity (BMI > 28 kg/m2), large abdominal girth, presence of hypertension, lower extremity edema
- CPAP first line therapy for moderate to severe OSA
- Weight loss essential and can be curative. Modest weight loss (10%) can relieve mild SDB (Peppard).
- Oral appliances (e.g., mandibular advancement devices) for mild disease or for CPAP intolerant patients
- Upper airway surgery is an option for those intolerant to CPAP therapy. Lack of consensus as to the most appropriate procedures for OSA patients.
- Supplemental oxygen may be necessary with severe sleep-related hypoxemia.
- Avoidance of alcohol, sedatives, and narcotics which can increase upper airway collapsibility during sleep.
- Optimizing habitual nighttime sleep duration to avoid sleep deprivation which can blunt hypoxic and hypercapnic ventilatory chemoresponsiveness.
- Stimulant therapy (e.g., Modafinil) approved for the treatment of residual sleepiness in OSA adequately treated with CPAP.
- After diagnosis, overnight CPAP titration study necessary to determine therapeutic pressure.
- Clinical improvement and compliance with CPAP assessed initially between 1 to 3 months.
- Yearly routine follow up for assessing CPAP compliance
- Repeat sleep testing indicated if sleepiness persists despite CPAP, weight increases or decreases by more than 10-15%, and patient has upper airway surgery or fabrication of an oral appliance for treatment.
- Health professionals managing patients at risk for type 2 diabetes or OSA should adopt clinical practices to ensure that a patient with one condition is considered for the other.
- Patients with type 2 diabetes should be assessed for snoring, observed apneas during sleep, and daytime sleepiness.
- A low threshold for referral to diagnose OSA should be used in type 2 diabetes because of the established benefits of therapy on daytime sleepiness, quality of life, and hypertension.
- Management of OSA should focus initially on weight reduction. CPAP is the current best treatment for moderate to severe OSA.
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