eMedicine Specialties > Pulmonology > Sleep-Related Disorders

Obstructive Sleep Apnea: Follow-up

Author: Ralph Downey III, PhD, DABSM, FAASM, Associate Professor of Medicine, Pediatrics, and Neurology, Loma University School of Medicine; Adjunct Associate Professor, Department of Psychology, University of California at Riverside; Chief, Sleep Medicine, Loma Linda University Medical Center and the Loma Linda University Children's Hospital
Coauthor(s): Philip M Gold, MD, Professor of Medicine, Chief of Pulmonary and Critical Care Medicine, Medical Director of Respiratory Care, Loma Linda University Medical Center; Himanshu Wickramasinghe, MD, MBBS, Attending Physician; Pulmonary, Critical Care, and Sleep Medicine; Henry Mayo Newhall Memorial Hospital, Valencia, California
Contributor Information and Disclosures

Updated: Jul 30, 2009

Follow-up

Further Outpatient Care

Nasal CPAP therapy 

Many obstructive sleep apnea (OSA) patients note an immediate improvement in alertness, concentration, and memory, but achieving maximum improvement in neurocognitive symptoms may take as long as 2 months. Adequate adherence is defined as routine use of CPAP for more than 4.5 hours per night. Follow-up visits should be scheduled at least once after CPAP treatment is first started and at least yearly thereafter. Follow-up evaluation is required to ensure symptomatic improvement, CPAP compliance, and equipment maintenance.

CPAP therapy - Compliance issues

Nasal congestion can be treated with antihistamines and/or topical corticosteroids. Nasal dryness can be treated with topical saline sprays or humidification. If the air generated by the unit is too cold, the patient should use a heated humidifier.

If excessive air leaks through the mouth, patients should use a chin strap to keep their mouths closed or they should try an oronasal mask. Consider consultation with an otolaryngologist to rule out sinus dysfunction. If a poorly fitting mask causes skin breakdown and/or air leaks, patients should try mask of different sizes and/or models; a variety of interfaces are now available.

Patients with claustrophobia may try using nasal pillows or behavioral management. If patients feel a sensation of increased resistance to expiration, use of a CPAP unit with a ramp feature is indicated. This unit permits the patient to fall asleep with little or no pressure applied, and the pressure gradually increases to the set optimal level over a predetermined interval (usually 15-30 min). BiPAP may be used as an alternative. 

OA therapy

Regular follow-up with a dental professional allows for adjustment of the dental appliance. The first adjustment is based on symptoms. Follow-up also helps ensure compliance with therapy and helps identify adverse effects or complications, device deterioration, or maladjustment.

Follow-up PSG after the final adjustment of the OA ensures that OSA is adequately treated. However, PSG should be deferred until an adequate symptomatic response and patient comfort are achieved with adjustments to the appliance.

Follow-up with a sleep disorders specialist ensures that OSA is adequately treated. Regular follow-up is required until patient's symptoms resolve and until PSG shows no evidence of clinically significant SDB. Follow-up also helps in determining if another treatment modality is required because of treatment failure or intolerance.

Close collaboration is required between the sleep disorders specialist and dental professional. Pay attention to compliance, comfort, dental complications, and evidence of recurrent OSA.

Surgery 

Follow-up with a sleep disorders specialist ensures that OSA resolves. Follow-up PSG is essential to determine if OSA has been treated adequately. It should be performed after the surgical site has adequately healed. The most effective timing appears to be 4-6 months after surgery to ensure steady body weight, completion of healing, and stabilization of sleep architecture.

Patient Education

A physician, trained technician, or nurse should train patients receiving CPAP for at least the first month of therapy. This training promotes long-term adherence with treatment. For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center and Sleep Disorders Center. In addition, see eMedicine's patient education articles Snoring, Sleep Disorders and Aging, and Insomnia.

Miscellaneous

Medicolegal Pitfalls

The following measures should be undertaken in patients with OSA:  

  • Assess the patient's risk for motor vehicle accidents. The patients at highest risk should immediately be warned of the potential risk of driving until effective therapy is started.
  • Warn any patient with OSA of the potential dangers of driving while sleepy. Inform the patient of the potential personal and social risk.
  • Provide additional counseling depending on other risk factors (eg, occupation).
  • Advise patients to not drive until their OSA is treated adequately.
  • Provide additional counseling to family members as appropriate, and help patients explore alternatives to driving if they are unaware of their sleepiness or if they are unwilling to acknowledge their increased risk. 
  • Diagnose and treat OSA expeditiously.
  • Document in writing any warnings, concerns, and/or recommendations given to the patient. This documentation reinforces the importance of the message to the patient and helps reduce the risk of legal liability for medical personnel.
  • Routinely plan follow-up to determine the effectiveness of therapy and compliance with therapy. Ascertain whether daytime sleepiness is substantially reduced or eliminated. Continue evaluations at regular intervals until therapy controls the patients' condition.

Assess the risk of driving in any patient with OSA. Criteria that increase this risk are as follows: 

  • The patient has had previous motor vehicle accidents.
  • The patient has had near-miss incidents while driving.
  • The patient has evidence of severe daytime sleepiness or impaired driving performance. 
Whether and under what circumstances patients with sleep apnea should be reported to the licensing authority depend on the laws of the state. Those who take care of patients with OSA must be aware of state statutes or regulations regarding reporting of high-risk drivers.

