SLEEP APNEA
The differential diagnosis of sleep apnea may be arrived at by
utilizing both physiology and anatomy. Normal sleep
requires an unobstructed pathway from the nasopharynx to the lung and an
intact central nervous system that responds to anoxia and the accumulation
of CO2 in the blood. It follows that sleep apnea may result from an
obstructed airway (obstructive sleep apnea) or central suppression of
respiration (central sleep apnea).
Obstructive sleep apnea. Think of the things that may
obstruct the airway and many causes will come to mind. A deviated nasal
septum, chronic infective or allergic rhinitis and sinusitis, tonsillitis
and enlarged tonsils, obesity causing an enlarged soft palate or tongue,
hypothyroidism, or acromegaly causing an enlarged tongue and nasal polyps
must be considered. A small chin, deep overbite, or short neck may be the
cause. Pickwickian syndrome may cause obstructive sleep apnea because of the
associated obesity.
Central sleep apnea. Conditions that contribute to
chronic anoxia such as congestive heart failure (CHF), Pickwickian syndrome,
arteriovenous (A-V) malformations (septal defects, e.g.), and pulmonary
fibrosis may be associated with this disorder. Conditions that cause chronic
CO2 retention such as pulmonary emphysema may also be causes. Finally,
diseases of the central nervous system that depress the respiratory center
may be involved. These include poliomyelitis, chronic drug or alcohol use,
residual damage from viral encephalitis, brainstem tumors, and multiple
sclerosis.
Approach to the Diagnosis
A thorough examination of the upper respiratory system is essential: It
may be wise to get an otolaryngologist to do this. A CBC to rule out anemia
and arterial blood gases to rule out anoxia and hypercarbia may be helpful.
Spirometry, chest x-ray, echocardiogram (ECG), and arm-to-tongue circulation
time will help to rule out pulmonary and cardiovascular disorders.
Ultimately, overnight polysomnography will be required to secure the
diagnosis. A pulmonologist or otolaryngologist ought to be consulted before
ordering this expensive test.
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
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