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October 1, 2013 Issue

Clinical Practice Points

Management of Obstructive Sleep Apnea in Adults: A Clinical Practice Guideline From the American College of Physicians

This guideline recommends that patients with obstructive sleep apnea (OSA) lose weight and that continuous positive airway pressure (CPAP) be used as initial therapy. Mandibular advancement devices should be considered for patient unwilling or unable to use CPAP.

Use this guideline to:

  • Start a teaching session with a multiple-choice question. We’ve provided one below.
  • Review the symptoms and signs that should prompt consideration of OSA.
  • Ask your residents how the diagnosis of OSA is made. Ask an expert in sleep medicine to review a sleep study report with your residents. Important definitions are provided in Table 1.
  • Review the tracings from a polysomnogram—there is an easy-to-follow, simple figure with an explanation in ACP Smart Medicine’s OSA module (“Polysomnogram Tracing of Obstructive Apnea”).
  • Review how CPAP works. Why do your residents think adherence with CPAP therapy can be a problem?

Screening for Glaucoma: U.S. Preventive Services Task Force Recommendation Statement

This guideline found there was insufficient evidence to assess the balance of benefits and harms of screening for primary open-angle glaucoma in adults.

Use this guideline to:

  • Review the symptoms and signs of glaucoma. What is the differential diagnosis?
  • Discuss the USPSTF’s discussion of the accuracy of available screening tests and what is known (and not known) about potential benefits and harms of screening and treatment.
  • How should an “I” statement (insufficient evidence) influence your residents’ practice?
  • What are the characteristics of a good screening test? Use the material in the High Value Care Curriculum discussed next—there is a teaching module on screening and prevention!

Other Teaching Resources from ACP

High Value Care Curriculum from the AAIM-ACP High Value Care Curriculum for Educators, Residents, and Students

This recently updated and eminently practical curriculum was developed by AAIM and ACP to aid in teaching residents to provide better care and be thoughtful and responsible members of the health care system. Materials include teaching slide sets, handouts, facilitators' guides, and a toolbox for program directors. Download these materials for free. The entire curriculum can be covered in six 1-hour sessions, or you can pick and choose ones that suite specific teaching needs.


In the Clinic: Systemic Lupus Erythematosus

This concise and eminently practical review asks—and provides answers to—questions all residents need to know. It includes 3 MKSAP questions—structure an interactive teaching session around them.

Use this review to:

  • Discuss how the diagnosis of systemic lupus erythematosus is made. What tests should be ordered?
  • What is the differential diagnosis?
  • What are the available therapies, and how should they be chosen and monitored?
  • Use the already prepared teaching slides available for download.
  • Get CME for yourself. You’ve reviewed the article and the questions—so log on and get credit by entering the answers!

Humanism and Professionalism

On Being a Doctor: Alligator Hands

Play an audio recording of this issue’s On Being a Doctor in which our colleague, Jessica Gold, describes her reaction to the first death she witnessed as a medical student. Ask your residents if they recall similar feelings when first encountering death in the hospital. Do they remember how it felt as they themselves mentor medical students and interns? How can remembering that experience help to make them better teachers?


mksap16

A 58-year-old man is evaluated for a 3-month history of loud snoring and “gasping” during sleep. He also frequently falls asleep in a chair while reading in the evening. His medical history is otherwise unremarkable.

On physical examination, temperature is 37.4 ° C (99.3 ° F), blood pressure is 130/82 mm Hg, pulse rate is 80/min, and respiration rate is 14/min; BMI is 34. Neck circumference is 45.7 cm (18 in), and a low-lying soft palate is noted. Polysomnography discloses severe obstructive sleep apnea, with an apnea-hypopnea index of 42 per hour.

Which of the following is the most appropriate next step in treatment?

A) Continuous positive airway pressure
B) Nocturnal oxygen therapy
C) Oral appliance
D) Upper airway surgery

Correct Answer
A) Continuous positive airway pressure

Key Point
Continuous positive airway pressure is first-line therapy in patients with obstructive sleep apnea and associated symptoms, particularly excessive daytime sleepiness.

Educational Objective
Treat obstructive sleep apnea with continuous positive airway pressure.

The most appropriate next step in treatment is continuous positive airway pressure (CPAP). Obstructive sleep apnea (OSA) is defined by upper airway narrowing or collapse resulting in cessation (apnea) or reduction (hypopnea) in airflow despite ongoing efforts to breathe. The severity of OSA is commonly measured using the apnea-hypopnea index (AHI), the sum of apneas and hypopneas per hour of sleep. An AHI of 5 to 15 indicates mild OSA, an AHI of 16 to 30 indicates moderate sleep apnea, and an AHI of more than 30 indicates severe OSA. It is estimated that 24% of men aged 30 to 60 years and 9% of similarly aged women have OSA (AHI of at least 5/hour). CPAP should be considered first-line therapy in any patient who has OSA and associated symptoms, particularly excessive daytime sleepiness. Optimal positive airway pressure therapy may have salutary effects on cardiovascular diseases that are associated with OSA. Suboptimal adherence to CPAP and bilevel positive airway pressure devices is common in clinical practice, and rates of discontinuation are high. Therefore, objective monitoring of use and periodic follow-up are important to ensure adherence.

Nocturnal oxygen therapy alone is inadequate to prevent complications associated with OSA because it does not correct upper airway obstruction, which is the primary problem related to oxygen desaturation.

Oral devices may be considered for patients who cannot tolerate or are unwilling to use positive airway pressure therapy but should be reserved for patients with mild to moderate OSA.

Surgery may be indicated for patients with specific underlying surgically correctable craniofacial or upper airway abnormalities that contribute to OSA, including nasal polyps, nasal septal deviation, tonsillar enlargement, or retrognathia, although positive airway pressure therapy may still be preferred for such patients. Upper airway surgery may also be considered in selected patients with OSA who desire surgery, reject other therapeutic modalities, and can undergo the procedure.

Bibliography Epstein LJ, Kristo D, Strollo PJ Jr, et al; Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5(3):263-276. PMID: 19960649

This question was derived from MKSAP® 16, the latest edition of the Medical Knowledge Self-Assessment Program.

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