Laws regarding impaired drivers, including those with OSA, vary from state to state. In some states, the clinician is obligated to report patients under specific conditions (ie, mandatory reporting statute), whereas other states permit reporting but do not require it (ie, permissive reporting statute). Mandatory statutes take 1 of the 2 following approaches:  
  • With the categorical approach, the clinician is obligated to report patients who have specified medical conditions, such as epilepsy. In these states, the reporting obligation is based on diagnosis alone.
  • With the functional approach, the clinician is required to report patients with certain medical conditions only if the clinician believes that a condition impairs the patient's driving ability. 
Each clinician is obligated to adhere to the requirements of the law in the specific state of practice, even if those laws do not reflect sound public policy or medical evidence. Irrespective of whether statutory reporting is required, clinicians may be liable for damages if a patient with OSA injures himself or herself or someone else while driving.

American Thoracic Society guidelines on reporting of patients to the appropriate state authorities are as follows36 :  
  • In states with permissive reporting mechanisms, the clinician should at a minimum notify the state's department of motor vehicles when a highest-risk patient (ie, a patient with OSA with severe daytime sleepiness and a previous motor vehicle accident or near-miss incident) (1) is unwilling to restrict driving until effective treatment is started, (2) is noncompliant or unwilling to accept treatment, or (3) has an untreatable condition or one that is not amenable to expeditious treatment ( £ 2 mo of diagnosis).
  • Increased occupational exposure to driving or increased occupational risk for an accident of substantial importance to the public may be other indications for reporting. Examples of patients in this situation are truck drivers who are transporting hazardous waste and school bus drivers. 
  • A diagnosis of OSA without additional risk factors for impaired driving should not be the basis for reporting a patient unless required by state law.
Categorical reporting may be most appropriate in the context of occupational licenses, but this is arguable. At a minimum, the threshold for suspecting an increased driving risk due to sleepiness should be low given the increased hazard. 

The US Department of Transportation convened a group of respiratory experts at its Conference on Pulmonary/Respiratory Disorders in Commercial Drivers in September 1990. The group recommends that operators with suspected sleep apnea should not be medically qualified for commercial vehicle operation "until the diagnosis has been eliminated or accurately treated."

A US Federal Aviation Administration specification letter entitled "Sleep Apnea Evaluation Specifications" states that the complications of OSA present a risk to flying safety and recommends an initial workup, acceptable treatments, and follow-up for pilots being evaluated for OSA.

 


More on Obstructive Sleep Apnea

Overview: Obstructive Sleep Apnea
Differential Diagnoses & Workup: Obstructive Sleep Apnea
Treatment & Medication: Obstructive Sleep Apnea
Follow-up: Obstructive Sleep Apnea
Multimedia: Obstructive Sleep Apnea
References
Further Reading
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Keywords

obstructive sleep apnea, OSA, sleep apnea, apnea, sleep disorder, snoring, sleep-related disorder, sleep disordered breathing, SDB, central apnea, obstructive apnea, mixed apnea, hypopnea, upper airway resistance syndrome, UARS, nasal continuous positive airway pressure, nasal CPAP, CPAP, apnea index, AI respiratory disturbance index, RDI, apnea-hypopnea index, AH, PSG, polysomnography, pickwickian syndrome, excessive daytime sleepiness, EDS, uvulopalatopharyngoplasty, UPPP, respiratory event–related arousal, RERA, oral appliance, OA, bilevel positive airway pressure, BiPAP, sleep-related breathing disorder, SRBD

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Contributor Information and Disclosures

Author

Ralph Downey III, PhD, DABSM, FAASM, Associate Professor of Medicine, Pediatrics, and Neurology, Loma University School of Medicine; Adjunct Associate Professor, Department of Psychology, University of California at Riverside; Chief, Sleep Medicine, Loma Linda University Medical Center and the Loma Linda University Children's Hospital
Ralph Downey III, PhD, DABSM, FAASM is a member of the following medical societies: American Academy of Sleep Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Philip M Gold, MD, Professor of Medicine, Chief of Pulmonary and Critical Care Medicine, Medical Director of Respiratory Care, Loma Linda University Medical Center
Philip M Gold, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Clinical Research, American Heart Association, American Lung Association, American Medical Association, American Thoracic Society, Association of Subspecialty Professors, California Medical Association, California Thoracic Society, Society of Critical Care Medicine, and Undersea and Hyperbaric Medical Society
Disclosure: Glaxo-Smith-Kline Honoraria Speaking and teaching; Covidien Honoraria Speaking and teaching; Boeringer-Ingleheim Honoraria Speaking and teaching

Himanshu Wickramasinghe, MD, MBBS, Attending Physician; Pulmonary, Critical Care, and Sleep Medicine; Henry Mayo Newhall Memorial Hospital, Valencia, California
Himanshu Wickramasinghe, MD, MBBS is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Nothing to disclose.

Medical Editor

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Daniel R Ouellette, MD, FCCP, Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System
Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

 
 
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