You evaluate a 49-year-old patient who has been referred to you because of excessive daytime sleepiness. His past medical history includes drug-controlled hypertension, obesity (body mass index [BMI] 36 kg/m2 ), and low back pain for which he has been taking daily nonsteroidal anti-inflammatory drugs (NSAIDs) and oxycodone for the past 5 years. Upon questioning his wife reports loud snoring during the night, to the point where she has sometimes had to sleep in another room. She does not think she has witnessed any apneic episodes but states she cannot be certain.
What is the MOST appropriate next step in the management of this patient?
A. Overnight PSG for further investigation of sleep apneaCorrect Answer: A
The patient in the presented case has an increased risk of moderate to severe OSA, as he presents with excessive daytime sleepiness, loud snoring, and diagnosed hypertension. The AASM guidelines on diagnostic testing for adult OSA (1) recommend that prediction algorithms, diagnostic tools, and questionnaires (such as the Berlin Questionnaire, the STOP-Bang questionnaire, the Epworth Sleepiness Scale, etc) should not be used to diagnose OSA in adults in the absence of PSG or HSAT (therefore answer C is wrong). An uncomplicated patient is defined by the absence of (A) conditions that place the patient at increased risk of nonobstructive sleep–disordered breathing (including chronic use of opioid medication); (B) concern for significant nonrespiratory sleep disorder(s) that require evaluation or interfere with the accuracy of HSAT; (C) environmental or personal factors that preclude the adequate acquisition and interpretation of data from HSAT. The guidelines recommend either PSG or HSAT in uncomplicated patients at an increased risk of moderate to severe risk of OSA, and in case of patients who do not fit this definition of uncomplicated, the guidelines recommend PSG rather than HSAT (answer A is therefore correct; answer B is wrong). Overnight pulse oximetry does not provide enough clinical or laboratory information to formulate a diagnosis of OSA (option D is incorrect).
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