OSCE Sleep Apnea

FM mock exam checklist for OSCE
Prepared by Dr. Mohammed AlAteeq @drmalateeq [email protected]

Dx: Obstructive Sleep Apnoea (OSA)
CANDIDATE SHOULD COVER THE FOLLOWING A B C
1. History (often detected during evaluation of another complain or condition)
• Ask about:
o Daytime sleepiness / inability to remain fully awake or alert during the wakefulness
portion of the sleep-wake cycle. Usually insidious and chronic. Feeling sleepy or falling
asleep in boring, passive, or monotonous situations
o Behaviors that may mask sleepiness, such as caffeine consumption
o Experience of nonrestorative sleep (i.e., do not wake up feeling refreshed) and nocturnal
restlessness
o Wakening with a dry mouth
o Morning headache: bifrontal and squeezing in quality, with no associated nausea,
photophobia, or phonophobia. daily or most days of the week and may last for several
hours after awakening
o Fatigue/ Tiredness / Low energy / Poor focus
o Sleep maintenance Insomnia: difficulty to maintain sleep
o Nocturia / urge to urinate
o May use Epworth Sleepiness Scale (ESS) to quantitatively document the patient’s
perception of sleepiness, fatigue, or both (score >9 indicates abnormal sleepiness)
o About risk factors: Smoking / Family Hx / nasal congestion / Exposure to high levels of
environmental nitrogen dioxide and particulate matter / substances and medications,
including alcohol, benzodiazepines, narcotics, and possibly gabapentinoids
o Abou medical conditions usually increase risk for OSA: Obesity hypoventilation syndrome
/ HF / AF / Pulmonary Hypertension / End stage kidney disease / Chronic lung disease/
Stoke and TIA / Hypothyroidsm / Acromegaly
o About complication of OSA, e.g., Dx of HTN
• Ask bed partner or relative about:
o Loud snoring, gasping, choking, snorting, or interruptions in breathing while sleeping /
snoring and associated events (i.e., resuscitative gasping or snorting, witnessed apneic
periods, periods of silence followed by loud snoring, restless or fitful sleep
• Screen for depression
• Consider other DDx: Excessive daytime sleepiness / Abrupt awakenings or abnormal sounds or
sensations during sleep / Primary snoring / Gastroesophageal reflux disease / nocturnal asthma /
swallowing disorders / nocturnal seizures
2.Physical examination:
• General: BP / Obesity (BMI) / Waist circumference / Waist-to-height ratio
• Signs of depression
• Large neck: collar size >17 inc. in men and >16 inc.in women
• Crowed neck: pharyngeal airway: retrognathia, micrognathia, lateral peritonsillar narrowing,
macroglossia, tonsillar hypertrophy, an elongated or enlarged uvula, a high arched or narrow
palate, nasal septal deviation, and nasal polyps.
• Signs of associated conditions and complications: most commonly HTN and HF, and less
commonly pulmonary hypertension
3.Diagnostic testing:
• OSA is not a clinical diagnosis and objective testing must be performed for Dx.
• Diagnostic testing for OSA should be performed on patients with excessive daytime sleepiness
(EDS) on most days and the presence of at least two of the following clinical features of OSA:
habitual loud snoring, witnessed apnea or gasping or choking during sleep, and diagnosed
systemic hypertension.
• Home Sleep Apnea Testing (HSAT) with a type 3 device is recommended for: patients with a high
likelihood of moderate or severe uncomplicated OSA (i.e., without non-OSA-related sleep-related
breathing disorders, and who have no other suspected non-respiratory sleep disorders (e.g.,
narcolepsy)
• In-lab polysomnography (PSG): should be done for: sever cases, mission-critical worker,
suspected non-respiratory sleep disorders, non-OSA-related conditions associated with sleep-
disordered breathing, Patients with negative, inconclusive, or technically inadequate home testing,
Patients in whom home testing is not feasible
• Polysomnography: Full-night study or Split-night study (if OSA diagnosed during the first part of
the night PAP therapy titrated during the second part of the night)
• if either PSG or HSAT is negative and the suspicion for OSA remains, PSG should be repeated or
performed, respectively.
4. Diagnosis
• Based on PSG: Dx is confirmed if either of the two criteria below is present:
•There are five or more predominantly obstructive respiratory events (obstructive and mixed
apneas, hypopneas, or respiratory effort-related arousals (RERAs) per hour of sleep in PSG in
a patient with one or more Sx.
•There are 15 or more events regardless the presence of associated symptoms or comorbidities.
• Based on HAST: respiratory event index (REI) ≥15 events per hour or REI 5 to 14 with
symptoms.
• Classification of severity: mild, moderate, or severe disease on the basis of the apnea-hypopnea
index (AHI) and symptoms.
5. Management
• Ref pt to Sleep Disorder Clinic for PSG and positive airway pressure therapy
• All patients diagnosed with OSA should be offered positive airway pressure (e.g., CPAP) as initial
therapy.
• In patients with mild to moderate OSA who prefer not to use positive airway pressure or who fail
to respond to it, oral appliances are an alternative therapy.
• Upper airway surgery may supersede oral appliances as alternative therapy in patients with severe,
surgically correctable, obstructing lesions of the upper airway
• Patient education:
o Educate about the risk factors, natural history, and consequences of OSA.
o Warned about the increased risk of motor vehicle accidents or operating other dangerous
equipment while sleepy.
o Counselling to avoid activities that require vigilance and alertness if sleepy.
o Should always inform their medical providers about their OSA, especially if they are to
have surgery or start opiate medications.
o Pharmacologic therapy (with agents such as modafinil or armodafinil) may be beneficial as
adjunctive therapy for excessive daytime sleepiness that persists despite documentation of
adequate and successful conventional therapy (e.g., positive airway pressure, oral appliances)
• Behavior modification:
o Encourage weight reduction and exercise
o Avoid Rx that exacerbate OSA: benzodiazepine receptor agonists, antiepileptic
medications, sedating antidepressants, antihistamines, and opiates.
o Change sleep position to non-supine if it corrects or improves OSA in AHI.
• FU:
o Should be evaluated frequently, especially during the first few weeks of therapy of CPAP
to check Adherence, efficacy, and SE.
o Repeat objective sleep evaluation is no or little improvement.
o Once optimized and symptoms resolved, long-term FU should be established

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FM mock exam checklist for OSCE

Prepared by Dr. Mohammed AlAteeq @drmalateeq [email protected]

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